Some orthopedic patients arrive in Karan Dua, MD’s office after nearly every conventional avenue has been exhausted. They have had MRIs. CT scans. Electrodiagnostic testing. Physical therapy. They may have seen orthopedic surgeons, spine specialists or vascular physicians.
And sometimes, after years of pain or dysfunction, they still do not have an answer.
“Why do people come to me after a decade of pain?” Dr. Dua, an orthopedic surgeon specializing in shoulder and upper-extremity care at New York City-based NewYork-Presbyterian/Columbia University Irving Medical Center, told Becker’s.
For Dr. Dua, part of the answer lies in an area of orthopedics that remains difficult to define, diagnose and teach: disorders involving the scapula. He describes the field as a kind of “black box.”
“We’re still finding out the words,” he said. “We’re still defining them. It’s an evolving science.” Opening that box has become a focus of his practice. It starts with changing the language surgeons use to describe what they see.
When the diagnosis doesn’t fit the traditional shoulder
Orthopedic training has historically given surgeons a familiar framework for shoulder problems: rotator cuff pathology, instability and arthritis, among others.
Scapular disorders do not always fit neatly into those categories. Even “scapular winging,” the term traditionally used to describe abnormal prominence of the shoulder blade, does not capture the full spectrum of problems Dr. Dua sees.
He prefers a broader term: scapulothoracic abnormal motion, or STAM.
The distinction matters because STAM can have structural or functional causes. Structural problems can involve an identifiable issue with a muscle, tendon, nerve or bone. Traditional scapular winging caused by paralysis of muscles controlling the scapula falls into this category.
Functional STAM is different. The structures may be intact, but the muscles controlling the scapula may not work together normally.
Dr. Dua explains it to patients by comparing the shoulder to two people dancing. Imagine two partners who both know the steps perfectly but are listening to different songs. Individually, each knows how to dance. Together, their movements become uncoordinated.
The same can happen around the scapula.
“Most scapular winging, or what we call STAM, is a functional problem,” Dr. Dua said. “It’s an imbalance in how the muscles around the shoulder and scapula fire.”
That distinction can help explain why conventional testing does not always reveal the problem.
The patient with a normal MRI who still can’t get an answer
Many patients who reach Dr. Dua have already undergone extensive testing.
“They’ve had EMGs, MRIs, CT scans,” he said. “They’ve done physical therapy.”
Yet those studies may not reveal a clear explanation for their symptoms. That is where Dr. Dua believes the physical examination becomes critical. “I don’t think we’re as good at conducting a detailed physical examination when it comes to really understanding the scapula,” he said.
The scapula moves with the arm, and dysfunction may become more apparent when a clinician observes that motion, assists or repositions the scapula, or tests how the shoulder responds under resistance. Targeted diagnostic injections and studies such as EMG, MRI and ultrasound can provide additional information. But for Dr. Dua, they complement rather than replace the examination.
“The purest thing really is your physical exam,” he said.
The diagnostic challenge becomes greater because symptoms can cross traditional specialty boundaries. Numbness or tingling may suggest a nerve or vascular problem.
Shoulder pain may lead to an orthopedic evaluation. Mid-thoracic pain can raise questions about the spine. Some patients are evaluated for thoracic outlet syndrome.
The result can be a patient whose symptoms overlap several specialties but fit neatly into none. “It’s ping pong,” Dr. Dua said. “We just don’t know how to help them.”
One shoulder blade, several possible problems
A better understanding of scapular mechanics is also changing how Dr. Dua thinks about conditions that can overlap around the shoulder. One structure he considers particularly important is the pectoralis minor, a muscle at the front of the shoulder that attaches to the coracoid process.
He uses another simple analogy: a seesaw. If the pectoralis minor pulls the front of the scapula down, the back can tip outward. That altered position can contribute to abnormal scapular motion and, in some patients, symptoms associated with neurogenic thoracic outlet syndrome.
It can also contribute to friction around the scapula and the painful popping associated with snapping scapula syndrome. Nerve entrapments can further complicate the picture.
That is why Dr. Dua sees STAM not as a single diagnosis with a single operation, but as a framework for distinguishing different functional and structural problems involving scapular motion. The challenge is determining which mechanism is driving an individual patient’s symptoms.
Surgery is moving through smaller openings
Better understanding of those mechanisms is also expanding treatment options. Physical therapy remains Dr. Dua’s starting point for many patients, particularly those with functional problems. But he emphasizes that therapy should target scapular mechanics rather than simply be prescribed as generic shoulder physical therapy.
That can include periscapular strengthening, pectoralis minor stretching and scapular retraction.
For selected patients whose symptoms persist despite nonsurgical treatment, procedures that historically required larger open approaches can increasingly be performed arthroscopically. Dr. Dua performs arthroscopic pectoralis minor release and decompression around the brachial plexus in selected patients. Arthroscopic techniques can also be used to address snapping scapula syndrome and decompress nerves around the shoulder.
“A lot of scapular surgery, if you’re not doing a major tethering, scapulopexy or tendon transfer, can now be done with limited incisions,” he said.
Not every condition can be treated that way. Structural STAM may require more extensive reconstruction. Dr. Dua pointed to tendon transfers for certain muscle paralysis patterns and scapulopexy for selected cases.
The technical options are expanding. The harder questions are deciding when to operate, which patients are appropriate candidates and how to perform the procedure.
The next challenge is getting patients to the right door
For Dr. Dua, developing better treatment options solves only part of the problem. They cannot help a patient whose condition is never recognized.
He considers scapular care so specialized that some patients effectively require a referral beyond the traditional tertiary level, sometimes reaching him only after evaluation by other orthopedic subspecialists.
That is why he believes progress now depends heavily on education. Patients need language to understand that these disorders exist. Primary care physicians, advanced practice providers, physiatrists, pain physicians and orthopedic surgeons need to recognize when symptoms may warrant a more specialized evaluation.
And clinicians need a clearer roadmap for where those patients go next. “It’s almost like a grassroots movement to understand that these things exist, but that we also have ways to help,” Dr. Dua said.
His practice has drawn patients from other states and internationally. But improving access cannot depend solely on patients eventually finding a highly specialized provider after years of searching.
For Dr. Dua, it starts with giving clinicians a common vocabulary. STAM rather than reducing every abnormal scapular movement to “winging.” Functional versus structural. A more deliberate examination of scapular motion. Targeted physical therapy before escalating treatment.
The concepts may sound straightforward compared with the complexity of the operations that can follow. But that is precisely the point.
Before clinicians can determine how to treat these disorders, they first have to recognize and describe what they are seeing. For a part of the shoulder Dr. Dua still describes as a black box, opening it begins with knowing what is inside.
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