How to treat long thoracic nerve injury: a case report

Ann Cools, From Practice / Wednesday, September 29th, 2021

Lena, 29 years old, is a midwife, active in assisting home births. Recently, she assisted a long-term home birth, and stayed in the same position, hanging over a bath with both arms, monitoring the baby’s heartbeat for nearly 3 hours. When coming home after a very tiring working day, she woke up the next morning with pain in the scapular area, being unable to lift up her arm above shoulder height. She also experienced an “odd” feeling sitting with her back against the backrest of a chair, feeling her shoulder blade was “popping out”. She consulted a medical doctor, specialized in shoulder pathology, and after an EMG-examination, a long thoracic nerve injury was confirmed. On clinical examination, patient reported pain during active elevation (mainly in the periscapular area), scapular dysfunction was apparent during active elevation (video 1), passive ROM was normal, and strength deficits were found for abduction and external rotation.

Scapular dysfunction during active elevation

A long thoracic nerve injury results in paralysis of the serratus anterior, and hence in obvious scapular dysfunction, mainly when elevating the arm, since the force couples around the scapula are out of balance. Usually recovery takes 1 to 3 years, and the final results or limitations are rather unpredictable. Education and information about the natural course of the injury are extremely important, in order to provide confidence to the patient. During the healing process, exercise therapy should be home-based, with a minimal amount of physiotherapy visits, easy to perform at home (not too much material), and not more than 3-4 exercises, in order to increase adherence of the patient to his/her daily exercises and to avoid that the patient would be quickly tired of the exercises and would drop out early.

The main goal of the exercises is to “keep the shoulder moving” with a minimal visible scapular dysfunction, and not primarily to focus on restoration of isolated serratus anterior strength. Exercises should be selected by trial and error, focusing on normal scapular position or movement, as much as possible. The videos 2-5 illustrate some examples of exercises performed with this patient.

Exercise 1: Resisted overhead shrug
Exercise 2: Bilateral wall slide with resisted external rotation
Exercise 3: Resisted bilateral external rotation in neutral
Exercise 4: 3-staged horizontal abduction + external rotation

Today, 6 months later, patient has returned to work, has no pain anymore, nearly full active elevation, however still with visible scapular dyskinesis, and the irritating feeling when touching her back against a chair or wall.

(informed consent from patient was provided)

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