Revista de Medicina Desportiva (English) January 2019 | Page 23

Rev. Medicina Desportiva informa, 2019; 21-24.
Medial Traumatic Winged
Scapula on a Futsal athlete:
clinical Case
Dr. Tiago Rodrigues Lopes 1,3 , Dra. Inês Machado Vaz 2,4 , Dra. Elza Pires 2,3
1
Resident and 2 Specialist on Physical and Rehabilitation Medicine. 3 Centro Hospitalar Trás-os-Montes e
Alto Douro, Vila Real;  4 Centro de Reabilitação do Norte, V.N. Gaia. Portugal.
RESUMO / ABSTRACT
Medial scapular winging is a rare pathological condition associated with dysfunction of serratus
anterior muscle due to injury of the long thoracic nerve, mostly related to trauma or iatrogeny.
This lesion results in a change in the scapulo-thoracic rhythm, known as scapular dyskinesis,
which causes significant functional limitations. The authors describe a rare case of medial scapular
winging due to traumatic injury of the long thoracic nerve during futsal practice and emphasize the
importance of early diagnosis and the role of rehabilitation in the clinical and functional recovery of
the athlete.
PALAVRAS-CHAVE / KEYWORDS
Brachial plexus neuropathies, long thoracic nerve, futsal, rehabilitation
Introduction
Winged scapula (WS) is defined as
a change on the posture and on
the rhythm of the scapulohumeral
joint, where the medial border or
the inferior angle of the scapula are
away from the thoracic wall, result-
ing a protrusion of the scapula with
a shape of a wing. 1,2 It was reported
for the first time in the medical
literature on 1723 by Winslow 3 , and
most of the times it is the result of
the injury on the long thoracic nerve
or, less frequently, because of the
paralysis of the trapezius mus-
cle due to the injury of accessory
nerve. 4-6 Rarely, it can be associated
to the paralysis of rhomboid mus-
cles due to the injury to the dorsal
scapular nerve. 7
The anterior serratus and infe-
rior trapezius muscles are the main
shoulder stabilizers, whereby the
change of their function causes
changes on the kinetic and on the
kinematics of the shoulder with
consequent disruption of the scapu-
lohumeral rhythm. As such, where
there is paralysis of these muscles
there is a medial or lateral transla-
tion of the scapula on the thoracic
wall by the involvement of the ago-
nists / antagonists muscular chains,
causing different phenotypes:
Medial scapula – paralysis of ante-
rior serratus muscle
Lateral scapula – paralysis of the
trapezius and rhomboid muscles. 1,7
The paralysis of the anterior
serratus muscle is a rare patholo-
gical condition, with an incidence
of injury to the long thoracic nerve
of only 1/38.500, and it is admitted,
however, a higher prevalence. 4,8  The
severity of the WS is variable and
pain, not always present, has the
tendency to spontaneously vanish
with time, even when there is com-
plete loss of the muscular function. 4
The injury of the long thoracic
nerve can be attributed to several
etiologies: traumatic, non-traumatic
and iatrogenic. 7,9  In the case of a
traumatic cause, the injury of tho-
racic nerve can be related to a great
stretch of the upper limb, causing a
traction / compression mechanism
between the cervical origin and the
terminal branches at the level of the
anterior serratus muscle. 4,9,10  The
direct trauma can also be one of the
mechanisms of injury, like when
there is a depression of the shoulder
together with cervical inclination
or rotation toward the opposite
direction. 4,9
The paralysis of the anterior ser-
ratus muscle has been reported on
professional and amateurs athletes
of several sports, including archery,
tennis, American football, ballet
and basketball. 4,11-13  The diagnosis is
mainly supported by clinical presen-
tation, whereby it is fundamental a
detailed anamnesis, later suppor-
ted by a systemized and integrated
physical exam. Actually, the elec-
troneuromyography (ENMG) of the
muscles that integrate the scapular
girdle is considered essential and
the main medical diagnostic exam
to find out which muscle is involved
and the degree of denervation. 14
Figure 1 – The long thoracic nerve.
Ref. http://fisioricardosena.blogspot.com/2007/03/dor-na-cintura-escapularconsideraes.html
Revista de Medicina Desportiva informa january 2019 · 21