Snapping Scapula Syndrome – Non-surgical options
Ross A. Hauser, MD.
Snapping Scapula Syndrome
Over the years we have seen many patients with scapula area problems. The people we see who have been diagnosed with snapping scapula syndrome come into our exam rooms and for many, the first thing they want to do is to make the “snapping” sound for us. Some patients can really make a loud noise, we have probably said “wow” on more than one occasion.
For some, the snapping noise is just as much of a problem as the pain and functional problems the Snapping Scapula Syndrome is causing them. In this article, we will discuss treatment options that will eliminate the snap and restore normal pain-free motion.
Part 1: Diagnosing snapping scapula syndrome
- The diagnosis of Snapping Scapula Syndrome is controversial.
- A clinical evaluation of altered shoulder kinematics is still complicated.
- Physical examination showed winging of the scapula and rotator cuff muscle atrophy.
Part 2: Treatments for snapping scapula syndrome
- 89% of computer workers had Scapular Dyskinesis.
- Conservative and Arthroscopic Treatment of Snapping Scapula Syndrome.
- Why physical therapy may have failed you.
- Failure of physical therapy – uncorrected instability.
- Addressing tendons and ligaments before you consider surgery.
- “high likelihood of persistent symptoms post-operatively.”
- Treating the scapulothoracic area.
Part 1: Diagnosing snapping scapula syndrome
If you have finally been diagnosed with Snapping Scapula Syndrome or are still searching for the correct diagnosis you have likely been on a journey that may include:
- MRIs of the scapula that never find anything.
- Your doctors are questioning the cause of your pain because you do not have an obvious physical abnormality, but you have severe scapular pain. So this means lots of tests including the “MRIs of the scapula that never find anything.”
- Next, there may be a focus on pain (maybe) from the cervical facets or C5-6 cervical radiculopathy.
- A search for a diagnosis may include a suggestion to look for a brachial plexus injury. However, if your problems have gone on more than a few weeks this may be eliminated as brachial plexus injury or nerve injury may resolve itself during this time.
Your doctor may have spoken to you about “Washboard syndrome,” Scapulocostal Syndrome, or Scapulothoracic Syndrome, these are also terms that can describe Snapping Scapula Syndrome and the cause of your grating, grinding, popping, or snapping sensation of the scapula.
Your medical history may include all these terms and more, possible confusion with something going on in your shoulder. The problem for you however is that no one can figure out what is going on, your condition can be quite painful and extremely irritating. You are constantly recommended to the same group of treatments: nonsteroidal anti-inflammatories, cortisone shots, trigger point injections, physiotherapy, chiropractic care, and surgery and you have continuous and frustrating suboptimal results.
The diagnosis of snapping scapula syndrome is controversial
The diagnosis of Snapping Scapula Syndrome is controversial because Snapping Scapula Syndrome is considered a rare condition. Except to the people who have it.) It is basically a problem of the normal interplay and movement between the anterior (or front) of the scapula and the posterior (or back of the) chest wall.
What you may have heard at the specialist’s office as they try to pinpoint your problem:
We are going to bring in the Department of Radiology, Keck School of Medicine, University of Southern California to help us here explain what you may have heard at the specialist’s office and try to help you understand it in more common terms. This description of the Snapping Scapula Syndrome appeared in the journal Skeletal Radiology.(1)
- “Symptomatic scapulothoracic disorders, (shoulder pain or pain at the scapulothoracic junction, especially with overhead activities, and your snapping or cracking (crepitus) noises, scapulothoracic crepitus and scapulothoracic bursitis (pain and swelling of the scapulothoracic bursa).
- Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly (at the same time) or independently. The constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome.
- Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects.”
All these terms may have been explained to you as your possible cause for your problems of:
- Muscle weakness, muscle spasms, or muscle tightness of the scapula muscles.
- Possible nerve injury that supplies sensation and function messages to these muscles.
- Injuries to the shoulder joint that has caused anatomical defects. Your scapula is “winging,” or out of place.
We have more information on how shoulder problems are related to scapula problems here in our article: Subacromial shoulder pain
A clinical evaluation of altered shoulder kinematics is still complicated
An April 2020 study in the International Journal of Environmental Research and Public Health (2) wrote: “A clinical evaluation of altered shoulder kinematics is still complicated. Limitations in observing scapular motion are mainly related to the anatomical position and function of the scapula itself and the absence of a tool for quantitative scapular dyskinesis clinical assessment.”
A May 2022 paper in the journal Sports Health (3) discusses the problems of diagnosis and treatment of snapping scapula syndrome and its relationship to the scapulothoracic joint. “Snapping scapula syndrome . . . is a commonly misdiagnosed and underreported condition of the scapulothoracic joint usually associated with painful crepitus and shoulder joint dysfunction when attempting overhead motion. . . symptoms are created by the excessive friction between the scapula and the thorax (the sternum, the thoracic vertebrae, and the ribs) with soft tissue (bursa, tendon, or muscle) entrapped between them. . .Physiotherapy and rehabilitation are the mainstay in the nonoperative management of snapping scapula syndrome and aim to address altered posture, scapular winging, or scapulothoracic dyskinesis. Scapular malposition can lead to abnormal force distribution throughout the shoulder joint, resulting in abnormal shoulder kinematics and problems with motion.”
Physical examination showing winging of the scapula and rotator cuff muscle atrophy
The caption of the image below reads: Physical examination showing winging of the scapula and rotator cuff muscle atrophy. The winging of the scapula is evident on the left, whereas obvious rotator cuff atrophy is seen on the right. This patient was shown a digital motion x-ray to have nerve compression of the left side while an MRI showed significant intrinsic shoulder pathology on the right side.
Part 2: Treatments for snapping scapula syndrome
In our practice, we often see that snapping scapula syndrome can be caused by several different reasons.
- One is a shoulder muscle imbalance this is called scapular dyskinesis.
- Another reason is shoulder instability. In many cases, instability in the acromial clavicular joint, the sternoclavicular joint, or the ball and socket glenohumeral joint, can throw off your shoulder blade and prevent it from moving in a smooth, normal motion.
- Instability in the thoracic rib region, which is considered part of your shoulder, if there is any imbalance or instability between the connection between the ribs and the shoulder blade moving over it can also lead to snapping scapula syndrome.
- We are seeing this condition more and more as people spend longer hours viewing electric devices, phones, computers, etc.
- Many people find success with physical therapy short term, but in the long term, physical therapy does not address the instabilities generated by ligament weakness. When we are in poor posture, and we are hunched over looking at devices, there is a strain on the ligament support of the shoulder, and the thoracic spine where these structures meet the ribs, becomes unstable.
- Generally speaking, if you move your arm and you hear clicking, grinding, and crunching noises, then there is probably a degree of instability and muscle weakness.
Dynamic digital radiography (DDR), a diagnostic tool we refer to, allows us to see the shoulder in real-time motion. In the video below, the patient is shrugging their shoulders so we can assess abnormalities in motion including shoulder instability.
89% of computer workers had Scapular Dyskinesis
A December 2023 study in the journal Medicina (4) assessed the occurrence of neck and shoulder pain with scapular dyskinesis in computer office workers. The authors write: “Scapular dyskinesis is associated with neck and shoulder pain. However, Scapular dyskinesis in computer office workers has not been (fully understood).” In this study, the researchers aimed to investigate the prevalence of Scapular Dyskinesis, neck and shoulder pain, disability, and working hours in computer office workers.
- 109 computer office workers participated in this study.
- The results of a scapular dyskinesis test (SDT), lateral scapular slide test (simply how far the scapula slides out of place, how much instability is present), neck disability index (NDI), shoulder pain and disability index (SPADI), visual analog scale (0 – 10 self-reported pain score) scores of the neck and shoulder, and working hours were recorded.
89% of computer workers had Scapular Dyskinesis
- Results: Ninety-eight computer office workers (89.9%) had scapular dyskinesis
- Computer office workers with scapular dyskinesis had significantly higher neck disability index (NDI) scores, neck VAS pain scores, and dominant shoulder pain scores.
- The lateral scapular slide test results showed a significantly greater distance (displaced scapular) in participants with scapular dyskinesis.
- Conclusions: “The prevalence of scapular dyskinesis was very high in computer office workers, and neck and shoulder pain were more prevalent in workers with obvious scapular dyskinesis.”
Conservative and Arthroscopic Treatment of Snapping Scapula Syndrome
Surgery of course is the last option following an extensive course of conservative, non-surgical treatments. If you are reading this article you may have had snapping scapula syndrome for some time and now you are searching for surgery alternatives.
For many people, conservative care options for snapping scapula syndrome work very well. These people who have had great results are usually not the people we see in our office. We see the people who did not have good results, perhaps someone like yourself who is now looking for different options.
Nonsteroidal anti-inflammatory medications
Because inflammation is nearly always thought to be involved in this problem, especially if bursitis is suspected or present, one of the first things you will be suggested to is Nonsteroidal anti-inflammatory medications (NSAIDs). For some of you, NSAIDs may have helped quite a bit initially. Eventually however as pain continued and increasing doses of NSAIDs were not helpful and possibly made your pain worse, other options needed to be explored.
In a December 2016 study in the journal Manual Therapy (5), “Subacromial infiltration (injections of Lidocaine) did not restore kinematics toward symmetrical scapular motion (correct movement). These findings suggest that subacromial anaesthesia is not an effective means to instantly restore the symmetry of shoulder motion.”
Why physical therapy may have failed you
For many people, physical therapy can offer a lot of benefits. You may have seen these benefits yourself. A restoration of normal scapula function. That is the movement that allows the scapula to guide over the rib cage and provide the support the shoulder needs to also move normally. If you are reading this article it is unlikely that physical therapy has benefited you as much as you would have hoped. Why and how did this happen?
One of the criteria for getting physical therapy is that the inflammation that is causing a distorted painful movement is eliminated. People do not do well in physical therapy if pain prevents them from achieving the exercises needed to help their problem. So strong anti-inflammatories and cortisone injections are recommended. Sometimes a simple numbing agent is given to get the patient through their exercises if the pain is a barrier.
Once convinced, the patient is ready for physical therapy, a routine that includes postural training, (stopping you from slouching), stretching, and strengthening will be offered.
Let’s look at a report in the Journal of Muscles Ligaments and Tendons (6) to help us understand the goals of physical therapy and why physical therapy may have failed you.
- Postural training aims to minimize kyphosis (hunchback), promote upright posture, and strengthen upper thoracic muscles. Thoracic kyphosis is associated with a forward head, rounded shoulders, and abducted and forward-tipped scapulae (your scapula is tilted).
- The tightened or affected muscles include pectoralis major and minor, levator scapulae, upper trapezius, latissimus dorsi, subscapularis, sternocleidomastoid, rectus capitis, and scalene muscles. Weakened muscles include the rhomboids, mid and lower trapezius, serratus anterior, teres minor, infraspinatus, posterior deltoid, and longus colli or longus capitis.
- Restoring scapular strength establishes static proximal stability to provide a stable base of support.
- Exercises aim to resolve muscle imbalance and correct scapular motion thus reducing pain and functional impairment.
- However, if pain persists, physical therapy must be avoided and local injection of anesthetics and steroids have to be considered
- Corticosteroid injections are usually repeated 3 to 4 times per year. (sometimes less).
- If all non-surgical measures fail to relieve the symptoms after 3 to 6 months, surgical options should be considered.
Failure of physical therapy – uncorrected instability
Patients are often very confused as to why a physical therapy program or exercise/activity program did not help their snapping scapula syndrome problem as much as they thought it would. Clinicians, doctors, and therapists are equally confused. This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved. Many of these patients have been listening and reading about “5 great exercises to help Snapping Scapula Syndrome” to strengthen their problem areas. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working for them, when physical therapy and exercise are so beneficial to so many others?
Loss of strength, muscle power, and range of motion are clearly indicators of an impending surgical recommendation. In patients with Snapping Scapula Syndrome, where connective tissue such as the tendons that attach muscles to the bones are damaged. It is very difficult to derive benefit from strength training where resistance is needed because the tendons that help provide that resistance are weak. Physical therapy results can be improved if you strengthen and repair weakened and damaged tendon attachments. The tendon’s enthesis is that piece of tissue that attaches your muscle to the bone. The term enthesopathy typically refers to a degenerated enthesis and this may have been discussed with you at one of your many doctor or PT visits. It is not only the tendons. It is the ligaments of the scapula region as well. These include the coracohumeral ligament and the glenohumeral ligament. When these ligaments are damaged because of degenerative wear and tear, the bones wander off and start floating around. They start to bang against each other in unnatural damaging contact. This can cause bursitis to develop.
In the image below, we see the various ligaments of the shoulder.
Addressing tendons and ligaments before you consider surgery
Many people will think, “I am too far gone,” I need the surgery. So they get themselves on a waiting list and manage themselves along with painkillers, anti-inflammatories, and YouTube videos on exercise. These are the very remedies that have already not been as helpful as hoped for but what else can they do until they wait for surgery? Secondly, is surgery worth the wait?
Doctors from the Steadman Philippon Research Institute provide an assessment of the Arthroscopic Treatment of Snapping Scapula Syndrome in the medical journal Arthroscopy. (7)
They looked at patients who underwent arthroscopic treatment for Snapping Scapula Syndrome after extensive nonoperative treatments failed. Nonoperative treatments include mainly physical therapy and anti-inflammatory medication.
- Seventy-four Snapping Scapulas who underwent arthroscopic surgery were examined in follow-up:
- Eight scapulae failed initial surgical management (10.9%) because of recurrent pain and underwent revision surgery at an average within one year of the first surgery
- Of the remaining 66, the average patient satisfaction rating post-surgery was 7 of 10.
Greater age, lower preoperative psychological score, and longer duration of symptoms before surgery correlated with lower postoperative outcome scores.
“high likelihood of persistent symptoms post-operatively”
A June 2023 paper in the journal Arthroscopic Techniques (8) suggests that “it is not uncommon for patients who present with Snapping Scapula Syndrome to have some degree of scapular dysfunction, especially with the tightness of the pectoralis minor muscle.” In this paper, the authors discuss their “preferred technique for arthroscopic scapulothoracic bursectomy (removal of bursa) and partial scapulectomy (partial removal of scapula) with concomitant pectoralis minor release for the treatment of symptomatic Snapping Scapula Syndrome and pectoralis minor muscle tightness. In the treatment of these patients, pectoralis minor muscle release is beneficial because arthroscopic scapulothoracic bursectomy or partial scapulectomy alone may result in residual scapular dyskinesis.”
Doctors at the Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre in Canada wrote in the journal Knee Surgery, Sports Traumatology, Arthroscopy: (9)
“Arthroscopic management of snapping scapula syndrome yields improvement in pain, crepitus, and range of motion in a majority of patients; however, most patients experience residual symptoms. Further studies are needed to compare the outcomes of shoulder arthroscopy with other available treatment options for snapping scapula syndrome. Shoulder arthroscopy for snapping scapula can improve patients’ symptoms; however, patients must be informed about the high likelihood of persistent symptoms post-operatively.”
Treating the scapulothoracic area
In our experience, the best chance at a good patient outcome of this condition is when we address with the patient the underlying instability in the scapulothoracic area, which allows the scapula and ribs to move normally, without the abnormal wear and tear. At our office, we have treated many cases of scapulocostal syndrome using comprehensive dextrose Prolotherapy. We will explain this treatment below.
Above I mentioned the cervical neck facet joints and cervical radiculopathy as diagnoses in the case of shoulder instability. The caption of this image says:
“Shoulder-cervical instability connection. Shoulder instability cause levator scapulae contraction which can increase the symptoms of cervical instability through its attachment at C1-C4. Sometimes to resolve upper cervical spine instability or shoulder instability, or both, treatments may be needed in the neck and shoulder.
Prolotherapy treatment of snapping scapula syndrome – A non-surgical option
The image caption reads: Prolotherapy to the shoulder. The frequent injection sites are demonstrated including the coracoid process, subscapularis tendon, and the greater tuberosity.
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and ineffective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle. This is why it is the Caring Medical treatment method of choice.
- Prolotherapy is considered a viable alternative to surgery and as an option to pain medications, cortisone, and other steroidal injections.
- The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
In this video, Ross Hauser, MD, gives an introduction to our treatments for Snapping Scapula Syndrome
A summary transcript is below
- (0:33 of the video) Prolotherapy can be curative for many people
- Dr. Hauser explains the bones snap against tendons or muscles because of the underlying joint instability (weakened and damaged tendons and ligaments that allow for hypermobility or a “winging,” of the scapula.
- (0:52 of the video) Underlying slipping rib syndrome or subluxation of the ribs
- A rib that is too mobile will surely rub on the underside of the scapula. When the patient receives chiropractic or osteopathic manipulation, the shoulder feels better for a while, but again the snapping returns. The snapping returns because the ligaments that attach the ribs to the vertebrae (costovertebral ligaments) remain injured. Prolotherapy treatments to these ligaments that are causing the snapping scapula syndrome can cure the condition.
- (1:20 of the video) Shoulder joint instability
- The scapula is half of the shoulder joint. If you have shoulder instability, ligament damage, or shoulder labral tear, this will cause scapula instability.
- We ask you, “What realistically could cause the scapula to start rubbing against a rib?” Is it likely going to come from an injury to the scapula? We feel that this is quite doubtful yet, almost 100% of the traditional medical treatments are performed on the scapula or the muscles that attach to the scapula. Doctors inject cortisone shots into and around the scapula. Patients get trigger point injections or massage therapy to break up “scar tissue.”
- (2:30 of the video) Prolotherapy injections are an effective treatment for repairing these weakened and damaged elements of the shoulder and the cause of Snapping Scapula Syndrome.
The typical physical therapy approach to Snapping Scapula Syndrome is to strengthen the serratus anterior muscle and/or put the patient through a scapular stabilization exercise program. Prolotherapy treatments can make this more effective by strengthening the muscle attachments and helping to increase resistance.
In September 2020, a case history of a 22-year-old woman was presented in the Turkish Journal of Physical Medicine and Rehabilitation. (10) The woman had a two-year history of pain in the right scapula. A loud snapping sound with particular overhead motions was observed. On the VAS Pain Scale of 0 – 10, the patient reported a “10” in both palpation and arm motions. On plain radiography, there was no abnormality. Inflammation was observed in the scapulothoracic bursa by ultrasound.
As previous treatments did not relieve her symptoms, dextrose solution (prolotherapy) injections were given. Prolotherapy was given into the scapulothoracic bursa, levator scapulae, and rhomboid muscles using ultrasound. After treatment, the VAS score was 5 at 1 hour. On Day 1 and at one week, the VAS score was indicated as 1, when she did overhead motion. Crepitus without sound was felt between 120° to 180° shoulder abduction. There was no tenderness with palpation of the previously sensitive areas.
The clinicians summarized: “In a systematic review, dextrose prolotherapy was found to be effective in chronic musculoskeletal conditions, particularly tendinopathies and osteoarthritis after three to six months of treatment. (11 that is a peer-reviewed study from our office).” In this case, the clinicians found an early improvement in pain, and the pain reduction was 50% (VAS decreased from 10 to 5) at 1 hour.
In our published research in the Journal of Prolotherapy, we described a case study of a 31 year-old-female patient in our article: Treatment of Joint Hypermobility Syndrome, Including Ehlers-Danlos Syndrome, with Hackett-Hemwall Prolotherapy.
The patient came in at the suggestion of her osteopathic doctor because of the diminishing benefits manipulation was having on her pain.
The patient stated that she “has always had loose joints” and for most of her adult life has needed either chiropractic or osteopathic care to function. Her significant pain started 10 years earlier while on the rowing team at college. Her primary pain was located in the left T1-T4 (thoracic spine) area and left shoulder. A previous MRI of the thoracic area was read as normal. She had tried acupuncture, electrical stimulation, physical therapy, and various medications and manual therapies without lasting relief.
On physical examination, she had noticeable ligament laxity in multiple thoracic/rib junctions (costovertebral), and her left shoulder was easily dislocated.
At the initial visit, dextrose Prolotherapy was given to her left thoracic facets and costovertebral junctions. When seen one month later, she felt 40% better, and another Prolotherapy treatment was given to the same area. She was not seen again for several months and felt her thoracic pain didn’t need treatment anymore but she wanted to start treatment for her left shoulder instability.
The patient did not return for one year because of the resolution of her thoracic and shoulder pain with the previous Prolotherapy treatments. Her return visit surrounded hip pain.
Summary and can we help you?
Snapping syndromes in the body, including the scapula, are due to underlying joint instability. The scapula lies over the ribs and helps make up the shoulder joint. In snapping scapula syndrome, the snapping occurs as the muscles that move the shoulder joint contract against an unstable base and allow the scapula to rub against the ribs. The problem is not due to muscle weakness, but rather, instability. This joint instability can occur where the ribs attach to the thoracic spine, causing a rib to stick out too far. Ot the instability can occur in the shoulder joint, such as from a labral tear or overstretched glenohumeral ligaments. For those with snapping scapula syndrome, once the instability is identified, Prolotherapy injections can provide good treatment outcomes.
If you have questions and would like to discuss your scapula pain issues with our staff you can get help and information from us.
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This article was updated February 14, 2024