Long thoracic nerve palsy is a syndrome characterized by paralysis of the muscles within the distribution of the long thoracic nerve, caused by various factors that result in injury or compression of the nerve.
The long thoracic nerve originates from the anterior rami of C5–C6 and a portion of C7. In the neck, it runs posterior to the brachial plexus cords, descends along the lateral aspect of the middle scalene muscle and the lateral thoracic wall to the medial side of the axilla, then passes between the subscapularis and serratus anterior muscles to innervate the serratus anterior muscle.
Due to the superficial course of the long thoracic nerve and its fixation by the scapula and anterior scalene muscle, it is susceptible to injury. Thoracic surgeries often damage this nerve, and inflammation or tumors of the scapula and anterior scalene muscle can easily involve or compress it, resulting in paralysis.
【Diagnostic Key Points】
When the long thoracic nerve is paralyzed, the following three distinct manifestations may occur:
1. Mild posterior displacement of the shoulder: including mild posterior displacement of the acromion.
2. The lower portion of the scapula exhibits winging (winged scapula).
3. Due to the actions of the rhomboid muscles and the levator scapulae, the scapula rotates internally, causing the inferior angle to lift away from the chest wall. Both the shoulder and scapula are positioned higher on the affected side compared to the healthy side. As a result of paralysis of the serratus anterior, when the patient is asked to raise the upper limb upward, under normal circumstances the scapula rotates around the sagittal axis, moving away from the spine, and the inferior angle rotates anteriorly and laterally to approximate the chest wall. In the presence of serratus anterior paralysis, the scapula remains close to the spine, its inferior angle lifts away from the chest wall, and the lateral chest wall muscles undergo atrophy.
【Treatment】
1. Acupoints and Needling Methods
1. Newly recognized acupoint (affected side): located 2 cun lateral to the 5th cervical vertebra. A 30-gauge, 1.5 cun filiform needle is used. After routine local disinfection, insert approximately 1.8 cun toward the spinal column. Needling sensation: local distension and pain or radiation to the shoulder.
2. ST9 (Renying) (affected side): Located 1.5 cun lateral to the laryngeal prominence, at the anterior border of the common carotid artery. Use a 30-gauge, 1.5 cun filiform needle. Routinely disinfect the local area, then insert obliquely toward the spine to a depth of about 1.3 cun. Needle sensation: distension and pain in the neck, or radiating to the back.
3. **GB21 (Jianjing)** (affected side): Located on the shoulder, at the midpoint of the line connecting GV14 (Dazhui) and the acromion. Insert a 30-gauge, 1.5 cun filiform needle perpendicularly toward the scapular spine to a depth of approximately 1.3 cun, after routine local disinfection. Needling sensation: local distension and pain.
4. **LU2 (Yunmen)** (affected side): Located 6 cun lateral to the Conception Vessel (CV), in the depression below the clavicle. After routine local disinfection, insert a 30-gauge, 2-cun filiform needle approximately 1.8 cun obliquely toward the shoulder joint. Sensation: local distension and pain.
II. Methods
The patient is seated. The above acupoints are needled according to the standard technique, with electrical stimulation applied. The needles are retained for 40 minutes and then removed. Treatment is given once daily, with 10 sessions constituting one course of treatment. A rest of 5 days is taken before the next course begins.
Commentary
Clinically, injuries of the anterior scalene muscle that involve the long thoracic nerve are more commonly seen. Treatment with the aforementioned method yields good results. Typically, as the muscle injury symptoms subside, the paralysis of the long thoracic nerve also gradually improves. In cases of surgical injury without nerve transection, application of this method also produces favorable outcomes.
The results are generally satisfactory, except in cases of nerve transection, which yield poor outcomes. If the long thoracic nerve is compressed by a tumor or other lesion, the secondary cause should be addressed first, followed by the above treatment, and satisfactory results can still be achieved.
Etiology and Pathophysiology of Long Thoracic Nerve Palsy
Long thoracic nerve palsy causes are diverse, typically involving mechanical injury or compression along the nerve’s course from the anterior rami of C5–C7. The nerve descends posterior to the brachial plexus, runs along the lateral aspect of the middle scalene muscle, and then courses along the lateral thoracic wall before innervating the serratus anterior muscle. Common causative factors include blunt trauma to the shoulder or neck, repetitive overhead motions (e.g., in weightlifting or throwing sports), prolonged compression during anesthesia or sleep, and iatrogenic injury during surgical procedures such as lymph node biopsy or mastectomy. Less frequently, viral infections (e.g., brachial neuritis) or inflammatory conditions may trigger the palsy. The resulting neuropraxia or axonotmesis disrupts motor signals to the serratus anterior, leading to functional loss of scapular stabilization.
Clinical Manifestations and Symptomatology
Patients typically present with characteristic long thoracic nerve palsy symptoms, most notably a winged scapula—the medial border and inferior angle protrude posteriorly when the arm is pushed against resistance. This scapular dyskinesia impairs normal shoulder mechanics, causing weakness in arm elevation above 90°, difficulty with overhead activities, and a dull ache in the periscapular region due to muscle imbalance. The classic “wall push” test exacerbates winging. Sensation is usually spared because the nerve is purely motor. Symptoms may develop acutely after trauma or insidiously in cases of repetitive strain. Without timely intervention, chronic scapular malposition can lead to secondary impingement or glenohumeral instability.
Therapeutic Approaches and Rehabilitation Strategies
Management of long thoracic nerve palsy treatment initially focuses on conservative measures, including activity modification, nonsteroidal anti-inflammatory drugs, and avoidance of aggravating movements. For patients with persistent deficits, targeted physiotherapy is essential. Long thoracic nerve palsy exercises aim to strengthen the serratus anterior and restore scapular control; examples include wall slides, push-ups plus, and prone scapular protraction with light resistance. Neural mobilization techniques may facilitate nerve recovery. If no improvement occurs within 6–12 months, surgical options such as nerve decompression or transfer (e.g., from the thoracodorsal or medial pectoral nerve) are considered. Prognosis varies: many patients achieve full recovery with early, appropriate rehabilitation, while those with severe axon loss may have residual winging.
I’ve dealt with nerve issues before, and acupuncture helped a lot. It’s good to see more research on using it for long thoracic nerve palsy—could be a game-changer for people with scapular winging. Thanks for sharing this!
와우, 긴흉곽신경마비에 대한 설명 정말 유익하네요! 침 치료가 도움이 된다니 신기해요. 운동 중 부상으로 생길 수도 있다는데, 평소 자세나 스트레칭도 중요할 것 같아요. 더 자세한 사례나 치료법
Interesting read! I’ve been dealing with some shoulder issues and never knew the long thoracic nerve could be affected like this. Acupuncture sounds promising for nerve recovery—has anyone here tried it for winging scapula or similar symptoms? Would love to hear about results.