When Painful Snapping Around the Shoulder Blade Becomes Debilitating…: The Snapping Scapula Syndrome

The shoulder blade area and surrounding muscles may become irritated and painful for multiple reasons. Some of the most frustrated patients I have seen in my practice complain of years and years of painful snapping around the upper shoulder blade region. Oftentimes, these individuals have been told that physical therapy exercises are all they need to improve; and in fact, many truly do improve with therapy. However, for some individuals, therapy will just not work! Did you know that clearing the bursal tissue under the shoulder blade and removing some scapular bone (if needed) may work like magic for some of these patients?… And the procedure can be done with endoscopic techniques: two or three small punctures holes, and the surgery is performed with a camera and small surgical tools!

What is the snapping scapula syndrome?

Scapula is the medical term to name the shoulder blade. The scapula glides over the chest wall with the majority of shoulder movements. Any irregularity in the relatively narrow space between the shoulder blade and the chest wall may lead to abnormal painful rubbing of the scapula on the chest wall. The term “scapular snapping syndrome” refers to individuals that experience painful snapping of their shoulder blade with active shoulder motion. Each of these symptoms may vary in intensity: some individuals can feel or hear snapping, but have no pain; others have exquisite pain with the snapping. Snapping or similar noises may be audible, or they may only be felt by the affected individual.

Superomedial border of the scapula.jpg
These images will help you understand how the superomedial border of the scapula can easily rub on the ribs with movement of the upper extremity.

What could be the reasons?

The snapping scapula syndrome can sometimes be linked to a very specific event: a fracture of the shoulder blade or ribs that never healed well, benign growths on the undersurface of the shoulder blade, prior chest surgery… However, in many individuals it may be due to a combination of abnormal development of the shape of the scapula, atrophy of the muscles between the shoulder blade and the chest (serratus anterior and subscapularis), or thickening of the bursal tissue under the scapula, either spontaneously or after an injury.

Scapular malunion.jpg
When the shoulder blade fractures and heals deformed, the abnormal shape and bulk (red circles) may lead to scapular snapping; however, in many individuals, gross abnormalities are not detected.

First line of management

If you suffer with snapping scapula syndrome, your shoulder specialist will perform a comprehensive evaluation of your shoulder region. It is particularly important to confirm that there is no structural damage to the muscles around the shoulder blade or their nerves. You will likely be asked if you sustained an injury in the past, particularly rib or shoulder blade fractures. Plain radiographs may not show much. Magnetic resonance and computed tomography imaging are helpful to exclude abnormal growths in the undersurface of the shoulder blade, and to determine whether the shape of the scapula is particularly prone to snapping.

Subscapularis and serrastus.jpg
The subscapularis (SS) and serratus anterior (SA) are two muscles in between the ribs and shoulder blade that may be exercised to treat scapular snapping. As they become larger, they increase the distance between the shoulder blade and the chest wall.

As a first line of management, patients with snapping scapula syndrome are typically recommended a trial or nonsteroidal antiinflamatory drugs (i.e., ibuprofen) and physical therapy. Increasing the bulk of the subscapularis and serratus anterior will create more space between the chest wall and the shoulder blade (see above); as such, physical therapy is directed to (1) scapular repositioning at rest, (2) comprehensive strengthening of the periscapular muscles, and (3) exercises directed to increase the muscular bulk of the subscapularis and serratus anterior. For individuals not responding to physical therapy, injecting steroids in the space under the scapula (supraserratus bursa) may help.

Subscapularis and serratus anterior strengthening
These exercises will increase the bulk of the subscapularis and serratus anterior.

Endoscopic surgery only when nothing will work

Unfortunately, some patients will not respond to the treatment modalities just outlined. Provided other reasons for snapping are excluded, these patients are considered for surgery. The goals of surgery are to remove any inflamed bursal tissue and oftentimes remove bone from the upper scapula. Surgeons call this procedure endoscopic bursectomy and partial resection of the superomedial border of the scapula. In the past, this procedure was performed through a conventional skin incision or cut, but currently we perform this procedure with endoscopic, minimally-invasive surgery.

Resected area.jpg
The goal of these procedure is to remove the area shaded on the image on your left to make it look like the image on your right.

An endoscopic camera is inserted under the shoulder blade through a small puncture hole and instruments inserted through a second separate puncture hole are used to remove bursal tissue and bone. Performing the procedure endoscopically minimizes muscle detachment and damage, and only leaves behind two very small skin scars.

Surgery is performed with the patient on his or her belly and the shoulder blade facing up. Small puncture holes are used to introduce an endoscopic camera and instruments for bursa and bone removal.

What to expect?

After surgery, most patients are recommended use of a sling just for comfort during the first week or two. Some individuals may not need therapy, but many do benefit from a program similar to what we described above for a few months after surgery. Watch the testimonial of one of our patients below!

Any possible complications?

In addition to the general complications of surgery, some of the nerves that activate muscles around the shoulder blade are relatively close to the surgical site. Your shoulder specialist will know how to use landmarks around the scapula to avoid inadvertent nerve damage. It may be difficult to remove just the right amount of bone: not removing enough bone may not solve the problem, but removing too much bone can create its own issues.

If you want to see how the procedure is done… click here

Leave a Reply