Scapula Pain
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Isolated scapula pain is uncommon, but very difficult to diagnose and manage. In this presentation I run through the known causes and an approach to the diagnosis, in order to guide best treatment.
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Scapula Pain
- 4. @thearmclinic CASE 1 • 16yr old competitive swimmer • Overstretched reaching for wall on breastroke turn 6 months ago • Lots of ‘Physio’ • Aching around scapula with any activities • Unable to raise her arm unaided
- 5. @thearmclinic • 38yr old road worker • No injury • Gradual onset of aching around scapula with heavy work • Painful clicking and clunking • Worse with Physio (cuff exercises) CASE 2
- 6. @thearmclinic CASE 3 • 56yr old Male Mechanic • Woke 6m ago with severe pain scapula & arm • Pain settled but now unable to move arm • Unable to work
- 7. @thearmclinic CASE 4 • 26yr old Male Javelin Thrower • Pain Right Scapula 6m • Weak throwing • Fatigues easily • Aching in axilla & shoulder
- 8. @thearmclinic CASE 5 • 26yr old Male Rugby Player • Pain Left Shoulder 6m • Aching around scapula & shoulder • Fatigues easily • Struggling with overhead weights
- 9. @thearmclinic CASE 6 • 26yr old Male Builder • Severe pain Right Scapula 6m • Now aching with work • Weak lifting & carrying • Fatigues easily
- 10. @thearmclinic CASE 7 • 26yr old Male • Grabbed railing falling on ladder 4yrs ago • Persistant severe scapula pain • Constant & worse with usage • Seen many Physios & specialists
- 13. @thearmclinic Atraumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Exostoses Deformities Dystrophy Functional Neuritis DSN Suprascapular N Axillary N Thoracic GHJ Unknown Radiculopathy Post.Instability T4 Syndrome
- 14. @thearmclinic Traumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Fractures Muscle Detachments Traction Direct Trauma Thoracic GHJ Fractures Post.Instability
- 15. @thearmclinic 1. Snapping Scapula 2. Neuralgic Amotrophy 3. Isolated Nerve Palsies 1. Long Thoracic 2. Suprascapular 3. Dorsal Scapular 4. Axillary 4. T4 Syndrome 5. Posterior GHJ Instability Atraumatic Conditions
- 16. @thearmclinic Traumatic Conditions 1. Scapula Muscle ‘Detachment’
- 17. @thearmclinic • Onset • Location & Distribution • Nature • Snapping • Exacerbating Factors • Relieving Factors Atraumatic Pain
- 18. @thearmclinic • Mech of Injury • Location & Distribution • Exacerbating Factors • Relieving Factors Traumatic Pain
- 19. @thearmclinic Snapping Scapula Patient Young, Active, Male Onset Acute, Sudden, No injury; Recent viral infection Location & Distribution Patchy - scapula, shoulder, arm Nature Severe; burning; constant; Lasts a few days/weeks - then flaccid paralysis (patchy) Other Factors Patchy weakness after acute pain Pain unaffected by movement Not relieved by analgesics or NSAIDs
- 20. !20 Gaskill & Millett J Am Acad Orthop Surg 2013;21: 214-224
- 21. !21
- 22. !22
- 24. !24
- 25. @thearmclinic Neuralgic Amyotrophy Patient Any age, Active, Male Onset Acute, Sudden, No injury; Recent viral infection Location & Distribution Patchy - scapula, shoulder, arm Nature Severe; burning; constant; Lasts a few days/weeks - then flaccid paralysis (patchy) Other Factors Patchy weakness after acute pain Pain unaffected by movement Not relieved by analgesics or NSAIDs
- 26. @thearmclinic • Brachial Neuritis / Parsonage-Turner Syndrome • Clinical Diagnosis (Parsonage & Turner, 1948) • Only 50% fit ‘classical NA’ (Van Alfen, 2009) Neuralgic Amyotrophy
- 28. @thearmclinic • Based on EMG & MRI: • Clinical Diagnosis: • 50% Sensitivity • 75% Specificity • 30% PPV • 88% NPV Neuralgic Amyotrophy Clarke et al. JSES, 2016
- 29. @thearmclinic • Based on EMG & MRI: • Clinical Diagnosis: • 50% Sensitivity • 75% Specificity • 30% PPV • 88% NPV Neuralgic Amyotrophy Clarke et al. JSES, 2016
- 30. @thearmclinic Neuralgic Amyotrophy Clarke et al. JSES, 2016 Clinical Dx NA 27% NA Confirmed EMGs 73% Other:
- 31. @thearmclinic Long Thoracic Nerve Palsy Patient Young, Active, Male Onset Insidious, not sudden Heavy manual worker overhead athlete Location & Distribution Scapula & shoulder Nature Pain with activity; Fatigues easily Other Factors ++ Inferior Border Winging Serratus Wall Test
- 32. @thearmclinic Long Thoracic Nerve Palsy From: Atlas of Uncommon Pain Syndromes, Waldmann
- 33. @thearmclinic Suprascapular Nerve Palsy Patient Young, Active, Male Onset Insidious, not sudden Heavy manual worker overhead athlete Location & Distribution Scapula & shoulder Nature Pain with activity; Fatigues easily Other Factors Supra / Infraspinatus Muscle Wasting (extreme)
- 36. @thearmclinic
- 37. @thearmclinic
- 38. @thearmclinic Axillary Nerve Palsy Patient Young, Active, Overhead Athlete / Worker Onset Insidious, not sudden Heavy manual worker overhead athlete Location & Distribution Teres Minor & Axilla Nature Pain with activity; Fatigues easily Other Factors Hornblower sign QUADRILATERAL SPACE SYNDROME
- 39. @thearmclinic Axillary Nerve Palsy QUADRILATERAL SPACE SYNDROME From: Atlas of Uncommon Pain Syndromes, Waldmann
- 40. @thearmclinic Dorsal Scapular Nerve Palsy Patient ??? Onset Insidious, not sudden Location & Distribution Medial border scapula Nature Constant deep pain; worse with activity & fatigues easily Other Factors Wasting Rhomboids only
- 41. @thearmclinic Gaskill & Millett J Am Acad Orthop Surg 2013;21: 214-224 Dorsal Scapular Nerve Palsy
- 42. @thearmclinic T4 Syndrome Patient Young, hyper mobile, female Onset Atraumatic Location & Distribution Vague, variable and diffuse Nature Persistant Other Factors Neck, thoracic & low back pain No winging / dyskinesis
- 43. @thearmclinic Posterior GHJ Instability Patient Young, hyper mobile, female Onset Minor trauma / Atraumatic Location & Distribution Vague and diffuse Nature Fatigue Other Factors Parathesias Tight Pec Major
- 44. @thearmclinic Scapula Modification Tests 1. Scapula Correction 2. Scapula Assistance 3. Scapula Stabilisation / Fixation 4. Posterior Cuff Activation 5. Core 6. Proprioceptive
- 45. @thearmclinic Scapula Muscle ‘Detachment’ Patient Any age Onset Wrenching or twisting traumatic injury Location & Distribution Localised medial scapula border; ++ localised tenderness Nature Severe, stabbing, worse with movement Other Factors Palpable defect rhomboid +/- lower Traps MRI negative in late cases
- 46. @thearmclinic Scapula Muscle ‘Detachment’ Patient Any age Onset Wrenching or twisting traumatic injury Location & Distribution Localised medial scapula border; ++ localised tenderness Nature Severe, stabbing, worse with movement Other Factors Palpable defect rhomboid +/- lower Traps MRI negative in late cases
- 48. @thearmclinic Scapula Muscle Tests • Standing: – Localised Defect & Tenderness – Low Row (lower Trapezius) – Akimbo position - with hands on the hips and elbows turned outwards. (Ben Rubin) – Serratus wall tests - low & high • Prone: – Upper Traps - High triangle / elevation test for upper trapezius – Mid Trapezius- (90deg) triangle/ elevation test – Lower Trapezius - Low elevation test – Rhomboid Batwing test – Rhomboid Lift-off Test (Tanya Mackenzie) – Elbows together in a modified elbow plank (superior rhomboid) (Ben Rubin)
- 50. @thearmclinic Atraumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Exostoses Deformities Dystrophy Functional Neuritis DSN Suprascapular N Axillary N Thoracic GHJ Unknown Radiculopathy Post.Instability T4 Syndrome
- 51. @thearmclinic Traumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Fractures Muscle Detachments Traction Direct Trauma Thoracic GHJ Fractures Post.Instability
- 52. @thearmclinic 1. Snapping Scapula 2. Neuralgic Amotrophy 3. Isolated Nerve Palsies 1. Long Thoracic 2. Suprascapular 3. Dorsal Scapular 4. Axillary 4. T4 Syndrome 5. Posterior GHJ Instability Atraumatic Conditions
- 53. @thearmclinic Traumatic Conditions 1. Scapula Muscle ‘Detachment’
- 55. @thearmclinic CASE 1 • 16yr old competitive swimmer • Overstretched reaching for wall on breastroke turn 6 months ago • Lots of ‘Physio’ • Aching around scapula with any activities • Unable to raise her arm unaided Posterior Shoulder Instability
- 56. @thearmclinic • 38yr old road worker • No injury • Gradual onset of aching around scapula with heavy work • Painful clicking and clunking • Worse with Physio (cuff exercises) CASE 2 Snapping Scapula
- 57. @thearmclinic CASE 3 • 56yr old Male Mechanic • Woke 6m ago with severe pain scapula & arm • Pain settled but now unable to move arm • Unable to work Neuralgic Amyotrophy
- 58. @thearmclinic CASE 4 • 26yr old Male Javelin Thrower • Pain Right Scapula 6m • Weak throwing • Fatigues easily • Aching in axilla & shoulder Quadrilateral Space Syndrome
- 59. @thearmclinic CASE 5 • 26yr old Male Rugby Player • Pain Left Shoulder 6m • Aching around scapula & shoulder • Fatigues easily • Struggling with overhead weights Suprascapular Nerve Palsy
- 60. @thearmclinic CASE 6 • 26yr old Male Builder • Severe pain Right Scapula 6m • Now aching with work • Weak lifting & carrying • Fatigues easily Long Thoracic Nerve
- 61. @thearmclinic CASE 7 • 26yr old Male • Grabbed railing falling on ladder 4yrs ago • Persistant severe scapula pain • Constant & worse with usage • Seen many Physios & specialists Scapula Muscle Detachment