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Arthroscopic and open management of scapulothoracic disorders in athletes


OVERVIEW

Chapter synopsis

  • Scapulothoracic bursitis, crepitus, dyskinesis, and winging are related conditions of the shoulder that are frequently seen together in different combinations. Crepitus, or snapping scapula, may be asymptomatic or may be seen with bursitis. Nonoperative treatment is often effective and includes corticosteroid injections in the scapulothoracic bursae and physical therapy. Surgery to resect inflamed bursae and/or bony prominences may be performed arthroscopically or via an open procedure. When long thoracic nerve palsies do not recover, a transfer of the sternal head of the pectoralis major muscle is recommended.

Important points

  • Scapulothoracic bursitis, crepitus, dyskinesis, and winging are often seen together.

  • Crepitus may be asymptomatic.

  • Physical therapy and injections of corticosteroids are often successful for the treatment of bursitis and dyskinesis.

  • Surgery to resect the bursa or remove bony prominences can be performed via an open procedure or arthroscopically with predictably good results.

  • Long thoracic nerve and spinal accessory nerve palsies may take over a year to recover; surgery should be reserved for patients who have no clinical or electromyographic improvement after a lengthy period of nonoperative treatment.

Clinical and surgical pearls

  • Imaging of the scapulothoracic articulation is important to identify bony or soft tissue tumors as a source of symptoms.

  • Arthroscopy of the scapulothoracic articulation is facilitated by putting the patient’s arm behind the back in a “chicken wing” position.

  • Open resection of the superomedial angle of the scapula is sometimes indicated, and if performed requires meticulous repair of the periscapular muscles.

  • When a pectoralis transfer is performed for a long thoracic nerve palsy, the end of the tendon (with or without a piece of bone) should meet the scapula with the graft used for augmentation.

Clinical and surgical pitfalls

  • Pneumothorax is a risk of injections of the scapulothoracic articulation. This risk may be reduced by placing the patient’s arm behind the back in a “chicken wing” position and by the use of imaging.

  • Portals placed too far from the medial border of the scapula during scapulothoracic arthroscopy may put the dorsal scapular nerve at risk.

  • The suprascapular nerve and artery are at risk when performing a too lateral dissection during open resection of the superomedial angle of the scapula.

Knowledge about the interplay of structures and biomechanics surrounding the scapula and its role in shoulder motion is evolving steadily. The result is that our understanding of shoulder disease is also increasing. It is becoming clear that processes affecting the scapula in turn greatly influence the function of the shoulder. Conditions of the scapulothoracic articulation can be broadly divided into four main disease processes: bursitis, crepitus, dyskinesis, and winging. Each of these is a unique entity, but they are often seen in combination.

Scapulothoracic bursitis manifests as posterior shoulder pain with range of motion. The patient can often localize the pain under the scapula. Two major bursae are consistently identified: the infraserratus bursa between the serratus and the chest wall and the supraserratus bursa between the subscapularis and the serratus ( Fig. 34.1 ). In addition, four minor adventitial bursae have been described. Clinically significant bursitis tends to affect two areas most commonly: the superior medial angle and the inferior angle. The bursae at these locations are minor adventitious bursae that may become apparent only when they are inflamed. Through a process that is similar to subacromial bursitis, repetitive motion of the scapula over the rib cage causes inflammation and edema in the bursae. As with other types of bursitis, this process can be initially treated with rehabilitation and judicious corticosteroid injections. This is often sufficient to quiet the process and relieve the patient’s symptoms. On occasion, the bursitis is refractory to medical management, and surgical intervention in the form of a bursectomy is indicated.

Fig. 34.1
Bursae about the scapula. A number of bursae have been described about the scapula, including the two major bursae (infraserratus and supraserratus) and the four minor or adventitial bursae.

(Modified from Kuhn JE, Hawkins RJ. Evaluation and treatment of scapular disorders. In: Warner JJP, Iannotti JP, Gerber C, eds: Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott-Raven; 1997.)

Scapulothoracic crepitus is a process whereby palpable and often audible noises are generated under the scapula. Of significance in this process is that not all crepitus is painful or pathologic, and the volume of the noise does not correlate with the severity of the pain. Crepitus ranges from mild, painless subscapular crunching to painless but loud snapping and from minimal discomfort to disabling pain. In most patients, symptomatic scapulothoracic crepitus is associated with bursitis.

Winging of the scapula is a finding that may result from many causes. In athletes, winging is typically seen as an isolated palsy of the serratus caused by a long thoracic nerve neurapraxic injury. Winging may also be seen with profound scapular bursitis or may manifest as part of scapular dyskinesis. Scapular dyskinesis is defined as abnormal motion of the scapula characterized by medial border or inferior angle prominence, early excessive scapular elevation and shrugging, or rapid downward rotation during lowering of the arm. A static abnormality of scapular position, called the SICK scapula ( s capular malposition, i nferior medial border prominence, c oracoid pain and malposition, and dys k inesis of scapular movement), probably represents a more severe state of this condition. Whereas dyskinesis is likely to be the most common finding in the athlete with shoulder pain, it is best treated with appropriate rehabilitation and will not be explored in detail in this chapter. Winging caused by bursitis typically resolves with treatment of the bursitis. Winging caused by long thoracic nerve injury resolves spontaneously in most athletes; when it persists, surgical intervention can be considered.

Preoperative considerations

History

Many scapulothoracic conditions in athletes are related to other pathologic processes in the shoulder, and therefore the history should include a thorough orthopedic review of systems. A typical history of the patient with a scapulothoracic disorder includes the following:

  • Pain with activity greater than pain at rest

  • Painful crepitus

  • Increased pain on carrying or lifting objects away from the body

  • Pain at the superior angle of the scapula

  • Pain near other scapulothoracic muscles

Physical examination

The physical examination for scapulothoracic disorders requires the physician to stand behind the patient, who is disrobed or wearing a sports bra or tube top. The scapular position at rest should be noted. A scapula that is depressed, anteriorly tilted, and internally rotated suggests a SICK scapula and typically has tenderness at the pectoralis minor insertion on the coracoid. The patient is asked to elevate and then lower the arms while the physician looks for dyskinesis. Crepitus can be heard, and the location of crepitus (superomedial angle or inferior angle) frequently can be determined by careful palpation. Provocative testing to elicit winging can be performed by having the patient push off from the wall or elevate the arms against resistance ( Fig. 34.2 ).

Fig. 34.2, Winging of the scapula. Winging can be accentuated by pushing off from a wall or by resisting forward elevation.

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