26/07/2026
⚡ Winging Scapula? Don't Ignore the Long Thoracic Nerve
Shoulder pain and difficulty lifting the arm are often blamed on a rotator cuff injury or shoulder impingement. But when the scapula protrudes like a wing, the real problem may be Long Thoracic Nerve (LTN) Palsy—an uncommon yet frequently overlooked peripheral nerve injury.
Failure to recognize this condition can lead to persistent shoulder dysfunction and delayed recovery.
🦴 What Is the Long Thoracic Nerve?
The long thoracic nerve arises from the C5, C6, and C7 nerve roots of the brachial plexus.
It supplies the serratus anterior muscle, which stabilizes the scapula against the rib cage during shoulder movement.
When the nerve is injured, the serratus anterior becomes weak or paralyzed, resulting in medial scapular winging and impaired overhead arm function.
⚙️ Common Causes
• Repetitive overhead activities (throwing, swimming, weightlifting)
• Heavy backpack use
• Direct trauma to the shoulder or chest wall
• Sports injuries
• Viral neuritis (Parsonage-Turner syndrome)
• Surgical injury (axillary, thoracic, or breast surgery)
• Motor vehicle accidents
🚩 Typical Symptoms
✔️ Shoulder pain followed by weakness
✔️ Prominent winging of the scapula
✔️ Difficulty reaching overhead
✔️ Rapid fatigue during pushing activities
✔️ Weakness while performing push-ups
✔️ Reduced athletic performance
🩺 Clinical Examination
✅ Wall Push-Up Test
Ask the patient to perform a wall push-up.
Medial scapular winging becomes more prominent due to serratus anterior weakness.
✅ Scapular Assistance Test
Manual stabilization of the scapula often improves shoulder elevation and reduces symptoms.
✅ Electromyography (EMG)
Confirms long thoracic nerve dysfunction and helps assess severity.
✅ Ultrasound
May demonstrate serratus anterior muscle atrophy and exclude other shoulder pathology.
⚠️ Commonly Misdiagnosed As
❌ Rotator Cuff Tear
❌ Shoulder Impingement Syndrome
❌ Frozen Shoulder
❌ Cervical Radiculopathy
❌ Trapezius Muscle Weakness
💡 Evidence-Based Management
Conservative Treatment
✔️ Activity modification
✔️ Serratus anterior activation exercises
✔️ Scapular stabilization training
✔️ Postural correction
✔️ Progressive strengthening
✔️ Neuromuscular re-education
Many patients recover gradually over 6–24 months, depending on the cause and severity.
Surgical Options
Persistent paralysis without recovery may require:
• Long thoracic nerve decompression
• Nerve transfer or grafting
• Muscle transfer procedures (selected chronic cases)
📌 Clinical Pearl
If a patient has:
⚠️ Shoulder pain
🪽 A winging scapula
💪 Difficulty pushing or reaching overhead
Don't focus only on the rotator cuff.
Evaluate the Long Thoracic Nerve and serratus anterior muscle. Early diagnosis and targeted rehabilitation can significantly improve functional outcomes.
📚 References
Martin RM, Fish DE. Scapular Winging: Anatomical Review, Diagnosis, and Treatments. Current Reviews in Musculoskeletal Medicine.
StatPearls. Long Thoracic Nerve Injury.
American Academy of Orthopaedic Surgeons (AAOS): Scapular Winging.
Wiater JM, Flatow EL. Long Thoracic Nerve Injury. Journal of the American Academy of Orthopaedic Surgeons.
💬 Have you seen a patient with scapular winging mistaken for a rotator cuff problem? Share your clinical experience below.
