John E Kuhn

In This Chapter

Scapular winging Scapulothoracic crepitus

Surgery—superomedial border resection Scapulothoracic bursitis

Surgery—endoscopic bursectomy Scapulothoracic dyskinesis

RELEVANT ANATOMY

Scapulothoracic Articulation

Seventeen muscles have their origin or insertion on the scapula (Table 28-1; Fig. 28-1) making it the command center for coordinated upper extremity activity. A number of muscles secure the scapula to the thorax, including the rhomboideus major and minor, the levator scapulae, the serratus anterior, the trapezius, the omohyoid, and the pectoralis minor. Scapular winging or scapulothoracic dyskinesia may occur as a result of dysfunction of these muscles. The rotator cuff muscles (supraspinatus, infra-spinatus, subscapularis, and teres minor) provide dynamic stability and help to control activities of the glenohumeral articulation. Disorders of these muscles are common in athletes and are covered in other sections of this text. The series of muscles that join the humerus to the scapula provide power to the humerus and include the deltoid, the long head of the biceps, the short head of the biceps, the coracobrachialis, the long head of the triceps, and the teres major. Nearly every functional upper extremity movement has components of scapu-lothoracic and glenohumeral motion.

While at rest, the scapula is anteriorly rotated relative to the trunk approximately 30 degrees.1,2 At rest, the medial border of the scapula is also rotated with the inferior pole diverging away from the spine approximately 3 degrees. When viewed from the side, the scapula is tilted forward about 20 degrees in the sagittal plane.1 Deviations in this normal alignment conceivably could contribute to glenohumeral instability3 and impingement4-6 and likely contribute to scapulothoracic crepitus and bursitis.

Interestingly, the resting scapular position may change with aging.7

Scapular Bursae

The location and orientation of the bursae about the scapu-lothoracic articulation have been known since Codman's time. Two major or anatomic bursae and four minor or adventitial bursae have been described (Table 28-2; Fig. 28-2). The major bursae are easily found,8,9 whereas the adventitial bursae are not. These two major bursae are found in the space between the serratus anterior muscle and the chest wall and in the space between the subscapularis and the serratus anterior muscles.8,10 The superomedial angle and the inferior angle of the scapula are the most common anatomic regions involved in patients with scapulothoracic bursitis. When inflamed and symptomatic, the bursae are easily found; however, these bursae may be adventitious as they are not found reliably in cadavers.8,11-13

When scapulothoracic bursitis affects the inferior angle of the scapula, the inflamed bursa will be found between the chest wall and the serratus anterior muscle.14-16 This bursa has been called the infraserratus bursa14 and the bursa mucosa serrata.16,17 The second and more common site of scapulothoracic bursitis occurs at the superomedial angle of the scapula. Codman14 described the superomedial angle bursa as an infraserratus bursa lying between the upper and anterior portion of the scapula and the back of the first three ribs. O'Donoghue18 agreed with Codman and described this bursa as a problem in athletes with pain and crepitus. Von Gruber,17 on the other hand, described the bursa mucosa angulae superioris scapulae lying between the sub-scapularis and the serratus anticus muscles. A third major bursa, the scapulotrapezial bursa, was recognized by Williams et al,9 lying between the superomedial scapula and the trapezius muscle. This bursa is not thought to be a source of scapulothoracic crepitus or bursitis and contains the spinal accessory nerve.

Codman14 also recognized a third minor or adventitial bursa called the trapezoid bursa found over the triangular surface at the medial base of the spine of the scapula under the trapezius muscle, which he believed was another site of painful crepitus in scapulothoracic crepitus. Some believe that these minor bursae are not anatomic major bursae and develop in response to abnormal pathomechanics of the scapulothoracic

INTRODUCTION

• The scapulothoracic articulation is an important, yet relatively unstudied component of upper extremity function, particularly in athletics.

• A variety of disorders have been described that affect the scapula directly. In addition, observations have been made in which the scapula functions abnormally in athletes with shoulder pain.

• For many of these observations, it is not known whether the scapulothoracic problem preceded the glenohumeral joint problem or vice versa, yet treating the scapulothoracic component of these disorders seems to be an important part of treating the athlete.

Table 28-1 Muscles with Origins or Insertions on the Scapula

Scapulohumeral Muscles

Long head of biceps

Short head of biceps

Deltoid

Coracobrachialis

Teres major

Long head of triceps

Scapulothoracic Muscles

Levator scapulae

Omohyoid

Rhomboid major

Rhomboid minor

Serratus anterior

Trapezius

Pectoralis minor

Rotator Cuff Muscles

Supraspinatus

Infrapinatus

Subscapularis

Teres minor articulation.8,11,13 This may help explain the variety of bursae and their different locations as described in these series.

WINGING OF THE SCAPULA

Winging of the scapula is one of the most common scapulotho-racic disorders encountered in athletes. Winging can be divided into primary, secondary, and voluntary types. Primary scapular winging results from identifiable anatomic disorders that directly affect the scapulothoracic articulation. Secondary scapular winging usually is associated with some form of glenohumeral pathology. This type of winging will resolve as the glenohumeral pathology is addressed. Voluntary winging is quite rare and may have an underlying secondary gain concern or psychological cause. Primary winging is most commonly due to nerve injuries in athletes and is the focus of this review.

Serratus Anterior Palsy Pathophysiology

The long thoracic nerve is the motor source for the serratus anterior muscle. It is found beneath the brachial plexus and clavicle and over the first rib. It then travels superficially along the lateral aspect of the chest wall, which makes the nerve susceptible to injury (Fig. 28-3). Blunt trauma or stretching of this nerve is particularly common in athletics and has been observed in tennis players, golfers, swimmers, gymnasts, soccer players, bowlers, weight lifters, ice hockey players, wrestlers, archers, basketball players, and football players.19-22

From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP, Williams GR Jr (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.

Trapezius muscle Coracoid

Omohyoid muscle

Superior angle Levator scapular muscle

Supraspinatus muscle Rhomboid minor muscle

Infraspinatus muscle

Medial border

Rhomboid major muscle

From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP, Williams GR Jr (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.

Omohyoid muscle

Medial border

Rhomboid major muscle

Inferior angle

Lateral border

Teres major muscle

Evaluation

Patients with serratus anterior palsy will complain of pain as the other periscapular muscles fatigue as they are used to

Conjoined tendon of coracobrachialis and biceps

Pectoralis minor muscle

Scapular notch

Omohyoid muscle

Acromion Deltoid muscle

Glenoid fossa Scapula neck

Triceps (long head)

Teres minor muscle

Lateral border

Teres major muscle

Inferior angle

Conjoined tendon of coracobrachialis and biceps

Omohyoid muscle

Glenoid fossa Scapula neck

Triceps (long head)

Teres minor muscle

Serratus anterior muscle

Subscapularis muscle

Serratus anterior muscle

Subscapularis muscle

Latissimus dorsi muscle

Figure 28-1 Muscles with origins or insertions on the scapula. Anterior and posterior views of the scapula demonstrate the multiple attachment sites for muscles of the scapula, making it the center for coordinated upper extremity motion. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Table 28-2 Bursae around the Scapula

Major/Anatomic Bursae

Infraserratus bursae: Between the serratus anterior and chest wall

Supraserratus bursae: Between the subscapularis and serratus anterior muscles

Minor/Adventitial Bursae

Scapulotrapezial bursae: Between the superomedial scapula and the trapezius

Superomedial angle of the scapula

Infraserratus bursae: Between the serratus anterior and chest wall Supraserratus bursae: Between the subscapularis and serratus anterior

Inferior angle of the scapula

Infraserratus bursae: Between the serratus anterior and chest wall

Spine of the scapula Trapezoid bursae: Between the medial spine of scapula and trapezius

From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJP lannotti JP Gerber C (eds): Complex and Revision

Problems in Shoulder Surgery. Philadelphia, Lippincott-Raven, 1997, pp

357-375.

compensate for the lost function. With a serratus anterior palsy, the scapula assumes a position of superior elevation and medial translation, and the inferior pole is rotated medially (Fig. 28-4). The patient will have difficulty with arm elevation above 120 degrees, which will magnify the degree of winging.23,24

Electromyography is recommended to confirm the diagnosis and follow the recovery of the injured long thoracic nerve. Because the majority of long thoracic nerve palsies will recover spontaneously, regular electromyographic examinations at 3-month intervals have been recommended to follow nerve recovery.25,26

Figure 28-3 Location of the long thoracic nerve. Its superficial location along the chest wall makes it susceptible to injury. (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, pp 357-375.)

Figure 28-3 Location of the long thoracic nerve. Its superficial location along the chest wall makes it susceptible to injury. (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, pp 357-375.)

Treatment

Nonoperative treatment with shoulder range-of-motion exercises is begun immediately after diagnosis in order to prevent glenohumeral stiffness. Many types of braces and orthotics have been developed, but their use is of questionable benefit.22,25 In general, these braces attempt to hold the scapula against the

Figure 28-2 Bursae of the scapula. The location of both anatomic (black) and adventitial (hatched) bursae are shown. (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, pp 357-375.)

Figure 28-2 Bursae of the scapula. The location of both anatomic (black) and adventitial (hatched) bursae are shown. (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, pp 357-375.)

Upper Extremity Ultrasound Anatomy

Figure 28-4 Resting location of the scapula with palsy of the serratus anterior, and trapezius palsy. (From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJF? lannotti JP Gerber C [eds]: Complex and Revision Problems in Shoulder Surgery. Philadelphia, LippincottRaven, 1997, pp 357-375.)

Figure 28-4 Resting location of the scapula with palsy of the serratus anterior, and trapezius palsy. (From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJF? lannotti JP Gerber C [eds]: Complex and Revision Problems in Shoulder Surgery. Philadelphia, LippincottRaven, 1997, pp 357-375.)

chest wall and may have some role if they provide symptom relief, despite their cumbersome nature.24,26-28 Most long thoracic nerve injuries recover spontaneously within 1 year20,23,24,26,27,29-38; however some may take as long as 2 years.23,39,40 Certainly, a trend for nerve recovery would be noted by at least 1 year.

There are few data in the literature regarding the results of neurolysis, nerve grafting, or repair of an injured long thoracic nerve.41 Nevertheless, penetrating injuries should undergo nerve exploration and early repair. Neurorrhaphy may be indicated when the lesion can be localized.26 Many patients with persistent impairment of the serratus anterior are able to compensate and not elect to have a surgical reconstruction.26 In patients with symptomatic serratus winging that persists for more than 1 year, surgical intervention may alleviate pain and improve function. While a number of procedures have been described for refractory serratus anterior palsy, transferring the sternocostal head of the pectoralis major with a fascia lata or hamstring graft extension has become the most popular25,26,31,32,42-46 (Fig. 28-5). While this surgery has been shown to be very helpful for patients with permanent palsy of the serratus anterior, there are no data in athletes, and it is highly unlikely that athletes who require the use of their upper extremity would return to their previous level of competition following this surgery. Fortunately, most athletic injuries to the long thoracic nerve are neuropraxic and recover spontaneously.

Figure 28-5 Pectoralis major transfer for scapular winging. As described by Marmor and Bechtol,114 the sternocostal head of the pectoralis major is sutured to a tubularized fascia lata graft and woven through a foramen made in the inferior angle of the scapula. (From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJP lannotti JP Gerber C [eds]: Complex and Revision Problems in Shoulder Surgery. Philadelphia, Lippincott-Raven, 1997, pp 357-375.)

Figure 28-5 Pectoralis major transfer for scapular winging. As described by Marmor and Bechtol,114 the sternocostal head of the pectoralis major is sutured to a tubularized fascia lata graft and woven through a foramen made in the inferior angle of the scapula. (From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJP lannotti JP Gerber C [eds]: Complex and Revision Problems in Shoulder Surgery. Philadelphia, Lippincott-Raven, 1997, pp 357-375.)

Figure 28-6 Location of the spinal accessory nerve. Its location in the posterior cervical triangle makes it susceptible to injury during surgical procedures in this area. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Figure 28-6 Location of the spinal accessory nerve. Its location in the posterior cervical triangle makes it susceptible to injury during surgical procedures in this area. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Carotid Artery Endarterectomy

Trapezius Winging Pathophysiology

The spinal accessory nerve, the only nerve to the large trapezius muscle, is superficial, lying in the subcutaneous tissue on the floor of the posterior cervical triangle. Its superficial location makes it susceptible to injury47,48 (Fig. 28-6). Injury to this nerve results in painfully disabling alterations in scapulothoracic function as well as significant deformity.47-55 This nerve can be injured by blunt trauma,55-57 stretching of the nerve,55 and penetrating trauma that includes surgical biopsy of lymph nodes in the posterior cervical triangle50,53,54 and radical neck dissection.58-60 In athletes, stretching and blunt trauma injuries are most common,56 particularly in contact sports like wrestling.

Evaluation

Patients will attempt to compensate for a palsy of the trapezius by straining other muscles of the shoulder girdle, including the levator scapulae and the rhomboid muscles which can lead to disabling pain and spasm.57 Patients can also develop pain from a stiff shoulder, shoulder subacromial impingement, and radiculitis from traction on the brachial plexus as the shoulder girdle droops.

Upon examination, patients will have difficulty when attempting to shrug their shoulder and will have weakness in forward elevation and abduction of the arm. The patient will assume a position with the shoulder depressed and the scapula translated laterally with the inferior angle rotated laterally (see Fig. 28-4). The diagnosis is confirmed by electromyography.

Treatment

The initial treatment for patients with trapezius winging is nonoperative. The arm can be placed in a sling to rest the other periscapular muscles. Physical therapy is helpful to maintain glenohumeral motion, preventing shoulder stiffness.61 In cases caused by blunt trauma, serial electromyographic analysis should be performed at 1- to 3-month intervals to follow the returning function of the nerve. In cases caused by penetrating trauma or when there is no evidence of nerve function on electromyo-graphic analysis, neurolysis and/or nerve grafting can be performed.50,54,62-64 The results of these procedures have been variable; however, the success rate seems to be improved if neu-rolysis is performed before 6 months.57

Patients who have had symptoms in excess of 1 year are unlikely to benefit from continued nonoperative treatment,53 and surgery can be offered. Historically, a variety of procedures have been described for the treatment of trapezius winging,49,65,66 but the Eden-Lange procedure67-69 is the most popular. In this procedure, the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred laterally (Fig. 28-7). The levator scapulae substitutes for the upper third of the trapezius; the rhomboid major substitutes for the middle third of the trapezius; and the rhomboid minor substitutes for the lower third of the trapezius. By moving these muscle insertions laterally, their mechanical advantage is improved and winging is eliminated. Bigliani et al57 recently reported their results using this procedure in 23 patients with trapezius scapular winging, with excellent and good results in 87%. Significant improvement in pain was seen in 91% of these patients, and 87% had significant improvement in function.57 This procedure, while effective at improving function for activities of daily living, would be unlikely to return a competitive athlete back to a high level of performance.

SCAPULOTHORACIC CREPITUS

Pathophysiology

Symptomatic scapulothoracic crepitus has been described by a number of different authors and has been called the snapping

Levator scapula muscle Rhomboideus muscle

Levator scapula muscle Rhomboideus muscle

Tipi Sioux

Figure 28-7 Eden-Lange procedure for trapezius palsy. In this procedure, the levator scapulae is transferred laterally to function as the upper trapezius, while advancement of the rhomboid major and minor compensates for the loss of the middle and lower trapezius. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Figure 28-7 Eden-Lange procedure for trapezius palsy. In this procedure, the levator scapulae is transferred laterally to function as the upper trapezius, while advancement of the rhomboid major and minor compensates for the loss of the middle and lower trapezius. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In lannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Table 28-3 Causes of Scapulothoracic Crepitus

Interposed Tissue

Muscle Atrophy15

Fibrosis15,17,76

Anatomic variation77

Bone

Rib osteochondroma78 Scapular osteochondroma76,79,80 Rib fracture1576 Scapular fracture81

Hooked superomedial angle of the scapula79,82 Luschka's tubercle15,81,83

Reactive bone spurs from muscle avulsion67,84,85

Other soft tissue

Bursitis86,87 Tuberculosis15 Syphilitic lues15

Abnormalities in Scapulothoracic Congruence

Scoliosis8

Thoracic kyphosis1

From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJP, lannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, Lippincott-Raven, 1997, pp 357-375.

Figure 28-8 Osteochondroma of the scapula causing scapulothoracic crepitus. Note the increased signal in the bursa surrounding this osteochondroma of the scapula. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In Iannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

Figure 28-8 Osteochondroma of the scapula causing scapulothoracic crepitus. Note the increased signal in the bursa surrounding this osteochondroma of the scapula. (From Kuhn JE: The scapulothoracic articulation: Anatomy, biomechanics, pathology and management. In Iannotti JP Williams GR Jr [eds]: Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 817-845.)

scapula,15 the grating scapula,43 the rolling scapula,11 the washboard syndrome,70 the scapulothoracic syndrome,71 and the scapulocostal syndrome.72 Boinet73 was the first to describe this disorder in 1867. Mauclaire,74 some 37 years later, classified scapulothoracic crepitus into three groups: froissement was considered physiologic and was described as a gentle friction sound, frottement was a louder sound with grating and was usually pathologic, and craquement was a loud snapping sound and was always pathologic. These noises are thought to occur from two sources, from either anatomic changes in the tissue interposed between the scapula and the chest wall or incongruence in the scapulothoracic articulation (Table 28-3). In reviewing Milch,15 frottement (the lower volume crepitus) may suggest soft-tissue pathology or bursitis while craquement may suggest bony pathology as the source of symptomatic scapulothoracic crepitus. Codman14 writes that he was able to make his own scapula "sound about the room without the slightest pain," and was likely demonstrating froissement. In every instance, the air-filled thoracic cavity will amplify these noises, acting like a resonance chamber of a string instrument.75

A number of pathologic conditions that could lead to crepitus that affect the muscle in the scapulothoracic articulation include atrophied muscle,15 fibrotic muscle,15,17,76 and anomalous muscle insertions.77 With regard to bony pathology, the most common source of scapulothoracic crepitus is an osteochon-droma, arising from either the ribs78 or the scapula76,79,80 (Fig. 28-8). Malunited fractures of the ribs or scapula are also capable of creating painful crepitus.15,76,81 Abnormalities of the supero-medial angle of the scapula, including a hooked superomedial angle79,82 and a Luschka's tubercle (which originally was described as an osteochondroma but has subsequently come to mean a prominence of bone at the superomedial angle15,81,83), have also been implicated as sources for scapulothoracic crepi-tus. Others67,84,85 implicate reactive spurs of bone that are created by repeated small periscapular muscle avulsions.

Any bony pathology that causes scapulothoracic crepitus is capable of forming a reactive bursa around the area of pathol-ogy.86,87 In fact, at the time of resection of bony pathology, a bursa is frequently seen. Bursae can become inflamed and painful in the absence of bony pathology and may, by themselves, become a source of crepitus.

Other soft-tissue pathologies that have been implicated in scapulothoracic crepitus include tuberculosis lesions in the scapulothoracic region and syphilitic lues,15 which are exceedingly rare in athletes. However, it is not uncommon for athletes to have abnormalities in congruence of the scapulothoracic articulation that could lead to scapulothoracic crepitus. Both thoracic kyphosis11 and scoliosis,88,89 have been identified as sources of scapulothoracic crepitus. In many sports, particularly swimming, thoracic kyphosis is common90,91 and may be the most likely source of scapulothoracic crepitus.

Evaluation

When evaluating the athlete, it is important to know the primary sport and training in which the athlete participates. Athletes who participate in sports that require repetitive overhead activity are commonly affected by scapulothoracic crepitus.13 There may be a familial tendency toward developing symp-toms.11 Patients may relate a history of mild trauma that precipitates symptoms,92 and scapulothoracic crepitus may be bilateral in some patients.10 If scapular winging or fullness is identified on inspection of the resting scapula, the examiner should consider a space-occupying lesion, such as an osteochon-droma. It is helpful to ask the patient with symptomatic scapu-lothoracic crepitus to point to the location of the pain. He or she will generally point to the superomedial angle or the inferior angle. Palpation or auscultation while the patient moves the shoulder may help to identify the source and location of the periscapular crepitus.10,93 Supplemental radiographs, which include tangential views of the lateral scapula, computed tomography, or magnetic resonance imaging may be helpful in identifying bony pathology.

Treatment

It is important to recognize that scapulothoracic crepitus is not necessarily a pathologic condition. Up to 35% of normal asymptomatic people can demonstrate scapulothoracic crepitus,94 including Codman.14 Therefore, scapular crepitus could potentially be used for secondary gain in patients with hidden agendas or psychiatric conditions. However, if the athlete presents with pain, winging, or other disorders of the scapulothoracic articulation, the scapulothoracic crepitus is considered to be pathologic.

Most athletes with scapulothoracic crepitus can successfully be treated nonoperatively, particularly if the crepitus is related to soft-tissue abnormalities, altered posture, or scapulothoracic dyskinesia.10,15 Nonoperative treatment includes postural exercises designed to prevent sloping of the shoulders.10,95 A figure-eight clavicle fracture brace may be a useful tool to remind patients to maintain upright posture. Exercises to strengthen periscapular muscles are also important.10,13,15 Oral nonsteroidal anti-inflammatory drugs as well as local modalities such as heat, massage, phonophoresis, ultrasound, and the application of ethyl chloride to trigger points may also prove useful.10,13,15 Injectable local anesthetics and corticosteroids into the painful area have also been recommended.11,13,15,42,92 Caution must be used, as there is a risk of creating a pneumothorax.92 Using these means, most athletes are expected to improve significantly.13,42 However, for those who fail, a number of operations have been described. Athletes with clearly defined bony pathology such as an osteochondroma generally require surgical treatment.15

Resection of the bony pathology is usually necessary to alleviate symptoms with a high likelihood of success.13,76,96

Historically, some authors have used muscle plasty operations to treat scapulothoracic crepitus.74,92 This is thought to be inadequate, however, because the muscle flap may atrophy with time and symptoms could return.15 The most popular method for the surgical treatment of scapulothoracic crepitus involves a partial scapulectomy, which has been performed on the medial border of the scapula97 and more commonly on the superomedial angle 11,15,82,85,93,98,99

Surgery

The surgical technique for the resection of the superomedial angle of the scapula begins with the patient in the prone position (Fig. 28-9). An incision following Langer's lines is made slightly lateral to the medial border of the scapula, from the superior angle to the scapular spine. The subcutaneous tissue is undermined, exposing the spine of the scapula. Following the spine of the scapula, the periosteum is incised and a plane is developed between the superficial trapezius and the underlying scapula and supraspinatus. Next a plane is developed between the supraspinatus and the rhomboids and levator scapulae muscles along the medial border of the scapula starting at the spine of the scapula. The supraspinatus is elevated in a subpe-riosteal plane from the supraspinatus fossa. The medial scapu-lothoracic muscles are dissected from the medial border of the scapula and the dissection in this subperiosteal plane is carried around the medial border and to the subscapularis fossa, elevating the serratus and subscapularis with the rhomboids and levator. The superomedial angle of the scapula is resected with an oscillating saw. It is important to avoid progressing too far laterally as the scapular notch is at risk with the potential for injury to the dorsal scapular artery and the suprascapular nerve. After resecting the bone, the reflected muscles fall back into place, and the medial border of the supraspinatus is repaired to the rhomboid/levator flap with permanent no. 2 polyester suture. Inferiorly, the periosteum is repaired back to the spine of the scapula using suture passed through drill holes. Postoperatively, the patient is placed in a sling and begins passive motion immediately. Active motion is begun at 6 weeks, and resistance exercises follow at 8 to 12 weeks.

Complications associated with partial scapulectomy include postoperative hematoma, pneumothorax, and mild residual winging. In younger patients, bone may try to form again, but this rarely produces symptoms. The exposure and potential for complications have led some to perform this procedure arthroscopically.100

The reported results for this procedure are generally good.11,15,82,98 However, it must be remembered that athletes typically do not require surgical intervention; as such, there are few data in the literature regarding the effect of superomedial angle resection of the scapula on athletic performance. It is also important to note that the bone resected is not pathologic and appears normal histologically, which has prompted some to perform bursectomies and avoid a partial scapulectomy.16,101,102

SCAPULOTHORACIC BURSITIS

When scapulothoracic crepitus is accompanied by pain, an inflamed scapulothoracic bursa is typically found. It is important to realize that, while these two conditions are frequently found

Charette Gauloise

Area of scapula resected

Suprascapular artery and nerve

Figure 28-9 Surgical approach for excision of superomedial angle of the scapula. A,Trapezius is elevated from the spine of the scapula. B, The supraspinatus, rhomboids, and serratus are elevated in a subperiosteal plane from the medial border, and the superomedial scapula is resected while protecting the suprascapular nerve and artery. C, The supraspinatus is sutured back to the spine of the scapula. (From Kuhn JE, Hawkins RJ: Evaluation and treatment of scapular disorders. In Warner JJP lannotti JP Gerber C [eds]: Complex and Revision Problems in Shoulder Surgery. Philadelphia, LippincottRaven, 1997, pp 357-375.)

together, an athlete may have crepitus without pain and another may have scapulothoracic bursitis without crepitus. As described previously, symptomatic scapulothoracic bursitis seems to affect two areas of the scapula: the superomedial angle and the inferior angle. These bursae, when inflamed, are thought to be adventitious.8,11,13

Evaluation

Patients with scapulothoracic bursitis generally complain of pain with activity and may have audible and palpable crepitus of the scapulothoracic articulation. Usually the scapular crepitus associated with bursitis is of a much lesser quality and nature than that described with bony pathology. Periscapular fullness is frequently appreciated in thinner athletes. This may become significant enough to produce subtle scapular winging. Scapular winging has been identified in 50% of patients with a snapping scapula and no bony abnormalities.13 Infrequently, patients may describe minor trauma as a predisposing event,93,101 but most have a history of repetitive overhead activities in work or athletics.16,42,101 The repetitive motion may irritate soft tissues until inflammation occurs and chronic bursitis develops. The bursa may undergo scarring and fibrosis, which may be the source of crepitus. Scapulothoracic bursitis in athletes may have its roots in postural abnormalities and scapulothoracic dyskinesia. In the evaluation of athletes with scapulothoracic crepitus, local anesthetic injected into the bursa may relieve pain and serve as a diagnostic aid.18

Treatment

Nonoperative measures (rest, analgesics, and nonsteroidal anti-inflammatory drugs) are the mainstay of treatment for scapu-lothoracic bursitis. Physical therapy to improve posture, heat, and local steroid injections has also been recommended.16,42 Efforts to strengthen periscapular muscles and stretching are frequently added.16,42 For patients who continue to have symptoms despite conservative treatment, surgery may be considered.

As recognized by Sisto and Jobe,16 baseball pitchers may be at risk of bursitis at the inferior angle of the scapula. They described an open procedure for resecting a bursa at the inferior angle of the scapula in four pitchers. Pitchers with this problem have difficulty pitching and tend to have pain during the early and late cocking phases as well as during acceleration (Fig. 28-10). While all pitchers had a palpable bursal sac ranging in size from 1 to 2 cm, best seen with the arm abducted to 60 degrees and elevated forward 30 degrees, only one of the four patients presented with scapulothoracic crepitus. All four pitchers failed conservative therapy and underwent a bursal excision via an oblique incision just distal to the inferior angle of the scapula. The trapezius muscle, and then the latissimus dorsi muscle, were reflected medially, exposing the bursa. The bursa was sharply excised and any bony prominence on the inferior pole of the scapula or ribs was removed. The wounds were closed routinely over a drain, and a compression dressing was applied. Physical therapy, stressing motion, was begun after 1 week and progressed to allow gentle throwing at 6 weeks with progression to full speed pitching as symptoms allowed. After this procedure, all were able to return to their former level of pitching.

Open excision of symptomatic superomedial scapulothoracic bursae have been described by many authors.42,101-103 In most of these reports, dissection is carried out until a plane is developed between the serratus anterior and the chest wall. The thickened bursa is resected and any bony projections removed. With this technique, more than 80% of patients with symptomatic scapulothoracic bursitis had good or excellent results.

Resection of the symptomatic scapulothoracic bursa has been performed endoscopically as well.8,10,104-107 Ciullo and Jones10 have the largest endoscopic series to date with 13 patients who underwent subscapular endoscopy after failing a conservative treatment program for symptomatic scapulothoracic bursitis. Debridement was performed for fibrous adhesions found in the bursa between the subscapularis and serratus muscles as well as the bursa between the serratus and chest wall. In addition, debridement or scapuloplasty of changes at the superomedial angle or inferior angle was performed. All 13 patients returned to their preinjury activity level, except for physician-imposed restrictions in a few patients, limiting the assembly line use of vibrating tools.10

Matthews et al106 have described the technique for scapu-lothoracic endoscopy. Patients can be placed in the prone or lateral position; however, the lateral position is preferred, as it allows arthroscopic evaluation of the glenohumeral joint and the subacromial space. In addition, if the arm is extended and maximally internally rotated, the scapula will fall away from the thorax, improving access to the bursae.

Three portals are used, placed at least 2 cm from the medial border of the scapula in the region between the scapular spine and the inferior angle. For the middle portal, a spinal needle is inserted into the bursa between the serratus anterior and the chest wall. This needle should be inserted midway between the scapular spine and the inferior angle, at least three finger breadths medial to the medial border of the scapula to avoid

Figure 28-10 Bursa at the inferior angle of the scapula in throwers. This is an infraserratus bursa, which has been described in baseball pitchers, where an excision of the bursa has allowed a return to throwing. (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, pp 357-375.)

injury to the dorsal scapular artery and nerve. The bursa under the serratus anterior can be distended with fluid before a stab wound is made in the skin and the blunt obturator and endoscope are inserted. Deep penetration may traverse the serratus entering the axillary space and should be avoided.

Once this initial middle portal has been established, a superior portal placed three finger breadths medial to the vertebral border of the scapula just below the spine will penetrate the interval between the rhomboideus major and rhomboideus minor. This portal will allow access to the superomedial angle of the scapula. Portals placed superior to the scapular spine jeopardize the dorsal scapular nerve and artery, the spinal accessory nerve, and the transverse cervical artery and should be avoided. A third inferior portal can be made in a similar fashion at the inferior angle of the scapula.

In the bursa between the serratus anterior and chest wall, landmarks are generally absent except the ribs. A motorized shaver and electrocautery are required to perform the bursec-tomy and obtain hemostasis. The arthroscopic pump should be kept at low pressure throughout the procedure. After completing the bursectomy, the portals are closed in a standard fashion and the patient is placed in a sling for comfort. Physical therapy, beginning with active range of motion, is initiated as tolerated by the patient. Early results suggest this condition can be treated successfully using the arthroscope with minimal risk.10,103,107

SCAPULOTHORACIC DYSKINESIS

Abnormalities in scapulothoracic motion are now receiving much more attention in the literature. Burkhart et al108 recently described a condition known as the SICK scapula. The acronym SICK stands for scapula malposition, inferior medial border prominence, coracoid pain and malposition, and dysfeinesis of scapular movement. The scapula assumes an abnormal position at rest characterized by a position that is inferior, protracted, and tilted anteriorly. Tenderness is typically found on the medial edge of the coracoid, and the pectoralis minor is thought to be in spasm. The authors recognized this pattern in throwing athletes with shoulder pain.

Myers et al109 studied this concept by measuring scapulotho-racic motion in a population of throwing athletes and compared this to scapulothoracic motion in a control population. They showed that throwing athletes demonstrated significantly increased upward rotation, internal rotation, and retraction of the scapula during humeral elevation, implying that throwing athletes may develop these adaptations for more efficient performance of the throwing motion. Su et al110 have demonstrated that scapular kinematics may be altered in symptomatic swimmers, an effect that is magnified with fatigue associated with a practice.

REFERENCES

Evaluation

Patients with scapulothoracic dyskinesis will not typically direct the physician toward the scapula and will commonly complain of pain in the glenohumeral joint. Inspection of the scapulae from the back will demonstrate asymmetry at rest, with the affected shoulder frequently depressed, the scapula protracted and tilted forward. Mild scapular winging may be present with the posterior angle and the medial border of the scapula prominent. Patients will frequently have pain to palpation at the medial coracoid, the insertion of the pectoralis minor. Asking the patient to elevate the arm in the frontal plane and in the scapular plane will reveal asymmetry of scapulothoracic motion. In the presence of rotator cuff pathology, this may be related to decreased firing of the middle and lower trapezius.111

Treatment

Treatment of scapulothoracic dyskinesis is with exercises and modalities of physical therapy. Kinetic chain-based rehabilitation programs have been recommended,112,113 as many of the patients with scapulothoracic kinematic abnormalities will have weakness in the core stabilizers of the trunk. This work is currently in its infancy. Clearly much more work is needed to clearly define pathologic scapulothoracic kinematics and their effect on other shoulder pathologies.

CONCLUSIONS

A variety of scapulothoracic conditions can affect the athlete's shoulder. These include winging of a variety of forms, crepitus and bursitis, and dyskinesia of the scapulothoracic articulation. Scapular winging in athletes most commonly results from a long thoracic nerve neuropraxic injury and will recover spontaneously. Scapulothoracic crepitus and scapulothoracic bursitis are two related conditions but may be found independently in athletes with periscapular pain. In general, treatment for athletes is nonoperative and requires postural exercises designed to prevent sloping of the shoulders10,95 and periscapular muscle strengthening.10,13,15 A figure-eight harness may be a useful tool to remind patients to maintain upright posture. Local modalities, nonsteroidal anti-inflammatory drugs, and local injections have also been recommended.10,11,13,15,42,92 In athletes with refractory symptoms, surgical correction may be considered; however, there are only a few reports in the literature for this select population and thus it is difficult to predict outcomes with regard to returning to sport. Scapular dyskinesia is only now under study as a source of shoulder pathology, and early results suggest the effects of scapular dyskinesia may be of critical importance. Clearly more work is needed to gain a complete understanding of scapulothoracic problems in the athlete.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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