Clicking/snapping shoulder

What is Clicking/snapping shoulder?

A shoulder joint is the most mobile joint of the body. It comprises three bones clavicle (collar bone), scapula (shoulder blade) and humerus (upper arm bone). The bones are kept in their positions by a number of muscles, tendons, and ligaments that make the shoulder and the arm stable. The shoulder joint has a unique range of motion and is more prone to injuries and other ailments. Clicking or snapping shoulder is a condition in which clicking, grinding or snapping of the bones and tissues happen while lifting or moving the arm. There can be a number of ailments related to bones or muscles involved in this area. It may be present with or without pain and sound.

The causes of clicking /snapping shoulder are bursitis, inflamed tendons, incorrect posture, incorrect training techniques in sports like overtraining or training before strengthening, repetition of activities as done in overhead sports and contact sports, injuries in overhead or contact sports, neck conditions, muscle weakness or tightness, unhealed fractures of the involved bones or other shoulder joint problems.

In most cases the problem lies in the scapula-thoracic joint between shoulder blade (scapula) and rib cage. It’s also called a snapping scapula syndrome or washboard syndrome or Scapulo-costal syndrome. The snapping could be due to soft tissue (bursa, band etc) or bony (exostosis) problems. This syndrome is often misdiagnosed

 

What are the symptoms of Clicking/snapping shoulder?

A person with clicking or snapping shoulder feels grinding, snapping, grating or popping sensation usually associated with sound while lifting the arm. Pain may or may not be felt. If the pain is felt, it is centered to the top of the shoulder. A feeling of weakness in the arm is also common. The range of motion is also restricted. Deformity in the affected scapula (shoulder blade) can be visible in some patients.

 

How is it diagnosed?

Your orthopaedic surgeon can diagnose the condition after evaluation of your complete medical history, physical examination, and if needed X-ray.  X-ray is not necessary in every case and in some patients the surgeon may request computer tomography scan (CT) or a magnetic resonance imaging study (MRI) scan or both.

 

How is it treated?

The treatment relies on the identification of causative ailment of the shoulder causing the clicking and snapping shoulder. It can be easily treated by non-operative treatment.  Majority of them could be treated conservatively with rest, ice application, anti-inflammatory medicines, and physical therapy.

Surgery is indicated in

  • Selected cases with failed conservative treatment
  • Persistent bursitis with worsening of the symptoms
  • Exostosis, osteochondroma
  • Malunited fracture of rib/scapula
  • Secondary to Labral Tears, Rotator cuff tears
  • Nerve problems

 

What are the non-operative treatments?

Non-operative treatment aims to return to help the patient normal lifestyle activities and improve quality of life.  It involves the following-

  • Rest– resting the shoulder is necessary to reduce inflammation and enhance the healing process and prevent new injury. The patient is also encouraged to have Activity modification by avoiding overhead activities or any activity that can provoke pain.
  • Ice application– ice application over the affected area for 20-30 minutes twice or thrice a day helps to reduce pain.
  • Medications– anti-inflammatory medicines like aspirin and ibuprofen and painkillers like codeine or paracetamol may be given to relieve pain if present.
  • Physical exercises– is the first line of treatment and specific exercises are designed by your physiotherapist to improve your motion, restore normal functions of the shoulder, improve flexibility and improve strength. It begins with gentle exercises of the shoulder with passive exercises of arm, wrist, and hands. Stretching and strenuous exercises are introduced gradually to prevent stiffness and improve strength. The recovery can up to 6 months.
  • Steroid injections- if all the above methods fail, your surgeon will give you steroid injections. Cortisone (an anti-inflammatory medicine) is directly injected into the bursa to relieve swelling and pain. Its effect could be temporary and physical exercises should be continued with it to gain fruitful results.

 

What does the operation involve?

The main aim of surgery is to remove the inflamed part of the bursa and in some patients remove the bone hook and create sufficient space for the rotator cuff to glide without impinging on the surrounding structures.

The surgery can be done by arthroscopy or mini-open repair based on the pathology and surgeon’s preference.

  • The operation is done as a day case under general anaesthesia, an incision or cut is made on the skin to reach the affected site. Size of cut depends on the surgical technique adopted. The pathology (bursa, bone hook etc) is removed and the muscles/tendons are repaired back.
  • Stitching of the skin is done with the help of absorbable sutures and a sling is applied for 2-4 weeks. The surgical time is usually 1 to 2 hours and the patient is discharged on the same day.

 

What happens after surgery?

  • The effect of local anaesthesia ends in 4- 10 hours after surgery. The patients are encouraged to take painkillers before they can experience pain usually for 48 hours. In this way, many patients do not report pain.
  • The patient is discharged on the same day and advised to take rest and modify his activities based on the procedure (avoid overhead activities and any new injury). A sling is applied for 2 to 4 weeks to support healing.
  • Before discharge, the patient is taught set of gentle exercises of the shoulder. These exercises can be started from the day one after the surgery. These exercises are important to reduce stiffness and pain and restore strength and normal range of motion of the shoulder and arm.
  • Light activities like using a keyboard or writing are allowed if they don’t cause excessive pain or discomfort. Besides gentle range of movement exercises are started as tolerated by the patients without restrictions.
  • The patient is reviewed again after 2 weeks for the check of wound and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • Physical therapy is advised to ensure rehabilitation. Following subacromial decompression, patients are allowed to mobilise as tolerated without restrictions. Your physiotherapists and surgeon will guide you for the choice and duration of the exercises. The exercises are designed in such a way that you can regain the range of motion of the shoulder with the strength of the arm and also improve posture.

 

 Are there any risks?

  • Infections
  • Nerve damage
  • Damage to blood vessels
  • Persistent shoulder pain, weakness, clicking and stiffness
  • Frozen shoulder
  • Pneumothorax

 

What are the results of the operation?

Correct patient selection is the key and the results of surgery are good with minimum complications and it reduces pain, restores range of motion and strength.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take a little bit longer if your job involves physical work. You should be able to resume driving in 2-4 weeks. The above time line could vary based on the severity of problem and the treatment modality.  Your physician will be able to advise you.

Clicking or snapping shoulder

20 year old gentleman presented with snapping shoulder and the radiographs/CT scan demonstrates an exostosis (white arrow) between rib cage (Yellow arrow) and shoulder blade (Red arrow).

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