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Overview

The shoulder blade, otherwise referred to as the scapula in medicine, is a flat, triangle-shaped bone that connects the bone of the upper arm (humerus) with the collarbone (clavicle).

Pathology

A few injuries may be associated with the shoulder blade but because of its location, injuries to this bone are not common occurrences. Fractures of the shoulder blade are rare but if they occur then one should also consider chest trauma in these individuals. 

If an abnormally protruding shoulder blade is visualised, this may be indicative of paralysis of the serratus anterior muscle. This gives the appearance of a "winged scapula".

In the scenario where the shoulder blade fails to properly elevate the part of the shoulder known as the acromion, such as with a throwing action, shoulder impingement (impingement of the rotator muscle tendons) may occur. The reason this happens is due to an imbalance between the serratus anterior and lower trapezius muscles.

Shoulder impingement

During impingement syndrome, the tendons of the rotator cuff muscles become irritated and inflamed due to the motion of overhead throwing, as mentioned above.

The patient will then complain of symptoms such as:

  • A dull pain that is worsened with overhead throwing. The pain may worsen at night, especially if the patient lies on the problematic shoulder. The pain is also worse during forward elevation of the arm from 60 to 120 degrees.
  • Weakness or decreased power in the arm.
  • Decreased or limited range of motion of the affected shoulder due to the pain.
  • Popping or grinding noises or sensation during movement of the shoulder may also be experienced.
  • Pain can be elicited on examination of the shoulder when on passive movement, a downward force is applied to the joint. The pain improves once the pressure is removed.

The diagnosis of shoulder impingement is suspected on the history given by the patient and the clinical findings made on examination.

The examining doctor may also inject a steroid medication combined with lidocaine into the bursa of the joint and if there's decreased pain and an improvement in the range of motion in the shoulder then this is considered a positive 'impingement test'.

The diagnosis of the condition will be confirmed on radiological imaging of the shoulder. Ultrasound examination may show fluid buildup around the affected tendons and muscles but an MRI scan is the best investigation as this helps to differentiate between the different soft tissues in the shoulder.

Management of impingement syndrome is performed conservatively with:

  • Rest.
  • Oral pain medication such as anti-inflammatories like ibuprofen, diclofenac, or naproxen.
  • Physical therapy focusing on strengthening the shoulder and shoulder blade muscles, improving posture, and maintaining the range of motion of the shoulder.
  • Discontinuation of the activity causing the pain.
  • Therapeutic injections with the mentioned steroid and local anesthetic medications for persistent problems.

If these therapies are not effective enough then surgical intervention is warranted. Depending on the severity of the condition, surgery may either be performed arthroscopically (where small incisions are made in the shoulder and cameras and small instruments are used to visualise the joint and perform the procedure) or as open surgery.   

 

 

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