Surgery for Scapular Problems

Without the scapula (shoulder blade), smooth and coordinated motion and function of the arm is compromised. Problems affecting the scapula that can disrupt the motion and rhythm of arm movement include bursitis, snapping scapula, and tumors (benign or malignant) of the bone or nearby soft tissues. Disorders of the scapula are rare and a thorough understanding of the anatomic features of this structure is needed to treat them successfully.

That’s why two orthopedic surgeons wrote this article reviewing the anatomy and physiology of the scapula motion and stability. They go on to discuss the conservative (nonoperative) and surgical management of a specific problem known as snapping scapula syndrome. Details of what they have learned performing arthroscopic surgery on the scapula are provided. They say that complete familiarity with the scapula and surrounding soft tissues (including easily damaged blood vessels and delicate nerves) is essential to avoid unnecessary problems caused by the surgery.

Snapping scapula syndrome is as the name suggests: when the arm moves, some portion of the scapula drags against the rib cage causing a snapping sound and sensation. Pain is often (though not always) a main feature associated with this problem. Patients present with a range of severity from mildly irritating to extreme debilitation. The people affected most often are usually young athletes involved in activities requiring repetitive overhead motion.

An understanding of the knowledge we have about this problem is important because surgery doesn’t always “fix” the problem. That’s why conservative care is recommended first. This approach may include medications and change in activity type/level to reduce inflammation. If these measures don’t help, then one to three steroid injections may be tried.

Physical therapy to address posture and weakness or imbalance in muscle function is a key feature of the nonoperative approach to snapping scapula syndrome. Patients are advised to be patient as the rehabilitation process can take up to six months to be effective. Only when there are tumors or “masses” should surgery be considered sooner.

When six months (or more) of conservative care fails to change the clinical picture, then surgery to remove a portion of the bone and/or inflamed bursae may be advised. The authors take the reader through both open and arthroscopic surgical techniques for snapping scapula syndrome.

Drawings, photos of patient positioning, arthroscopic images, and CT scans are used to illustrate the step-by-step approach described. Special tips are provided to aid the surgeon in avoiding injury to the nerves and blood vessels. Newer portal placements (insertion points for the arthroscope needle) developed for this surgery are described.

Specific surgical tools are recommended (e.g., shielded round burr) when performing scapular resection (removal of part of the scapular bone). And instructions are given to assist the surgeon in avoiding removing muscle fibers along with the bone. The removal of any kind of masses in the area depends on type, size, and location of these tumors. And finally, the authors review the rehabilitation protocols they use and summarize results of surgical management of snapping scapula syndrome from published reports.

In summary, disorders and diseases of the scapula don’t come in neat, tidy packages. There is a wide variation of symptoms and treatment must be tailored to each individual patient. The goal of pain relief and improved (or restored) function may be met with nonoperative care. When surgery is necessary, understanding of the anatomy and careful surgical technique are both very, very important. Patients should be counseled that results reported for surgical treatment of this condition are not always as expected or hoped for.