United Brachial Plexus Network, Inc.

Hello. My son had a ACR surgery when he was almost 2. Immediately after the surgery I noticed that his shoulder was drooping down which wasn't the case before he had the surgery. The doctors and therapists told me to give it some time but my son is 4 and a half now and still has the droopy shoulder. Although his ROM has improved since having the surgery, I am still concerned about his droopy shoulder. Has anyone else had this same problem? If so, is there anything that can be done about it? Opinions needed!! Thanks!

Our son had the same thing after ACR surgery and for a short period afterward. If you look at your son closely, you will probably see the angle between the upper arm and the top line of the scapula is larger than the normal 90 degrees when his arm is all the way down at his side (angle of the "L" between the top of his shoulder/scapula and his upper arm). I personally think this results from an overactive deltoid (or maybe supraspinatus) trying to stabilize the odd-feeling shoulder joint right after surgery. The muscles that govern that angle (middle deltoid and supraspinatus) are not going to full extension but instead partially holding on which causes the scapula to tip up. The result can either be the scapula rising up into the neck area or the shoulder sloping down towards the upper arm. Either compensation allows for shortened muscles between the top of the scapula and the upper arm.

For us, I noticed this right after surgery and started an active stretching program involving stabilizing our son's scapula in position and stretching his arm down to his side. For your son, the muscle shortening may be more fixed at this point. I would check if he actually has the passive ROM to bring his arm all the way down to his side without his scapula tipping up or dropping down to maintain an angle larger than 90 degrees. If he can, then his body is actively not releasing these muscles most of the time but they are not mechanically shortened yet. If he doesn't have the passive ROM, you might have some success with stretching but it will be harder.

HOWEVER... it is important to note that some children who have this sloped shoulder also have better overhead abduction. Our son does not have abduction above about 100 degrees. It is possible that a shortened deltoid/supraspinatus may actually be beneficial in achieving overhead motion with a weakened BPI arm. What I mean is, that bit of shortening of the muscle may actually make it easier for the other muscles to fully raise up the arm, sort of like how a shortened biceps can actually give a weak biceps a better mechanical advantage. The Triangle Tilt surgery, for instance, seems to sometimes fix this part of the problem - some doctors believe this happens from temporarily putting the deltoid out of commission because it is detached/reattached to the scapula and/or reattached in a more relaxed position essentially lengthening the muscle. But most children who have that surgery temporarily lose overhead along with losing the "sloped shoulder" and many don't actually regain overhead until the shoulder starts sloping again (ie the deltoid again gets short). I wonder if botox of the muscle would work in a similar way without surgery, helping to stretch out the tightened muscles and assisting the shoulder in learning to stabilize without an overactive deltoid and/or supraspinatus. But the thought also is scary for risk of shoulder subluxation... Suffice it to say, it appears to be a very complicated question and not all the answers are in.

Kate

Kate, you have just explained the question I have had since Alannah was 2 - She has the droopy shoulder, however, she could not have any better function as far as overhead, behind the back, etc - guess there is still not a sure fix for this injury-