Winged scapula, am I screwed? advice, suggestions?

[fleshconsumed]

To make long story short I crashed on a mountain bike 3 months ago at the very end of October and hit my left arm pretty bad. I iced it, and after a week or two most of the pain has gone away. However, ever since then my left shoulder blade, or scapula, has been bulging from my back a little and my left shoulder area (Acromion?) has been shifted slightly forward, so whereas my right shoulder is straight, my left one is crooked and out of place. The damage is especially apparent if I raise my left arm parallel to the floor and try to move my shoulder back, in which case the inner side of my scapula sticks out by about 1-1.5" from my back. I still have full range of motion to my arm. I do not feel like I can do any type of explosive motion that involves my left shoulder, but I can do slow controlled pushups and pullups no problem. I also have been having dull pain around my left scapula which goes away if I do not do anything but comes back if I do any upper body exercise such as pull ups.

I finally went to see several doctors, primary, neurologist and sport injury specialist who diagnosed me with Winged Scapula. They did x-rays, whatever EMG tests they could (shocked my arm with electricity to measure nerve response). X-Rays look fine, EMG is sort of inconclusive, if I understood doctors correctly the type of EMG they do, they cannot really test partial nerve damage, the EMG machines are simply not designed to do that. The neurologist did measure both of my shoulders for comparison and left shoulder was significantly less responsive to the test, but I was told it was still on the border of normal difference between shoulders. So consensus is that I have a slight nerve damage to the left long thoracic nerve, but they are not sure.

So the sports specialist told me to undergo a physical therapy for a month and then have a follow up appointment with him, if things do not improve he will refer me to one of the guys who deals specifically with shoulder injuries.

I have yet to set up physical therapy, but there are several things that have been bothering me and I was wondering what resident H&F guys can say about it. First I'm just dissatisfied in general about the whole experience. I know medicine is not precise science, but after 4 doctor visits and two tests they are still not sure what's going on, they just think it's long thoracic nerve damage. Second, I asked neurologist and sports guy a question if I can exercise with my shoulder being like that and they gave me completely opposite answers, the sports guy said it's A-OK to do pull ups, rock climb, etc... Neurologist however said that assuming it is nerve damage I should completely lay off exercise for another 3-6 months to give my nerve a chance to heal. So who's right? Third, from what I understood there is generally nothing that can be done to help the nerve heal, all I can do is hope it does on its own, so potentially if it doesn't, am I screwed for the rest of my life? Also, if I can't really help the nerve heal, how is physical therapy going to help me? Yes, I'm going to be working out general muscles in the area, but if nerve is not firing, those muscles are never going to be utilized... I guess I'm just confused...

 

[The Sauce]

Wow that is a very tricky question. I can see why you are getting varying advise. Long thoracic nerve injuries are quite uncommon. Nerve damage in general is potentially reversible, but not reliably so, and I have never heard of LTN recovering simply because the mechanism tends to cause greater trauma to the nerve than, say, a simple cut would. I doubt PT would impair healing but I would be hesitant to lift heavy until I had at least given it a chance to heal and you will not know for up to 6-12 months. The purpose of PT is more to build up compensatory muscles and movements than fix the damaged nerve. As far as LTN nerve specifically, I doubt you will find anyone who has a wealth of experience in treating that so most opinions will be just that - opinion. I haven't looked, but I doubt there is good evidence based information available for it.

In this sort of situation no one really has the right answer. Is there a possibility LTN will heal? Sure...probably small. Will exercising prevent that? Maybe, not known. If your most important priority is to try to get the nerve to heal at all costs then it would make sense to not exercise. If your most important priority is to return to activity as soon as possible, and you don't have 6 months to wait and see, then starting PT/rehab now might make more sense.

Your frustration in understandable. Medicine doesn't have an answer to every problem yet, and nerve damage less than most. FWIW, I have a cousin who is a neurologist. He had an LTN injury and started rehabbing it immediately. I havent heard yet how it came out.

 

[fleshconsumed]

Thanks for detailed response. To clarify a little bit I do not lift. I do not have gym membership and probably never will, that's just not what I want, I just lead an active lifestyle. In the summer I bike on local trails, mountain bike, occasionally kayak, in the winter I ski, I picked up climbing 2 years ago so I climb all year round and prior to this injury I also did a lot of bodyweight exercises at home such as pull ups, chin ups, push ups, dips. I haven't been climbing or doing any bodyweight exercises lately because that seemed to cause a dull annoying pain in the general scapula area. As far as my priority goes, as much as I would like to get back into being active again, and I would love that very much, I would rather give my nerve a chance to heal (assuming it is nerve damage) so that when I do become active again I won't be hindered by fucked up shoulder.

As weird as it sounds, I suppose it is somewhat reassuring that no one can give me a straight answer because that's such an uncommon and difficult injury. However, I would still like to know if I can do mild exercises such as climbing or bodyweight exercises. On one hand those are not as taxing as lifting on the body, but it's still putting quite a bit of load on my upper body/shoulders. Or mountain bike which, along with dips I think is the most stressful thing on my shoulders. Would those activities be enough to cause further damage to the nerve, or would they be OK?

 

[The Sauce]

Here is what I know about nerve healing - and that is not much. One of the most important factors in nerve healing is the proximity of the severed nerve endings. Sometimes the ends of severed nerves will be sewn back together in places like the hand to facilitate healing. Theoretically putting any strain on that area might increase separation of the damaged nerve endings and hence potentially impair healing. Another factor is the mechanism of injury and amount of trauma to the nerve. A nerve that is cut, as in with a knife, has a better chance of healing than a nerve that has been beat-up, burned, etc. That being said, LTN injuries usually result from the nerve being ripped apart, in which case the chances of it healing are poor to begin with.

That's the theory anyway. There probably aren't any studies comparing immobilization or varying levels of activity to healing rates so really, I doubt anyone knows for sure what is better. I have not done any research on the subject so I do not know if this has been studied. Might be worthwhile doing an online search to see if this has been researched.

 

[DeckardBlade]

When you went for the EMG test did they do a NCV (Nerve Conduction Velocity) test as well? I was under the assumption that they generally do both when testing (that was my experience anyways). If you haven't had a NCV test that would be what would test specifically for nerve damage.

 

[SociallyChallenged]

To make long story short I crashed on a mountain bike 3 months ago at the very end of October and hit my left arm pretty bad. I iced it, and after a week or two most of the pain has gone away. However, ever since then my left shoulder blade, or scapula, has been bulging from my back a little and my left shoulder area (Acromion?) has been shifted slightly forward, so whereas my right shoulder is straight, my left one is crooked and out of place. The damage is especially apparent if I raise my left arm parallel to the floor and try to move my shoulder back, in which case the inner side of my scapula sticks out by about 1-1.5" from my back. I still have full range of motion to my arm. I do not feel like I can do any type of explosive motion that involves my left shoulder, but I can do slow controlled pushups and pullups no problem. I also have been having dull pain around my left scapula which goes away if I do not do anything but comes back if I do any upper body exercise such as pull ups.

I finally went to see several doctors, primary, neurologist and sport injury specialist who diagnosed me with Winged Scapula. They did x-rays, whatever EMG tests they could (shocked my arm with electricity to measure nerve response). X-Rays look fine, EMG is sort of inconclusive, if I understood doctors correctly the type of EMG they do, they cannot really test partial nerve damage, the EMG machines are simply not designed to do that. The neurologist did measure both of my shoulders for comparison and left shoulder was significantly less responsive to the test, but I was told it was still on the border of normal difference between shoulders. So consensus is that I have a slight nerve damage to the left long thoracic nerve, but they are not sure.

So the sports specialist told me to undergo a physical therapy for a month and then have a follow up appointment with him, if things do not improve he will refer me to one of the guys who deals specifically with shoulder injuries.

I have yet to set up physical therapy, but there are several things that have been bothering me and I was wondering what resident H&F guys can say about it. First I'm just dissatisfied in general about the whole experience. I know medicine is not precise science, but after 4 doctor visits and two tests they are still not sure what's going on, they just think it's long thoracic nerve damage. Second, I asked neurologist and sports guy a question if I can exercise with my shoulder being like that and they gave me completely opposite answers, the sports guy said it's A-OK to do pull ups, rock climb, etc... Neurologist however said that assuming it is nerve damage I should completely lay off exercise for another 3-6 months to give my nerve a chance to heal. So who's right? Third, from what I understood there is generally nothing that can be done to help the nerve heal, all I can do is hope it does on its own, so potentially if it doesn't, am I screwed for the rest of my life? Also, if I can't really help the nerve heal, how is physical therapy going to help me? Yes, I'm going to be working out general muscles in the area, but if nerve is not firing, those muscles are never going to be utilized... I guess I'm just confused...

Lol, if that's your way of making a story short, I'd hate to see your long stories

Firstly, you probably didn't damage your arm. It was more likely damage under your arm or to your thorax. The long thoracic nerve (innervated by spinal nerves C5, C6, and C7) innervates the serratus anterior, a muscle very important for proper scapulothoracic motion. Considering around one third of shoulder flexion is a result of movement at the scapula (rather than at the true shoulder - the glenohumeral join), that can significantly affect the stability of your arm and shoulder complex, especially in overhead positions.

I don't know who your neurologist works for, but exercise is a stimulant for neurogenesis in most cases, especially if you can work with a physical therapist that can get you to increase your coordination of a given muscle. The problem with this is that, if your long thoracic nerve is severed, this is not something that can be changed. However, physical therapy can attempt to re-train whatever musculature necessary to make your shoulder movement as safe as possible. To be perfectly honest, the neurologist doesn't know about scapular movement and the sports med doctor doesn't know all that much about nerve regeneration. The physical therapist SHOULD know about both, if he/she is good. Try PT - it's conservative treatment and really the only viable treatment option in this situation.

Also, ask PT about the exercises you can do, but things that don't put weight through the shoulder joint and don't utilize the full ROM of the shoulder should be ok. I'd say biking, running, anything leg intensive, etc. I would also say NO PUSHING exercises. This will push your scapulae through your back and decrease the surface area between the scapula and humerus. That will decrease the stability of the joint significantly and increase the likelihood of injury.

 

[SociallyChallenged]

When you went for the EMG test did they do a NCV (Nerve Conduction Velocity) test as well? I was under the assumption that they generally do both when testing (that was my experience anyways). If you haven't had a NCV test that would be what would test specifically for nerve damage.

Agreed, but the long thoracic nerve is pretty small and its exact position varies based on the individual. I'm unsure if it could be localized for proper NCV tests, but then again, I don't do them so I don't know for sure.

 

[eits]

chiropractic care and physical therapy.