Question about Scapular Muscle Dysfunction

[mtomaino]

I recently received this email on www.drtomaino.com regarding severe scapular winging, and would like to respond:

Dr. Tomaino, I would like to know your opinion on a condition I was diagnosed with. In November 2011 after 5 years of dealing with a VERY painful shoulder condition that 9 doctors couldn\'t figure out, I was diagnosed with Spinal Nerve Palsy and secondary Scapular palsy. I was told by the doctor that diagnosed me that because I had the condition for so long that I would have to have the Eden-Lange proceedure done but he thought that because it had be over 6 years since initial onset, that it probably wouldn\'t do any good. He said that there was only a few doctors that would touch me because it is so severe and the fact that it could have something to do with my brain stem and long thoracic nerve. I would like to know you honest opinion. I am in so much pain that I can\'t take it anymore! My right shoulder is almost 5\" lower than my left - I have VERY severe decreased function in my right arm. My right scapula sticks almost straight out like a chicken wing. I am having a hard time doing just simple task. My right hand is purple at times. My shoulder joint pops violently - both as a spasm and sometimes I have to move my arm because the joint and shoulder blade get stuck and if I don\'t move my arm around and pop it back to where it should be the pain doubles. My father has to adjust my shoulder often to get the pain to go down. I was put on pain meds because I failed the initial consult for pain management. I now live in the worst pain you can imagine daily. Some days are worse than others. Some days aren\'t too bad but I pay for it the following days. I also get a knot underneath my arm in my arm pit and part in my chest that appears from time to time and it is EXTREMELY painful I don\'t know what it is and none of the doctors I have been to know what it is either. I was told the function numbers are all 0/5 and I was told that there is nothing that can be done because of the time from onset. I was told that this doctor he wanted me to see - Dr. xxxxx, would probably not agree to see me and probably wouldn\'t touch me because of the severity of it. So what I would like to know, what is your professional opinion? I don\'t have a lot of money and I have to live with my parents. I have insurance but I don\'t have a doctor around here that seems to be able to give me an answer or a solution. Thank you so much for your time

Thank you for your question. I am sorry you are in so much pain. It sounds as though you have severe scapular winging, which appears to be the result of a generalized neuritis---that is---you have not had a traumatic injury/laceration to either the long thoracic or spinal accessory nerve. This sounds as though the trapezius muscle, and possibly the serratus anterior muscle are involved. I have had to address thi problem in the past after a gentleman suffered a permanent complex palsy after cardiac surgery--felt secondary to nerve traction during the procedure.

Although the Eden Lange procedure has provided a reasonable functional outcome for isolated trapezial palsy (by transferring the levator scapulae and rhomboid muscles more laterally) your problem may also require medial stabilization to account for a more extensive scapular muscle weakness. This is what I had to do for the man I mentioned above; a pectoralis transfer to the inferior scapula, and a medial tenodeis to several ribs with tendon graft resulted in much improved motion and diminished pain. Another option is scapulothoracic fusion; the problem that exists is that when one limits scapular rotation, so too will overhead motion be limited. So, the goal is to try to stabilize the fulcrum to allow at least some modicum of forward elevation--90 degrees or so. The pain you are having may be related to the scapular dysfunction, in large part. Although these types of problems are very unusual, and in that light, outcome is hard to predict, even modest improvements for you might be of immeasurable benefit. I have attached a picture that reveals the type of winging I am talking about, as well as photo of the improvement after surgery.