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]
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