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» LymeNet Flash » Questions and Discussion » Medical Questions » Anyone else with Wings?

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Author Topic: Anyone else with Wings?
Melanie Reber
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Winged Scapulas?

In the last couple of months I have discovered that my right scapula is obviously sticking out more than the left.

This was a bit alarming to me, and also painful. So, of the two TBD friends that I asked about this phenomenon...BOTH had experienced the very same thing!

This got me thinking, and that is sometimes a hard thing...but, it did lead to some pretty interesting research on Winged Scapulas. Apparently, this is not as uncommon as I had thought, and can be linked to many various causes, including...and get this...

VIRAL infections! Hmmmm.

Further research revealed that it is also a symptom of Connective Tissue Disorders, Palsy of the Long Thoracic Nerve and Nutrient Deficiencies, such as magnesium...hmmmm.

Below is just the tip of the iceberg on info re: this condition, but these were the most intriguing to me, and possibly to you as well, IF you are getting wings!

I would really like to hear from others who have experienced this condition, and more importantly- WHAT did you do about it? Apparently, the sooner it is addressed, the better.

Thanks so much in advance!


*** Neuralgic amyotrophy is considered to be one of the commonest causes of long thoracic nerve palsy (Ball 1939, Bunker 1998, Parsonage et al 1948, Post 1998, Radin 1968). This condition presents with severe pain in the shoulder and arm. Often it is preceded by a generalized aching and fever.

These symptoms mimic influenza. After a few days of intense pain, the shoulder girdle feels weak. If serratus anterior is involved, and it usually is, the scapula wings and the patient has difficulty raising his arm upwards and outwards. This type of condition was first documented by Spillane (1943). There appear to be similarities with "Gulf War Syndrome" (Bunker 1998). In both instances the affected parties were treated for tick infestation with insecticides.

*** Flowers and Cowling (1993), maintain that human parvovirus 19 is a cause of neuralgic amyotrophy. The serratus anterior, and other muscles including deltoid, biceps and triceps, may be involved. Men appear to be more affected than women, and the right arm is more usually involved. Sensation can be involved. EMG investigations present with positive waves and fibrillation. Bunker (1998) adds that "the condition goes by a large number of differing names, such as brachial neuritis, brachial plexus neuropathy, and Parsonage-Turner syndrome, all of which add to the confusion".

*** Zander et al (2001) report a case of a 38-year-old woman suffering from erythema infectiosum (human paravirus B19) complicated by arthritis and severe brachial plexus neuritis resulting in scapula winging.

*** Wiater et al (1999) state that "viral illnesses, immunizations, Parsonage-Turner syndrome, and isolated long thoracic nerve neuritis all have been implicated in palsy of the serratus anterior".

*** Vanpee et al (2000) report a case of brachial plexus neuropathy due to cytomegalovirus infection.

*** Goodman et al (1975) believe that injury resulting from infection, allergies, toxins, or idiopathic causes will have a more favorable recovery than those resulting from acute trauma.

Percy EC, Birbrager D, and Pitt MJ (1988), entitled "Snapping scapula: A review of the literature and presentation of 14 patients" Canadian Journal of Surgery, 31, 248-250.

Norris C (1998) "Sports Injuries: Diagnosis and Management", 19, 433 (Butterworth& Heinemann). Norris writes that "this unusual condition occurs especially in adolescent females just after skeletal maturity, and in both sexes following surgery. Patients experience a snapping sensation, which is sometimes audible, near the vertebral border of the scapula. Pain is often localized to the rhomboids and levator scapulae over the medial scapular border or the trapezius over the medial aspect of the scapular spine. It appears to be a form of tendonitis to these muscles. This occurs through micro trauma from excessive shearing forces beneath the scapular during abnormal scapulo-thoracic rhythm.

*** Winged Scapula (Shoulder Blades That Stick Out)
An Overlooked Cause and Treatment

``When my fibromyalgia was at its worst, one of the many orthopedic problems I had was winged scapula. While I didn't feel any particular pain in my shoulder blades, it looked pretty bad. I did have pain that radiated up into my neck, giving me chronic neck pain. If you looked at me from behind my shoulder blades were very pronounced and stuck out from my body at a weird angle.

Most of the physical therapists I went to told me my problem was caused by back muscles that were stretched out and weak. They gave me back tightening exercises to do to strengthen my back. However, the back exercises just made me worse and made my neck hurt. In the end I figured out that the physical therapists were only half right. My back muscles were indeed weak and stretched out causing my shoulder blades to separate too easily from my body, but that was a symptom of my problems -- not the cause. They presumed that where my dysfunction occurred was also the location of the cause of my problem, which in my case, and probably many others, was not true at all. It was a gross over simplification of a complex, interrelated set of factors.

The root cause of my scapula issues was that my chest muscles were overly tight from a combination of having a connective tissue disorder, a magnesium poor diet that kept my muscles from relaxing and sitting at a computer for long time periods. In my experience, there are some great physical therapists out there (and I eventually found a good one) but many PTs have difficulty distinguishing between where pain occurs and the source of the pain. They are not necessarily the same place. With the winged scapulae and many other of my orthopedic problems, the pain and dysfunction were often a symptom of a problem somewhere else in my body, and not the root cause.

In the end, the main thing I did was yoga postures to loosen up my tight chest muscles, change my diet to get more magnesium to release my tight muscles, and take frequent computer breaks. With these changes the winged scapula condition cleared up completely over time. I think it was because my shoulder blades were no longer being pulled out of position by tight muscles from the front of my body.''

*** Decompression and Neurolysis of the Long Thoracic Nerve is Effective in Reversing Scapular Winging
(it is my opinion that surgery should always be the last resort)

Rahul K. Nath, M.D.1,2 and J. P. Wolinsky, M.D.2
Division of Plastic Surgery, DeBakey Department of Surgery and Department of Neurosurgery 2, Baylor College of Medicine, Houston, Texas.

Long thoracic nerve injury leading to scapular winging is a common entity. Inciting causes include closed trauma through compression, stretching, traction, and direct application of extrinsic force. Other causes include penetrating injury and neuritides such as Parsonage- Turner syndrome. The current paper describes our surgical experience in 17 consecutive patients presenting with long thoracic nerve palsy with closed mechanisms of injury.

This is the largest reported series of long thoracic nerve decompression and neurolysis in the literature. Three of these seventeen patients exhibited bilateral scapular winging and underwent bilateral surgery. Eighteen of twenty (90%) long thoracic nerve decompressions and neurolyses resulted in improvement of scapular winging. In patients less than 10 years out from onset of winging, 100% exhibited at least some degree of improvement. Pain was a common concurrent condition (35%), and this was improved in less than half (43%) of patients with pain. Shoulder instability persisted in 4 patients out of 17 following surgery, even in 2 patients who received some relief from the winging itself.

Surgical decompression and neurolysis of the long thoracic nerve results in significant improvement in scapular winging in appropriate patients and should be considered a primary functional reconstructive modality in these patients. ( no thank you! )

Winging of the scapula due to long thoracic nerve palsy is a common diagnosis 1,2,3,4,5,6,7,8,9,10 and should be treated as a significant functional problem. It must be recognized that scapular winging is not simply an aesthetic issue; the compensatory muscular activity required to improve shoulder stability is associated with secondary pain and spasm due to muscle imbalances and tendonitis around the shoulder joint . Other described resultant anomalies include adhesive capsulitis, subacromial impingement and brachial plexus radiculitis 5. Traditional management has relied on conservative therapy 2,3,11,12, 13,14 and in some refractory cases, pectoralis tendon transfers for stabilization of the scapula 4,5,12,13,15. Scapulothoracic arthrodesis is considered in other instances 16. Probably in most patients, surgery is not undertaken and relief of symptoms is inadequately obtained. Chronic shoulder instability and pain are the result.

Scapular winging often results from insults to the long thoracic nerve. Part of the susceptibility of the nerve to injury arises from unique anatomical features. The nerve itself is small in diameter and fragile- appearing, in contrast to the relatively robust adjacent nerves of the brachial plexus. The lengthy course of the nerve from its C5 through C7 root origins through to the inferior border of the serratus anterior muscle also presents multiple anatomic locations for potential injury. Surgical dissections in the axilla as during mastectomy can cause direct injury to the nerve in the infraclavicular region, with an incidence as high as 30% 17.

Perhaps the most important anatomic feature associated with injury is the course of the long thoracic nerve through the fibers of the middle scalene muscle in the supraclavicular region 18, 19, 20. Several patients in the current study were thought to have sustained an insult to the nerve through direct compression by the middle scalene muscle during contraction while exercising. Another category of patients included those who sustained a direct extrinsic crush to the nerve in the region of the middle scalene muscle; in this group, the middle scalene was thought to be a possible secondary source of injury.

The anatomic basis for long thoracic nerve injury by the middle scalene was first described by Skillern in 1913 20: ``the long thoracic nerve is exposed to trauma as it traverses the scalenius medius''. The proposed mechanism for injury has been succinctly described by Birch and colleagues: ``stabilization of the forequarter on the chest wall [is] commonly associated with a strong sustained inspiration...[this action will] bring the scalenius medius into action to stabilize the first rib and the thoracic cage...[therefore] there is a liability to trapping of the nerve to the serratus at or near its point of emergence from the muscle''18. Certainly in our experience, strenuous upper extremity activity or a history of lifting heavy weights is present in most patients. Two patients had a specific history of direct compression of the supraclavicular fossa during deep massage treatments with associated pain and paresthesia during treatment. Disa described four patients with stretch or traumatic causes of their winging; the middle scalene contributed to the injuries in all cases19.

Management of this problem by resection of the scalene muscle and neurolysis of the long thoracic nerve appears to have been first described by Birch in 1998 18, although a 1995 paper by Chen reports scalene resection as a way to free compression of the dorsal scapular nerve 21. Chen planned the operation for the dorsal scapular nerve, but does incidentally mention the long thoracic nerve as also passing through the middle scalene. The largest previous series to the current one is by Disa and colleagues in 2001 in which experience with 4 patients is described 19.

Patients and Methods
Seventeen consecutive patients were operated upon after evaluation for a winging scapula. Three patients had symptomatic bilateral winging, and 3 more had clear winging of the contralateral side, although not symptomatic. The most common symptoms were initial discomfort and spasm of the affected shoulder girdle muscles, with eventual shoulder instability and winging of the scapula. Twelve patients (60%) had a history of weight-lifting preceding their winging, either during bodybuilding or by lifting heavy objects such as furniture. Three patients (15%) had onset of winging following rigorous throwing exercises playing softball or tennis over an extended period of time. Two patients (10%) noted winging immediately after deep massage in the area of the supraclavicular fossa, and one patient (5%) was a postal worker with a several year history of repetitive overhead movement performed in the course of daily work activities. One patient (5%) gave a detailed history of direct trauma to the supraclavicular area by a ladder falling on him at work. One patient (5%) had immediate onset of winging following a motorbike accident where the affected arm and shoulder were jerked forward sharply while holding the handlebars during a fall. Seventeen of twenty nerve surgeries were performed on the right side, which was the dominant extremity in all patients. Operations to the left side were in bilateral patients only.

Patient Evaluation
The physical examination of each patient formed the basis for management and evaluation. Examination was performed by the senior author in each case, an experienced brachial plexus surgeon. All surgical procedures followed the same protocol (defined below) and were performed by the senior author. Followup evaluation was also performed by the senior author at an average of 19.9 months.

The physical examination of all patients revealed medial deviation of the inferior angle of the scapula and prominent winging of the medial border of the scapula with backward pressure on the shoulder as in pushing off a wall. Superior elevation of the scapula was also noted. Overhead movements of the arm and shoulder caused significant discomfort and feelings of shoulder instability, and fully ten of twenty (50%) of patients were unable to flex or abduct the shoulder beyond 90 degrees.
In the absence of established grading systems for the serratus anterior muscle, the degree of winging was quantified by centimeters of posterior projection of the inferior scapular border at the point of maximal winging. British Motor Grading (BMG) was applicable to upper trunk examination. Twenty of twenty (100%) examined upper extremities had a physical examination consistent with weakness of the deltoid, spinati and biceps muscles, having BMG ranging between 3 and 4. This finding is consistent with concurrent injury to the upper trunk of the brachial plexus, an observation also made by Disa et al.

All patients underwent electromyography of the brachial plexus and long thoracic nerve prior to physical examination. In 12 of 20 extremities (60%), no serratus anterior abnormalities were found, in 7 examinations (20%) subtle, transient abnormalities in the serratus examination were described, and in one patient (5%), evidence of supraclavicular long thoracic nerve injury was clearly documented prior to surgery, with possible loss of continuity. Six extremities did exhibit electrical abnormalities consistent with upper trunk injury. In most abnormal EMGs, neuropraxic injury was described, with no loss of axonal continuity. Ten of seventeen (59%) patients had undergone MRI testing prior to surgery and all were read as normal, except for a single report describing possible atrophy of shoulder girdle muscles.

All 17 patients had undergone regular physical therapy prior to surgery. Five patients, all with symptoms greater than 7 years did describe possible minor improvement with conservative management, but all felt constrained in terms of the scope and intensity of their physical activity at work, in daily living and during recreational activity.

The final determination of surgical suitability was made by considering several parameters. Patients generally had to have been out at least 6 months from their injury. Two exceptions were made, one in a patient who had an outstanding result from a previous contralateral decompression and neurolysis, and the other in a patient with severe winging and instability following major trauma in a motorcycle accident. In the latter case, the patient had a markedly abnormal EMG with possible loss of long thoracic nerve continuity, and the surgery was planned as an exploration with possible nerve grafting. Patients should not have had progressive improvement with physical therapy, but rather exhibited slowly progressive symptoms or lack of functional improvement with conservative management.

Another preoperative consideration was the presence of a strong history suggestive of injury to the long thoracic nerve in the region of the middle scalene muscle. Scapular winging and proximal extremity weakness after lifting of heavy weights and aggressive throwing motions does support the theory of middle and anterior scalene compression of contained nerves. Direct extrinsic pressure to the relatively superficial long thoracic nerve and the upper plexus in the supraclavicular area was also thought to be an important causative factor. Stretching and axial traction of these nerve elements by various mechanisms was considered significant. The presence of electrophysiologic abnormalities was considered confirmatory of severe injury but the absence of electrical testing abnormalities was not a contraindication to surgery in the presence of a strong clinical picture.

After establishing indications for surgery, all patients participated in a thorough discussion of the risks and potential benefits of surgery. Patients were informed of the options of continuing conservative management or of pectoralis tendon transfer or scapulothoracic fusion. Patients understood that those out 18 months or more from onset of winging were less likely to have an excellent outcome based on known physiologic properties of denervated skeletal muscle, including the serratus anterior.

Following surgery, all patients were followed with serial physical examination by the preoperative examiner. Results were tabulated over time.

Surgical Technique
At surgery, patients were placed in the lawn- chair position, with a transverse shoulder roll. The head and neck were abducted away from the side of surgery, usually the right side. The entire supraclavicular area was prepared and draped with a thyroid sheet. The skin incision was created one fingerbreadth posterior and parallel to the clavicle. The incision was sinusoidal and extended 6 to 8 cm. lateral to the palpated lateral clavicular border of the sternocleidomastoid muscle. Dissection proceeded through the platysma muscle, taking care to protect the underlying supraclavicular nerves.
The omohyoid muscle was resected to allow access to the scalene fat pad and to remove a potential compressive structure of the brachial plexus. The scalene fat pad was elevated from inferior to superior, revealing the upper brachial plexus. Great care must be taken to identify the suprascapular branch of the upper trunk, as it tends to travel within the middle layers of the scalene fat pad, and is theoretically prone to iatrogenic injury at this point.

Once the scalene fat pad was elevated, the upper trunk and its trifurcation into the anterior and posterior divisions and the suprascapular nerve was explored. Typically, epineurial scarring was evident at this point, and external neurolysis with microsurgical instruments and technique was performed. Anterior scalene resection was also performed at this time, although this was generally partial, and only sufficient to release the most superficial fibers compressing the upper trunk. This typically amounted to 15 or 20% of the thickness of the anterior scalene muscle.

The long thoracic nerve was then exposed laterally and posteriorly to the upper trunk. Disa and colleagues point out the underappreciated anatomy of the long thoracic nerve in the supraclavicular area, and discuss the inadequacy of standard gross anatomic descriptions showing the nerve to be more medial. It is worth noting that the long thoracic nerve is delicate and no more than 2 to 3 millimeters in diameter in this location. Its lack of substance in relation to the bulk of the serratus anterior muscle teleologically predisposes the neuromuscular unit to dysfunction. The situation is made worse by the passage of the nerve through the thick middle scalene muscle.

Once the nerve was isolated, it was then neurolysed using microsurgical instruments and the operating microscope. This was necessary because of the delicate nature of the nerve and to decrease surgical scar formation within the operative field. As with the anterior scalenectomy, the middle scalene was resected sufficiently to decompress the long thoracic nerve as it traversed and exited the muscle. In 6 of 20 surgical procedures (30%), a demarcated area of compression within the nerve was clearly noted, more so toward the exit point of the nerve from the muscle. This took the form of a narrowing and rubor of the epineurium, perhaps representing neovascularization at the site of compression. In one case, a complete resection of the middle scalene was required, and in the other 19 cases, a partial release of 15% or slightly more was accomplished. This was suitable to expose the long thoracic nerve and at least remove the circumferential muscle fibers of the middle scalene.

Direct electrical stimulation of the long thoracic nerve and upper trunk was performed in all cases, with a Radionics � intraoperative nerve stimulator. Current of up to 10 milliamps was used to stimulate contraction of the serratus anterior and the muscles supplied by the upper trunk. It was interesting that the contractions of the serratus anterior appeared uniformly to improve following decompression and neurolysis. It is a point of speculation as to the importance of this electrical ``overstimulation'' of the nerves in assisting recovery of the paralyzed muscles. It is compelling to note that even in cases where no clear anatomic point of epineurial compression could be noted, recovery of serratus function was excellent. Further, in fully 50% of cases, recovery was noted within 24 hours, an unusual circumstance in most situations of nerve decompression.

Prior to closure, an examination of the superior- most and inferior margins of the surgical wound was performed to identify and release compressive fascial bands potentially capable of causing compression of the upper trunk and the long thoracic nerve. This was accomplished sharply under direct vision and with blunt digital dissection into the recesses of the wound.

Wounds were closed in three layers with reconstruction of the platysma and two skin layers. No drains were used. Postoperative management consisted of immediate active range of motion at the shoulder and neck. By the third postoperative day, patients were to have a full range of motion at preoperative levels or beyond, where capable.

Our surgical experience includes 17 consecutive patients presenting with long thoracic nerve palsy, 14 unilateral and 3 bilateral. This is the largest reported series of long thoracic nerve decompression and neurolysis in the literature. Eighteen of twenty (90%) decompressions and neurolyses resulted in significant improvement of scapular winging. In patients less than 10 years out from onset of winging, 100% exhibited measurable improvement in winging. Pain was a common concurrent condition (35%), and this was improved in 43% of those with pain. Shoulder instability persisted in 4 patients out of 20 following surgery, even in 2 patients who received some relief from the winging itself.

In 3 0f 20 extremities (15%), patients reported the development of a 4 cm.2 swelling at the area of incision between 3 and 6 weeks after surgery. This in every case resolved spontaneously within one week and may have represented a seroma, although the late appearance of the swelling makes this an unusual presentation.

No infections or other complications were noted. One patient who sustained the injury while playing softball had an initial improvement in function followed by a partial recurrence 6 months after surgery. The recurrence was unrelated to physical activity and occurred apparently spontaneously. This patient is being considered for a pectoralis tendon transfer.

Scapular winging is a significant public health problem and an important cause of functional disability. The morbidity associated with long thoracic nerve dysfunction is underappreciated by the health care community, and much more awareness of management options is needed. We are in agreement with Fery, who argues that the traditional approach to scapular winging by conservative treatment is based on inadequate data, and favors a more aggressive approach with surgery 22. In our series, 9 of 20 (45%) nerves evaluated were more than 6 years out from onset of injury and all of these patients were left with significant functional deficits. Seven of nine of these patients (78%) responded to surgery, and five of seven (71%) did so within 1 week of surgery. The average time to improvement was 5 days, with a range of 1 day to 3 months. In addition, many patients greater than 2 years out from the onset of winging experienced improvement following surgery. These findings support the efficacy of nerve surgery as a modality of treatment, and diminish the likelihood that spontaneous improvement was the cause of improvement.

Surgical decompression and neurolysis appears to be an effective and rational treatment modality in specific instances where supraclavicular injury to the long thoracic nerve is identified. Risk factors for supraclavicular nerve injury include a history of vigorous athletic maneuvers with the affected extremity, lifting of heavy weights, and direct external pressure on the area as in deep massage. Injury to the upper trunk of the brachial plexus is also associated with the proposed stretch or compression mechanisms causative of the injury. In terms of upper trunk pathology, the shoulder examination is somewhat unreliable, as the long- standing scapular instability will secondarily affect deltoid and spinati strength. However, biceps weakness to BMG 3 or 4 was invariably found in the current patient group, and this is direct evidence of upper trunk injury.

Anatomically, the long thoracic nerve and the upper trunk are intimately related; the long thoracic nerve occurs immediately posterior and lateral to the upper trunk. It is easy to understand that an axial load along the course of the brachial plexus will affect these structures both by direct stretch forces and by compression of the intramuscular scalene portions of the upper trunk and long thoracic nerve. The relatively delicate structure of the long thoracic nerve is contrasted with the densely- composed upper trunk and predicts the consequences of trauma to each element: the upper trunk will exhibit lesser degrees of dysfunction than the long thoracic nerve given similarly applied forces.

It is therefore understandable that electrophysiologic examination of the upper trunk- supplied muscles of the extremity often will not reveal clear abnormalities, the upper trunk injury being relatively minor, although present 19,23. EMG testing of the serratus anterior, however, might be expected to find a greater degree of dysfunction in many cases. The lack of supportive electrical data is probably related to the difficulty of placing a recording needle within the substance of the serratus anterior muscle, given its relatively deep location on the chest wall. It has been our experience that electromyographers are sometimes reluctant to approach the serratus anterior with a recording needle for fear of traversing the chest wall and causing a pneumothorax. The tendency toward normal readings after serratus anterior testing in our population may then be inferred as arising from inadvertent testing of the latissimus dorsi, teres major or other unaffected chest wall muscles. The long thoracic nerve was in continuity in all cases and this also might decrease the ability of EMG studies to uncover subtle denervation abnormalities that yet have significant functional consequences.

Previous case reports have proposed the concept of surgical long thoracic nerve decompression and described positive effects of nerve surgery 18, 19. The current study expands the data base of nerve- based management of scapular winging caused by supraclavicular long thoracic nerve injury. Muscle and tendon- based surgical procedures should remain an important tool in management of refractory, symptomatic scapular winging. However, the growing understanding that long thoracic nerve decompression is effective and associated with minimal morbidity suggests that it is the initial treatment of choice in appropriate cases of scapular winging.

The suggested paradigm for scapular winging of long thoracic nerve origin, then is:
(1) Evaluation of the clinical picture with attention to cause of injury or associated events, if known. Patients with symptomatic scapular winging related to injury localized at the long thoracic nerve near the middle scalene are candidates for nerve surgery (2) direct physical examination with attention to scapular movements and strength; Kuhn's thorough discussion of the differentiating evaluative factors between long thoracic injury and other causes is worth following 5. Strength of the serratus anterior muscle can be quantified by measuring the maximal protrusion at the inferior scapular angle in centimeters. Normal is 0 centimeters, with extreme loss of function recognized as greater than 5 cm. (3) electrical studies should be ordered, in order possibly to recognize loss of continuity in the long thoracic nerve, indicating possible need for nerve grafting or nerve transfer; the lack of abnormal findings electrically should not negate the indication for surgery should clinical findings suggest surgical intervention (4) patients less than 7 years out from injury are candidates for nerve surgery in the absence of other contraindications such as established loss of continuity of the nerve greater than 18 months; patients between 7 and 10 years out from injury are relative candidates for nerve surgery and good outcomes are less predictable. Patients greater than 10 years out from injury should primarily be approached with tendon transfers, with nerve surgery a secondary option.

It should be noted that associated pain and inflammation related to established scapular instability do not automatically improve even with successful flattening of the scapula. In our experience these symptoms usually do improve, but unpredictably so. We have noted that established pain as the presenting primary symptom with varying degrees of associated winging does not always respond favorably to surgery, and unhappy patients can be the result, even if the goal of surgery, i.e. reversal of winging is met.

Postoperative management is generally restricted to gentle range of motion therapy and electrical stimulation. Patients with longstanding winging are placed on daily stretching protocols for up to one year following surgery, and strengthening to begin after that time. Patients with winging less than 2 years begin strengthening after 3 months of ROM therapy. As mentioned by Kuhn and Hawkins 5, ROM therapy is important in preventing and treating adhesive capsulitis at various shoulder girdle joints.

Winging of the scapula is an important public health problem. The scope of the problem is not well- appreciated by treating physicians and many if not most sufferers are left with pain and ongoing functional deficits. Peripheral nerve surgical techniques increasingly have a role in managing long thoracic nerve- related scapular winging. Long thoracic nerve decompression and neurolysis treats the cause of the problem in many cases, rather than the result of the injury. The effectiveness and low morbidity of nerve surgery in these situations suggests that it is the treatment of choice in many cases. Ongoing research efforts in surgical techniques and conservative management will be needed to improve the management of scapular winging.

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[ 09-20-2012, 09:45 PM: Message edited by: Melanie Reber ]

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Hi Melanie,

I don't think I have wings. But, I have been thinking of you lately and wondering how you are doing. Good to see you posting. You may have been all along and i just missed your posts.

So, will wings improve with treatment for lyme?

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I am not 100% sure but think my right one protrudes slightly. My right side of my clavicle is pronounced. Maybe the two things are related.

I have always considered them genetic. All of the women in my mother's family have a back curvature that is supposedly not osteo. Figured mine was starting.

Good luck. I will try to keep an eye on your findings.. lymemomtooo

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Dear Melanie,

I believe I have that on both sides....

However, I use my broom to fly around on....

Missed you. Hope you are doing well.

Thanks for the interesting information.

Are you sure we are not twins, once removed?



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Hey Miss K!
Nice to see you. You are correct; I have sort of taken a break from massive posting recently. Just too much else going on right now.

Ya know, I am 4 years into treatment now, so it is difficult to know if this too will go away with continued treatment...I sort of doubt it at this point from my research. But, that sure would be nice, wouldn't it?

Take special care of you! Oh, I need to ask you something, but will email it, OK? [Smile]

Hi there LMT!
It is nice to see YOU posting again, and I do hope things are a bit better overall? My last link below does speak to genetic factors, but that one was way too much, so I'm ignoring it for now [Eek!]

My Mother and Grandmother also had rounded backs, so I was especially concerned when I just happened to see this bone sticking out of mine. I do NOT want to end up that way, and try very hard to maintain a proper posture when I think of is just the thinking of it that becomes difficult when I am too focused on other things.

Everything IS connected actually, and I have found that my right front chest wall muscles are extremely tight and, I do think that may be contributing to the ``pulling'' of the back muscles, in effect, contributing to the winging.

Miss Geneal,
Well, I hate to be one of those strawberry daiquiri sippin' gossipy southern bells, but ya know what ``they say'' don't cha?

...we were all inbred down there anyway, right? Welcome to tha family, suga! [Razz]

More related sites I forgot to include:

It may be time to stop researching now...and get back to my taxes...way too scary!

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If you have wings, it's because you're such an angel!


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Melanie Reber
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Oh Carol! You are such a sweetheart. I have missed you!

Still trying to get to the bottom of this condition. I'm finding lots of stuff, but not necessarily things on the infection aspect.

Sooo, I will continue to add to this post, so it may help others eventually, and when I DO find what I am looking for, I am hoping it will really help!

*** R. Shane Tubbs1, 2, 3 and W. Jerry Oakes2

Department of Cell Biology, University of Alabama at Birmingham, Birmingham, AL, USA

Section of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA

Department of Pediatric Neurosurgery, Children's Hospital, 1600 7th Avenue South ACC 400, Birmingham, AL 35233, USA

Received: 27 March 2006 Published online: 13 October 2006

Case report We report a 19-year-old girl with a 4-month history of an inability to fully elevate her upper extremity past the horizontal position. Physical examination revealed a winged scapula. MRI was demonstrative of a Chiari I malformation with a small cervical syrinx eccentrically placed to the same side as the dysfunctional extremity.

We believe this to be the first report of dysfunction of the long thoracic nerve via a hindbrain hernia-induced syrinx with a resultant winged scapula. We would hypothesize that enough anterior horn motor neurons and their axons destined for the long thoracic nerve were injured by the syringomyelia to result in isolated deinnervation of the serratus anterior muscle.

The clinician may wish to include syringomyelia in the differential diagnosis of a winged scapula.

Keywords Chiari I malformation - Syringomyelia - Long thoracic nerve

*** Scapular winging

* Dystrophy
o LGMD2A (Calpain 3)
o LGMD 2E (β-Sarcoglycan)
o Emery-Dreifuss
o Myopathy + Paget's disease of bone
 with Dementia: 9p13
 Type 2

* Scapuloperoneal syndromes
o Centronuclear myopathy: Adult-onset; Dominant
o Davidenkow's syndrome
o FSH phenotype with ragged red fibers & cardiomyopathy
o Glycogen storage
 Acid maltase deficiency with scapuloperoneal weakness
 Phosphorylase deficiency (McArdle)
o Mitochondrial
o Reducing body myopathy: Adult onset
o Scapuloperoneal muscular dystrophy (SPMD): 1; 2
o SPMD with Retardation + Cardiomyopathy
o Scapuloperoneal neuronopathy

* Other neuromuscular disorders
o Holt-Oram
o King-Denborough
o OAT deficiency
o Syndromes with severe muscle wasting: See congenital myopathies
o AR-CMT2A: Later in disease course

* Focal muscle weakness
o Trapezius
 Etiology: Nerve lesion (Spinal accessory); Absent muscle
 Winging most evoked by: Lateral abduction of arms
 Lateral displacement of scapula
 Associated with drooping shoulder
o Serratus anterior
 Etiology
o FSH dystrophy
o Nerve lesion (Long thoracic)
o Neuralgic amyotrophy
 Winging evoked by: Anterior abduction of arms
 Symmetric shoulder shrug
 External link: Case report

* Orthopedic disorders
o Rotator cuff
o Fracture
o Scapular osteochondroma
o R/O Sprengel deformity

(most of the above are links for explanations when clicked...but you must go to the website below, sorry)

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This is a simple explanation of what is happening.. hope it helps.

Muscles are affected/infected by infections.. because keets are eating and pooping in them basically. Due to the "invasion", the muscles spasm to try to push out the unwanted offenders. When they spasm.. it causes pain, less blood flow, less clearing of toxins.

Then.. to understand this part...

The leg bone's connected to the knee bone.. the knee bone's connected to the shin bone.. and so-forth. ALONG with the bones are the muscles, tendons, ligaments.

If one group of muscles, tendons, and ligaments is "affected" by Lyme (like the shoulder)... it is going to go beserk. When it does and spasms tight (one side or another- or above/below the blade)... then it pulls tight on the muscles connected to the ribs, spine, lower back, neck, etc.

Sometimes, like in what happens to me.. it pulls hard enough to do things like pull the individual spine bones out of line, often pinching nerves... which causes more pain and disfunction of neurological systems and organ systems.

Other times it pulls hard enough in the front that it can actually twist ribs out of place.. or dislocate shoulders... or tear rotar (sp) cuffs, etc.

Sometimes the muscles in back are loose from being so stretched (like a palsy kind of).. and muscles in front very tight. The loose muscles and tendons, etc. can allow bones to slip a bit out of place.. causing a lot of pain too.

The experts can "assume it comes from X-Y-Z".. and can name it a thousand names... but bottom line.. the infection in our case, is the cause.

Note- Parvo folks are often NOT tested for Lyme.. and many have it. Of course tests for Lyme can be negative too.. making people think it is from anything but Lyme... hence all the confusion.

And I am not saying it can't be from other causes. But just because it is named X-Y-Z.. or many other things... doesn't mean it is a separate entity.

What helps?

Treatment to kill all forms of the diseases.

Lemon juice and water to help eliminate lactic acid which builds in muscles and causes pain.

Chiropractic adjustments to help put things back in place when they pull out.

Massage/heat to relax muscles. Sauna heat helps relax muscles.

Anti-inflammatory to reduce swelling and pain.

Gentle stretching.

My chiropractor actually pulls up the shoulder blade and works the muscles and releases the tension on the muscles UNDER the shoulder blade which normally can't be reached. THAT helps a lot.

Ok.. that's my story and I'm sticking to it.

[Big Grin]


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I know two female lymies who have had one shoulder blade just disappear for a while. (this of course cancels out two of you with 'wings' now don't you feel better?)

And I have one shoulder that is at least an inch lower than the other. This was not the case pre lyme because somebody would have noticed and it's real obvious.

Wonder if the two conditions aren't related? If you google 'shoulder droop" you get an ILADS article on it.

It doesn't bother me but it's curious.

lopsided Charlie

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Another piece of the puzzle if this is due to Lyme. Makes sense. I have this. I have a piano teacher and she says that my chest muscles are contracted and so are causing the rounded back with the winging scapulae.
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Good morning TC, Charlie and Robin!

Sorry it took me so long to get back to this...I got a bit pre-occupied with other things.

Yes, I am sure this must have a strong correlation to TBDs...and the old literature does support that. I was just wanting to find that missing piece of the studies and read and post it...but so far, no such luck.

I'm sure a neuro-chairo would help tremendously...but to get at the root cause is what I am really after. Although, from what I am reading...this could have many causes...and I DO fit the criteria for most. I suppose temporary relief would be nice though, and I will try and look into that possibility, thanks.

Charlie, you didn't appear lopsided to me! But, if I had to pick a side to lop to...I sort of do like yours [Smile] Do these muscular-skeletal issues cause you much pain still?

Yes, contracted chest muscles on the right are a big issue for me as well. I have been trying to do gently stretching to loosen them, and hoping that will have a cascade effect.

Thanks again everyone! I really do appreciate your input!

Much love,

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Treating bartonella has gotten rid of a lot of stiffness and tension in my case.

I believe it was in my muscles and tendons but who knows for sure. All I can say is that the difference is dramatic.

I struggled with this symptom for years trying anything and everything and nothing helped significantly until treating the bart.

Have you treated cos successfully?

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Melanie Reber
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Well Good morning Miss Dolphin!

Nice to see you...and HOW are you doing? Yes, I have been through lots of co-infection protocols.

Many months on IV and orals for Bart, and now Mepron and orals for Babs...along with IM and orals for the Lyme stuff.

Not sure I have gotten rid of any of them to tell you the truth, so treatment continues [Smile]

I actually feel pretty blessed that I am doing as well as I am considering this began back in the early '80's, and treatment did not begin until 20+ years later.

So, I try not to complain too much! I just get perplexed when these new things show up and try to figure out why and what can be done.

Hoping you are doing as well as can be expected!
Much love,

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From the description, it sounds like I have this on the left side.

I have DDD at C-6 and C-7, which I was told was responsible for the radiculopathy to my shoulder blade and down my arm. The article here says the involved nerve runs from C-5 to C-7, so that makes sense.

My left shoulder blade pops, grinds, and moves as if it was not attached to anything else in there. It sometimes hurts like I'm being stabbed, and before I learned some exercises to help it from a Physical Therapist, it hurt so bad I could not breathe, and it often made my arm go numb.

I do my PT exercises 3 X week,even though they make my neck hurt all the rest of that day, and it keeps the pain away. I was told the alternative was surgery, and there is no way I am having back surgery.

I also have obviously enlarged elbow and wrist bones. The points on the elbow bones curve the wrong direction too, which looks really strange.

Luckily, nobody else has noticed except my DH, who was appalled that none of my ducks have noticed it. I reminded him that ducks never actually look at their patients anymore, only at test results, lol.


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Melanie Reber
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*** Dengue Fever and Long Thoracic Nerve Palsy in a Traveler Returning from Thailand
Fran�ois Chappuis, Jean-Claude Justafr�, Lobsang Duchunstang, Louis Loutan, and Walter R. J.Taylor

A healthy 23-year-old male traveler to Thailand developed winging of the right scapula 2 days after resolution of classic dengue fever caused by serologically confirmed dengue virus type 1. Right long thoracic nerve palsy with dysfunction of the right serratus anterior muscle was confirmed clinically and by electromyography. Recovery began after 3 months, but mild scapula winging was still evident after 9 months.

Isolated dysfunction of the long thoracic nerve is a well-described but uncommon nerve palsy. Most cases are idiopathic and right-sided, and have been labeled as neuralgic amyotrophy, after the classic series of Parsonage and Turner.[14,15] Reported secondary causes include trauma, external compression (e.g., due to reading with the arm placed behind the neck), surgery involving the thoracic cage, serum or antitoxin injections, systemic lupus erythematosus, and infections, e.g., Lyme disease, infectious mononucleosis, and dengue.[12,14,16-20]

When infections have been implicated as the cause of long thoracic nerve palsies, the latter have almost always started during convalescence.[14] In the 13 cases of nerve involvement due to dengue fever reported by Kaplan and Lindgren, all started several days to 1 month after disease or fever resolution.[12]

19. Monteyne PH,Dupuis MJM,Sindic CJM.N�vrite
du grand dentel� associ�e � une infection par Borrelia burgdorferi.
Rev Neurol 1994; 150:75-77.

>>>Can anyone access the above French citation??<<<

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Melanie Reber
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*** Neuralgic amyotrophy as a presenting feature of infective endocarditis
Postgrad. Med. J. 2000;76;710-711
P English and D Maciver

Neuralgic amyotrophy typically presents with sudden onset of severe unilateral shoulder girdle pain followed by weakness and wasting of some of the C5, C6, and C7 innervated muscles. The long thoracic (nerve roots: C5 predominantly, C6, C7; supplies serratus anterior) and suprascapular nerves (nerve roots: C5; supplies supraspinatus and infraspinatus muscles) are the most commonly affected and involvement of serratus anterior with scapula winging is one of the most consistent signs.[1] Involvement may be patchy and include the trapezius, sternomastoid, and diaphragm.

The right arm is more frequently involved than the left and bilateral involvement is reported to occur in up to one third of patients. There is a male preponderance of between 2 and 11.5:1.[2,3] Diagnosis is clinical, investigations mainly aiding in the exclusion of alternative diagnoses. No treatment is known to affect the long term outlook but steroids may diminish the severity of pain in some cases and full symptomatic recovery of strength occurs in 90% by three years.[2,3]

Hereditary forms of the disorder (hereditary neuralgic amyotrophy, McKusick number 162100 and hereditary neuropathy with liability to pressure palsies, McKusick McKusick number 162500[4]) exist but in sporadic cases the cause is unknown. Both cellular and humoral immune mechanisms have been postulated[5] and there are myriad associations.

The most commonly reported of these are serum sickness and inoculations. Others include pregnancy, viral infections (Epstein-Barr virus, cytomegalovirus, parvovirus B19,[6] HIV seropositivity[7]), malignancy, post-streptokinase,[8] paraproteinaemia,[9] borrelia infections, brucella, IL2/interferon therapy, and the postoperative period.[10] It has not, to our knowledge, been previously reported in association with infective endocarditis. Its temporal association in this case, its hypothesised immune aetiology, and the multiple immunological phenomena associated with endocarditis make infective endocarditis a most plausible cause.

Infective endocarditis is a serious condition associated with multiple immunological phenomena. Prompt treatment may obviate the need for valve replacement and decreases both morbidity and mortality. In this patient's case the diagnosis may have been delayed because the association with neuralgic amyotrophy was not recognised. We suggest that infective endocarditis be added to the list of associations for neuralgic amyotrophy.

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Allison Smith
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They found my lyme after a year of routine testing after I was diagnosed with the B19 Parvovirus over 10 years ago...which by the way is VERY painful if you get it as an adult.

But the past 6 years I kept getting this horrible shoulder pain. I would get a rash on my shoulders, followed by cold/flu like symptoms that seem to never end and I can not for the life of me lift my arms outward or forward.

I kept going to my doctor who said it was just because I had so many kids (lifting them that is). I get that almost monthly. And I too have a clavical that is more pronounced and extrudes on my right side that is more affected my the shoulder pain.

That's interesting. Thanks so much for sharing!

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*** Neuralgic amyotrophy
J M S Pearce
Journal of Neurology Neurosurgery and Psychiatry 2005;76:389

A year later Aldren Turner[7] provided a similar account. The disorder is sometimes named after Parsonage and Turner,[8] who provided further examples. In 66 of their original 136 patients, they found possible precipitating causes that included operations, infections, inoculations, and trauma to remote areas.

Familial, post-infective (for example influenza, coxsackievirus, infectious mononucleosis, Borrelia burgdorferi) and post-vaccination factors have been described, but the aetiology is unknown in many examples. Meuleman et al suggested that Dreschfeld[9] (1885) may have published the first report of hereditary neuralgic amyotrophy, that of a 43 year old woman who had suffered three episodes of painful upper limb weakness and whose sister had suffered seven similar attacks.

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Hi mel

Haven't earned my wings yet [Smile]

I am very thin & don't do much for upper body strength because of my lyme. I think this is why my scapula's stick out so much. Have been very inactive since my last relaspe 4 years ago & have noticed they are sticking out more than ever.

Some times I get pain. But for me I think it's because of my wasting muscles. And my muscles get pulled back there lot.

Don't know if this will helps at all. Not able to read the other posts tonight.

I hear a bell ring...maybe that's my wings coming in [Smile]

Hope you can feel better soon [group hug]


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Hey Klutzo, Allison and Dana,

Thank you each for your input. It seems like many of us are experiencing this in one manner or another. I am so sorry to know that, but at least we can compare notes and experiences.

This sure gets complicated once you start researching, but I think I am finally getting to the ``good stuff'' [Smile]

(too bad much of it is not accessible or is in another language or both)


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Hi Melanie,

I just noticed that my answer to you did not post. Not sure why but anyhow here goes again:

I'm making slow and steady progress. Like you, I feel lucky to be doing as well as I am under the circumstances, 13 year late diagnosis etc.

I feel the best I have in years but I'm not where I want to be yet. So treatment continues

I'm glad you posted about the wings. Its great new info I hadn't come across before.

So thank you and nice chatting.

Wishing you all the best,

DL [Wink]

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This posting has been very useful. I chanced across the site while trying to track down the cause of my Parsonage Turner Syndrome and Kiloh Nevin Syndrome.

I had a cancer (lymphoma) a few years back that came along shortly after a case of lyme disease. Last spring the Parsonage-Turner/Kiloh Nevin happened. It occurred to me that either the cancer or the lyme disease might be the cause.

But can lyme disease manifest itself in such an odd way a few years after the tick bite???

Kind regards,

P.S. There are lots of connections to the winged scapula story that are traceable by using one of the various synonms for Parsonage Turner ... e.g., Neualgic amyotrophy.

P.P.S although the following link has to do with West Nile it almost exactly describes my symptoms

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I have lyme caused muscle wasting. A lyme doc, in my physical exam, looked at the scapular region because he said muscle wasting was most noticeable there. As in, could be detected easier there.

Not sure why, since the asymmetry elsewhere makes the wasting evident too.

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Melanie Reber
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Hey Steven and welcome to LymeNet,

"But can lyme disease manifest itself in such an odd way a few years after the tick bite???"

Most definitely yes. You would be amazed at the various manifestations of this disease and the co-infections most commonly associated with it.

If I were you...I would do more reading here. And then, don't hesitate to ask if we can help answer any other questions, OK?

Hey Lou...nice to see you.
That is really interesting about the comment on scapular muscle wasting. I'm just very sorry that you are having such a difficult time with it.

Have you found anything to help?

Hi there DolphinLady,
You must have snuck in w/out me noticing way back. Didn't want you to think I was ignoring you. [Smile]


Although my right scapula isn't protruding as much as it was when I first posted is still bothering me.

And I am still hoping that it will go away eventually.

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Melanie Reber
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Bringing this old thread back up for further input...

Unfortunately this issue has reemerged with a Bart relapse, so I know things must be connected here too somehow.

I was referred to a PT a few weeks ago, and was told that this most likely has NO connection to an inflamed nerve but was most likely due to my scoliosis and leg length descrepancy.

I let her talk, taking all her insights into consideration and learned the new exercises like a good patient... then realized later on... that while the exercises may help to ease the pain a little... the ONLY thing that actually took away the pain in the past, for me at least, was additional antibiotics!

(on a side note... it saddens me to read Charlie's post here again. I miss him more than I can say. He was a special soul and a good friend. And will never be forgotten by anyone who had the good fortune to know him. I pray he is finally free of pain and enjoying a cold one somewhere special. Love you Charlie...)

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I had constant pain behind my wings, until I went on abx for lyme. Now I have joint pain, but most of my "fibromyalgia" is gone.
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