Orthopedics

Feature Article 

Predictive Factors of Recovery in Long Thoracic Mononeuropathy

Mauro Mondelli, MD; Alessandro Aretini, NFT; Federica Ginanneschi, MD

Abstract

The aim of the study was to identify specific factors that affect the outcome in patients with long thoracic mononeuropathy. The authors reviewed all medical records of patients with long thoracic mononeuropathy from the archive of the electromyography service over the past 16 years. Age, sex, occupation, pain at onset, symptom duration, neuropathy causes and side, and electromyography findings were collected. The outcome was evaluated by performing standard telephone interviews consisting of 9 queries about use limitations in the affected upper limb. If no limitation existed, the recovery was considered complete. If partial limitations only affected the upper limb in performing 5 or fewer of 9 specific activities, the outcome was considered good; if limitations affected more than 5 activities, the outcome was considered poor. The authors performed a multivariate logistic regression to calculate the association between good outcome or full recovery and poor outcome with demographic, clinical, and electromyography findings. Forty-one patients were included (mean±SD age, 39±14 years; 68.3% men). Causes were shoulder-arm overuse or trauma in 19 patients, iatrogenic in 5, idiopathic in 9, and inflammatory in 8. Twenty-seven patients had a good outcome and full recovery and 14 had a poor outcome. No patient underwent surgery. Age, sex, occupation, pain at onset, symptom duration, neuropathy side, and electromyography findings were not predictive of the outcome. The probability of full recovery and good outcome was 7.5 times greater in long thoracic mononeuropathy secondary to idiopathic or inflammatory causes compared with other etiologies.

The authors are from the Electromyography Service (MM, AA), Local Health Unit 7; and the Department of Medical, Surgical and Neurological Sciences (FG), University of Siena, Siena, Italy.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mauro Mondelli, MD, Servizio di EMG, ASL 7, Via Pian d’Ovile 9, Siena, Italy 53100 (m.mondelli@usl7.toscana.it).

Abstract

The aim of the study was to identify specific factors that affect the outcome in patients with long thoracic mononeuropathy. The authors reviewed all medical records of patients with long thoracic mononeuropathy from the archive of the electromyography service over the past 16 years. Age, sex, occupation, pain at onset, symptom duration, neuropathy causes and side, and electromyography findings were collected. The outcome was evaluated by performing standard telephone interviews consisting of 9 queries about use limitations in the affected upper limb. If no limitation existed, the recovery was considered complete. If partial limitations only affected the upper limb in performing 5 or fewer of 9 specific activities, the outcome was considered good; if limitations affected more than 5 activities, the outcome was considered poor. The authors performed a multivariate logistic regression to calculate the association between good outcome or full recovery and poor outcome with demographic, clinical, and electromyography findings. Forty-one patients were included (mean±SD age, 39±14 years; 68.3% men). Causes were shoulder-arm overuse or trauma in 19 patients, iatrogenic in 5, idiopathic in 9, and inflammatory in 8. Twenty-seven patients had a good outcome and full recovery and 14 had a poor outcome. No patient underwent surgery. Age, sex, occupation, pain at onset, symptom duration, neuropathy side, and electromyography findings were not predictive of the outcome. The probability of full recovery and good outcome was 7.5 times greater in long thoracic mononeuropathy secondary to idiopathic or inflammatory causes compared with other etiologies.

The authors are from the Electromyography Service (MM, AA), Local Health Unit 7; and the Department of Medical, Surgical and Neurological Sciences (FG), University of Siena, Siena, Italy.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mauro Mondelli, MD, Servizio di EMG, ASL 7, Via Pian d’Ovile 9, Siena, Italy 53100 (m.mondelli@usl7.toscana.it).

Long thoracic mononeuropathy occurs infrequently and causes serratus anterior muscle weakness. Paralysis of the serratus anterior muscle produces medial scapular winging and loss of shoulder stabilization during scapulohumeral movements. Patients with serratus anterior palsy develop weakness of upper rotation, poor fixation of the scapula against the chest, and impairment in shoulder abduction. The serratus anterior muscle contributes to scapulohumeral motion by allowing congruency of the glenohumeral joint. During elevation of the arm, the muscle brings the scapula forward and rotates the inferior angle upward and laterally. Actions such as pushing, pulling, lifting a heavy object, and performing manual activities with the arm above the shoulder level are impaired or impossible.1–3 

Long thoracic mononeuropathy can be due to traumatic and nontraumatic causes. Traumatic causes produce acute or subacute neuropathy and result from overuse and strenuous exercise of the shoulder, from blunt trauma, such as a blow to the thorax, or from sudden depression of the shoulder that occurs during a fall and road and sport accidents.2–8  Iatrogenic nerve injury may occur after axilla or chest surgery or following incorrect positioning of the arm during general anesthesia.9,10  Long thoracic mononeuropathy is infrequently associated with infectious diseases,4,11  natural delivery,12,13  cervical chiropractic manipulation,14  electric burn,15  C7 radiculopathy,16  or use of a single axillary crutch.17  Idiopathic long thoracic mononeuropathy has been reported. Some neuropathies begin acutely and are characterized by a severe aching, dull, or burning shoulder pain that sometimes radiates to the neck and arm. These are considered the forme fruste of the neuralgic amyotrophy (Personage-Turner syndrome). Other nontraumatic mononeuropathies may present an insidious onset and are painless.18 

The natural history of neuropathy is not completely known because studies reported in the literature are often retrospective, involve a small number of patients, report heterogeneous causes, sometimes have short follow-up, sometimes have in-sufficient clinical data, and do not always include electromyography (EMG). In the literature, no statistical analysis supports the outcome results except for 1 study in which univariate statistical analysis was used.18  These authors showed that long thoracic neuropathy generally had a good prognosis irrespective of the EMG findings and that traumatic neuropathy was associated with a poor outcome compared with idiopathic or presumed inflammatory neuropathies.18 

The aim of the current study was to identify factors predictive of a good outcome of long thoracic mononeuropathy using multivariate statistical analysis because some predictors may be interrelated.

Materials and Methods

The local ethics committee approved the study, and patients gave informed consent. The authors reviewed all medical records of patients with long thoracic mononeuropathy diagnosed between January 1995 and December 2010 at their outpatient EMG Service using the electronic database (dbIV software; Ashton-Tate, Culver City, California) of the archive. Diagnosis of long thoracic mononeuropathy was based on symptoms, clinical examination, and EMG anomalies of the serratus anterior muscle. All patients were investigated for the presence and severity of a winged scapula, upper-limb muscle strength, sensitivity, and deep reflexes. Only patients with only long thoracic mononeuropathy were enrolled, regardless of the cause. All patients with multiple mononeuropathies, brachial plexopathy, or polyneuropathy were excluded on the basis of the clinical and electrophysiological findings. Patients with coexistent cervical spine spondyloarthropathy and long thoracic nerve symptoms were included if clinical and EMG anomalies were limited in the serratus anterior muscle. Standard needle EMG of the serratus anterior muscle was performed by inserting a concentric needle-electrode at the inferior angle of the scapula. Electromyography was considered abnormal when denervation activity at rest or neurogenic decreased recruitment at full effort (fewer motor unit action potentials firing at a higher rate) were recorded or when voluntary activity was absent. The following parameters were collected in a database: age, sex, occupation, hand dominance, symptom duration, presumed neuropathy cause, neuropathy side, presence or absence of pain at onset, EMG findings (presence or absence of denervation activity at rest and presence or absence of voluntary activity in the serratus anterior muscle), and clinical and EMG follow-up, if performed. In a previous study, nontraumatic long thoracic mononeuropathies were classified as inflammatory when the onset was acute and pain was a prominent presenting symptom.18  Painless neuropathy without a history of preceding trauma was classified as idiopathic.18 

Because the clinical and EMG follow-up was only available in 14 patients, the outcome was assessed in all patients via telephone interview. Patients answered questions regarding the presence or absence of a winged scapula and use limitation in the affected upper limb in performing certain movements according to a questionnaire already used to evaluate long-term follow-up in a sample of patients with iatrogenic serratus anterior palsy. The questionnaire included 9 questions (Table ). Three answers were possible for each question: impossibility, slight difficulty, and no limitations. Recovery was considered full if all activities were possible without difficulty and if no winging of the scapula existed. The outcome was considered good if the limitation was partial and related to 5 of the 9 activities listed in Table , even in referred presence of winged scapula; otherwise, the recovery was considered poor. The limit value of 5 activities used to identify a good recovery resulted from the clinical follow-up of 10 patients. Patients without winged scapulas at follow-up or with minimal protrusion of the scapula at the provocative test (ie, asking the patient to push forward against a wall flexing the parallel arms forward 90° and extending the elbows) who did not report pain during heavy or prolonged shoulder activity were satisfied with recovery, and they corresponded with the patients who reported a slight limitation in up to 5 movements on the questionnaire. The authors also acquired information about therapy and changes in occupation or manual hobbies.

 
Telephone Interview Queries on Limitations in the Use of the Affected Upper Limba 

Table 1: Telephone Interview Queries on Limitations in the Use of the Affected Upper Limb

The authors used the nonparametric Mann-Whitney U test for continuous variables and χ2 for dichotomous variables to test the differences between the group that achieved a full or good recovery and the group that had a poor or unchanged outcome and between the groups with or without traumatic mononeuropathy causes. Multivariate forward logistic regression analysis was performed to calculate the odds ratio and 95% confidence interval to assess the strength of association between the dependent variable (poor or unchanged outcome=0; good outcome or full recovery=1) and the independent variables represented by patient age (continuous variable, years), sex (dichotomous variable: women=0, men=1), symptom duration (continuous variable, months), pain at onset (dichotomous variable: absent=0, present=1), neuropathy cause (dichotomous variable: nontraumatic=0, traumatic=1), neuropathy side (dominant=0, nondominant=1), EMG denervation activity at rest (dichotomous variable: absent=0, present=1), voluntary EMG activity (dichotomous variable: present=0, absent=1), and follow-up time (continuous variable, months).

Statistical analysis was conducted using SPSS version 13.0 software (SPSS, Inc, Chicago, Illinois). An alpha-error of 0.05 was accepted.

Results

The authors identified 46 patients with long thoracic mononeuropathy. Five patients were lost to follow-up: 1 died, 3 were not found, and 1 was not willing to participate. Therefore, they enrolled 41 patients (mean±SD age, 39±14 years; 68.3% men; 58.5% heavy laborers). Most patients were referred by general practitioners (n=12; 29.3%), followed by orthopedists (n=9; 22%), neurologists (n=7; 17.1%), neurosurgeons (n=6; 14.6%), physiatrists (n=5; 12.2%), a heart surgeon (n=1; 2.4%), and an occupational physician (n=1; 2.4%). Four patients were left-handed, and the neuropathy affected the dominant side in 27 (66%) patients. Twenty-four (58.5%) patients had traumatic causes: motor vehicle accidents in 6 patients, iatrogenic in 5 (after chest surgery in 4 patients and after incorrect intraoperative upper-limb positioning for prostate cancer in 1), sport blunt trauma or shoulder overuse in 4, work shoulder overuse in 5, and other accidental trauma in 4. Nine patients had idiopathic forms and 8 had inflammatory. The age decade of the patients showed Gaussian distribution, and most patient ages ranged from 40 to 49 years (n=12). At the first examination, all patients showed a winged scapula with weakness in raising the arm above horizontal level without involving other nerves. Table shows the results of the telephone interview, and the Figure  shows the mean questionnaire scores according to the presumed cause of injury. Tables and report demographic, clinical, EMG, and follow-up results of all patients and in the 2 groups separated by cause (traumatic vs nontraumatic) and of the outcome (good outcome and full recovery vs poor outcome). No patient had a neurological disease or diabetes mellitus. Baseline EMG results reported in the tables and in the statistical analysis referred to the electrophysiological examination performed between 3 weeks and 2 months after symptom onset.

 
Mean and SD of the questionnaire scores according to the presumed cause of the injury. White columns refer to traumatic causes, grey columns to nontraumatic causes. The overall score of each patient is the sum of the scores for each response to the questions as follow: score 2, impossibility; score 1, slight difficulty; score 0, no limitations. 

Figure: Mean and SD of the questionnaire scores according to the presumed cause of the injury. White columns refer to traumatic causes, grey columns to nontraumatic causes. The overall score of each patient is the sum of the scores for each response to the questions as follow: score 2, impossibility; score 1, slight difficulty; score 0, no limitations.

 
Results of All Patients and in the 2 Groups Obtained on the Basis of the Presence Vs Absence of the Deficit Recovery 

Table 2: Results of All Patients and in the 2 Groups Obtained on the Basis of the Presence Vs Absence of the Deficit Recovery

 
Demographic, Clinical, Electrophysiological and Follow-up Results and the Statistical Differences Between the Groups Separated According to the Cause (Traumatic Versus Nontraumatic). 

Table 3: Demographic, Clinical, Electrophysiological and Follow-up Results and the Statistical Differences Between the Groups Separated According to the Cause (Traumatic Versus Nontraumatic).

Mean annual incidence of neuropathy during the 16 years of recruitment was 0.16% for all patients admitted to the EMG service (46 of 29,267 patients who had an EMG examination). No significant increasing or decreasing trend in the number of enrolled patients existed in respect with that of all the patients who underwent EMG during the 16 years of the study (χ2 for trend with Mantel extension=0.19; P=.66).

Follow-up was performed via telephone interview between 10 months and 14 years after the onset of long thoracic neuropathy. Twelve patients were treated with a shoulder brace and physical therapy, 8 with a shoulder brace, 6 with physical therapy; among these 26 patients, 8 were also treated with various dosages of steroids (6 of these 8 had inflammatory neuropathy). The remaining 15 patients received no treatment. No patient underwent surgery. Groupings by treatment type were too small and heterogeneous for adequate statistical analysis, so the treatment was not included in the logistic regression.

Due to achieving a partial recovery, 7 patients changed work, 2 stopped work and were unemployed, 3 retired on a pension within 2 years after neuropathy onset, and the remaining patients, including 3 who had poor recoveries, continued the work or hobbies.

Tables and show the differences in demographic, clinical, and electrophysiological findings and outcome of all the patients between the groups based on the presence or absence of the recovery and whether the cause was traumatic or nontraumatic. At follow-up, 5 patients reported no motion limitation and the paralysis was considered healed (full recovery), 22 patients reported up to 5 partially limited movements and were considered partially recovered (good outcome), and the remaining 14 patients had a poor outcome or remained unchanged. The only predictor of a full or good recovery was a non-traumatic (idiopathic or inflammatory) cause (odds ratio, 7.5; 95% confidence interval, 2.8–20.1).

Discussion

In this retrospective study, the authors investigated the outcome predictors in an outpatient-based cohort of patients with long thoracic mononeuropathy. Only nontraumatic causes were associated with a full or good recovery. Patients’ age, sex, occupation, pain at onset, neuropathy side, EMG findings, symptom duration, and follow-up extension were unable to predict the outcome of long thoracic neuropathy. Table summarizes the studies published in literature reporting the outcome in at least 10 patients with long thoracic mononeuropathy.9,12,13,18–24  The current authors excluded the surgical series concerning the palliative surgery of scapulothoracic arthrodesis, tendon transposition, or fascial graft25–27  and anecdotal cases. The studies shown in Table seem to show contradictory outcome results in traumatic and iatrogenic neuropathies, likely due to the causes of injury and treatment. The idiopathic and inflammatory forms seem to have a good recovery. In some series, the follow-up was evaluated by mail questionnaire or telephone interview.

 
Literature Findings for Long Thoracic Mononeuropathya 

Table 4: Literature Findings for Long Thoracic Mononeuropathy

In the current study, the mean annual incidence of neuropathy in the 16 years of observation was 0.16% of overall patients admitted to the EMG laboratory, which was similar to that found by Fardin et al20  20 years previously (15 patients out of 7000 EMG examinations in 4 years =0.21%). Long thoracic traumatic neuropathy is more common in men and on the dominant side. The EMG findings are unable to predict the outcome of long thoracic neuropathy: the absence of voluntary activity or the presence of denervation activity at rest (positive sharp waves and fibrillation potentials) does not predict poor outcome. The probability of a good or full recovery is 7.5 times greater in idiopathic and inflammatory forms compared with other etiologies. It is possible that the disagreement between baseline EMG results and good outcome may be due to the functional recovery of shoulder movements for the compensatory action of other muscles, especially the trapezius, which may vicariate the action of serratus anterior muscle remained partially involved.18  The same mechanism has been suggested for other mononeuropathies of the lower limb.28  Disagreement between EMG and clinical outcome was also found at follow-up by Fardin et al.20  They showed that 6 of 10 patients completely recovered at follow-up, but EMG was only normalized in 4 patients.20  Therefore, EMG is an invaluable diagnostic tool to confirm the clinical diagnosis of long thoracic mononeuropathy and exclude more diffuse pathologies of peripheral nervous system, but EMG results should be interpreted with caution in the prediction of the prognosis and in the indication of the time for possible surgical correction of a winged scapula. Conservative therapies, such as adequate active physical therapy (which avoids certain movements or postures that may further stretch the nerve), a simple shoulder brace, or no treatment, could produce the same or a better outcome than surgical therapy.3,13,18,29 

Outcome predictivity was calculated using multivariate logistic regression that eliminates interference on the results due to possible confounding factors because some factors may be interrelated (such as male sex and a traumatic event). Previous studies were only descriptive; they lacked a statistical elaboration or the statistical analysis was univariate.18 

The current series is sufficiently large and can be considered representative of the authors’ general population. The current authors’ EMG laboratory is a primary outpatient service and admits only unselect and unsolicited patients and performs approximately half of the EMG examinations in the area. The patients in this study were all consecutive patients with EMG-confirmed long thoracic mononeuropathy, referred by general practitioners and specialists because they reported upper-limb symptoms. Therefore, it is likely that a several long thoracic mononeuropathies were diagnosed in the authors’ laboratory.

This study had some limitations. No adequate graduation of weakness existed because the follow-up was based on subjective patient reports. Therefore, the functional outcome was qualitatively expressed and modalities of recovery supposed and self-reported by the patients through a questionnaire administered via the telephone. However this questionnaire was standardized, reproduced the real residual muscular deficit affecting daily functional limitations, was administered in the same way for all patients, and was already used in another study to assess the long-term outcome of serratus anterior paralysis. The other bias regards the treatments. The therapy was recommended by doctors who had prescribed EMG or by other physicians and was often different from patient to patient, which could influence the outcome. These limitations are common in almost all previous reports.9,12,18,20,22  In addition, the patients with iatrogenic long thoracic injury could represent a specific subset of traumatic patients in terms of outcome; the authors did not perform a separate analysis of this subgroup because the number of iatrogenic long thoracic neuropathies was too small for adequate statistical analysis.

Only prospective multicenter studies that can recruit, in a relatively short time, a sufficient number of patients with long thoracic mononeuropathy resulting from various causes for reliable statistical analysis and can include adequate and standardized clinical and electrophysiological follow-up and treatment can assess whether baseline electrophysiological results can predict long-term outcomes and whether the recovery depends on the cause of the neuropathy or treatment.

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Telephone Interview Queries on Limitations in the Use of the Affected Upper Limba

Limitation in Affected Upper-limb UseNo., (%)
ImpossibilitySlight DifficultyNo Limitation
Lifting heavy objects14 (34.1)22 (53.7)5 (12.2)
Pulling heavy objects11 (26.8)20 (48.8)10 (24.4)
Pushing heavy objects9 (21.9)17 (41.5)15 (36.6)
Playing sports or performing hobbies3 (7.3)13 (31.7)25 (61)
Working with hands above shoulder level11 (26.8)17 (41.5)13 (31.7)
Lifting objects to shelves above table level11(26.8)14 (34.1)16 (39.1)
Combing hair2 (4.9)9 (21.9)30 (73.2)
Brushing teeth0 (0)8 (19.5)33 (80.5)
Carrying groceries4 (9.8)11 (26.8)26 (63.4)
 

Results of All Patients and in the 2 Groups Obtained on the Basis of the Presence Vs Absence of the Deficit Recovery

VariablePatients, No. (%)
Between Groups
TotalWith Full or Good OutcomeWith Poor or Unchanged Outcome
No.4127 (58.5)14 (41.5)
Mean±SD age, y39±1439.3±14.738.4±12.9Z=0.29, P=.77
SexF, 13 (31.7); M, 28 (68.3)F, 7 (25.9); M, 20 (74.1)F, 6 (42.9); M, 8 (57.1)χ2=1.22, P=.27
OccupationHeavy laborers, 24 (58.5); other 17 (41.5)Heavy laborers, 17 (63); other, 10 (37)Heavy laborers, 7 (50); other, 7 (50)χ2=0.64, P=.42
Symptom duration, mo5.2±3.84.7±3.16±4.8Z=−0.62, P=.53
CauseTraumatic, 24 (58.5); nontraumatic, 17 (41.5)Traumatic, 12 (44.4); nontraumatic, 15 (55.6)Traumatic, 12 (85.7); nontraumatic, 2 (14.3)χ2=6.47, P=.018a (Fischer test)
Neuropathy sideD, 27 (65.9); ND, 14 (34.1)D, 17 (63); ND, 10 (37)D, 10 (71.4); ND, 4 (28.6)χ2=0.59, P=.73 (Fischer test)
Pain at onsetPresent, 25 (61); absent, 16 (39)Present, 17 (63); absent, 10 (37)Present, 8 (57.1); absent, 6 (42.9)χ2=0.13, P=.72
EMG (positive sharp waves and fibrillation potentials at rest)Present, 26 (63.4); absent, 15 (36.6)Present, 17 (63); absent, 10 (37)Present, 9 (64.3); absent, 5 (35.7)χ2=0.93, P=1.00
EMG (voluntary activity)No activity, 15 (36.6); reduced activity, 26 (63.4)No activity, 9 (33.3); reduced activity, 18 (66.7)No activity, 6 (40); reduced activity, 8 (57.1)χ2=0.36, P=.55
Follow-up, mo34.6±30.331.9±31.932.1±28.0Z=0, P=1.00
 

Demographic, Clinical, Electrophysiological and Follow-up Results and the Statistical Differences Between the Groups Separated According to the Cause (Traumatic Versus Nontraumatic).

VariablePatients With Mononeuropathy, No. (%)
Traumatic vs Nontraumatic
TraumaticNontraumatic
No. of patients24 (58.5)17 (41.5)
Mean±SD age, y37.8±13.540.7±14.9Z=−0.52, P=.61
SexF 6 (25), M 18 (75)F 7 (41.2), M 10 (58.8)χ2=1.2, P=.32
OccupationHeavy laborers 13 (54.2), other 11 (45.8)Heavy laborers 11 (64.7), other 10 (35.3)χ2=0.46, P=.5
Symptom duration, mo5.5±4.44.7±2.6Z=−0.28, P=.78
Neuropathy sideD 19 (79.2), ND 5 (20.8)D 8 (47.1), ND 9 (52.9)χ2=4.56, P=.048a
Pain at onsetPresent 7 (29.2), absent 17 (70.8)Present 9 (52.9), absent 8 (47.1)χ2=2.36, P=.2
EMGbPresent 16 (66.7), absent 8 (33.3)Present 10 (58.8), absent 7 (41.2)χ2=0.26, P=.61
EMGcNo activity 8 (33.3), reduced activity 16 (66.7)No activity 7 (41.2), reduced activity 10 (58.8)χ2=0.26, P=.61
Follow-up, mo.28.1±2843.8±31.9Z=−1.6, P=.11
 

Literature Findings for Long Thoracic Mononeuropathya

AuthorEnrollment SitePatients (M/F)Recruitment PeriodEMG ExaminationCauseTreatmentPeriod and Way of Follow-upOutcome
Goodman et al19Department of Physical Medicine and Rehabilitation, Georgetown University, Washington, DC12 (5/7)14 yEMG in 95 trauma (2 sport, 2 iatrogenic, 1 car accident); 4 infection, allergic ,or toxic; 3 idiopathic10 physical therapy, 2 unknown1–7 y; 11 clinical examination, 1 phone interview5 (traumatic) poor recovery or unchanged; 7 full or good recovery
Fardin et al20Department of Neurological and Mental Diseases, Padua University, Italy10 (5/5)4 yEMG in all2 trauma (downfall), 8 idiopathicUnknown in all7–45 mo; clinical examination, EMG6 full recovery; 3 partial recovery; 1 unchanged
Gregg et al21Graduate Hospital University Pennsylvania, Philadelphia10 (9/1)3 yEMG in 5Trauma (due to various sports) in allRest in all1–14 y; clinical examination7 full recovery; 2 partial recovery; 1 unchanged
Gozna and Harris22Division of Orthopaedic Surgery, Toronto Hospital, Ontario, Canada14 (unknown)9 yEMG in 12Trauma (8 blow to the shoulder, 2 downfall, 4 pull down of the arm)Unknown, 3 with poor recovery underwent surgerybNot indicated in all, clinical examination and EMG7 full recovery within 6 mo; 4 incomplete recovery; 3 good recovery after surgery
Duncan et al23Department of Rehabilitation Medicine, National Institute of Health, Bethesda, Maryland12 (sunknown)UnknownNot performedIatrogenic following axillary lymphadenectomy for breast carcinoma or melanoma in allPhysical therapy in all6 mo; clinical examinationFull recovery in all
Foo and Swann12Department of Orthopaedic, Heatherwood Hospital, Ascot, United Kingdom20 (8 M, 12 F)13 yNot performed10 idiopathic, 6 trauma, 1 infection, 1 after delivery, 1 iatrogenic, 1 drug overusePhysical therapy in 5, no therapy in 156 mo-12 y clinical examination; 13 had follow-up over 2 y; 2 lost; 5 had 3–9 mo follow-up14 full recovery within 6 mo-2 y; 4 no or partial recovery between 6–9 mo
Kaupilla and Vastamäki9Department of Hand Surgery, Orthopaedic Hospital of Invalid Foundation, Helsinki, Finland26 (sex unknown)12 yEMG in allIatrogenic after surgery or anesthesia (all)Physical therapy in 13, shoulder brace in 172–11 y; questionnaire by mail and clinical data obtained from medical record3 full recovery; 23 residual deficits of varying degrees and shoulder pain after strenuous exertion
Marin13Physical Medicine and Rehabilitation Clinic, Landstuhl, Germany14 (12 M, 2 F)2 y 9 moEMG in 1012 various traumas; 1 postinfective disease; 1 delivery; 1 woke up; 1 while eatingNew scapula winger’s brace1–7 mo (10 physical examination, 4 phone interview)6 patients who maintained compliance showed muscle strength increased
Friedenberg et al18Department of Neurology, Mayo Clinic, Rochester, Minnesota50 (41 M, 9 F)21 y 6 moEMG in all17 trauma (3 iatrogenic, 5 blunt trauma, 9 stretch); 20 inflammation; 13 idiopathicUnknown in allMean 48 mo, 29% medical record, 71% phone interview10 poor; 28 good; 12 not valuable
Nath et al24Texas Nerve and Paralysis Institute, Houston, Texas50 neuropathies in 47 patients (26/21)UnknownEMG in 4731 heavy weight-lifting; 2 deep supraclavicular massage; 1 direct trauma, 1 motor bike accident; 6 repetitive movements; 9 idiopathicSurgery,c postoperative physical therapy in allMean 26 mo, clinical examination and questionnaire by phone interview regarding quality of life49 patients improved scapular winging within 3 mo; 46 patients good or excellent
 
 

10.3928/01477447-20130523-13

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