Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer
28 April 2015
21 September 2015
06 November 2015 (eFirst)
Background In neurological diseases, winging of the scapula occurs because of serratus anterior muscle dysfunction due to long thoracic nerve palsy, or trapezius muscle dysfunction due to accessory nerve palsy. Several sports can cause long thoracic nerve palsy, including archery and tennis. To our knowledge, this is the first report of long thoracic nerve palsy in an aquatic sport.
Objective The present study is a rare case of winging of the scapula that occurred during synchronized swimming practice.
Methods The patient's history with the present illness, examination findings, rehabilitation progress, and related medical literature are presented.
Results A 14-year-old female synchronized swimmer had chief complaints of muscle weakness, pain, and paresthesia in the right scapula. Upon examination, marked winging of the scapula appeared during anterior arm elevation, as did floating of the superior angle. After 1 year of therapy, right shoulder girdle pain and paresthesia had disappeared; however, winging of the scapula remained.
Conclusions Based on this observation and the severe pain in the vicinity of the second dorsal rib, we believe the cause was damage to the nerve proximal to the branch arising from the upper nerve trunk that innervates the serratus anterior.
- 1 Tsuchisawa N, Fujino H, Miyaoka H. Case report of osteochondroma presenting with winging of the scapula [in Japanese]. J East Jpn Orthop Traumatol 2004; 16: 158-161
- 2 Wataya M, Maeda K, Sakamoto T, Ohwada O, Iioka K. Treatment of a patient complaining of shoulder pain associated with winging of the scapula [in Japanese]. Hokkaido J Phys Ther 1994; 11: 30-32
- 3 Shimizu J. Case report of long thoracic nerve palsy presenting with winging of the scapula associated with archery practice [in Japanese]. Clin Nephrol 1990; 30: 873-876
- 4 Johnson JTH, Kendall HO. Isolated paralysis of the serratus anterior muscle. J Bone Joint Surg Am 1955; 37-A (3) 567-574
- 5 Gregg JR, Labosky D, Harty M , et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am 1979; 61 (6A): 825-832
- 6 Toda N. Long thoracic nerve palsy [in Japanese]. Jpn J Surg 1992; 11: 505-508
- 7 Fiddian NJ, King RJ. The winged scapula. Clin Orthop Relat Res 1984; (185) 228-236
- 8 Harada M, Mura N, Takahara M, Naruse T, Ogino T. Long thoracic nerve palsy caused by fence picket penetration from axillary region to neck [in Japanese]. Tohoku J Orthop Traumatol 2007; 51 (1) 106-109
- 9 Vastamäki M, Kauppila LI. Etiologic factors in isolated paralysis of the serratus anterior muscle: a report of 197 cases. J Shoulder Elbow Surg 1993; 2 (5) 240-243
- 10 Nasu H, Yamaguchi K, Nimura A, Akita K. An anatomic study of structure and innervation of the serratus anterior muscle. Surg Radiol Anat 2012; 34 (10) 921-928
- 11 Prescott MU, Zollinger RW. Alar scapula: an unusual surgical complication. Am J Surg 1944; 65 (1) 98-103
- 12 Takagishi K. Long thoracic nerve palsy. In: Toda N, ed. Diagrams of New Shoulder Clinical Practice [in Japanese]. Tokyo: Medical View Co. Ltd.; 2006: 234-240
- 13 Iceton J, Harris WR. Treatment of winged scapula by pectoralis major transfer. J Bone Joint Surg Br 1987; 69 (1) 108-110
- 14 Izumi S, Kasumi F. Preventing and dealing with intraoperative trouble [in Japanese]. J Clin Surg 1989; 44: 1342-1369
- 15 Toizumi T, Kondo S, Mitsubashi N , et al. Case report of long thoracic nerve palsy in a javelin thrower [in Japanese]. J Jpn Clin Orthop Assoc 1997; 32: 1341-1344
- 16 Sakamoto K, Fujimaki E, Maruyama T, Kimura T, Kuriyama S. Case report of isolated paralysis of the serratus anterior muscle in a basketball player [in Japanese]. Higashi Nihon Supootsu Ikenkaishi 1981; 2: 27-30
- 17 Isayama T, Takagishi N, Takeshita M. Five cases of winging of the scapula due to long thoracic nerve palsy [in Japanese]. Shoulder Joint 1982; 6: 40-42
- 18 Yasuda T, Morimoto K, Terao A. Long thoracic nerve palsy due to sports injury [in Japanese]. Neurol Med 1982; 17: 513-514
- 19 Ohno T, Ishii Y, Kawaji W. Case report of paralysis of the anterior serratus muscle during calisthenics [in Japanese]. Tohoku Arch Orthop Surg Traumatol 1984; 27: 383-384
- 20 Fukuzawa K, Uemura S, Maruyama T, Fujimaki E, Sakamoto K. Two cases of isolated paralysis of the serratus anterior in the young athlete [in Japanese]. Jpn J Physical Fit Sports Med 1985; 34: 569
- 21 Hamada J, Ogawa K, Akita K. The long thoracic nerve and serratus anterior muscle: dissection and clinical practice [in Japanese]. Shoulder Joint 2010; 34 (3) 861-865
- 22 Horwitz MT, Tocantins LM. An anatomical study of the role of the long thoracic nerve and the related scapula bursae in the pathogenesis of local paralysis of the serratus anterior muscle. Anat Rec 1938; 71: 375-385
- 23 Ebata A, Kokubun N, Miyamoto T, Hirata K. Case report of long thoracic nerve palsy in which muscle training was considered to be involved in bilateral winging of the scapula [in Japanese]. Clin Nephrol 2005; 45 (4) 308-311
- 24 Takagishi K. The shoulder joint and shoulder girdle. In: Ochi T, ed. Outline of New Orthopedic Surgery [in Japanese]. Tokyo: Nakayama Shoten; 2006: 306-311
- 25 Wood VE, Frykman GK. Winging of the scapula as a complication of first rib resection: a report of six cases. Clin Orthop Relat Res 1980; (149) 160-163
- 26 Yazar F, Kilic C, Acar HI, Candir N, Comert A. The long thoracic nerve: its origin, branches, and relationship to the middle scalene muscle. Clin Anat 2009; 22 (4) 476-480
- 27 Hamada J, Igarashi E, Akita K, Mochizuki T. A cadaveric study of the serratus anterior muscle and the long thoracic nerve. J Shoulder Elbow Surg 2008; 17 (5) 790-794
- 28 Foo CL, Swann M. Isolated paralysis of the serratus anterior. A report of 20 cases. J Bone Joint Surg Br 1983; 65 (5) 552-556
- 29 Gozna ER, Harris WR. Traumatic winging of the scapula. J Bone Joint Surg Am 1979; 61 (8) 1230-1233
- 30 Hester P, Caborn DN, Nyland J. Cause of long thoracic nerve palsy: a possible dynamic fascial sling cause. J Shoulder Elbow Surg 2000; 9 (1) 31-35