Scapulothoracic bursitis of the chest wall: sonographic features with pathologic correlation

Magnetic Resonance Imaging (MRI) of Snapping Scapula in a 10-Year-Old Boy

Background

Snapping scapula syndrome, also known as scapulothoracic crepitus or bursitis, is a manifestation of a mechanical abnormality of the scapulothoracic joint. In addition to characteristic findings on physical examination, magnetic resonance imaging (MRI) exquisitely reveals soft tissue changes such as muscle edema and scapulothoracic bursitis.

Case Report

We present a case of a 10-year-old boy who had snapping scapula syndrome of the right scapula that was associated with edema of the serratus anterior muscle at the scapulothoracic interface and with scapulothoracic, specifically supraserratus, bursitis on MRI.

Conclusions

MRI in snapping scapula syndrome, which is a clinical diagnosis, exquisitely reveals soft tissue changes such as muscle edema and scapulothoracic bursitis. Such soft tissue findings of snapping scapula syndrome need to be kept in mind while evaluating routine shoulder and/or scapular region MRI, especially in the absence of relevant clinical information at the time of the imaging study.

Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management

Symptomatic scapulothoracic disorders, including scapulothoracic crepitus and scapulothoracic bursitis are uncommon disorders involving the scapulothoracic articulation that have the potential to cause significant patient morbidity. Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly or independently. Nonetheless, the constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome. Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects. Imaging is an important adjunct to the physical examination for accurate diagnosis and appropriate treatment management. Non-operative management such as physical therapy and local injection can be effective for symptoms secondary to scapular dyskinesis or benign, non-osseous lesions. Surgical treatment is utilized for osseous lesions, or if non-operative management for bursitis has failed. Open, arthroscopic, or combined methods have been performed with good clinical outcomes.

Scapulothoracic bursitis in a patient with quadriparesis: a case report

Scapulothoracic bursitis is a rare disease and presents as pain or swelling around the bursa of the scapulothoracic articulation. It has been reported to be related to chronic repetitive mechanical stress of the periscapular tissue, trauma, overuse, and focal muscle weakness. The authors experienced an atypical case of scapulothoracic bursitis with shoulder and periscapular pain after quadriparesis.This case implies that muscular atrophy around the scapula and chest wall from quadriparesis may contribute to the development of scapulothoracic bursitis with shoulder and periscapular pain. In addition, clinician should be alert to it as a possible cause when a patient with quadriparesis complains of shoulder and periscapular pain and consider proper diagnostic options such as ultrasonography or magnetic resonance imaging.

Scapulothoracic bursitis and snapping scapula syndrome: a critical review of current evidence

BACKGROUND

Symptomatic scapulothoracic disorders, such as painful scapular crepitus and/or bursitis, are uncommon; however, they can produce significant pain and disability in many patients.

PURPOSE

To review the current knowledge pertaining to snapping scapula syndrome and to identify areas of further research that may be helpful to improve clinical outcomes and patient satisfaction.

STUDY DESIGN

Systematic review.

METHODS

We performed a preliminary search of the PubMed and Embase databases using the search terms "snapping scapula," "scapulothoracic bursitis," "partial scapulectomy," and "superomedial angle resection" in September 2013. All nonreview articles related to the topic of snapping scapula syndrome were included.

RESULTS

The search identified a total of 167 unique articles, 81 of which were relevant to the topic of snapping scapula syndrome. There were 36 case series of fewer than 10 patients, 16 technique papers, 11 imaging studies, 9 anatomic studies, and 9 level IV outcomes studies. The level of evidence obtained from this literature search was inadequate to perform a formal systematic review or meta-analysis. Therefore, a critical review of current evidence is presented.

CONCLUSION

Snapping scapula syndrome, a likely underdiagnosed condition, can produce significant shoulder dysfunction in many patients. Because the precise origin is typically unknown, specific treatments that are effective for some patients may not be effective for others. Nevertheless, bursectomy with or without partial scapulectomy is currently the most effective primary method of treatment in patients who fail nonoperative therapy. However, many patients experience continued shoulder disability even after surgical intervention. Future studies should focus on identifying the modifiable factors associated with poor outcomes after operative and nonoperative management for snapping scapula syndrome in an effort to improve clinical outcomes and patient satisfaction.

Operative management in a patient with scapulothoracic bursitis

Scapulothoracic bursitis, an uncommon lesion, has been reported to be a painful disorder of scapulothoracic articulation. The articulation may become inflamed secondary to trauma when overused because of sports or work that requires repetitive or constant movement of the scapula against the posterior chest wall. The bursitis usually appears as a growing mass at the scapulothoracic interface and is often confused with a soft tissue tumor. We report on a patient with scapulothoracic bursitis who underwent surgical excision.

Scapulothoracic anatomy and snapping scapula syndrome

The scapulothoracic articulation is a sliding junction between the deep aspect of the scapula and thoracic rib cage at the levels of ribs 2 through 7. Motion at this articulation is dynamically stabilized by a variety of muscular attachments, allowing for controlled positioning of the glenoid to assist in glenohumeral joint function. A thorough understanding of the complex anatomic relationships, including the various muscles, and bursa, is critical to the evaluation of patients presenting with scapulothoracic disorders. The snapping scapula syndrome is caused by either osseous lesions or scapulothoracic bursitis and can be difficult to recognize and treat. The purpose of this review is to discuss the anatomy of the scapulothoracic articulation with an emphasis on the pathology associated with snapping scapula syndrome.

The snapping scapula: diagnosis and treatment

As a largely under-recognized problem, snapping scapula stems from the disruption of normal mechanics in scapulothoracic articulation. It is especially common in the young, active patient population, and symptoms are frequently seen with overhead and throwing motions. Understanding the anatomy of the scapula and surrounding neurovascular structures is crucial in making a differential diagnosis and providing both nonoperative and surgical treatments. Common causes of snapping scapula include bursitis, muscle abnormality, and bony or soft-tissue abnormalities. Anatomic variations, such as excessive forward curvature of the superomedial border of the scapula, may also be a cause for snapping. Benign tumor conditions of the scapula can also predispose one to snapping scapula syndrome and should be thoroughly investigated during the course of treatment. Patients with snapping scapula syndrome typically present with a history of pain with overhead activities. Snapping scapula is associated with audible and palpable crepitus near the superomedial border of the scapula. Various imaging studies may be used to rule out soft-tissue and bony masses, which may cause impingement at the scapulothoracic articulation. In most cases nonoperative treatment is curative and includes physical therapy for scapular muscle strengthening and nonsteroidal anti-inflammatory medications. Corticosteroid injections may also be used for therapeutic and diagnostic purposes. In most cases overuse injuries and repetitive strains respond well to nonoperative treatments. When nonoperative measures fail, surgery is a proven modality, especially if a soft-tissue or bony mass is implicated. Both open and arthroscopic techniques have been described with predictable results.

Snapping scapula syndrome

Snapping scapula syndrome arises from either a soft-tissue or a skeletal anomaly within the scapulothoracic space that creates a cracking sound during scapulothoracic motion that patients associate with pain. Nonoperative measures consisting of supervised physical therapy, anti-inflammatory medications, and therapeutic injections are the mainstay of treatment. Open, arthroscopic, and combined operative approaches have been described for the treatment of refractory cases, with good overall outcomes in many relatively small case series. However, the optimal operative approach has yet to be determined.