Rare Cause Of Scapular Crepitus And Clicking In A Golfer

Abstract

TITLE: Rare cause of scapular crepitus and clicking in a golfer AUTHORS: Isaac Sada, Kenneth Vitale MD FACSM HISTORY: An 81-year old male avid golfer and swimmer presented with chronic right posterior shoulder pain and a sensation of clicking/popping. PHYSICAL EXAMINATION: Examination of the shoulder was unremarkable during rotator cuff and labral assessment, no loss of glenohumeral ROM. Palpable snapping over the medial scapula during range of motion. Normal neurovascular exam. No periscapular atrophy or gross winging. DIFFERENTIAL DIAGNOSIS: Subclinical scapular winging, scapular dyskinesis, rib subluxation, snapping scapula syndrome TEST AND RESULTS: X-rays of the shoulder were unremarkable. Due to continued symptoms, MRI was obtained and showed an osseous prominence of the right scapular medial border consistent with tubercles of Luschka, resulting in pseudo-articulation with the ribs and a scapulothoracic bursitis. Upon review of a prior chest CT for unrelated pulmonary assessment, tubercles and pseudoarticulation were apparent. FINAL WORKING DIAGNOSIS: Snapping scapula syndrome due to Tubercles of Luschka. TREATMENT AND OUTCOMES: Patient received physical therapy and was educated on importance of activity modification. The tubercles of Luschka are a rare radiological finding which can result in pseudoarticulation with the ribs, a painful clicking/snapping, and scapulothoracic bursitis. The patient did not want surgery or injections; with physical therapy he was able to maximize his shoulder range of motion and strength and return to golf and swimming with a reduction in symptoms. This case illustrates importance of proper awareness of uncommon conditions in common locations to avoid missed diagnosis as in this case, as the tubercles were missed on a routine prior chest CT.