Shoulder pain and weakness are common in athletes, but not all causes are due to rotator cuff or labral injuries. One less frequent but essential condition is long thoracic nerve injury, which can result in weakness of the serratus anterior muscle and a “winged scapula.” In athletes, recognising long thoracic nerve palsy early is essential, as it affects both performance and long-term shoulder function.
What Is the Long Thoracic Nerve?
The long thoracic nerve arises from the cervical nerve roots (C5–C7) and supplies the serratus anterior muscle. This muscle plays a critical role in stabilising the scapula against the rib cage and enabling smooth overhead movement. Damage to the nerve results in weakness of the serratus anterior, leading to abnormal scapular movement (scapular dyskinesis). We often see a winged scapula. This presentation is usually described as long thoracic nerve palsy.
Damage can occur due to inflammation of the nerve (also called brachial neuritis) or injury from surgery or blunt or sharp trauma to the chest wall. Sometimes, a muscle disease called myopathy can lead to long thoracic nerve palsy.
Symptoms of Long Thoracic Nerve Injury
Athletes with long thoracic nerve injury may present with:
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Pain around the shoulder or scapula, often vague in location
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Weakness during overhead or pushing movements
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Visible “winging” of the scapula, particularly when pushing against a wall. These changes should be differentiated from a ‘flipped’ shoulder blade that occurs in spinal accessory nerve injury.
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Fatigue or heaviness in the shoulder with prolonged activity
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Reduced performance in sports requiring overhead activity, such as swimming, tennis, and volleyball
Clinical Presentation
On examination, the hallmark of long thoracic nerve palsy is a winged scapula. This becomes more obvious when the athlete pushes forward against resistance, such as performing a wall push-up. The scapula lifts away from the rib cage. Often, the doctor will go against the arm as the patient attempts to raise it, leading to an increase in scapula winging.
Investigations
The diagnosis is primarily clinical, but additional investigations can help confirm and rule out other causes of scapular winging:
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Nerve conduction studies: These can confirm long thoracic nerve injury by demonstrating denervation of the serratus anterior. Additionally, repeated tests can confirm improvement in the muscle’s innervation.
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MRI of the shoulder, cervical spine and scapula: Useful for excluding structural causes such as cervical nerve compression or shoulder joint pathology. Images of the chest wall reveal atrophy and wasting of the serratus anterior muscle.
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Ultrasound: Can assess the serratus anterior muscle bulk and sometimes visualise nerve continuity.
Treatment of Long Thoracic Nerve Injury
Management of long thoracic nerve palsy is typically conservative, especially in athletes, as spontaneous recovery is common.
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Rest and activity modification: Reducing overhead or repetitive pushing activities in the acute phase.
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Physiotherapy: Focus on scapular stabilisation, strengthening compensatory muscles (trapezius, rhomboids), and correcting biomechanics.
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Pain management: NSAIDs or supportive therapy for symptomatic relief.
In cases where recovery does not occur after 12–18 months, surgical options may be considered, such as nerve decompression or grafting, muscle transfer (e.g., pectoralis major), or scapulothoracic fusion in cases that are longstanding and severe.
Oulook of Long Thoracic Nerve Injury
Most athletes with long thoracic nerve injury improve with conservative management, though recovery may take 6 months to 2 years. Early recognition and rehabilitation are crucial for restoring function and preventing long-term shoulder issues.
The cause of the injury determines the outlook. Studies suggest that trauma-induced palsy often takes less than 6 months to recover, while inflammatory causes can take longer than 2 years. One study showed that 30% of patients still had signs of weakness at 2 years.
Final Word from Sportdoctorlondon about Long Thoracic Nerve Injury
Although uncommon, long thoracic nerve injury is an essential cause of shoulder weakness and a winged scapula in athletes. Diagnosis relies on clinical assessment, supported by nerve conduction testing. With rehabilitation and appropriate management, most cases of long thoracic nerve palsy resolve, allowing athletes to return to full participation in sports.
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