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]

• Winged Scapula

  It is known as winged scapula as the medial (inner) border of the scapula can appear to be wing-like on the back. [sportsinjuryclinic.net]

  What is a Winging Scapula? A winging scapula is a shoulder injury or condition in which the scapula or shoulder blade sticks out at the back, particular when lifting the arm up or pushing against something. [liverpoolshoulderclinic.com]

  A winged scapula is an injury in which the scapula (shoulder blade) sticks out in the back. Sports injuries or any trauma to the neck and shoulder can result in a winged scapula. [nerve.wustl.edu]

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

• 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

  Campbell WW (ed) (2005) Peripheral Neuroanatomy and Focal Neuropathies. In: Campbell WW (ed) DeJong’s The Neurologic Examination. 6th edition. Harper and Row Publisher Inc, pp 548–564 Google Scholar 12. [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]

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]

BACKGROUND: Scapular winging resulting from long thoracic nerve palsy is uncommon but debilitating, and the choice of surgical treatment is inconsistent. [ncbi.nlm.nih.gov]

Surgery, vol. 24, no. 7, pp. 1028-1035. https://doi.org/10.1016/j.jse.2014.12.014 @article{11d0a4e634f94d84bb06699bb34a3178, title = "A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy", abstract = "Background: In the treatment [uthealth.influuent.utsystem.edu]

Treatment of LTN Palsy Physiotherapy is the mainstay of treatment. Input from a neurologist is required in certain cases. [nerveclinic.co.uk]

The treatment of long thoracic nerve palsy depends upon the level of nerve damage that may range from acute injury to severe damage. [mistysurimd.com]

A combination of treatment is often required for the best results. [laserneuropathypaintreatment.com]

The occurrence of a prolonged interval between onset of symptoms and institution of therapy was found to adversely affect prognosis. [ncbi.nlm.nih.gov]

The prognosis for long thoracic neuropathy is quite variable with some authors reporting spontaneous recovery while other cases fail to respond to any treatment, including surgery. Initial management is typically conservative. [chiroup.com]

The indications for operation seem meager in a condition in which there is such a relatively good prognosis on a conservative regimen. [oandplibrary.org]

It is conceivable that the fact that the parties relied on Keller's incorrectly diagnosed injuries rather than her correctly diagnosed injuries would not rise to the level of a material fact, were the treatment, prognosis, and symptoms of the injuries [caselaw.findlaw.com]

It was found that those patients whose lesions were due to acute trauma had only partial or no recovery of serratus function, while those with infectious, toxic, allergic or idiopathic etiologies had partial or complete recovery. [ncbi.nlm.nih.gov]

Unprovable etiologic contentions were frequent. [medlit.info]

Thirteen were of unknown etiology. In addition. Hansson ascribed thirteen cases to exposure to cold. [oandplibrary.org]

You could also look for the following: Role of scapular stabilizers in etiology and treatment of impingement syndrome. Schmitt L, Snyder-Mackler L. J Orthop Sports Phys Ther. 1999 Jan;29(1):31-8. [physicaltherapy.rehabedge.com]

Scapular winging has also been classified anatomically according to whether the etiology of the lesion is related to nerve, muscle, bone, or joint disease ( Table 18.1 ). [clinicalgate.com]

[…] shoulder and upper arm level, left arm, initial encounter A- initial encounter D- subsequent encounter S- sequela Scapular Winging ICD-9 907.4 (Late effect of injury to peripheral nerve of shoulder girdle and upper limb) Scapular Winging Etiology / Epidemiology [eorif.com]

Midha R (1997) Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 40;1182–1189 PubMed CrossRef Google Scholar 6. [link.springer.com]

INTRODUCTION: Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. [ncbi.nlm.nih.gov]

PubMed Google Scholar Lundborg G, Dahlin LB: The pathophysiology of nerve compression. Hand Clin. 1992, 8 (2): 215-227. PubMed Google Scholar Copyright © Nath et al; licensee BioMed Central Ltd. 2007 [bmcmusculoskeletdisord.biomedcentral.com]

[…] deltoid Sensory: C5 and C6 dermatomes No protective coverings (epineurium and perineurium) on the nerves after they exit the foramina Increased risk of stretch injury at neck and shoulder regions Contusion or compression of upper trunk at Erb point Pathophysiology [aafp.org]

Physiotherapy will be needed following surgery to help re-train your muscles to prevent any future shoulder problems occurring. [physio.co.uk]

Additional studies are needed to confirm the conclusion that the device's benefits derive from proprioceptive feedback that prevents muscle overuse or overstretch and from its transfer of contralateral shoulder protraction force to the affected scapula [ncbi.nlm.nih.gov]

Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎ [books.google.es]

If memory serves, this is the article that incorporated a brace to support the scapula and prevent winging in active shoulder exercises. _____________________________ Charles Sheets PT OCS Dip MDT Re: Long thoracic nerve palsy - February 15, 2006 9:52 [physicaltherapy.rehabedge.com]

Eliminating muscle spasms leads to a better life experience overall and prevents nasty flare ups before they even start. It took ten years to realize this and hopefully others can learn from this. [chrisshort.net]

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.