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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00782-9
10.1016/j.radcr.2024.07.189
Case Report
Spontaneous stress fracture of scapular spine associated with rotator cuff tendinopathy: A rare complication in an elderly patient
Baashar Abdulrahman MD Baashar10.a@gmail.com
⁎
Alsalman Hashim MD
Alsalman Mohammed MD
Al Rehaily Haniyya MD
Alzahrani Ahmed MD
King Abdulaziz Medical City, Riyadh, Saudi Arabia
⁎ Corresponding author. Baashar10.a@gmail.com
02 9 2024
11 2024
02 9 2024
19 11 54195423
22 6 2024
30 7 2024
31 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Spontaneous stress fracture of the scapular spine associated with rotator cuff tendinopathy is a rare complication in an elderly patient. Rotator cuff tendinopathy is a common condition characterized by degeneration and inflammation of the rotator cuff tendons. On the other hand, stress fractures are small cracks or breaks in bones that occur in response to repetitive or excessive mechanical loading. We present a rare case of a 79-year-old female patient complaining of persistent right shoulder pain that was unresponsive to medication which worsened in the last week and associated with a limited range of motion and inability to raise her arms above her head. Imaging studies revealed a nondisplaced fracture involving the mid-aspect of the scapular spine with surrounding callus formation and adjacent reactive changes. Stress fractures are often observed in weight-bearing bones, but they can also occur in non-weight bearing bones like the scapular spine. The association between rotator cuff tendinopathy and stress fractures of the scapular spine is uncommon and not well-documented in the literature. The biomechanics of the shoulder joint and altered force transmission due to rotator cuff pathology may contribute to the development of stress fractures. This case highlights the need to consider uncommon complications, such as stress fractures, in patients with shoulder pain. A comprehensive approach and early recognition of rare complications can guide appropriate diagnostic and treatment strategies to prevent potential complications and optimize patient outcomes.

Keywords

Spontaneous
Stress Fracture
Scapular Spine
Rotator Cuff Tendinopathy
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pmcIntroduction

The rotator cuff is a group of 4 muscles and their tendons including supraspinatus, infraspinatus, teres minor, and subscapularis which surround the shoulder joint, providing strength and stability. The rotator cuff stabilizes the shoulder joint and allows for smooth and coordinated arm movement. These muscles work together to support the shoulder during overhead movements, such as reaching, lifting, and throwing. The rotator cuff can become injured or strained due to overuse, trauma, or aging, resulting in pain, weakness, and limited mobility in the shoulder [1].

Rotator cuff tendinopathy refers to a spectrum of degenerative conditions affecting the shoulder rotator cuff muscles and tendons. It is commonly characterized by pain, weakness, and restricted range of motion in the shoulder joint. Risk factors for rotator cuff tendinopathy include repetitive overhead activities, aging, trauma, and underlying systemic conditions such as diabetes and thyroid disorders [2]. If left untreated, rotator cuff tendinopathy can progress to partial or full-thickness tears of the rotator cuff tendons, leading to significant functional impairment and pain.

Complications of untreated rotator cuff tendinopathy include the development of rotator cuff tears, joint instability, and subacromial impingement syndrome. These complications can further exacerbate pain and disability in affected individuals. Shoulder pain is the hallmark of rotator cuff tendinopathy and is often exacerbated by movement or overhead activities [3]. Imaging modalities such as MRI can help diagnose and assess the extent of rotator cuff pathology.

Stress fractures, on the other hand, are defined as small cracks or breaks in bones that occur in response to repetitive or excessive mechanical loading. They are commonly observed in weight-bearing bones such as the tibia, metatarsals, and femur. However, stress fractures in non-weight bearing bones like the scapular spine are relatively rare and often attributed to underlying pathology or mechanical stressors [4].

The association between rotator cuff tendinopathy and stress fractures of the scapular spine is uncommon and not well-documented in the literature. The scapular spine, a thin bony ridge on the dorsal surface of the scapular, is subjected to forces transmitted through the rotator cuff tendons during shoulder movement. Chronic rotator cuff tendinopathy or tears, osteoporosis or alterations in the biomechanics of the shoulder joint can lead to increased strain on the scapular spine, potentially predisposing it to stress fractures [5].

Due to the rarity of stress fractures of the scapular spine and their association with rotator cuff pathology, there is a limited understanding of the diagnostic challenges and management strategies for such cases. Recognizing this unique association and its implications for patient care is crucial in the evaluation and treatment of individuals presenting with shoulder pain and dysfunction associated with rotator cuff tendinopathy.

Case presentation

Patient: A 79-year-old female patient presented to the orthopedics clinic with a chief complaint of persistent right shoulder pain that had been unresponsive to medication for several months. Over the past week, the pain had worsened, and she reported difficulty performing daily activities such as dressing and grooming due to limited range of motion. She was unable to raise her arms above her head without significant discomfort. The patient denied any history of trauma or recent injury to the shoulder. On physical examination, the patient had a limited range of motion in the right shoulder joint with significant pain limiting full shoulder examination. The patient's medical history included hypertension, hyperlipidemia, and diabetes, but no prior shoulder-related complaints. The patient underwent multiple imaging studies, including plain radiographs, CT, and MRI of the shoulder to further elucidate the nature of the patient's symptoms. The plain radiographs and CT imaging findings revealed a nondisplaced fracture involving the mid-aspect of the scapula spine, characterized by surrounding callus formation and adjacent reactive changes (Fig. 1). Furthermore, MRI studies disclosed chronic massive rotator cuff tears with significant structural damage evident in 3 out of the 4 rotator cuff tendons. Specifically, a complete tear of the supraspinatus tendon with medial retraction, the tear is extending into the anterior one-third of the infraspinatus tendon, accompanied by mild to moderate loss of muscle volume. Additionally, a complete tear of the subscapularis tendon was identified, with medial retraction associated with severe atrophy of the subscapularis muscle (Fig. 2). These imaging findings provided crucial information for understanding the complex pathophysiology underlying the patient's symptoms and informed our treatment approach. The diagnosis of a spontaneous stress fracture of the scapular spine associated with rotator cuff tendinopathy was made. Regular follow-up appointments were scheduled to monitor symptom progression, range of motion, and radiological healing of the stress fracture. The combination of these 2 conditions suggest a potential biomechanical interplay between the rotator cuff pathology and the stress fracture, highlighting the importance of addressing both issues in the management of the patient's shoulder symptoms. This association underscores the complexity of shoulder pain presentations in elderly patients with osteoporosis and underlying rotator cuff issues, emphasizing the need for a multidisciplinary approach to treatment as well as comprehensive evaluation to identify and treat all contributing factors.Fig. 1 Two-view right shoulder radiograph (A and B) and CT scan (C) were performed and showed a nondisplaced fracture involving the mid-aspect of the scapula spine with callus formation and adjacent reactive changes (white arrows).

Fig 1

Fig. 2 (A and B) Sagittal STIR and coronal STIR MR images show the fracture at the scapular spine with callus formation and significant reactive bone marrow edema and mild soft tissue edematous thickening (white arrows). Coronal STIR image at the level of the supraspinatus tendon (blue arrow) reveals a complete supraspinatus tendon tear with medial retraction (C). (D) Sagittal STIR image demonstrates a complete tear involving the subscapularis tendon with medial retraction (red arrow).

Fig 2

Discussion

Stress fractures, a common overuse injury often seen in athletes and military personnel, result from repetitive microtrauma exceeding the bone's ability to repair itself, leading to the propagation of a fracture line. Several intrinsic and extrinsic predisposing factors can contribute to the development of stress fractures, including biomechanical issues, hormonal imbalances, nutritional deficiencies, and training errors. Understanding the pathophysiology of stress fractures is essential in recognizing individuals at risk and implementing preventive measures to reduce the incidence of these injuries [6]. By addressing underlying predisposing factors and modifying training regimens, healthcare providers can help athletes and active individuals minimize the risk of stress fractures and optimize bone health.

Rotator cuff tendinopathy is a common shoulder condition characterized by degeneration, inflammation, and mechanical impingement of the rotator cuff tendons. The repetitive overhead movements and abnormal biomechanics associated with rotator cuff tendinopathy can lead to altered force transmission and loading patterns on the shoulder complex, potentially affecting the adjacent structures. In the context of scapular spine stress fractures, the altered biomechanics and increased stress placed on the scapula's bony structures due to rotator cuff pathology may contribute to the development of stress fractures [7]. This suggests a potential mechanistic link between rotator cuff tendinopathy and scapular spine stress fractures, highlighting the importance of effectively addressing both soft tissue and bony abnormalities in managing shoulder pain and dysfunction. Further research is needed to elucidate the precise mechanisms underlying this relationship and guide targeted treatment strategies for individuals with concurrent rotator cuff tendinopathy and scapular spine stress fractures (Fig. 3).Fig. 3 (A and B) Coronal and axial T1 weighted MR images demonstrate mild to moderate loss of supraspinatus muscle volume with fatty infiltration (yellow arrows) as well as severe atrophy of the subscapularis muscle (white arrows).

Fig 3

A literature review of similar cases has shown varying outcomes in individuals with concurrent rotator cuff tendinopathy and stress fractures in the scapular spine [8,9]. While some studies report successful outcomes with conservative management strategies such as rest, physical therapy, and activity modification, others suggest the need for surgical intervention in refractory cases [9,10]. Moreover, diagnostic challenges often arise in the evaluation of shoulder pain in patients with rotator cuff disease, as symptoms of tendinopathy may overlap with those of stress fractures, leading to potential delays in diagnosis and treatment. It's important for the radiologist to be aware of this uncommon entity when reading X-rays, CTs and MRIs of the shoulder joint for patients who fall in this category. Healthcare providers should therefore consider a comprehensive approach to assessment, including a thorough clinical examination, imaging studies, and possibly referral to a specialist for further evaluation, to accurately diagnose and effectively manage shoulder pain in this patient population. Emphasizing the importance of early recognition of rare complications to prevent potential complications and optimize patient outcomes.

Conclusion

In conclusion, this case highlights the importance of considering uncommon complications in patients presenting with shoulder pain. Radiologists must be aware of this entity while reading shoulder X-rays, CTs, and MRIs with massive rotator cuff tears. Understanding the pathophysiology of stress fractures, predisposing factors, and biomechanical implications of rotator cuff tendinopathy is crucial for effective management. By recognizing these coexisting conditions promptly, healthcare providers can improve outcomes and optimize patient care.

Patient consent

I hereby confirm that written, informed consent for the publication of this patient case was obtained from the patient. The patient has thoroughly reviewed the details of their case, understands the implications of publication, and has granted explicit permission for their information to be included in this report. This consent ensures that the patient's rights and privacy have been respected and safeguarded throughout the publication process.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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