[Red Arrow]

8 months ago I fell while skiing. It was a pretty dumb fall, I just wasn't paying attention and my skis crossed and I fell forward stretched out in a superman position. It didn't hurt that bad when I fell, but a few days later I was in serious pain. I went to a dr and based on xrays he determined that I fractured my scapula. I was in a sling for a while and at about 6 weeks the pain went away for the most part but I had very limited range of motion and hardly any strength.

I scheduled an appointment with a physical therapist who was surprised at my lack of strength and range of motion due to a fractured scapula. He had me take off my shirt and noticed that my scapula was winging and thought I may have long thoracic nerve palsy. He referred me to a neurologist to do an EMG. The first neurologist ran me through a bunch of tests but said he couldn't test for long thoracic nerve palsy and there was only 1 guy in Utah that would do that kind of EMG. So I went to that guy and he said he couldn't find anything, although he said because I have muscular lats he may not have got the needle in the right place and he was hesitant to try anymore because he didn't want to go through the lung.
So I have a few of questions.
Has anyone had this type of injury?
Is there a doctor that you would recommend? I would fly about anywhere.
I understand that the course of action is generally to wait and it usually gets better. My injury has not improved at all and it's been 8 months. Has anyone had surgery? How were your outcomes and is there a doctor you would recommend?

It seems like there are very few doctors who have experience with this type of injury and I don't know what to do next. Any help would be greatly appreciated

[Sea Pines 50]

It's nice to meet you but I am sorry about the injury which brought you to us. A couple of things for you to try: Using the Forum Search function (should be in the upper right-hand portion of your screen), type in the words "winged scapula," which should call up a number of posts and threads from other TOS forum members - some of whom have suffered an injury to the long thoracic nerve as you have, either during surgery or as a result of an accident or other trauma.

I also remember a fellow from Australia who went by the name "Towelhorse," which you could search as well (his 'name', that is) to pull up his material from approximately 7 or 8 years ago now, I'd say. (He had some interesting theories about TOS, you might say, but as I recall he also shared lots of ideas about what he found useful in the healing process and what was less so, etc.)

Off the top of my head there are a couple of top TOS specialists who do take complicated cases, and are not too far from Utah: Dr. Brantigan, in Denver, and Dr. Pearl, in Dallas (or Houston? I need to double-check that for you). There's Dr. Donahue, in Boston, as well.

You could also check the Drs. and PTs "sticky" thread at the very top of this forum, to see who's in your state… but they may or may not be one of the top docs out there. And because I've been away for awhile, I'm not exactly sure how up-to-date the list is, either…

But keep in mind, we tend to talk about our docs and other healthcare providers on here, so in combing through the searched threads and posts you're likely to spot some names, get new ideas and hopefully, start to put together an awesome treatment team to give yourself the best chance for a good recovery!

Please avail yourself of some of the links captured in the "sticky" threads at the top of the forum as well. The last one, for example, has some excellent peer-reviewed articles about TOS and related matters in it. Keep posting here, will you, to let us know how you're doing or if you have any other questions or concerns? We're here to support you in any way we can.

Take care,

Alison

[Akash]

Please try PT before surgery. It can take 2-3 years for serratus function to recover.

[Hiker]

I developed weakness and winging in my left shoulder 4 months ago. I was diagnosed with the LTN injury. EMG did not show anything.
I am convinced the diagnosis was incorrect though and my symptoms are due to lower trapezius weakness (accessory nerve).

After 2 months my symptoms started improving slowly. But recently I developed the same problem on the right side. Ugh. Doctors just shrug their shoulders so I am scheduled for another EMG.

From what I read about the LTN injury, if the nerve was severed, it may not recover without surgery. If it was simply compressed, it usually recovers on its own though it takes a long time.
The surgery may not be beneficial long time (after 1 year) after the injury.

[jkl626]

Originally Posted by Hiker

I developed weakness and winging in my left shoulder 4 months ago. I was diagnosed with the LTN injury. EMG did not show anything.
I am convinced the diagnosis was incorrect though and my symptoms are due to lower trapezius weakness (accessory nerve).

After 2 months my symptoms started improving slowly. But recently I developed the same problem on the right side. Ugh. Doctors just shrug their shoulders so I am scheduled for another EMG.

From what I read about the LTN injury, if the nerve was severed, it may not recover without surgery. If it was simply compressed, it usually recovers on its own though it takes a long time.
The surgery may not be beneficial long time (after 1 year) after the injury.

Hi Hiker,
I am curious how you were diagnosed with an LTM injury. I have been trying to get someone to test that nerve , even tho I have already had 2 EMG tests but they didnt test the LTM. I have scalpular pain and it seems to be where the pain starts before progressing to a full blown flare up from my face down to my ribs. And also once you get that diagnosis what is the surgery that you would get?
I am in So. Cal. Thanks,JKL

[Hiker]

The doctor just looked at my winging scapula and said it was the long thoracic nerve. He then did an EMG (he said it was difficult to test the LTN, but possible). The EMG showed nothing unusual.

As I understood, the surgery is to decompress and repair the nerve, but one must know for sure where it is injured/compressed because the nerve is long as its name implies.

I still don't know if I have a problem with that nerve. My serratus anterior is definitely weak on both sides. But it may simply be weak due to imbalance...

[booklover]

Originally Posted by Red Arrow

8 months ago I fell while skiing. It was a pretty dumb fall, I just wasn't paying attention and my skis crossed and I fell forward stretched out in a superman position. It didn't hurt that bad when I fell, but a few days later I was in serious pain. I went to a dr and based on xrays he determined that I fractured my scapula. I was in a sling for a while and at about 6 weeks the pain went away for the most part but I had very limited range of motion and hardly any strength.

I scheduled an appointment with a physical therapist who was surprised at my lack of strength and range of motion due to a fractured scapula. He had me take off my shirt and noticed that my scapula was winging and thought I may have long thoracic nerve palsy. He referred me to a neurologist to do an EMG. The first neurologist ran me through a bunch of tests but said he couldn't test for long thoracic nerve palsy and there was only 1 guy in Utah that would do that kind of EMG. So I went to that guy and he said he couldn't find anything, although he said because I have muscular lats he may not have got the needle in the right place and he was hesitant to try anymore because he didn't want to go through the lung.
So I have a few of questions.
Has anyone had this type of injury?
Is there a doctor that you would recommend? I would fly about anywhere.
I understand that the course of action is generally to wait and it usually gets better. My injury has not improved at all and it's been 8 months. Has anyone had surgery? How were your outcomes and is there a doctor you would recommend?

It seems like there are very few doctors who have experience with this type of injury and I don't know what to do next. Any help would be greatly appreciated

hi Red Arrow,
I developed long thoracic nerve palsy (about 18 years ago) from vaulting a fence using my left arm to a escape a charging pit bull trying to attack me whilst camping with friends. Unknown to me I had pre-existing bilateral TOS which set up a compression /traction injury. Initially was told I had a brachial plexus syndrome but they couldn't find the injury on the nerve conduction tests because they didn't test far enough down nerve trunk. 11 years later neurosurgeon had tests redone prior to implanting SCS and included LTN - nerve damage showed up as well as chronic denervation of Anterior Serratus muscle. I had an opinion from a neurosurgeon about whether they could do anything surgically at this late stage. He said no. There are a lot of risks operating on nerves.My impression is unless there is something structural obstructing, placing pressure on the nerve (e.g. neuroma, tumour) or it is severed they won't usually operate. However, I'm in Australia and they don't have the economies of scale here so it's hard to get highly specialised treatment. This neurosurgeon had actually only operated on one LTN and it was a complete sever. My LTN palsy started with the winged scapula but over the years have done lots of PT -in particular clinical Pilates and a technique called Bobath. The neurosurgeon said you would never pick mine by looking at me whereas my neurophysiological results are very poor so I hope this gives you some encouragement for getting more function than you should have. I went ahead with the SCS because I continue to get severe nerve pain which became centralised CRPS. I think this would be a risk of operating on a long thoracic nerve and because it connects in with your arm/neck/back, there's a lot to be said for the conservative approach if you're not in too much pain. Just make sure you get a really good physiotherapist to work with you if you decide to give clinical Pilates or Bobath a go. I have a second hand pilates reformer at home and it's part of my fitness routine along with regular walking.

good luck!
Booklover

[Hiker]

After two months my shoulder weakness is greatly improved.
The lateral winging is mostly gone (or is minor and symmetric on both sides )
So I suppose my trapezius has recovered from whatever the nerve damage was.
Still have my usual medial winging though. But I feel this is simply due to a weak serratus anterior muscle rather than a LTN nerve problem.
Second EMG came back notmal.

I can feel my serratus anterior working if I do scap push ups, but I cannot figure out a way to do an isolated activation of it. Scap push ups are flaring up TOS symptoms in my arms and give me wrist pain so they probably do more harm than good...
Push ups from a wall don't seem to do much: I cannot feel that serratus anterior is even working.
Are there any good safe serratus exercises?

[SnappleofDiscord]

Ugh sorry for your scapula pain!
I didn't break my scapula like you (which must have been s special dose of misery), but I too have some severe scapula winging with possible LTN injury.
Waiting hasn't helped, and my symptoms have only gotten worse. PT hasn't gone far, as most scapular stabilizing exercises further irritate the secondary problems Caused by it in my neck. I'm still searching for a doctor too.

I wouldn't wish this chase on everyone. I think you're right that most doctors are unfamiliar with this type of injury and scapula winging in general outside of a text book. I am endlessly frustrated by doctors telling me "they've never seen anything like it", and then referring me to a friend.


It's my understanding that basic EMG will only pick up a pronounced issue (i also had to do a chase to find someone willing to perform the EMG), and that it's a positive result is not always needed to diagnose LTN injury since it is so very easy to miss the nerve altogether.
I've got a negative results on my LTN EMG, but no matter what the print out says I still have a scapula you could rest a drink on and other symptoms of serratus dysfunction like trouble expanding my chest, fasiculations, shoulder instability, pain, etc.
I've been told nerve dysfunction and symptoms can happen from compression and chronic irritation/inflammation as well, and an EMG is testing for total compression, impingement, lesions, or severed nerves.
My symptoms seem to vary positionally and on how bad my compensating muscles are spasming. I can make the symptoms stop sometimes if I hold very still in a certain pose and never move, however, EMG isn't conducts in a comparison basis.

There's also some literature that I've found that puts together what seems like a fairly medically obvious case for scapular winging and LTN dysfunction without loss of nerve signal, in that the altered position and rhythm of the scapula compresses the brachial plexus, narrows the thoracic outlet, and grinds on muscles, tendons, and nerves it shouldn't be able to.
I'm too new in the forum to be allowed to post links in my comments, but I can message you some links to articles on this.

In your case there may be issues with the LTN being irritated by your scapular bursa (which may be remedied by some cortisone shots), scar tissue, or even bone spurs and change of shape from the original break. Even an inflamed irritated nerve from when the scapula was broken and untreated..

Being mostly confined to my house or bed because of the associated symptoms, I spend a lot of time researching how to Escape this hell cycle. I've turned to looking up doctors cited in medical literature..
Here's a few resources I'm looking in to chasing down myself as soon as this next round of doctors invariably bounces me...
Dr Nath- Houston
Dellon Institue- Baltimore and some others too
Washington University in St. Louis seems to have some winged scapula expertise as well.

I hope this helps you some.

[booklover]

Quote"There's also some literature that I've found that puts together what seems like a fairly medically obvious case for scapular winging and LTN dysfunction without loss of nerve signal, in that the altered position and rhythm of the scapula compresses the brachial plexus, narrows the thoracic outlet, and grinds on muscles, tendons, and nerves it shouldn't be able to.
I'm too new in the forum to be allowed to post links in my comments, but I can message you some links to articles on this."

Thanks SnappleofDiscord

From my experience surgery wasn't really an option, as I was advised the nerve was tractioned along its whole course. During rehab/tmt I was given the impression that many LTN/ brachial plexus injuries are "stretch" injuries rather than compression injuries eg water skiing. I don't know how accurate that is?

I'd be very interested in looking at the articles you mentioned, if it's not too much trouble to get the reference details/links from you?

cheers
Booklover