Rapid Recovery After Thoracic Outlet Decompression in a Series of Adolescent Athletes With Chronic Atraumatic Shoulder-Girdle Pain, Scapular Winging/Dyskinesis, and Normal Electrodiagnostic Studies

Spontaneous shoulder-girdle pain and scapular winging/dyskinesis can be caused by several neuromuscular disorders identifiable by electrodiagnostic studies (EDX). We describe a group of adolescent athletes with this clinical presentation but normal EDX, followed by later development of neurogenic thoracic outlet syndrome (NTOS). We identified adolescent patients referred for the evaluation of NTOS who had a history of chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX. Each was refractory to conservative management and underwent supraclavicular decompression and brachial plexus neurolysis for NTOS. Functional disability was quantified by Disability of the Arm, Shoulder, and Hand (QuickDASH) scores. There were five female patients with a mean age at symptom onset of 14.2 ± 0.4 years, including spontaneous severe pain in the shoulder, scapula, and arm, along with prominent scapular winging/dyskinesis (Table). EDX were normal, and symptoms had persisted for 18.9 ± 4.0 months before referral, with pronounced upper extremity disability (mean QuickDASH, 54.6 ± 6.9). By 3 months after surgical treatment for NTOS, all five patients experienced near-complete symptom resolution, including scapular winging/dyskinesis, with markedly improved function (mean QuickDASH, 2.2 ± 1.3) and a return to normal activity (Fig). A subset of patients with chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX may develop dynamic brachial plexus compression characteristic of NTOS, exhibiting an ischemic “Sunderland-zero” nerve conduction block for which surgical decompression can result in rapid and substantial clinical improvement. The presence of surgically treatable NTOS should be considered for selected patients with longstanding scapular winging/dyskinesis who fail conservative management.TablePresenting characteristics, diagnostic findings, and surgical treatmentPatient No.12345Mean ± SEInitial presentation Age, years131415131514.2 ± 0.4 BMI, kg/m220.022.119.821.132.323.1 ± 2.3 Sport(s)TennisBasketball/soccerSoftballBasketballBasketball/golf Dominant sideRightRightRightLeftRight Symptoms sideRightRightRightRightRight Initial painShoulder/scapula/armShoulder/scapulaShoulder/anterior chestShoulder/armShoulder Scapula wingingYesYesDyskinesisDyskinesisDyskinesis Steroid RxYesYesNoNoNo EDX studyNormalNormalNormalNormalNormal Interval, monthsa12.34.07.811.86.78.5 ± 1.6Diagnosis of NTOS Age, years141517161615.7 ± .0.5 Symptoms, months12.58.425.230.318.318.9 ± 4.0 Pain VASb5/109/107/108/106/107.0 ± 0.7 ParesthesiaYesYesYesYesYes MedicationsNoneNaproxen, GbNoneTylenol, IBPNone QuickDASH527348346654.6 ± 6.9 SC tenderc2+/31+/31+/31+/32+/31.4 ± 0.2 PM tenderc1+/31+/30/31+/32+/31.0 ± 0.3 EAST, secondsd4030180180180122 ± 36 # Dx criteriae11/1411/1410/149/1410/1410.2 ± 0.4Surgical treatment ASM Wt, g897787.8 ± 0.4 MSM Wt, g7451176.8 ± 1.2 Bone anomalyWide C7NoneNoneNoneNone PMT includedYesYesNoYesYes OP time, minutes174161141152163158 ± 6 LOS, days433543.8 ± 0.4ASM, Anterior scalene muscle; BMI, body mass index; CORE-TOS, Consortium for Research and Education on Thoracic Outlet Syndrome; Dx, diagnostic; EAST, 3-minute elevated arm stress test; EDX, electrodiagnostic; Gb, gabapentin; IBP, ibuprofen; LOS, length of hospital stay; MSM, middle scalene muscle; NTOS, neurogenic thoracic outlet syndrome; OP, operation; PM, pectoralis minor; PMT, pectoralis minor tenotomy; QuickDASH, 18-item form of the Disability of the Arm, Shoulder, and Hand survey; Rx, treatment; SC, supraclavicular; SE, standard error of the mean; VAS, visual analog scale; Wt, resected specimen weight.aInterval from symptom onset to the EDX study.bVAS scaled from 1 to 10 for the patient-rated average intensity of pain.cThe intensity of localized tenderness to palpation scaled from 0 to 3+, as rated by the examining physician.dTime that the patient was able to continue the EAST.eThe number of the 14 possible CORE-TOS diagnostic criteria for NTOS that were present for each patient. Open table in a new tab