Botox Update & After Cast Removal Question

[katep]

If we had started seeing Dr. Kozin (or a number of other doctors around the country) when his 3-month MRI showed dramatic glenoid malformation and the beginnings of posterior subluxation, this procedure would probably have been recommended. Perhaps he would have better function now if his external rotators, which worked when his capsule release relieved the dislocation, had been given a chance to develop normally, instead of being mechanically paralyzed for 6, 8 or 10 months!

I'm very excited to see docs taking such a proactive approach to the shoulder joint development. They are starting to understand that the shoulders and hips have so much in common - once the joint gets going on the wrong foot (from birth due to hip dysplasia or slow nerve recovery due to BPI) it needs help to get things "back on track".

Unfortunately, our son's bad shoulder was missed until it was too late for this non-invasive approach to be able to fix it. I hope and pray it works for Kanaan. Please keep us informed!

Kate

[KMD & KMD]

Thanks for your detailed explanation! It sounds like a great procedure. You are fortunate to be in good hands with the opportunity of preventing a surgery. Please keep us posted on your progress.

Do you know if this can only be done for the kids that have not needed the primary surgery?

Kim

[chrystalhurst]

My assumption is YES b/c my son did not need primary surgery.

Chrystal

[chrystalhurst]

Kate,

can you explain why shoulder sloping occurs. I think I get scapular winging but I think I see the beginnings of shoulder sloping in my son and am curious about what causes it.

Also

[katep]

For our son, the shoulder sloping was caused by his supraspinatus starting to work. He was using different muscles to stabilize the joint once the internal rotation contracture had been relieved, but then we needed to stretch him into *adduction* (arm to the side) in order to prevent contracture of the supraspinatus. This resolved the issue very quickly and effectively.

The supraspinatus is a muscle that connects the top of the scapula to the humerus. If the scapula is held fixed (by other muscles) it works to lift the upper arm into abduction. If the upper arm is fixed it rotates the scapula so that it is sloped downward toward the shoulder. So when the supraspinatus contracts against excessively tight lats holding the arm to the side or with weak scapula stabilizing muscles, it will cause a shoulder blade that "rides up" so that there is a sloping shoulder.

When a muscle first starts functioning again, it is weak, less effective, and the child doesn't have as much voluntary control of it. The natural physical response to this is for the muscle to stay "on" much of the time. Any muscle is strongest when it is half-contracted; it is weakest either fully extended or fully contracted. So a weakened muscle tends to only be effective near it's middle range - if it fully extends, it may not have enough strenth to move the joint.

This same way, a child whose biceps have just come in will suddenly keep the arm flexed nearly all the time, so that the weakened biceps are able to flex the joint against gravity and against the stronger triceps.

This half-contraction will convert to shortened, fibrotic muscle (ie., a contracture) if the muscle is allowed to behave this way for too long. This is the body's way of maximizing the effectiveness of the muscle. It is important to help each newly innervated/activated muscle "learn" to release and extend. This also allows the muscle to exercise in the extended state, which helps strengthens it.

Personally, I believe that scapular winging often has a similar cause. The new muscles that are now trying to stabilize the shoulder joint are still not fully strong enough and tend to maintain a constant, half-flexed state. Just as the middle deltoid and supraspinatus can pull the scapula into a sloping position, the external rotatoes (infraspinatus and teres minor) can pull the scapula into winging. It's important to passively range all the muscles in the shoulder (as soon as the doctor allows it) in order to try to maintain the ability to extend of all these newly working muscles.

Kate

[chrystalhurst]

Tightness in the supraspinatus is exactly what I think we are facing right now. It's amazing how much common sense plays a role in knowing what to do for your child. All I was told by our doctor between now and our two week followup was to do gentle ROM. I had to notice on my own, the tightness of the shoulder and use common sense to stretch his arm to his side. Thanks for the affirmation.

[katep]

bumping up for Sharon.

[admin]

Kate,

You said:

"For our son, the shoulder sloping was caused by his supraspinatus starting to work. He was using different muscles to stabilize the joint once the internal rotation contracture had been relieved, but then we needed to stretch him into *adduction* (arm to the side) in order to prevent contracture of the supraspinatus. This resolved the issue very quickly and effectively."

In your case, what was very quickly and effectively?

I know everyone is different, just trying to hang my hope on something.

Chrystal

[katep]

Chrystal,

Sorry, I never saw your question.

With stretching and massage, Joshua's upward sloping shoulder was mostly resolved in about two months, and we didn't start actively working on it until he'd been out of his ACR cast for about 2 months (so it was better about 4-5 months after surgery). It still pops up occasionally, when the muscles kick in all at once or unbalanced, but it doesn't *stay* up all the time anymore.

I hope Kanaan is doing better! We are due for an update

Kate