Scapular stress fracture in a professional cricketer and a review of the literature

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May 2005, Vol. 95, No. 5 SAMJ
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Although stress fractures are well described in certain areas of
the skeleton, e.g. the tibia, we believe a case of scapular stress
fracture in a cricketer has not been described previously. This
article describes such a case, illustrating the clinical course and
the radiological investigations used to diagnose this rare
problem.
A 21-year-old professional cricketer presented with
atraumatic right shoulder pain. He was a right-hand-dominant
fast bowler. He reported several weeks of night pain but no
history of morning stiffness or other generalised symptoms.
Towards the end of a season of English county cricket that had
run on immediately following a season in South Africa he
developed an acute exacerbation of the shoulder pain severe
enough to cause him to retire from a match. The injury had
been treated as a possible teres minor strain by a club
physiotherapist for a period of 3 weeks with no success and the
pain continued, causing inability to bowl.
On presentation to us the cricketer was found to have
normal symmetry of the shoulders with no obvious wasting of
the periscapular muscles. The pain was well localised to the
posterolateral aspect of the shoulder and he was found to have
maximal tenderness over the upper aspect of the lateral border
of the scapula. He was noted to have what appeared to be a
mildly painful arc and pain on active external rotation,
although all active and passive movements were symmetrical.
He had no clinical signs of impingement or instability and
testing of the supraspinatus was pain free. However on power
testing of external rotation he was found to be mildly weak and
suffered moderate pain. At this stage teres minor pathology
remained a possibility but the presence of a stress fracture was
considered.
Preliminary plain films performed were originally reported
as normal, but following review showed an abnormality at the
lower aspect of the glenoid neck on the inferolateral border of
the scapula (Fig. 1).
The findings on plain films warranted further investigation
and subsequently a computed tomography (CT) scan was
performed (Figs 2a - c). This confirmed an area of intense new
bone formation associated with a lucent line travelling
superomedially across the inferolateral pillar of the scapula.
The appearances were typical of a stress fracture with no
insidious findings.
Scapular stress fracture in a professional cricketer and a
review of the literature
R V P de Villiers, M Pritchard, J de Beer, J Koenig
Dr R V P de Villiers is a radiologist in private practice with Van
Wageningen and Partners in Somerset West and Stellenbosch
Mediclinics. He is a consultant radiologist at the SA Sports
Science Institute and an honorary consultant at Tygerberg
Academic Hospital.
Dr M Pritchard is an orthopaedic surgeon currently attached to
the Cape Shoulder Institute as a research fellow.
Dr J de Beer is a specialist shoulder orthopaedic surgeon at the
Cape Shoulder Institute and an honorary consultant at Tygerberg
Academic Hospital. He is actively involved in research and has
spoken at numerous international congresses.
Dr J Koenig is a sports physician at the SA Sports Science
Institute and Stellenbosch Mediclinic.
Fig. 1. Plain film showing a fracture of the lateral scapular border.
CLINICAL IMAGES
Corresponding author: R V P de Villiers (rmldev@mweb.co.za)

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An additional magnetic resonance image (MRI) of the
scapula demonstrated bone marrow and soft-tissue oedema,
which confirmed the stress fracture (Fig. 3).
The diagnosis was discussed with the patient and in view
of the fact that his symptoms had begun to improve following
a period of rest, a conservative management plan was decided
upon. After approximately 2 months of rest the cricketer has
now returned to full competition and has had complete
resolution of symptoms.
May 2005, Vol. 95, No. 5 SAMJ
Fig. 2b. CT scan of the scapula, coronal multiplanar reconstruction,
showing a stress fracture of the scapular blade. Note the fracture line
and surrounding sclerosis.
Fig. 2c. 3D reconstruction of the scapular stress fracture. Note the
close proximity of the stress fracture (white arrow) and the nutrient
foramen (black arrow).
Fig. 3. MRI scan showing the scapular stress fracture. An axial
STIR image shows bone marrow oedema of the surrounding bone
marrow as well as surrounding soft-tissue oedema.
Fig. 2a. CT scan of the scapula showing a stress fracture. The axial
image shows an exuberant callus at the fracture site.

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Discussion
Scapular fractures are uncommon, accounting for less than 1%
of all fractures, and are normally associated with high-impact
injury.
1-3
The commonest form of trauma is as a result of road
traffic accidents but scapular fractures have been described in
sportsmen.
4,5
Acute scapular fractures have also been reported
in so-called low-trauma, indirect electrical injuries.
6,7
The
proposed mechanism behind these electrical injuries is muscle
tetany, leading to forces greater than the maximum failure
stress of the scapula. Other unusual fractures described are
avulsion fractures
8,9
due to injuries and fractures due to sudden
strenuous exercise.
10
Stress fractures are well described in the
sporting population, the commonest sites being the lower limb
such as the foot,
11-13
tibia
14
and femur.
15,16
However the upper
limbs are not immune to stress fractures with reports in the
clavicle,
17,18
ulna,
19
humerus
20
and olecranon.
21
These occurred in
gymnasts, polo players, bodybuilders and throwers
respectively. Other sites that can be affected are the sacrum
22
and lumbar spine.
23,24
Stress fractures of the scapula are
extremely rare and we are aware of only 4 cases described in
the literature. The first of these was a 30-year-old jogger
25
who
had recently begun using hand weights. The second was a
39-year-old assembly worker,
26
the third a 68-year-old
27
using
crutches after knee arthroplasty, and the last an above-knee
amputee ambulating on crutches.
26
Except for the stress fracture
in the jogger we could find no reports of scapular stress
fractures in active sports people. The fracture in the jogger was
in the upper border in the supraspinous fossa.
Our case in the professional cricketer occurred following an
extended season. The professional nature of sport together with
the ease of long-distance travel will undoubtedly lead to
sportspeople having an extended, if not year-round, season
and it is possible that we may see an increase in this type of
pathology. The repetitive nature of bowling obviously puts
unusual stresses on the scapula. In our case the fracture
occurred along the lower border of the neck/body junction; it
may be that the anatomy of this area, including muscle origins,
may predispose it to stress fractures. It is important to note that
the diagnosis of a stress fracture was made on the basis of
clinical history and radiological investigation. There were no
insidious radiological findings and nothing of note in the past
medical history. Stress fractures have been related to
underlying pathology such as inflammatory arthropathy
28
and
also metabolic and hormonal disturbance in female athletes.
29
Other pathology such as osteoid osteoma is in the radiological
differential
30,31
but with appropriate imaging this can be

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excluded. While non-union is a recognised complication of
stress fractures,
32
we are confident that in our patient resolution
of symptoms indicates that the fracture has healed and there is
no immediate need for follow-up investigation.
We have described the first case of stress fracture in a
cricketer. It is important to rule out other pathology and causes
of shoulder pain; we feel this can be done with appropriate
clinical and radiological evaluation. It is possible to treat such
cases conservatively with rest.
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