Question
I am actually writing on behalf of my husband, as he doesn't think anything can be done. He started complaining of pain in his shoulder in basic training (2005). The Army Doctors kept telling him he had a lose shoulder and treating him with cortisone injections. He was finally diagnosed in 2007 with long thoracic nerve palsy with winging scapula by an army orthopedic doctor. They suggested surgery and told us that it might make his condition worse and disable him completely. We opted for a discharge instead. Since then he has had no care.

He experiences severe, Debilitating pain in his left shoulder. As well I can hear loud cracking and popping from across the room. He has had numbness in his left hand. And he has recently started to complain of pain in his back and neck. The pain seems to be getting worse. It hurts him at rest now, before it was only with activity. As well When he leans against the wall you can see his shoulder blade almost completely protrude from his back. Also he has a large mass of bone protruding from his clavicle on the left side.

I am concerned they made the wrong diagnosis or that it is getting worse. He does not want surgery. He has done physical therapy in the army and says it does no good and only worsens the pain. All the research I have done on the web has said that this condition could be treated in a year or less with the right therapies, so why did they give the option of surgery or discharge? Why did the physical therapy not do any good? And is there some way to alleviate his pain? I am concerned that he may lose use of his arm if something isn't done.

Thank you for any help you can give,
Danielle  

Answer
Dear Danielle,

Yes, the cause of a winged scapula is damage to the long thoracic nerve of Bell. The long thoracic nerve is composed of fibers that originate in the fifth, sixth and seventh cervical nerve roots. It descends along the lateral chest to supply the serratus anterior muscle which is the muscle responsible for holding the scapula to the chest wall. Damage to it allows abnormal positioning of the scapula (rotating outward) otherwise known as winging.

I am not sure how your husband got the damage to the nerve, but common causes are injury by carrying heavy weights on the shoulder, diabetes, neuralgic amyotrophy, systemic disorders and a traction injury may damage it. Some cases are classified as idiopathic which means no specific cause was found. With his complaints hand numbness and shoulder pain, it could be that his injury is really in the brachial plexus rather than the long thoracic nerve itself.

You see the brachial plexus innervates the entire arm, and  is composed of fibers that originate in the fifth, sixth, seventh, and eighth cervical nerve roots as well as the first thoracic nerve root. The largest & most frequently injured branch is the posterior portion of the brachial plexus.  The predominant fibers are from the C7 nerve root which do extend into the hand along the median and ulnar nerves.  Having said that, I must also tell you that the sensory portion of the fifth cervical nerve root relates to lateral shoulder pain.

In the supraclavicular region (above the collar bone), the long thoracic nerve (upper division) has a trajectory parallel to the brachial plexus, therefore an injury at this site could easily affect both structures and create issues into the hand, or the actual problem could be at the nerve roots.

So what does this mean?  It means that the injury causing your problem is likely to have occurred either at the base of the neck as the nerve roots exit the spinal cord from trauma, or that you have a central cord/disk type of injury/dysfunction that has affected both the serratus anterior and fibers that extend down the arm. The big issue is what nerve root because of the overlapping fibers, and at what location... cord/nerve root/peripheral fibers?  Or is there injury to the long thoracic nerve and the other nerve roots?

It is important to determine the amount of injury to the nervous tissue, this will allow a better prognostic indicator of return to function.   Two types of recoverable injury exist: NEUROPRAXIA and AXONOTMESIS:

Neuropraxia is the least severe injury and is characterized by a conduction block or nerve impulses. The structures are preserved but there is focal demyelination (loss of nerve covering/insulation). Recovery is evident and function may return within days.  Once the myelin insulation is restored the conduction block is restored complete healing is said to have occurred (taking weeks to months).

Axonotmesis is a more severe injury, with disruption of axons (central fiber of the nerve)& surrounding tissues.Recovery can still be good but may require many months.  Regeneration called axonal sprouting begins within 96 hours.  If axonal regeneration is delayed damage becomes more severe with time and recovery takes longer.  These types of injuries may not ever fully heal, but most function can be restored.

The bottom line Danielle, your husband may have a good chance of regaining the function to the left shoulder/arm in question, but remember that nerve regeneration/healing will take time.  You may also have residual nerve damage that will never heal fully.  The only way to truly evaluate the functional level of the nerve supply to the affected arm is with a nerve conduction velocity test. A nerve conduction velocity test (NCV) is an electrical test that is used to determine the adequacy of the conduction of the nerve impulse. This is used to detect nerve injury.

In this test, the nerve is electrically stimulated while a second electrode detects the electrical impulse 'down stream' from the first. This is usually done with surface patch electrodes (they are similar to those used for an electrocardiogram) that are placed on the skin over the nerve at various locations. (This test may also be performed with actual needles that are placed into the nerve.) One electrode stimulates the nerve with a very mild electrical impulse. The resulting electrical activity is recorded by the other electrodes. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to calculate the speed of impulse transmission (nerve conduction velocity). A decreased speed of transmission indicates nerve disease. A nerve conduction velocity test is often done at the same time as an electromyogram (EMG) in order to exclude or detect muscle conditions.

As far as the surgery or nothing outlook, I have no idea why they would not be willing to try other routes or more diagnostic testing.  Unfortunately, I have heard that the military hospitals often do not offer the best care...the docs are overworked with less resources, and often have their hands tied due to bureaucracy.  Other soldiers have told me that their concerns juste get placed aside and opt to be treated outside of the base system utilizing their Tricare when they can and paying cash out of pocket. Concerning the physical therapy, often this will increase pain with a nerve injury, but sometimes that is part of the care.  I am not quite sure he has the most accurate diagnosis at this point, and electrodiagnostic testing should be the first step to verify if the long thoracic nerve is the true problem or if it is closer to the spine in the nerve roots.  

Clear as mud right?  Listen , I know this is a lot of information, but I want you to be able to understand the complexity of the issue. I hope I have been able to relate this information to you without confusing the issue and getting to the root of your question.  My best advice to you is verify the diagnosis first and then focus on possible courses of action for rehab or pain management. If you have any further comments or questions, feel free to write back.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net