Conservative management of a patient with snapping scapula: A case study Amy Curtis, SPT, Mary Beth McLees, SPT, Doug Keskula, PT, PhD, ATC Department of Physical Therapy, Georgia Health Sciences University, Augusta, GA, USA INTRODUCTION Snapping scapula syndrome is a disorder of the scapulothoracic joint characterized by an audible crepitus during over-head shoulder motion due to abnormal movement of the scapula over the posterior rib cage (Lazar 2009 and Manske 2004). Functional implications of snapping scapula syndrome include inefficient shoulder and arm movement due to poor scapulothoracic mechanics, an unstable base of support for glenohumeral motion, and altered length-tension relationships among scapular muscles (Lazar 2009 and Manske 2004). Possible causes include bursitis, muscle atrophy, muscle fibrosis, structural spinal deformities, overuse, osteochondroma, muscular imbalances, or bony abnormalities of the ribs or scapula (Lazar 2009, Manske 2004, Kuhne 2009). PATIENT PROGRESSION INTERVENTION Date Initial Treatment Plan and HEP Progression • Sidelying shoulder external rotation • Prone shoulder extension • Prone scapular retraction • Chin retractions • Push-up plus • Doorway pectoralis stretch • Upper trapezius stretch • Upright shoulder external and internal rotatio n • Bilateral shoulder external rotation • Standing shoulder extension • Prone shoulder external rotation • Prone shoulder abduction • Horizontal shoulder adduction • Scapular rows • D2 PNF pattern • Stick-Up • Isometric scapular retraction with depression •Initial evaluation 9/28 •Modifications to treatment plan •Addition of 4-point scapular motion exercise performe d through limited ROM to avoid snapping •Addition of shoulder IR with yellow theraband •Ultrasound •Manual therapy: deep soft tissue mobilization performed but stretching not tolerated •Slight increase in ROM noted, but limitation during exercise due to snapping remains •Follow up in 1 week •Some difficulty reported with carrying book bag reported •Pain: 3-4 initial, 3 final 10/14 •Improvement in •Modifications to treatment plan •Some strengthening exercises scapular mechanics •Performed upper trapezius and pectoralis stretch were not performed regularly due •Performed shoulder IR, ER, and extension x 30 reps noted to limited availability of a theraband with red theraband at home •Addition of isometric horizontal shoulder adduction, •Gravity was used when scapular rows and depression, and stick-up exercise appropriate to replace band x 30 reps •Overall decrease in symptoms •Ultrasound with some remaining popping •Manual therapy: deep tissue mobilization performed b reported ut manual stretching still not tolerated •Pain: 3-4 initial, 2-3 final •Follow up in 1 week 10/22 •Exercises performed with more consistency •Crepitus while reaching overhead and pain when donning book bag continue •Modifications to treatment plan •Performed all exercises 10 reps x 2 sets •Advanced to green theraband for scapula rows and shoulder extension •Addition of bilateral ER with yellow theraband •Ultrasound •Manual therapy: stretching tolerated along with continued deep soft tissue mobilization •Overall improvement noted •Follow up in 1 week •Modifications to treatment plan •All previous exercises performed with green tube for scapular rows, shoulder IR, shoulder ER, and shoulde r extension •Performed bilateral scapular retraction/depression wit h resisted isometric scapular depression •Addition of D2 diagonal patterns with yellow theraban d •Pectoralis stretch performed •Ultrasound •Manual therapy: tolerated stretching and moderate – deep soft tissue mobilization •Greater ability to reach overhead slowly versus quickly noted •Follow up in 1 week N/A •Follow up in 1 week •Pain: 4-8 initial, 3-4 final 11/5 •Exercises performed regularly •Difficulty and pain when reaching overhead and carrying book bag with left arm continue •General decrease in symptoms reported •Pain: 4-8 initial, 1-2 final The purpose of this case report is to provide detailed information regarding non-invasive treatment techniques for snapping scapula syndrome by describing a successful physical therapy plan. 11/11 D2 PNF Pattern CASE STUDY Element Isometric Scapular Retraction with Depression Pectoralis Stretch 12/2 Findings • 17 year old female Patient Characteristics • Chief complaint: L shoulder pain • MOI: MVA 2 years prior to initial evaluation Initial Evaluation Goals • Difficulty sleeping and performing ADLs due to pain • Crepitus associated with painful shoulder movement • Poor scapular and glenohumeral movement • L scapula protrusion and winging • Periscapular tenderness • Pectoral tightness • Decreased L neck and shoulder PROM and MMT • Short Term: Reduce pain to no more than 3/10, maintain scapula rstabilization during L shoulder motion, and achieve independenc e with HEP • Long Term: Achieve full AROM, eliminate pain at rest, and reduc e pain with activity to no more than 1/10 Treatment Plan • 7 visits over 2 month period • Therapeutic exercise focused on restoring alignment and muscular control of the scapulothoracic region • Manual therapy • Ultrasound • Patient education •Unable to perform exercises due to •Modifications to treatment plan •All previous exercises performed illness •Advance to yellow theraband for stick-up exercise •Carrying book bag continues to •Addition of prone shoulder abduction cause pain •Ultrasound •Overall decrease in •Manual therapy: tolerated stretching and deep soft pain and crepitus reported tissue mobilization •Pain: 3-4 initial, 3 final •Overall improvement reported •Some pain and crepitus while reaching overhead and carrying book bag remain •Pain: 0-2 initial, 6 final RESULTS Patient reported an overall decrease but not elimination of symptoms after 7 physical therapy sessions. Pain was rated at the beginning and end of each treatment session. The patient initially rated pain as 5-8/10 VAS and decreased the rating to 02/10 VAS at the beginning of her final treatment session. After the seventh visit, the patient became increasingly busy with school and sport commitments and was unable to return to therapy. Lingering symptoms included pain and crepitus during functional activities such as reaching overhead and carrying a book bag. Possible barriers to full recovery include lack of total compliance with home exercise program and missed physical therapy visits. Plan •Initial evaluation Stick-Up Current literature concerning this disorder provides ample information about various surgical treatment options but very limited advice about conservative management such as physical therapy. Assessment •Initiation of treatment plan •Therapeutic exercise: side-lying shoulder ER, prone shoulder extension, prone scapular retraction, chin retraction, push-up plus *Patient progressed from no resistance or low level theraband resistance to higher level resistance as tolerated and as directed by therapist Horizontal Adduction Objective 9/22/09 •Initial evaluation *Patient instructed to perform all exercises 10-15 repetitions, 1-2 times per day Prone Scapular Retractions Subjective •Modifications to treatment plan •Advance to blue theraband for scapular rows and shoulder extension •Advance to red tube for stick-up exercise •Performed terminal shoulder extension standing with red band •Performed sitting scapular depression •All exercises performed x 30 reps without crepitus or pain •Ultrasound •Manual therapy: tolerated stretching and moderate to deep soft tissue mobilization •Symptoms continue •Follow up in 2 weeks to improve SUMMARY & CONCLUSIONS ● This case report indicates that conservative management of snapping scapula syndrome, including therapeutic exercise focused at improving scapulothoracic alignment and muscular control, may be beneficial for decreasing pain and crepitus associated with overhead shoulder motion. ● The use of outcome measurement tools, measurable goals, and complete documentation will be beneficial in further research. ● Further research is needed to be able to generalize the findings of this study. REFERENCES 1.Lazar MA, Kwon YW, Rokito AS. Snapping scapula syndrome. The Journal of Bone & Joint Surgery. 2009;91-A(9):2251-2262. 2.Manske RB, Reiman MP, Stovak ML. Nonoperative and operative management of snapping scapula. The American Journal of Sports Medicine. 2004;32(6):1554-1565. 3.Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008;36(9):17891798. 4.Millar AL, Jasheqy PA, Eaton W, Christensen F. A retrospective, descriptive study of shoulder outcomes in outpatient physical therapy. Journal of Orthopaedic and Sports Physical Therapy. 2006;36(6):403-414. 5.Kuhne M, Boniquit N, Ghodadra N, Romeo AA, Provencher MT. The snapping scapula: Diagnosis and treatment. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2009;25(11):1298-1311. 6.Mozes, Gavriel; Jacob, Bickles; Ovadia, Dror; Dekel, Samuel. (1999). The Use of Three-Dimensional Computed Tomography in Evaluating Snapping Scapula Syndrome. Orthopedics, 22(11), 1029-1032. 7.Van Riet, Roger, and Bell, Simon. (2006). Scapulothoracic Arthroscopy. Techniques in Elbow and Shoulder Surgery, 7(3), 143-146. 8.Harper GD, McIlroy S, Bayley JIL, Calvert PT. Arthroscopic partial resection of the scapula for snapping scapula: A new technique. The Journal of Shoulder and Elbow Surgery. 1999;8(1):53-57. 9.McMullin, John; Uhl, Timothy. (2000). A Kinetic Chain Approach for Shoulder Rehabilitation. Journal of Athletic Training,35(3), 329-337. 10.Stiller, Jennifer, ATC; Uhl, Timothy, PhD, ATC, PT. (2005). Outcomes Measurements of Upper Extremity Function. Athletic Therapy Today, 10(3), 24-26. dkeskula@georgiahealth.edu