Author's Reply

Article Outline

• Reference
• Copyright

We appreciate the letter from Dr. Kibler regarding our article, “The Snapping Scapula: Diagnosis and Treatment.”¹ First, we would certainly like to acknowledge that Dr. Kibler is a world-recognized expert in the treatment of conditions affecting the scapula. He brings out some excellent points, and we believe that his comments should serve as an important supplement to some of our topics that were discussed in the article. We should point out that we were unable to provide an exhaustive review on the topic because of space constraints of the journal, and we believe that his points are important aspects that were not intentionally ignored. We agree with him that an understanding of the biomechanical function of the scapula is important to consider, especially coordinated muscular motion, as well as the importance of anterior/posterior tilting in the development of the bursitis associated with snapping scapula syndrome. Posterior tilt and the corrective measures that he has described are important aspects of understanding the pathophysiology and eventual treatment of the disorder, although the basis of this understanding is Level V expert opinion.

In our treatment recommendations, we recommend an extensive trial of nonoperative care and emphasized this in the article, although we are unaware of any publication that clearly defines the most effective nonoperative treatment, the expected outcome of this treatment, and the duration of treatment that is generally indicated for the management of this condition. It is our opinion that nonoperative care is the mainstay of treatment; however, as we both suggested, operative treatment should be considered earlier if there is an underlying anatomic abnormality (osteochondroma and so on). We also addressed the issue of anterior tilt with a tight pectoralis minor and outlined the nonoperative care for this. Again, this is based on our personal experience supported by published expert opinion, not a well-controlled clinical trial.

In terms of surgical treatment, it is our opinion that operative intervention should be considered if the patient continues to have significant disability in his or her daily life after a trial of appropriate and patient-directed therapy addressing the underlying cause of the problem. Arthroscopic bursal resection for recalcitrant cases is the mainstay of our surgical treatment and is why we believed this article was appropriate for Arthroscopy. In terms of bone resection, we provided a review of prior open surgical techniques that have recommended bone resection and muscle reattachment. In theory, we are certainly in agreement with Dr. Kibler's assessment that the anatomy should be preserved as much as possible, and we presented the open techniques from what has historically been published in the literature. We are unaware of any studies that have documented clinical outcome differences with open versus arthroscopic treatment. We are also unaware of any study that shows a high failure rate of muscle reattachment after bone resection, and we are unaware of any study that documents a permanent superior position of the scapula after bone resection and muscle reattachment. We agree that all treatments for snapping scapula syndrome—both nonoperative and operative—should be individualized and tailored to each patient.

We would like to thank Dr. Kibler for both his constructive and instructive comments. His letter has served to highlight the complexity of this problem and the fact that additional well-designed clinical studies are necessary to define optimal diagnosis and treatment strategies.

Back to Article Outline

Reference 

1. Kuhne M, Boniquit N, Ghodadra N, Romeo A, Provencher M. The snapping scapula: Diagnosis and treatment. Arthroscopy. 2009;25:1298–1311
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (2372 KB)
   • CrossRef