Revista de Medicina Desportiva (English) January 2019 | Page 26

and inferior margins close to the vertebral column and superiorly dislocated when comparing with the opposite side, worsening on the movements of anterior eleva- tion and resisted proctration of the scapula. 4,7,9,24  The scapulohumeral rhythm is quite often compromi- sed 25 , with premature rotation of the scapula, whereby the anterior and lateral elevation of the shoulder above 90° can be limited. 7,24   It can coexist decrease muscle trophism of the anterior serratus muscle. 24 The differential diagnosis of the long thoracic nerve injury includes cervical discopathy, brachial plexitis (Parsonage-Turner syndrome), trape- zius paralysis, tendinopathy / rup- ture of the rotators cuff), adhesive capsulitis, degenerative disease of the glenoumeral and acromioclavi- cular joints, glenoumeral instability, suprascapular nerve entrapment, scoliosis, scapular osteochondroma and neurological pathology, like fascioscapuloumeral dystrophy and Guillain-Barré syndrome. 7,24 The diagnosis of anterior serratus paralysis is essentially clinical and the ENMG is the unique diagnos- tic medical exam for the definitive diagnosis, with the capacity to determine the degree of denerva- tion. 7,24  Although its capacity to find out the injured structures, the degree of injury initially found on the ENMG might not have any predictive value regarding the prog- nosis. 14 The neurographic MR has a growing interest for its capacity to identify changes on the morphology and intensity of the signals from the peripherical nerves, as well as secondary changes that are com- patible with denervation of skeletal muscle, like edema, muscle atrophy and fat deposition. 15 The simple X-ray of the cervical and thoracic spine and of the shoulder, although rarely diagnostic, they must be done to exclude other diagnostic hypothe- sis. The CT-scan and the MR can be useful to exclude disc pathology and radiculopathy, neurofibromatosis related diseases and cancer inju- ries. 7,24 The isolated anterior serratus muscle paralysis has a good out- come with conservative treatment, with functional resolution between 1 a 24 months, although the traumatic 24 january 2019 www.revdesportiva.pt cases are associated with a worse prognosis. 4,7,10,24  As such, it is a gene- ral consensus the implementation of conservative treatment for 6-24 months, taking into consideration the spontaneous resolution of most cases already described during this period of time. 4,7,13,24  In case of fai- lure after 12-24 months of conserva- tive treatment, and with no signi- ficant improvement on the ENMG, surgery must be considered with dynamic transposition of muscles, namely the sternal head of pectoral major to the inferior angle of the scapula. 7,9,24 In summary, WS is a rare problem that causes significant functional limitation of the upper limb and it can result from a direct trauma during sports activity, like in futsal. Physiotherapy is the first-line treatment, usually with clinical and functional recovery during a period of 6-24 months. The described clinical case pretends to show that the injury of the long thoracic nerve must be included on the differential diagnosis of WS, since its recognition and precocious therapeutic inter- vention have positive implications on the prognosis and functional recovery. The authors declare no conflict of interests. Correspondence: Tiago Rodrigues Lopes Serviço de Medicina Física e de Reabili- tação Centro Hospitalar Trás-os-Montes e Alto Douro 5000-508 Vila Real, Portugal. [email protected] Bibliography 1. Meininger AK, Figuerres BF, Goldberg BA. Scapular winging: an update. J Am Acad Orthop Surg. 2011; 19(8):453-62. 2. Nawa S. Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer. J Brachial Plex Peripher Nerv Inj. 2015; 10(1):e57-e61. 3. Winslow J. 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