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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.

Published in: Health & Medicine
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Scapula Pain

  1. 1. @thearmclinic Scapula Pain Lennard Funk
  2. 2. @thearmclinic Further Reading
  3. 3. @thearmclinic CASE EXAMPLES
  4. 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. 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. 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. 7. @thearmclinic CASE 4 • 26yr old Male Javelin Thrower • Pain Right Scapula 6m • Weak throwing • Fatigues easily • Aching in axilla & shoulder
  8. 8. @thearmclinic CASE 5 • 26yr old Male Rugby Player • Pain Left Shoulder 6m • Aching around scapula & shoulder • Fatigues easily • Struggling with overhead weights
  9. 9. @thearmclinic CASE 6 • 26yr old Male Builder • Severe pain Right Scapula 6m • Now aching with work • Weak lifting & carrying • Fatigues easily
  10. 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
  11. 11. @thearmclinic Scapula Pain Lennard Funk
  12. 12. @thearmclinic Causes PRIMARY SECONDARY TRAUMATIC ATRAUMATIC
  13. 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. 14. @thearmclinic Traumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Fractures Muscle Detachments Traction Direct Trauma Thoracic GHJ Fractures Post.Instability
  15. 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. 16. @thearmclinic Traumatic Conditions 1. Scapula Muscle ‘Detachment’
  17. 17. @thearmclinic • Onset • Location & Distribution • Nature • Snapping • Exacerbating Factors • Relieving Factors Atraumatic Pain
  18. 18. @thearmclinic • Mech of Injury • Location & Distribution • Exacerbating Factors • Relieving Factors Traumatic Pain
  19. 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. !20 Gaskill & Millett J Am Acad Orthop Surg 2013;21: 214-224
  21. 21. !21
  22. 22. !22
  23. 23. @thearmclinic Snapping Scapula
  24. 24. !24
  25. 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. 26. @thearmclinic • Brachial Neuritis / Parsonage-Turner Syndrome • Clinical Diagnosis (Parsonage & Turner, 1948) • Only 50% fit ‘classical NA’ (Van Alfen, 2009) Neuralgic Amyotrophy
  27. 27. @thearmclinic Neuralgic Amyotrophy
  28. 28. @thearmclinic • Based on EMG & MRI: • Clinical Diagnosis: • 50% Sensitivity • 75% Specificity • 30% PPV • 88% NPV Neuralgic Amyotrophy Clarke et al. JSES, 2016
  29. 29. @thearmclinic • Based on EMG & MRI: • Clinical Diagnosis: • 50% Sensitivity • 75% Specificity • 30% PPV • 88% NPV Neuralgic Amyotrophy Clarke et al. JSES, 2016
  30. 30. @thearmclinic Neuralgic Amyotrophy Clarke et al. JSES, 2016 Clinical Dx NA 27% NA Confirmed EMGs 73% Other:
  31. 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. 32. @thearmclinic Long Thoracic Nerve Palsy From: Atlas of Uncommon Pain Syndromes, Waldmann
  33. 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)
  34. 34. @thearmclinic Suprascapular Nerve Palsy
  35. 35. @thearmclinic Suprascapular Nerve Palsy
  36. 36. @thearmclinic
  37. 37. @thearmclinic
  38. 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. 39. @thearmclinic Axillary Nerve Palsy QUADRILATERAL SPACE SYNDROME From: Atlas of Uncommon Pain Syndromes, Waldmann
  40. 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. 41. @thearmclinic Gaskill & Millett J Am Acad Orthop Surg 2013;21: 214-224 Dorsal Scapular Nerve Palsy
  42. 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. 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. 44. @thearmclinic Scapula Modification Tests 1. Scapula Correction 2. Scapula Assistance 3. Scapula Stabilisation / Fixation 4. Posterior Cuff Activation 5. Core 6. Proprioceptive
  45. 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. 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
  47. 47. @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)
  48. 48. @thearmclinic Causes PRIMARY SECONDARY TRAUMATIC ATRAUMATIC
  49. 49. @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
  50. 50. @thearmclinic Traumatic Causes PRIMARY SECONDARY Bony Muscular Nerve Fractures Muscle Detachments Traction Direct Trauma Thoracic GHJ Fractures Post.Instability
  51. 51. @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
  52. 52. @thearmclinic Traumatic Conditions 1. Scapula Muscle ‘Detachment’
  53. 53. @thearmclinic CASE EXAMPLES
  54. 54. @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
  55. 55. @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
  56. 56. @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
  57. 57. @thearmclinic CASE 4 • 26yr old Male Javelin Thrower • Pain Right Scapula 6m • Weak throwing • Fatigues easily • Aching in axilla & shoulder Quadrilateral Space Syndrome
  58. 58. @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
  59. 59. @thearmclinic CASE 6 • 26yr old Male Builder • Severe pain Right Scapula 6m • Now aching with work • Weak lifting & carrying • Fatigues easily Long Thoracic Nerve
  60. 60. @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
  61. 61. @thearmclinic Further Reading

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