Physiotherapy for Snapping Scapula Syndrome: Exercises That Help

Snapping Scapula Syndrome also known as washboard syndrome or scapulothoracic crepitobursitis, is a condition characterized by audible or palpable crepitus, grinding or snapping sensations around the scapula during shoulder movement, often associated with pain or discomfort. It is linked to repetitive overhead activities (e.g., swimming, pitching, gymnastics, weightlifting).

 

Causes of Snapping Scapula Syndrome

• Bony abnormalities such as scapular dyskinesis or abnormal scapular contours.
• Luschka’s tubercle (hook-shaped extension on scapula’s superomedial border) or osteochondromas on the scapula.
• Inflammation or fibrosis of the bursae (scapulothoracic bursitis).
• Thickening of the soft tissues between the scapula and thoracic wall.
• Weakness or dysfunction of the serratus anterior, trapezius or rhomboid muscles, leading to poor scapular mechanics.
• Overhead activities or repetitive shoulder movements causing irritation of the scapulothoracic interface.
• Direct trauma to the scapular region.
• Post-surgical changes or scarring.
• Scoliosis or thoracic kyphosis altering scapular movement.
• Rib deformities or abnormalities in the thoracic cage.

 

Clinical Presentation

• audible or palpable crepitus
• localized pain around the scapula
• pain may radiate to the shoulder or upper back
• reduced shoulder range of motion
• tenderness around the scapulothoracic region, sometimes associated with bursitis
• fatigue or weakness of the shoulder girdle muscles, potentially affecting functional tasks
• sensation of catching or friction during scapular movement

 

Diagnosing Snapping Scapula Syndrome

Diagnosing Snapping Scapula Syndrome as a physiotherapist involves a thorough assessment, including history-taking, physical examination and functional testing. Here's the process:

Diagnostic Approach for Snapping Scapula Syndrome:

Plain Radiography

• Projections used are anterior-posterior, trans-scapular (scapular Y), and axillary.
• Used to evaluate anatomical features of the scapula and thoracic cage.

Computed Tomography (CT):

• Best for assessing bony morphology of the scapula.
• 3D CT is particularly useful for detecting subtle bony irregularities causing irritation.

Magnetic Resonance Imaging (MRI):

Preferred for evaluating soft tissue pathology, such as:

• Inflamed bursae.
• Potential soft tissue tumors.

Ultrasonography:

• Cost-effective alternative for differentiating scapulothoracic bursitis from other conditions (e.g., elastofibroma dorsi).
• Less commonly used but valuable for targeted assessments.

 

Differential Diagnosis

• Rotator cuff tendinopathy
• Subacromial impingement syndrome
• Scapular dyskinesis (secondary to other conditions)
• Brachial plexus neuropathy
• Thoracic outlet syndrome
• Glenohumeral joint instability
• Serratus anterior or trapezius muscle dysfunction
• Rib or thoracic spine dysfunction
• Subscapular bursitis
• Osteochondroma or scapular exostosis

Physiotherapy Management of Snapping Scapula Syndrome

The management approach is tailored to address inflammation, improve biomechanics, reduce pain and restore functional movement. Here's a detailed outline based on the mentioned interventions:

Modalities for Pain Management

Cryotherapy/Heat Packs

• Cryotherapy reduces acute inflammation and pain in irritated scapulothoracic tissues.
• Heat therapy promotes blood flow, relaxes muscles, and reduces chronic stiffness.

Therapeutic Ultrasound

• Deep heating modality to improve tissue extensibility and reduce pain in deeper layers of the scapulothoracic region.
• Focused on the superior angle of the scapula and surrounding tissues.

Diathermy

• Improves circulation and enhances soft tissue healing by providing deep heat through electromagnetic energy.
• Especially beneficial for chronic stiffness and tightness.

Electrical Stimulation (TENS/IFC)

• Alleviates pain and reduces muscle spasm.
• May be used during the acute or subacute stages.

Laser Therapy

• Stimulates cellular repair, reduces inflammation, and accelerates healing in irritated tissues.

Manual Therapy Techniques

Soft Tissue Massage of the Scapula

• Releases adhesions and reduces tension in the scapulothoracic and peri-scapular muscles.
• Enhances blood flow and improves tissue mobility.

Trigger Point Releases

• Focused on trigger points in the chest, neck and shoulder (e.g., pectoralis major/minor, levator scapulae).
• Reduces referred pain and improves flexibility.
• May involve ischemic compression or sustained pressure techniques.

Passive Mobilizations

• Passive motion of the scapula, arm, neck and shoulder to restore joint play and relieve stiffness.
• Includes rhythmic scapular retraction, protraction, elevation and depression.

Therapeutic Exercises

Strengthening Exercises:

Target muscles include serratus anterior, mid/lower trapezius, rhomboids, and rotator cuff muscles.

Exercises:

• Wall slides with scapular protraction.
• Prone Ys, Ts, and Ws.
• Serratus punches in supine or standing with resistance bands.
• External rotation with resistance bands.

Stretching Exercises

Target muscles include pectoralis major/minor, levator scapulae, upper trapezius, latissimus dorsi, subscapularis, sternocleidomastoid, rectus capitis, and scalene muscles.

Stretches include:

• Doorway stretch for pectoralis.
• Neck lateral flexion stretch for scalenes and levator scapulae.
• Overhead shoulder stretches for latissimus dorsi.
• Child's pose with scapular reach for subscapularis.

Posture Training

Postural Education

• Correct forward head posture, rounded shoulders and kyphotic tendencies.
• Incorporate ergonomic advice for workstation setup and daily activities.

Kinetic Chain Approach

• Assess and align the kinetic chain from head to pelvis.
• Focus on scapulothoracic rhythm and avoid compensatory movements during activities.

Adjunct Techniques

Kinesio-Taping:

• Provides proprioceptive feedback and supports scapular positioning during movement.
• Techniques to offload strained areas or facilitate weak muscles like the serratus anterior.

Progression and Maintenance

• Gradually progress from pain relief to strengthening and dynamic control exercises.
• Integrate functional exercises that mimic the patient’s daily activities.
• Maintain scapular mobility and muscle balance through a home exercise program.