Working Diagnosis:
Long thoracic nerve palsy

Treatment:
We discussed the gradual healing process of a nerve injury. We recommended a course of physical therapy focusing on strengthening the supportive muscles of the scapula and neck as well as stimulation techniques of the serratus anterior. We did not restrict her from swimming but did discuss modifying to symptom tolerance.

Outcome:
She was referred to physical therapy. In the interim, she completed her graduate school internship, moved, and was lost to follow-up.

Author's Comments:
The long thoracic nerve originates from the ventral rami roots of C5, C6, and C7. It is a pure motor nerve and supplies only the serratus anterior muscle that protracts and stabilizes the scapula and also serves as an accessory inspiratory muscle. Long thoracic nerve palsy can be the result of acute or chronic repetitive trauma, or brachial neuritis. Proposed mechanisms include impingement of the long thoracic nerve between the clavicle and second rib as well as traction with simultaneous cervical spine movement with arm elevation and extension. It is reported in tennis, archery, basketball, golf, gymnastics, and wrestling. It has also been observed in backpacking. In this patient with underlying scoliosis and long-time swim training we suspect that these led to asymmetric dyskinesia and predisposed her to such an injury. Long thoracic nerve palsy can be treated with a scapular winging brace. Surgical treatment is indicated for patients who have persistent symptoms and no EMG changes despite two years of therapy. Transfer of the pectoralis major or minor to the scapula can provide it with support.

Editor's Comments:
Compression of the long thoracic nerve is the thought to be the mechanism of injury that occurs from carrying heavy objects (like a backpack) across the shoulder. In addition, sports in which there is repetitive motion in an overhead, outstretched position (such as in swimming) can potentially stretch the nerve or cause traction and injury to the nerve. In most cases where the injury occurs from carrying a heavy object or repetitive activity, symptoms will resolve in 6-24 months. Avoiding the precipitating activity or limiting activity which exacerbates symptoms are the key to resolution. Physical therapy is beneficial during this time as well. Surgery is considered for those who fail to respond to conservative measures or cases where significant nerve damage is detected on EMG.

References:
DeLee & Drez's Orthopedic Sports Medicine, 4th edition, p. 661-2.

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