Clinical Musings

Recently I saw a young patient that plays in several sports that require ballistic shoulder movements. She stated that while pitching in fast pitch softball she felt severe pain in her shoulder and that the pain has not improved in the past few weeks. She stated that the shoulder was tender to the touch and with movement above shoulder height.

Many orthopedist and therapist would suspect only ONE thing… rotator cuff injury. Although this is a perfectly logical assumption one must always be thorough in their examination.

Upon inspection, one thing was immediately noticeable. There was a significant difference in shoulder height (painful shoulder was lower). With this it was important to see if the scapulas are winging. Upon inspection it was seen that her affected shoulder was in fact “winging”.

There are varying degrees of winging and illustrated below is an example of a severely winging scapula. A winging scapula could be more subtle and less noticeable.  

http://muscletesting.com/blog/2011/08/12/experiments-in-muscle-testing-episode-02-the-problem-with-bicep-curls/rhomboids-3/

These signs should raise a little red flag in a good diagnostician for a possible long thoracic nerve injury.

The long thoracic nerve innervated that serratus anterior (SA). The SA is a muscle that looks much like the serrated end of a knife thus its name the serratus anterior.

http://conornordengren.com/category/anatomy/

The SA is only of the primary stabilizer for the shoulder complex in conjunction with the RTC therefore a long thoracic nerve palsy could be misdiagnosed as a  rotator cuff injury. The primary way of differentiating the two is to look for the winging scapula. 

Working on stabilization of the shoulder and using functional electric stimulation to cause activation of the SA has been very effective in treating this patient. In just two weeks she has improved 70% and is now able to raise her shoulder above her head with no pain.