Conservative management of a patient with snapping scapula: A case study

Conservative management of a patient with
snapping scapula: A case study
Amy Curtis, SPT, Mary Beth McLees, SPT, Doug Keskula, PT, PhD, ATC
Department of Physical Therapy, Georgia Health Sciences University, Augusta, GA, USA
INTRODUCTION
Snapping scapula syndrome is a disorder of the scapulothoracic
joint characterized by an audible crepitus during over-head shoulder
motion due to abnormal movement of the scapula over the posterior
rib cage (Lazar 2009 and Manske 2004).
Functional implications of snapping scapula syndrome include
inefficient shoulder and arm movement due to poor scapulothoracic
mechanics, an unstable base of support for glenohumeral motion,
and altered length-tension relationships among scapular
muscles (Lazar 2009 and Manske 2004).
Possible causes include bursitis, muscle atrophy, muscle fibrosis,
structural spinal deformities, overuse, osteochondroma, muscular
imbalances, or bony abnormalities of the ribs or scapula (Lazar
2009, Manske 2004, Kuhne 2009).
PATIENT PROGRESSION
INTERVENTION
Date
Initial Treatment Plan and HEP
Progression
• Sidelying shoulder external rotation
• Prone shoulder extension
• Prone scapular retraction
• Chin retractions
• Push-up plus
• Doorway pectoralis stretch
• Upper trapezius stretch
• Upright shoulder external and internal rotatio
n
• Bilateral shoulder external rotation
• Standing shoulder extension
• Prone shoulder external rotation
• Prone shoulder abduction
• Horizontal shoulder adduction
• Scapular rows
• D2 PNF pattern
• Stick-Up
• Isometric scapular retraction with depression
•Initial evaluation
9/28
•Modifications to treatment plan
•Addition of 4-point scapular motion exercise performe
d
through limited ROM to avoid snapping
•Addition of shoulder IR with yellow theraband
•Ultrasound
•Manual therapy: deep soft tissue mobilization
performed but stretching not tolerated
•Slight increase in
ROM noted, but
limitation during
exercise due to
snapping remains
•Follow up in 1 week
•Some difficulty reported with
carrying book bag reported
•Pain: 3-4 initial, 3 final
10/14
•Improvement in
•Modifications to treatment plan
•Some strengthening exercises
scapular mechanics
•Performed upper trapezius and pectoralis stretch
were not performed regularly due
•Performed shoulder IR, ER, and extension x 30 reps noted
to limited availability of a theraband
with red theraband
at home
•Addition of isometric horizontal shoulder adduction,
•Gravity was used when
scapular rows and depression, and stick-up exercise
appropriate to replace band
x 30 reps
•Overall decrease in symptoms
•Ultrasound
with some remaining popping
•Manual therapy: deep tissue mobilization performed b
reported
ut
manual stretching still not tolerated
•Pain: 3-4 initial, 2-3 final
•Follow up in 1 week
10/22
•Exercises performed with more
consistency
•Crepitus while reaching overhead
and pain when donning book bag
continue
•Modifications to treatment plan
•Performed all exercises 10 reps x 2 sets
•Advanced to green theraband for scapula rows and
shoulder extension
•Addition of bilateral ER with yellow theraband
•Ultrasound
•Manual therapy: stretching tolerated along with
continued deep soft tissue mobilization
•Overall
improvement noted
•Follow up in 1 week
•Modifications to treatment plan
•All previous exercises performed with green tube for
scapular rows, shoulder IR, shoulder ER, and shoulde
r extension
•Performed bilateral scapular retraction/depression wit
h
resisted isometric scapular depression
•Addition of D2 diagonal patterns with yellow theraban
d
•Pectoralis stretch performed
•Ultrasound
•Manual therapy: tolerated stretching and moderate –
deep soft tissue mobilization
•Greater ability to
reach overhead
slowly versus
quickly noted
•Follow up in 1 week
N/A
•Follow up in 1 week
•Pain: 4-8 initial, 3-4 final
11/5
•Exercises performed regularly
•Difficulty and pain when reaching
overhead and carrying book bag
with left arm continue
•General decrease in symptoms
reported
•Pain: 4-8 initial, 1-2 final
The purpose of this case report is to provide detailed information
regarding non-invasive treatment techniques for snapping scapula
syndrome by describing a successful physical therapy plan.
11/11
D2 PNF Pattern
CASE STUDY
Element
Isometric Scapular Retraction
with Depression
Pectoralis Stretch
12/2
Findings
• 17 year old female
Patient
Characteristics • Chief complaint: L shoulder pain
• MOI: MVA 2 years prior to initial evaluation
Initial
Evaluation
Goals
• Difficulty sleeping and performing ADLs due to pain
• Crepitus associated with painful shoulder movement
• Poor scapular and glenohumeral movement
• L scapula protrusion and winging
• Periscapular tenderness
• Pectoral tightness
• Decreased L neck and shoulder PROM and MMT
• Short Term: Reduce pain to no more than 3/10, maintain scapula
rstabilization during L shoulder motion, and achieve independenc
e with HEP
• Long Term: Achieve full AROM, eliminate pain at rest, and reduc
e pain with activity to no more than 1/10
Treatment
Plan
• 7 visits over 2 month period
• Therapeutic exercise focused on restoring alignment and
muscular control of the scapulothoracic region
• Manual therapy
• Ultrasound
• Patient education
•Unable to perform exercises due to •Modifications to treatment plan
•All previous exercises performed
illness
•Advance to yellow theraband for stick-up exercise
•Carrying book bag continues to
•Addition of prone shoulder abduction
cause pain
•Ultrasound
•Overall decrease in
•Manual therapy: tolerated stretching and deep soft
pain and crepitus reported
tissue mobilization
•Pain: 3-4 initial, 3 final
•Overall improvement reported
•Some pain and crepitus while
reaching overhead and carrying
book bag remain
•Pain: 0-2 initial, 6 final
RESULTS
Patient reported an overall decrease but not elimination of symptoms
after 7 physical therapy sessions.
Pain was rated at the beginning and end of each treatment session. The
patient initially rated pain as 5-8/10 VAS and decreased the rating to 02/10 VAS at the beginning of her final treatment session.
After the seventh visit, the patient became increasingly busy with school
and sport commitments and was unable to return to therapy.
Lingering symptoms included pain and crepitus during functional
activities such as reaching overhead and carrying a book bag.
Possible barriers to full recovery include lack of total compliance with
home exercise program and missed physical therapy visits.
Plan
•Initial evaluation
Stick-Up
Current literature concerning this disorder provides ample
information about various surgical treatment options but very limited
advice about conservative management such as physical therapy.
Assessment
•Initiation of treatment plan
•Therapeutic exercise: side-lying shoulder ER, prone
shoulder extension, prone scapular retraction, chin
retraction, push-up plus
*Patient progressed from no resistance or low level theraband resistance to higher level resistance as tolerated and as directed by therapist
Horizontal Adduction
Objective
9/22/09 •Initial evaluation
*Patient instructed to perform all exercises 10-15 repetitions, 1-2 times per day
Prone Scapular Retractions
Subjective
•Modifications to treatment plan
•Advance to blue theraband for scapular rows and
shoulder extension
•Advance to red tube for stick-up exercise
•Performed terminal shoulder extension standing with
red band
•Performed sitting scapular depression
•All exercises performed x 30 reps without crepitus or
pain
•Ultrasound
•Manual therapy: tolerated stretching and moderate to
deep soft tissue mobilization
•Symptoms continue •Follow up in 2 weeks
to improve
SUMMARY & CONCLUSIONS
● This case report indicates that conservative management of snapping
scapula syndrome, including therapeutic exercise focused at improving
scapulothoracic alignment and muscular control, may be beneficial for
decreasing pain and crepitus associated with overhead shoulder motion.
● The use of outcome measurement tools, measurable goals, and complete
documentation will be beneficial in further research.
● Further research is needed to be able to generalize the findings of this study.
REFERENCES
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