Scapular Winging (Serratus Anterior Palsy, Long Thoracic Nerve Injury)

Description

Scapular winging is an uncommon nerve condition that causes pain and sometimes weakness in the shoulder. It involves injury to the long thoracic nerve in the back near the shoulder blade. The long thoracic nerve runs from the neck along the chest wall to the serratus anterior muscle. This nerve can be stretched as the result of a fall on the shoulder while the neck is bent toward the other shoulder, it can be the result of repetitive injury, or it may occur without injury; sometimes it is associated with a viral illness. Injury to this nerve results in weakness of the serratus anterior muscle, causing the shoulder blade (scapula) to pull away from the chest wall with attempted shoulder movement, called winging. The scapula is the base from which the shoulder functions. With winging, the shoulder works off a weak base, making shoulder function weak as well.

Common signs and symptoms

• Pain and discomfort, usually a burning or dull ache, that is poorly localized, often in the back of the shoulder or shoulder blade

• Heaviness or fatigue of the arm

• Loss of power in the shoulder

• Difficulty raising the arm above shoulder level

• Pain in the back when sitting in a chair with a high back as a result of the scapula hitting the back of the chair

• A bump in the back of the shoulder at the scapula that is more obvious when trying to do push-ups or when reaching forward overhead

Causes

• Viral illness

• Repetitive stretch injury

• Falling on the shoulder with the head and neck stretched away from the shoulder

Factors that increase risk

• Contact sports

• Sports that require overhead throwing-type activities, such as baseball, volleyball, and tennis

• Poor physical conditioning (strength, flexibility)

Preventive measures

• Appropriately warm up and stretch before practice and competition.

• Maintain appropriate conditioning that includes shoulder flexibility, muscle strength, and endurance training.

Expected outcome

Recovery from scapular winging is usually complete and spontaneous within 18 months. Surgery is rarely necessary.

Possible complications

• Permanent weakness of the shoulder, particularly in lifting power and when working with the arm overhead

• Persistent pain in the shoulder

• Stiffness of the shoulder

• Increasing weakness of the extremity

• Disability and inability to compete

General treatment considerations

Initial treatment consists of rest from the offending activity and nonsteroidal antiinflammatory medications to reduce inflammation and pain. The nerve usually spontaneously recovers, although this may take from 12 to 24 months. Performing shoulder range of motion exercises while waiting for nerve recovery is of paramount importance. Referral to a physical therapist or an athletic trainer may be recommended for further treatment, including ultrasound and other modalities. If this conservative treatment is not successful, surgery may be necessary to replace the lost function of the serratus anterior muscle with the function of another muscle. Such surgery is considered a salvage operation; it is not meant to allow the athlete to return to sports but to allow pain-free activities of daily living.

Medication

• Nonsteroidal antiinflammatory medications, such as aspirin and ibuprofen (do not take for 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician, and contact your doctor immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

• Pain relievers may be prescribed as necessary, usually only after surgery. Use these only as directed, and take only as much as you need.

Heat and cold

• Cold is used to relieve pain and reduce inflammation for acute and chronic cases. It should be applied for 10 to 15 minutes every 2 to 3 hours as needed and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

Figure 1

From Rockwood CA, Jr., Matsen FA, III: The shoulder, ed 2, Philadelphia, 1998, W.B. Saunders, p 136.

• Heat may be used before performing stretching and strengthening activities prescribed by your physician, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

When to call your doctor

• Symptoms get worse or do not improve in 6 weeks despite treatment.

• New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

Range of Motion and Stretching Exercises

Scapular Winging

These are some of the initial exercises you may use to start your rehabilitation program, until you see your physician, physical therapist, or athletic trainer again, or until your symptoms resolve. Please remember:

• Flexible tissue is more tolerant of the stresses placed on it.

• A gentle stretching sensation should be felt.

Range of motion shoulder pendulum

1. Lean forward at the waist, letting your weak arm hang freely. Support yourself by placing your opposite hand on a chair, table, or counter as shown.

2. Sway your whole body slowly forward and back. This will cause your arm to move. Let your arm hang freely, and do not tense it up.

3. Repeat the motion above, swaying side to side and moving in circular patterns, clockwise and counterclockwise.

4. Do ____ repetitions in each direction.

5. Repeat this exercise ____ times, ____ times per day.

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Birth Control and Sports Biceps Tendon Subluxation Exercise-Induced Bronchospasm Dislocation or Subluxation Meniscal Cyst Clavicle Fracture (Distal)

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree