idiopathic snapping scapula in a moroccan patient a rare cause of shoulder pain

The Egyptian Rheumatologist (2016) xxx, xxx–xxx Egyptian Society of Rheumatic Diseases The Egyptian Rheumatologist www.rheumatology.eg.net www.elsevier.com/locate/ejr CASE REPORTS Idiopathic snapping scapula in a Moroccan patient: A rare cause of shoulder pain Kona Kaut Ire`ne *, Awassi Se`nami Florine, Essouiri Jamila, Tahiri Latifa, Harzy Taoufik Sidi Mohammeh Ben Abdellah University, Faculty of Medicine and Pharmacy, Fes, Morocco Department of Rheumatology, CHU Hassan II, Fes, Morocco Received 14 August 2016; accepted 15 August 2016 KEYWORDS Scapula; Jump and idiopathic Abstract Introduction: The jumped shoulder blade or ‘‘snapping scapula” is a rare cause of shoulder pain that entails cracking of the scapula in connection with multiple causes In 30% of cases no etiology is found Case presentation: We report a case of a 54 year old Moroccan male patient with left shoulder pain lasting for 14 years associated with pain at the anterior-upper corner of the scapula Clinical examination did not reveal any deformation of neither cervical nor thoracic spine on inspection; testing of the tendons of the shoulder rotators and active and passive shoulder mobility were normal and an audible crack was noted during the arm movement or apprehension test with left arm pain on mobilization of the scapula ‘‘vital sign” without limitation of the range of motion The anterior drawer sign of laxity and refocusing sign were negative Imaging performed including plain radiographs, musculoskeletal ultrasound and CT scan of the scapula with 3D image reconstruction found no bone or soft tissue abnormalities that could explain this syndrome The diagnosis of jumped scapula of unknown origin was made and symptomatic treatment with non-steroidal anti-inflammatory drugs and a rehabilitation protocol based on isometric and isotonic strengthening periscapular muscles, posture and endurance exercises were instituted Conclusion: Our case illustrates a new case of a jumped shoulder blade of unknown origin after completion of all etiological imaging Further analysis of clinical events is needed to better understand this type of jumped shoulder blade Ó 2016 Egyptian Society of Rheumatic Diseases Publishing services provided by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction * Corresponding author at: Department of Rheumatology, CHU Hassan II, Sidi Mohammeh Ben Abdullah University, Faculty of Medicine and Pharmacy, Fes, Morocco E-mail address: irkadebene@ymail.com (K.K Ire`ne) Peer review under responsibility of Egyptian Society for Rheumatic Diseases The scapula is a thin triangular-shaped bone that serves as an attachment site for most of the extrinsic and intrinsic muscles providing movement and stability to the glenohumeral and scapulothoracic joints [1] The scapulothoracic articulation is a sliding junction between the deep aspect of the scapula and http://dx.doi.org/10.1016/j.ejr.2016.08.001 1110-1164 Ó 2016 Egyptian Society of Rheumatic Diseases Publishing services provided by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: Ire`ne KK et al Idiopathic snapping scapula in a Moroccan patient: A rare cause of shoulder pain, The Egyptian Rheumatologist (2016), http://dx.doi.org/10.1016/j.ejr.2016.08.001 K.K Ire`ne et al thoracic rib cage at the levels of ribs through Motion at this articulation is dynamically stabilized by a variety of muscular attachments, allowing for controlled positioning of the glenoid to assist in glenohumeral joint function [2] This biomechanical construct provides the smooth gliding movement of the relatively concave scapula on the convex thoracic cage [1] The scapula is attached to the axial skeleton via the clavicle, which acts as a strut allowing scapular rotation and translation along the thoracic wall and opposing medially directed forces of the periscapular muscles [3] The jumped shoulder blade, otherwise called shoulder impingement syndrome, may be defined simply as pain and cracking of the shoulder during mobilization of the scapula It was described for the first time in 1987 by Boinet [4] Symptomatic scapulothoracic disorders are often poorly understood Possible causes include direct or indirect trauma, overuse syndromes, glenohumeral joint dysfunction, osseous abnormalities, muscle atrophy or fibrosis and idiopathic [1,5] Each cause leads to the common pathway of disruption of the normal motion between the anterior surface of the scapula and the underlying bony thorax [1] Idiopathic jumped scapula was reported in 30% of cases [1,6] This rare condition is also known as ‘snapping scapula syndrome’ caused by the disruption of the gliding articulation between the anterior scapula and the posterior chest wall In addition to the multifactorial etiology contributing factors include scapular dyskinesis, bursitis from repetitive use or trauma, and periscapular lesions [7] Scapulothoracic crepitus is defined by a grinding, popping, or thumping sound or sensation secondary to abnormal scapulothoracic motion It can be a source of persistent pain and dysfunction in the active overhead throwing athlete [1] Patients with snapping scapula syndrome typically present with a history of pain with overhead activities and the associated audible and palpable crepitus is near the superomedial border of the scapula [5] Various imaging studies may be used to rule out soft-tissue and bony masses, which may cause impingement at the scapulothoracic articulation [5] Three-dimensional CT and MRI aid in detecting these abnormalities [8] Nonsurgical therapy is the initial treatment of choice but is less successful than surgical management in patients with anatomic abnormalities In many cases, scapular stabilization, postural exercises, or injections eliminate symptoms [5,8] Although the majority of cases are initially treated with nonoperative modalities, recalcitrant snapping scapula syndrome can warrant surgical management [7] Open and endoscopic techniques have been used with satisfactory results [8] The clinical history and physical examination of the patient is the key element of making this diagnosis We report a case of a jumped scapula of unknown origin in a Moroccan male patient rotators and active and passive shoulder mobility were normal We noted an audible crack during the armed arm movement (abduction-external rotation) or apprehension test with left arm pain on mobilization of the scapula ‘‘vital sign” without limitation of the range of motion The anterior drawer sign of laxity and refocusing sign were negative Imaging performed in search of any etiology included plain radiographs (Fig 1), the musculoskeletal ultrasound and CT scan (Fig 2) of the scapula with 3D image reconstruction was then performed in sequential acquisition with cuts of mm rebuilt every mm with multiplanar reformations and three-dimensional in neutral and armed arm position, had found no bone or soft tissue abnormalities that could explain this syndrome The diagnosis of jumped scapula of unknown origin was made and symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and rehabilitation was instituted The rehabilitation was focused on posture, strength, and endurance The rehabilitation protocol was progress along a continuum: from isometric and isotonic periscapular and rotator cuff strengthening to endurance eccentric strengthening of the periscapular muscles [1] The case management was approved by the local ethics committee and the patient gave an informed consent Discussion The jumped shoulder blade or scapulothoracic syndrome also called snapping scapula by the English‘‘ entails pain and cracking in the mobilization of the scapula The positive armed arm sign in an essential element in physical examination for diagnosis [4,8,9] Several etiologies have been cited in the literature Case presentation A 54 year old man without significant past medical history consulted in the rheumatology department for mechanical left shoulder pain lasting for 14 years associated with pain at the anterior-upper corner of the scapula Clinical examination did not reveal any deformation of neither cervical nor thoracic spine on inspection; testing of the tendons of the shoulder Figure Plain X-ray of the shoulder and scapular region to exclude any underlying cause Please cite this article in press as: Ire`ne KK et al Idiopathic snapping scapula in a Moroccan patient: A rare cause of shoulder pain, The Egyptian Rheumatologist (2016), http://dx.doi.org/10.1016/j.ejr.2016.08.001 Idiopathic snapping scapula in a Moroccan patient Figure CT image of the scapula reconstructed in 3D with no detected underlying cause [6,10,11] For example acquired bone abnormalities such as exostosis, hypertrophic callus bone fractures of the ribs and the scapula, osteochondroma of the scapula anterior face and a history of surgery of thoracic outlet syndrome Muscle abnormalities such as edema or atrophy of the serratus anterior and subscapularis The soft tissue abnormalities including elastofibroma, the fibrous strip and scapular thoracic bursitis superolateral to the medial angle of the scapula are the most frequent causes of shoulder blade to jump The prevalence of cases of idiopathic jumped shoulder blade have been reported in 30% [1,6] However, some studies have reported that there are non-pathological bone structures that predispose to the development of the scapula to jump based inter alia on the morphology of the medial border of the scapula which has been measured and classified into convex, right and concave to detect the variety of the scapula [8,11,12] The most important non-pathological bone structures of the scapula that predisposed to slam – are not uncommon, and include the concave inner edge of the scapula (11.4%), the tuber of Luschka (3%) and the articular process curled toward the chest wall’s teres major muscle (3.4%) [2,13,14] In addition, the presence of a concave medial border is usually associated with muscle weakness which can lead to abnormal scapular movement which is also included in the pathogenesis of the scapula to jump [2,15] Hence the interest to achieve imaging especially CT scan of the shoulder blade with 3D reconstruction has a paramount importance in the etiological research of the jumped scapula [6,16] Regarding our patient, he had a jumped shoulder blade in whom no etiology was found, no anomalies nor have non-pathological bone variants been objectified The jumped shoulder blade is a clinical entity, usually secondary to a known etiology The presence of changes in nonpathological bone structures has been included in its pathogenesis In conclusion, our case illustrates a new case of a jumped shoulder blade of unknown origin after completion of all etiological imaging Further analysis of clinical events is needed to better understand this type of jumped shoulder blade Conflict of interest None References [1] Conduah AH, Baker 3rd CL, Baker Jr CL Clinical management of scapulothoracic bursitis and the snapping scapula Sports Health 2010;2(2):147–55 [2] Frank RM, Ramirez J, Chalmers PN, McCormick FM, Romeo AA Scapulothoracic anatomy and snapping scapula syndrome Anat Res Int 2013;2013:635628 [3] Kibler WB The role of the scapula in athletic shoulder function Am J Sports Med 1998;26:325–37 [4] Bionet W Fait clinique Bull Mem Soc Chir Paris 1867;8:458 [5] Kuhne M, Boniquit N, Ghodadra N, Romeo AA, Provencher MT The snapping scapula: diagnosis and treatment Arthroscopy 2009;25(11):1298–311 [6] Sans N, Jarlaud T, Sarrouy P, Giobbini K, Bellumore Y, Railhac JJ Snapping scapula: value of 3D imaging J Radiol 1999;80:379–81 [7] Wang ML, Miller AJ, Ballard BL, Botte MJ Management of snapping scapula syndrome Orthopedics 2016;39(4):e6–e783 [8] Gaskill T, Millett PJ Snapping scapula syndrome: diagnosis and management J Am Acad Orthop Surg 2013;21(4):214–24 [9] Carlson HL, Haig AJ, Stewart DC Snapping scapulae syndrome: three cases reports and an analysis of the literature Arch Phys Med Rehabil 1997;78:506–11 [10] Edelson JG Variations in anatomy of the scapula with reference to the snapping scapula Clin Orthop Relat Res 1996;322: 111–5 [11] Totlis T, Konstantinidis GA, Karanassos MT, Sofidis G, Anastasopoulos N, Natsis K Bony structures related to snapping scapula: correlation to gender, side and age Surg Radiol Anat 2014;36(1):3–9 [12] Spiegl UJ, Petri M, Smith SW, Ho CP, Millett PJ Association between scapula bony morphology and snapping scapula syndrome J Shoulder Elbow Surg 2015;24(8):1289–95 [13] Parsons TA The snapping scapula and subscapular exostoses J Bone Joint Surg Br 1973;2:345–9 Please cite this article in press as: Ire`ne KK et al Idiopathic snapping scapula in a Moroccan patient: A rare cause of shoulder pain, The Egyptian Rheumatologist (2016), http://dx.doi.org/10.1016/j.ejr.2016.08.001 [14] Merolla G, Cerciello S, Paladini P, Porcellini G Snapping scapula syndrome: current concepts review in conservative and surgical treatment Muscles Ligaments Tendons J 2013;3(2):80–90 [15] Roos DB Recurrent thoracic outlet syndrome after first rib resection Acta Chir Belg 1980;79(5):363–72 K.K Ire`ne et al [16] Bell SN, Troupis JM, Miller D, Alta TD, Coghlan JA, Wijeratna MD Four-dimensional computed tomography scans facilitate preoperative planning in snapping scapula syndrome J Shoulder Elbow Surg 2015;24(4):e83–90 Please cite this article in press as: Ire`ne KK et al Idiopathic snapping scapula in a Moroccan patient: A rare cause of shoulder pain, The Egyptian Rheumatologist (2016), http://dx.doi.org/10.1016/j.ejr.2016.08.001