The long thoracic nerve is responsible for supplying the serratus anterior muscle, whose function is to maintain the scapula in a balanced position while upper extremity movements are performed [1]. A case of long thoracic nerve palsy (LTNP) corresponds to a weakened serratus anterior muscle [2] [3]. The most easily observed manifestation related to the long thoracic nerve palsy is winging of the scapula (a protrusion of the scapula from the back) [1] [4].

Patients are mainly adults which are between 20 and 60 years old. They present with marked scapular winging and inability to elevate the arm or push efficiently [3]. Loss of normal shoulder mobility is the primary complaint of the affected patients, that can also be followed by a feeling of instability. Athletes experience a restriction in their exercising potential, whereas non-athletic patients report a significant difficulty in performing everyday tasks, such as getting dressed or pushing. Pain in the shoulder region is also experienced when the back is resting upon a firm surface.

Long thoracic nerve palsy and subsequent paralysis of the serratus anterior muscle is a medical condition encountered frequently which, in general, leads to a considerable disability in everyday activities [5] [6]. Tendonitis may also arise in the affected shoulder joint, and so may brachial plexus radiculitis, adhesive capsulitis, and subacromial impingement [7]. Paresthesia of the shoulder girdle is another possible symptom [8].

• Pleural Effusion

  Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome [mistysurimd.com]

• Ulcer

  After years of taking a variety of NSAIDs like ibuprofen and naproxen multiple ulcers have formed in my stomach. Turmeric has been known to have anti-inflammation effects. I also take fish oil for its joint and heart health benefits. [chrisshort.net]

• Red Eye

  6 March 2005 Meaning of each component Y Cb Cr does not exist Image compression mode 4 APEX exposure bias 0 Maximum land aperture 3 APEX (f/2.83) Metering mode Pattern Light source Unknown Flash Flash fired, strobe return light detected, auto mode, red-eye [commons.wikimedia.org]

• Winged Scapula

  This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function. [ncbi.nlm.nih.gov]

  Damage of the long thoracic nerve may result in abnormal protruding of the scapula or shoulder blade, commonly known as winged scapula. [mistysurimd.com]

  This odd positioning has led to the name “winged scapula.” Shoulder pain and loss of movement occur as the imbalance in muscle functioning causes stress to the muscles of the shoulder. [chrisshort.net]

  Winged Scapula Exercises A winged scapula is usually as a result of weakened shoulder blade stabilisers, especially the Serratus Anterior. The serratus anterior is also known as the punching muscle. [sportsinjuryclinic.net]

• Suggestibility

  Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P .009) and had lower active forward elevation (P CONCLUSIONS: Level V and III evidence suggests [ncbi.nlm.nih.gov]

  Also, if you have any suggestions on exercises that I can give him for strengthening- it would be very helpful. [physicaltherapy.rehabedge.com]

• Distractibility

  Spurling, -Distraction, -ULTT and he denies any numbness or tingling. I am currently applying NMES to his serratus ant while he does a scapular stab program. [physicaltherapy.rehabedge.com]

  The initial trauma caused L1-L2 flexion-distraction injury. The patient was first treated by posterior spinal fusion and instrumentation from T11 to L3. Figure 2 Nine months after the primary surgery. [link.springer.com]

• Impulsivity

  Once the nerve recovers and neural impulses to the serratus anterior resume, a continued strengthening program should be maintained to facilitate full function of the serratus anterior allowing normal resumptions of activities during daily living and [digitalcommons.hope.edu]

• Peripheral Neuropathy

  In: Dyck PJ, Thomas PK, Griffin JW, et al (eds) Peripheral Neuropathy, vol 2. 3rd edition. WB Saunders, Philadelphia, p 911 Google Scholar 10. Narakas AO (1988) Pain syndromes in brachial plexus injuries. [link.springer.com]

• Neck Stiffness

  He did occasionally experience mild right periscapular pain and right-sided neck stiffness, however. His past medical history was unremarkable except for an allergy to acetylsalicylic acid. He took no medications. [neupsykey.com]

• Dysesthesia

  He did not complain of decreased sensation, paresthesia, or dysesthesia in the periscapular area. He did occasionally experience mild right periscapular pain and right-sided neck stiffness, however. [neupsykey.com]

Long thoracic nerve palsy is typically diagnosed clinically; even though electromyography can provide a clear confirmation of the diagnosis, it brings desired results only after 6 weeks from the initial symptomatology.

The following clinical findings constitute sufficient evidence for the existence of LTNP:

• Inability to fully flex the upper limb forward
• Scapular winging, visible from the lateral or posterior side
• Asymmetry of the scapulae during arm elevation, viewed from the posterior side.
• Positive scapular compression test: pressure is applied on the scapula from the posterior side, while the thorax is stabilized from the anterior side with the other hand. The patient is asked to flex the presumably affected arm forward. The test is compatible with long thoracic nerve palsy when this maneuver alleviates pain and enables better movements.
• Manual muscle testing (MMT) and shoulder joint range of motion (ROM) should also be performed [8].

Radiographs are not expected to illustrate abnormalities in a case of LTNP, except for an occasional, slight discrepancy in the positioning of the scapulae. They are obtained in order to exclude the possibility of a scapular mass. Electromyography is carried out at least six weeks after the symptoms have developed and offers the final confirmation of LTNP.

• Multiple Ulcerations

  After years of taking a variety of NSAIDs like ibuprofen and naproxen multiple ulcers have formed in my stomach. Turmeric has been known to have anti-inflammation effects. I also take fish oil for its joint and heart health benefits. [chrisshort.net]

• Pleural Effusion

  Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome [mistysurimd.com]

1. Hollinshead WH. Anatomy for Surgeons. 3. Harper and Row; 1998.
2. Bertelli JA, Ghizoni MF. J Bone Joint Surg Am. 2005. pp. 993–998.
3. Gozna ER, Harris WR. Traumatic winging of the scapula. J Bone Joint Surg Am. 1979;61:1230–1233.
4. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res. 1999;368:17–27.
5. Gregg JR, Labosky D, Harty M, et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979;61:825–832.
6. Pugliese GN, Green RF, Antonacci A. Radiation-induced long thoracic nerve palsy. Cancer. 1987;60:1247–1248.
7. Kuhn JE, Plancher KD, Hawkins RJ. Scapular Winging. J Am Acad Orthop Surg. 1995;3:319–325.
8. Shiro Nawa. Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer. J Brachial Plex Peripher Nerve Inj. 2015;10(1):e57–e61.