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Independent Research - Case Study
SCAPULOCOSTAL BURSITIS - A CONDITION OFTEN OVERLOOKED: A CASE STUDY
James R. Brandt, DC, MPS, FACO
Coon Rapids Chiropractic Office - Minneapolis, MN
Purpose: To help the clinician recognize and successfully treat this condition. Scapulocostal bursitis is often overlooked or misdiagnosed. History, examination and treatment of this condition will be outlined. Properly treated, this condition responds favorably to conservative chiropractic management.
Anatomy: An understanding of the anatomy and physiology of the scapulothoracic articulation is required to understand the pathogenesis of scapulothoracic disorders. The scapula is a triangular-shaped bone articulating with the posterior thorax. It is attached to the axial skeleton by only the acromioclavicular joint, and therefore its stability is dependent on surrounding musculature.
The periscapular musculature creates stability of the scapulothoracic articulation. The levator scapulae and rhomboids attach to the medial border of the scapula, whereas the subscapularis is on its anterior surface. (1)
The serratus anterior originates on the ribs and inserts on the medial scapular anterior surface. A cushion between the scapula and the thoracic wall is created by the serratus anterior and the subscapularis. Two spaces, the subscapularis space and the serratus anterior space, are created by the musculature of the joint. The serratus anterior space is located between the chest wall, serratus anterior, and rhomboids. The subscapularis space is bounded by the serratus anterior, subscapularis, and axilla. Three muscles of the rotator cuff originate at the scapula: the supraspinatus and the infraspinatus on the posterior surface of the scapula and the subscapularis on the anterior surface. (4) Seventeen muscles have their origin or insertion on the scapula making it the command center for coordinated upper extremity activity. A number of muscles secure the scapula to the thorax, including the rhomboids major and minor, the levator scapula, serratus anterior, trapezius, omohyoid and pectoralis minor. (3, 9)
There are several important neurovascular structures surrounding the scapula. The accessory nerve goes through the levator scapulae muscle near the superomedial angle of the scapula and runs along the medial scapular border deep to the trapezius muscle. The transverse cervical artery branches into the dorsal scapular artery (deep branch) and a superficial branch that travels with the accessory nerve. The dorsal scapular artery travels with the dorsal scapular nerve 1 cm medial to the medial border of the scapula. They pierce the scalenus medius and travel deep to the rhomboid major and minor. The nerve innervates both of these structures. The long thoracic nerve is located on the surface of the serratus anterior. The suprascapular nerve and artery pass toward the suprascapular notch on the superior scapular border medial to the base of the coracoid.
Several scapular bursae have been implicated in the development of scapular bursitis, which can lead to pain and snapping. Bursae are located in areas of friction and are potential spaces lined by a synovial membrane. Two major bursae are found consistently in patients: the infraserratus bursa located between the serratus anterior and the chest wall and the supraserratus bursa located between the subscapularis and serratus anterior. (3, 4, 9) Scapulothoracic movements are of a gliding nature and occur at an interface between the ventral surface of the scapula and the rib cage. The contacting surfaces involve the subscapularis and bare areas of the scapula with the serratus anterior overlying the second through seventh ribs. Normally the scapula is set obliquely on the thorax at an angle of 30°. (6)
Methods: A 36-year-old Caucasian female presented for care and treatment of chronic upper back pain and a burning sensation in the area. It had been getting more intense and frequent over the past two years. She had increasing upper posterior arm pain that did not radiate below the elbow and an ache just below the clavicle and adjacent to the humeral head. Imaging studies read by a chiropractic radiologist of the neck and thoracic spine revealed spondylosis at C5-C6 and C6-C7 with moderate disc space narrowing at C5-C6. She had a slight right dorsal scoliosis. The upper lung field on the left was negative.
The patient was treated with active chiropractic manipulative therapy (CMT) at C6 and T5. Ultrasound and EMS was applied to the upper back and scapulocostal bursa. Elastikon tape was placed over the left scapula. Cryotherapy was outlined for self-care. Exercises were given to the patient when the acute phase subsided. Visual analog scale (VAS) was used to measure her response.
Results: The patient presented with classic scapulocostal bursitis. She responded to the treatment and was pain-free for the first time in two years. She received active CMT to the lower neck and upper back. In addition, ultrasound was applied to the bursa area and EMS to the lower cervical and mid-thoracic paraspinals. Elastikon tape was applied twice during the treatment. Cryotherapy was used for the first 48 hours and then discontinued. Upper thoracic stretches and lower cervical exercises were given after the second visit. She was treated a total of four sessions.
The presenting complaints were treated for numerous diagnostic presentations prior to admittance to this treatment facility. This included the following: "pinched nerve", muscle spasms, subluxations and muscle strain. Obtaining a thorough history and understanding her job requirements were instrumental in arriving at the causation of her complaints.
Background: This condition is not well understood and should be considered in any presentation of lower neck, upper back pain, paresthesias medial to the scapula, anterior and posterior shoulder discomfort without range of motion restriction and upper extremity pain that does not radiate below the elbow (2).
A 36-year-old Caucasian female presented to the office with a two year history of increasing upper back and lower neck discomfort. Pain was present into the posterior aspect of the left upper arm and chest region. She described an ache and burning in the upper back next to the spine on the left. She works as a Registered Nurse (RN) with primarily administrative duties. Her symptoms are worse when she has the telephone trapped between her neck and top of the left shoulder while working with her computer entering data. She has pain and stiffness arising in the morning and does not sleep well because of her pain. She has tried various pain and anxiety medications, physical therapy and adjustments with a hand held (mechanical) device to the spine. She had a motor vehicle accident four years prior and her left shoulder hit the door frame. She had a brief course of medical care and she reported that her symptoms resolved.
Her pain severity scale was 7/10 on the day of the initial examination. Her Oswestry back index was 17/50 or 34%. Her height was 66 inches and her weight was 115 lbs. She was afebrile with a pulse rate of 66 per minute and a respiration rate of 14 per minute. The blood pressure on the left was 110/68, and on the right was 102/64 at 1400 hours. LMP: Two months ago, she recently had an ablation. She demonstrated a flattening of the cervical lordosis. A review of the HEENT was unremarkable. Optic disc margins were sharp and clear. Point tenderness was +1 (0/+4 scale) at C5/C6 on the left. Cervical distraction was negative. Cervical flexion (90) 60°, extension (70) 50°, left lateral bending (45) 30°, right lateral 35°, left rotation (90) 60° and right rotation 55°. Muscle stretch reflexes were +2/+2. No motor or sensory changes were noted. Triad of Dejerine was negative. Her left shoulder range of motion was unencumbered.
Internal and external rotation was adequately accomplished. Auscultation of the thorax was unremarkable. Point tenderness was +1 on the left side T4-5. She had +2 pain at the superior medial aspect of the left scapula. She exhibits the classic "jump sign" when the bursa area was palpated. She commented that it felt "like the pain I get". There was +1 spasm in the rhomboid muscle on the left. Myofascial trigger points were present in the rhomboid and subscapularis muscles on the left. The Approximation Test was negative for upper thoracic nerve root problems. (2) The shoulder examination was unremarkable. A 3 view cervical and a two view thoracic imaging studies were ordered. No prior imaging studies of any kind were taken of this area. With the failure of treatment, arm pain and difficulty sleeping these were appropriate studies. The films were read by a chiropractic radiologist. He reported that they were unremarkable for the exception of moderate degenerative changes at C5-C6 and to a lesser extent C6-C7. There was a very slight right dorsal scoliosis.
Treatment consisted of active CMT to C6 and T5. Diversified technique was used to the two areas of biomechanical dysfunction. Manual myofascial treatment to the trigger points, and Ultrasound was applied to the scapulocostal bursa (Figure 1). The left arm needs to be placed on the chest with the hand on the right shoulder. This exposes the bursa as it moves the scapula so the bursa could be treated.
Figure 1 - Ultrasound being applied to the superior scapulocostal bursa. The left hand is placed on the opposite shoulder to open the space between the scapula and the rib cage. The ultrasound head is directed at an angle towards the bursa and not flat against the back.
Low volt EMS was applied to the rhomboid muscles for 10 minutes using the intermittent cycle. Adjustment to the scapula was also performed (Figure 2).
Figure 2 - Scapular Adjustment
a) The scapula is moved by gently rocking it back and forth several times. Be careful as aggressiveness may work against your goals for treatment.
b) The second part of the adjustment of the scapula is done by taking the medial boarder of the scapula and gently pulling it away from the rib cage. All treatment to the scapula is predicated on the comfort of the patient.
Elastikon tape was applied (Figure 3) to the left scapula.
Figure 3 - Progression of applying the support to the posterior shoulder.
a) In this example, the left hand is placed on the front of the right shoulder for taping of the left scapula. Anchor straps are used to prevent or limit peeling of the Elastikon strips.
b) Proceed from the medial to lateral aspect to complete the procedure.
The following demonstrates taping of a bilateral scapulocostal bursitis (Figure 4):
Figure 4 - Bilateral Scapulocostal problems. The arms are crossed to tape the bilateral condition.
The Elastikon should be applied from bottom to top of the scapula.
The tape was to be left on until the next day's appointment. She was 50% better the next day and the same treatment was provided. Discussion was held about her pillow and sleep surface. She and her husband had been contemplating getting a new mattress. Time was spent discussing the various types of sleep surfaces. The third visit her pain was no more than 1/10 on the VAS scale. Elastikon tape was not applied and she was given standard range of motion (ROM) and isometric exercises for the lower neck and upper back. Additional exercises were outlined for the mid-back to include the rhomboids and subscapularis. The ergonomics of her work were also discussed and she was able to get a head set and a wrist support for her mouse pad.
A discussion about good posture while sitting to include obtaining the proper chair height resulting in the "90°/90°" sitting posture. This posture includes feet flat on the floor, knees, hips and elbows at 90° when at the computer. With a short person, a phone book may have to be placed under the feet. Her last appointment was 10 days later and she did not have a return of her symptoms. Her pain severity scale was 0-1/10. She reported that she had only a slight stiffness and was feeling no pain. She and her husband elected to get a sleep set with an air controlled firmness. She chose a pillow that is designed for side sleeping. This was the first time in two years she had been pain free in the upper back. There was a marked positive attitudinal change in her demeanor.
The scapulocostal syndrome is a clinical syndrome characterized by pain and paresthesias over the medial border of the scapula that radiates into the neck, upper triceps, chest wall and the distal upper extremity. (1) The condition has also been called "snapping scapula", "washboard”, scapulothoracic syndrome and scapulothoracic dissociation. (3, 4, 5, 9) Scapular winging has been identified in 50% of patients with a scapula without bony abnormalities. (2) There have been many factors that contribute to this syndrome as described in Table 1. (2, 3, 4, 5, 7, 10)
Table 1 - Causes That Contribute to Scapulocostal Bursitis or Snapping Scapula
- Swimming, weight lifting, throwing and gymnastics
- Posture of daily living to include work and sleeping
- Rib or scapula osteochondroma
- Poor union of a rib fracture
- von Luschka's tubercle (superior medial angle)
- Skeletal exostosis
- Surgical resection 1st rib, cervical rib, breast implants
- Computer use
- Telephone cradled between neck and shoulder
- Repetitive activity above shoulder height (construction and factory)
- Chronic strain
Infectious and soft tissue:
- Lyme disease
- Infectious arthritis
- Villonodular synovitis
- Rheumatoid arthritis
- Abnormal scapular motion
- Myofascial trigger points of the shoulder and upper thoracic spine
- Injury to the long thoracic nerve
- Rotator cuff injury
- Direct trauma
- Pancoast tumor, Ischemic chest pain,
- Vertebral artery dissection
- Pneumonia, Peptic ulcer
- Dental Pain
The clinician should examine the scapula as a contributing factor to lower neck and upper back pain. Correct diagnosis and treatment of this condition may make the difference between failure of care and successful results. This current case is an example - multiple examinations and treatment without benefit. This condition is most often confused with cervical radiculopathy. The differential diagnosis is made easier as scapulocostal bursitis does not exhibit nerve root signs such as weakness and numbness. (2, 4)
Conservative chiropractic case management can be effective and dramatic in some cases of scapulocostal bursitis. The clinician must determine if there could be other contributing factors causing the complaints that need to be managed. (2)
Treatment of this patient included active diversified adjustments to C6 and T5 based upon the examination and imaging studies. Supportive modalities were used to the bursa and muscles. Myofascial trigger points were also treated manually and with modalities. Supportive Elastikon tape, exercises, ergonomic changes at work and the addition of an air support sleep set with the appropriate pillow have been successful in resolving the presenting complaints. Successful treatment must reduce and work to eliminate the cause. It has been the authors experience with this condition that it has the tendency to return if ergonomic changes are not made and patient compliance is lacking.
If the patient does not respond to conservative management, additional investigation or referral needs to be considered. Table 1 outlines several other factors that could contribute to similar complaints. Medical management varies from oral pharmacology, steroid injections, physical therapy, rehabilitation and surgery. (2, 3, 4) These treatment protocols are outside the intent of this article, but it is the chiropractic clinician’s responsibility to work with the care and treatment of their patients that do not respond to care and be able to discuss alternatives in treatment and co-manage problems if necessary.
With a good history and examination, this condition can be treated successfully and economically with chiropractic care. It is the application of the proper treatment plan and procedures that makes a dramatic and successful conclusion to either an acute or chronic manifestation of this condition. Understanding the differential diagnosis with this presentation is essential to minimize patient suffering and expense. If the patient does not respond to conservative management, additional investigation or referral needs to be considered. Table 1 outlines several other factors that could contribute to similar complaints.
The author has no competing interests.
The author has obtained consent from the patient for publication of this case report as well as the photographs.
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