Purpose: To help the clinician recognize and successfully treat this condition. Scapulocostal bursitis is often overlooked or misdiagnosed. History, examination and treatment of this condition will be outlined. Properly treated, this condition responds favorably to conservative chiropractic management.
Anatomy: An understanding of the anatomy and physiology of the scapulothoracic articulation is required to understand the pathogenesis of scapulothoracic disorders. The scapula is a triangular-shaped bone articulating with the posterior thorax. It is attached to the axial skeleton by only the acromioclavicular joint, and therefore its stability is dependent on surrounding musculature.
The periscapular musculature creates stability of the scapulothoracic articulation. The levator scapulae and rhomboids attach to the medial border of the scapula, whereas the subscapularis is on its anterior surface. (1)
The serratus anterior originates on the ribs and inserts on the medial scapular anterior surface. A cushion between the scapula and the thoracic wall is created by the serratus anterior and the subscapularis. Two spaces, the subscapularis space and the serratus anterior space, are created by the musculature of the joint. The serratus anterior space is located between the chest wall, serratus anterior, and rhomboids. The subscapularis space is bounded by the serratus anterior, subscapularis, and axilla. Three muscles of the rotator cuff originate at the scapula: the supraspinatus and the infraspinatus on the posterior surface of the scapula and the subscapularis on the anterior surface. (4) Seventeen muscles have their origin or insertion on the scapula making it the command center for coordinated upper extremity activity. A number of muscles secure the scapula to the thorax, including the rhomboids major and minor, the levator scapula, serratus anterior, trapezius, omohyoid and pectoralis minor. (3, 9)
There are several important neurovascular structures surrounding the scapula. The accessory nerve goes through the levator scapulae muscle near the superomedial angle of the scapula and runs along the medial scapular border deep to the trapezius muscle. The transverse cervical artery branches into the dorsal scapular artery (deep branch) and a superficial branch that travels with the accessory nerve. The dorsal scapular artery travels with the dorsal scapular nerve 1 cm medial to the medial border of the scapula. They pierce the scalenus medius and travel deep to the rhomboid major and minor. The nerve innervates both of these structures. The long thoracic nerve is located on the surface of the serratus anterior. The suprascapular nerve and artery pass toward the suprascapular notch on the superior scapular border medial to the base of the coracoid.
Several scapular bursae have been implicated in the development of scapular bursitis, which can lead to pain and snapping. Bursae are located in areas of friction and are potential spaces lined by a synovial membrane. Two major bursae are found consistently in patients: the infraserratus bursa located between the serratus anterior and the chest wall and the supraserratus bursa located between the subscapularis and serratus anterior. (3, 4, 9) Scapulothoracic movements are of a gliding nature and occur at an interface between the ventral surface of the scapula and the rib cage. The contacting surfaces involve the subscapularis and bare areas of the scapula with the serratus anterior overlying the second through seventh ribs. Normally the scapula is set obliquely on the thorax at an angle of 30°. (6)
Methods: A 36-year-old Caucasian female presented for care and treatment of chronic upper back pain and a burning sensation in the area. It had been getting more intense and frequent over the past two years. She had increasing upper posterior arm pain that did not radiate below the elbow and an ache just below the clavicle and adjacent to the humeral head. Imaging studies read by a chiropractic radiologist of the neck and thoracic spine revealed spondylosis at C5-C6 and C6-C7 with moderate disc space narrowing at C5-C6. She had a slight right dorsal scoliosis. The upper lung field on the left was negative.
The patient was treated with active chiropractic manipulative therapy (CMT) at C6 and T5. Ultrasound and EMS was applied to the upper back and scapulocostal bursa. Elastikon tape was placed over the left scapula. Cryotherapy was outlined for self-care. Exercises were given to the patient when the acute phase subsided. Visual analog scale (VAS) was used to measure her response.
Results: The patient presented with classic scapulocostal bursitis. She responded to the treatment and was pain-free for the first time in two years. She received active CMT to the lower neck and upper back. In addition, ultrasound was applied to the bursa area and EMS to the lower cervical and mid-thoracic paraspinals. Elastikon tape was applied twice during the treatment. Cryotherapy was used for the first 48 hours and then discontinued. Upper thoracic stretches and lower cervical exercises were given after the second visit. She was treated a total of four sessions.
The presenting complaints were treated for numerous diagnostic presentations prior to admittance to this treatment facility. This included the following: "pinched nerve", muscle spasms, subluxations and muscle strain. Obtaining a thorough history and understanding her job requirements were instrumental in arriving at the causation of her complaints.
Background: This condition is not well understood and should be considered in any presentation of lower neck, upper back pain, paresthesias medial to the scapula, anterior and posterior shoulder discomfort without range of motion restriction and upper extremity pain that does not radiate below the elbow (2).
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