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Musculoskeletal clinical topic of the month – Scapular Injuries

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

scapular injuries Musculoskeletal clinical topic of the month - Scapular Injuries

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

Scapular Injuries 1 Musculoskeletal clinical topic of the month - Scapular Injuries

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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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.