Revista de Medicina Desportiva (English) January 2019 | Page 24
The neurographic magnetic reso-
nance (MR) has assumed a greater
role to confirm the diagnosis of
the long thoracic neuropathy, not
only because of the increase of its
positive predictive value, but also
because it is a non-invasive exam. 15
The aim of this clinical case is to
describe a rare case of medial WS
secondary to the injury of the long
thoracic nerve during the practice
of futsal and to point out that the
timely recognition and diagnosis can
prevent a substantial dysfunction.
Case report
It was a male, 31 years old patient,
federated futsal athlete, without
any personal or familiar relevant
background, that was observed on a
visit to a physical and rehabilitation
medical consultation, due to a clini-
cal state lasting for two weeks that
included an insidious and moder-
ate pain, like burning, with distal
irradiation though the upper limb
reaching the elbow and scapular
area. There was gradual worsening
associated to weakness and a feeling
of instability of the upper limb on
the overhead movements. There was
a spontaneously resolution of the
pain after one week, but he kept the
feeling of weakness and instability
of the shoulder.
On physical examination there was
anterior winding of the shoulders,
preserved muscular trophism at the
level of the scapular girdle and WS
on the right side, with superior and
medial rotation of the inferior angle
of the scapula (Figure 2), aggravated
with anterior and lateral elevation of
the upper limb and flection against
the wall (Figure 3). There are was
decreased joint amplitudes during
active movement of the right shoul-
der, namely during anterior and late-
ral elevation (90° e 60°, respectively),
with severe scapular dyskinesia. The
neurologic exam was normal.
Conventional simple X-rays were
made for the shoulder, clavicle, sca-
pula, and also an ultrasonography,
which didn’t reveal any changes.
The MR of the brachial plexus didn’t
show any suggestive signs of injuries
compressing the right long thoracic
nerve, decreased thickness of the
right anterior serratus muscle that
22 january 2019 www.revdesportiva.pt
could be consequence of denerva-
tion, favoring the diagnosis of long
thoracic neuropathy. The ENMG
revealed an isolated injury of the
right anterior serratus, characterized
by increased insertion activity with
acute positive waves and fibrillation
in the anterior serratus, indicating
active denervation.
A functional and neuromotor
rehabilitation program for the right
upper limb was prescribed that
included articular kinesiotherapy
techniques for the shoulder, streng-
then exercises with special interest
for the anterior serratus, medium
and inferior trapezius and rhomboid
muscles, with the focus on functio-
nal tasks, with adequate positioning
of the scapula and integration of clo-
sed kinetic chain exercises. Masso-
therapy to relax the scapular girdle
muscles and exercises to stretch the
anterior chains, especially the minor
pectoral muscle, was included. The
rehabilitation program also included
the teaching of take-home exercises.
There was a positive evolution of the
clinical situation, with progressive
functional recovery of the upper
limb since the beginning of the
rehabilitation and nine months after
the beginning there was complete
recovery of the joint amplitudes
and there wasn’t protrusion of the
scapula in shape of a wing.
Discussion
The paralysis of anterior serratus
muscle is the most frequent cause
of WS 4,9 , resulting from traumatic,
non-traumatic and iatrogenic
injuries to the long thoracic nerve. 7
There are three functional com-
ponents of this muscle: the supe-
rior component favors the lateral
rotation of the inferior angle of the
scapula on the over-head activi-
ties; the intermediate acts on the
scapula protraction; and the inferior
component is responsible for the
scapula protraction and also for
the rotation of the inferior angle of
the scapula superiorly and later-
ally. 16 The anterior serratus muscle
is exclusively enervated by the long
thoracic nerve, that originates on
the anterior branches of the 5 th , 6 th
and 7 th cervical roots (this is, C5,
C6 and C7, respectively) 4,9,14 , being
Figure 2 – Inspection of the athlete and it
can be seen the anterior winding of the
shoulders and medial WS with marked
prominence of the inferior angle of the
right scapula on a patient with traumatic
injury of the long thoracic nerve.
Figure 3 – Flection against the wall to
put in evidence the medial margin of the
right scapula of the same patient.
exclusively a motor nerve. 4,17 The
superior branch of the long thoracic
nerve, formed by C5 and C6, travels
through the medium scalene nerve
before it joints to C7, which is the
inferior branch of the long thoracic
nerve, that traveled anteriorly to the
scalene muscle, creating this way
the common branch. 4,9,14,17,18 The
long thoracic nerve deeply plunges
into the brachial plexus and clavi-
cle, travelling therefore between the
clavicle and the first rib, in a syno-
vial sheath at this level 7 , continu-
ing its caudal course on the lateral
of the thoracic wall to the level of
the 8 th – 9 th to enervate the anterior
serratus muscle 4,9 , being 24cm long,
on average (Figure 1). 17 The main
function of the anterior serratus
muscle is to make the proctration
and stabilization of the scapula, cor-
rectly guiding the glenoid during the
ascending rotation. 19
It is postulated, considering the
anatomic topography, that is on this