Scapular Injuries in Sport
The scapular bone is often overlooked when it comes to diagnosing musculoskeletal pathology. The shoulder joint and ribs are much more commonly identified as sites or injury or upper limb pain.
Like most bone injuries, scapular injuries can broadly be categorised into 2 types; Traumatic and Non-Traumatic. This case presentation describes 2 cases, one from each category.
Traumatic Scapular Injury
Scapular fractures are usually associated with significant trauma via a direct or indirect mechanism. High-energy blunt trauma, such as those experienced in a motor vehicle collision or falling from a significant height, can cause a scapula fracture. There are often other major injuries accompanying scapular fractures such as shoulder, clavicle, ribs fractures or internal viscera damage e.g. head, lungs, or spinal cord.
One or more parts of the scapula may be fractured.
- Scapular body (50% to 60% of patients)
- Scapular neck (25% of patients)
- Glenoid
- Acromion
- Coracoid
When is this suspected, a full trauma screen is often required to ensure that is no internal organ compromise. These types of cases are best managed in the hospital setting.
Non-Traumatic Scapular Injury
Non-traumatic or stress fractures are much more uncommon. They typically occur in people performing high-stress activities that involve large volumes of force transmission through the scapular (e.g. throwing). In the sporting context, these include cricket, tennis and swimming.
Scapular stress fractures typically occur in the acromion or coracoid, where there are ligamentous and tendinous attachments. This causes a traction related stress phenomena from overuse. Scapular body stress are much rare and need a full biomechanical assessment to understand the force distribution throughout the scapular, upper limb and kinetic chain.
Case 1
Clinical history;
- 55 year old pain involved in motor bike accident whilst speedway racing in Greece
- Mechanism – Motorbike flipped over and landed on rider in high velocity crash
- Patient lost consciousness on impact
- Patient did not receive adequate track side care or immobilisation
- Self presented to A+E later on that day with trunk and rib pain
- X-ray of chest and ribs identified 2 rib fractures on right mid axillary line
- X-ray of shoulder report as normal with Rotator Cuff tear diagnosed (MRI or Ultrasound not performed)
- Given analgesia and sent home
Past Medical history;
- Previous trauma injuries to lower limbs from motorcycling
- Nil anti-coagulants
Exercise history;
- Avid motorcross and motorbike enthusiast
- Participated in occasional strength and conditioning and gym routines
Further context;
- On return to UK 2 weeks later, presented to LBSM with ongoing rib pain and right shoulder pain
- Examination revealed pain localised to spine of scapular and loss of shoulder abduction power in scapular plane
- Ultrasound in clinic shows spine of scapular fracture and partial supraspinatus tear
Imaging
Left image – Ultrasound scan in clinic showing spine of scapular fracture with surrounding haematoma
Middle image – MRI saggital sequence showing oedema throughout the spine of the scapular and surrounding muscle oedemea
Right image – MRI axial sequence imaging shows fracture line through spine of scapular and bone oedema
Diagnosis
Scapular fracture along the spine from blunt trauma. Accompanying partial thickness rotator cuff tear.
Management
Medical management and rehabilitation
- Patient placed in collar and cuff for 6 weeks for relative immobilisation to aid fracture healing and for pain relief
- Daily shoulder exercises for rotator cuff activation to help with tear healing
- Ongoing lower body training open chain exercises e.g. seated knee extensions, static bike
- Rescan with x-ray in 8 weeks to confirm bony union of fracture
Patient Self monitoring tools
- LBSM pain and symptom diary
- LBSM load monitoring diary
Case 2
Clinical history;
- 31-year-old man presented to LBSM with a 6 week history of right sided chest pain
- Pain worse on deep breathing and certain movements including pushing with right arm
- Initially treated for chest infection by GP with antibiotics which did not resolve the pain
- Went to A+E who did x-ray of chest which reported normal and ruled out Pulmonary Embolus with normal D-Dimer
Past Medical history;
- Non-smoker
- Nil significant history
Exercise history;
- Very fit and active.
- Performs advanced callisthenic training, one hour daily.
Social history;
- Works as a lawyer in the city.
Clinical examination;
- On initial examination, tenderness medial border of scapular and lateral ribs on right side
- Pain on Serratus Anterior activation on push up testing
- Good thoracic spine mobility maintained
Next steps;
- Rib stress injury suspected so MRI thoracic cage requested
Imaging
Top image – MRI axial sequence showing oedema throughout the medial border of the scapular and surrounding muscle oedema in Serratus Anterior
Bottom image – MRI imaging with Coronal view showing oedema throughout the medial border of the scapular and surrounding muscle oedema and presence of a fracture line
Diagnosis
Scapular body stress injury (with hairline fracture) along the medial border of the scapular, due to excessive traction from Serratus Anterior muscle/tendon.
Management
Rehabilitation
- Patient allowed to continue heavily modified calisthenic workout, removing excessively intense upper limb holds (e.g. human flag, muscle ups)
- Change in duration and volume of workouts
- Gentle Serratus Anterior activation drills (not into pain) with bands
- Rest days incorporated into week training volume
Medical
- Optimisation of bone health
- Rescan MRI at 8 weeks with graduated return to high loading
- Muscle stimulation (Compex) targeted to medial border of scapular and serratus anterior muscle
- Calorie and nutritional intake optimise
- Sleep hygiene optimise, referred for sleep counselling
Patient Self monitoring tools
- LBSM pain and symptom diary
- LBSM load monitoring diary
Key Summary – Scapular Injury
- Scapular injury should be considered as a differential for posterior lateral chest wall/rib pain and shoulder injury
- The scapular should be fully assessed when assessing traumatic and non-traumatic shoulder injury
- If traumatic scapular injury is found, a full trauma work up is required
- The scapular is vulnerable to stress and overuse injury, particular around the acriomion and coracoid due to their tendinous insertions
- Scapular body stress injury is much less common but should also be considered
- When performing imaging of the scapular (e.g. x-ray,MRI), specific scapular view fields are required.
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