Scapula winger's brace: A case series on the management of long thoracic nerve palsy

doi:10.1016/S0003-9993(98)90266-0

Archives of Physical Medicine and Rehabilitation

Volume 79, Issue 10, October 1998, Pages 1226-1230

https://doi.org/10.1016/S0003-9993(98)90266-0 Get rights and content

Abstract

Objective: To evaluate the clinical utility of a new scapula winger's brace.

Design: A case series.

Setting: A tertiary military clinic serving a young population.

Participants: Fourteen patients referred to the clinic for thoracic nerve palsy of a least 3 months' duration.

Outcome Measures: Manual muscle tests with and without the brace and patients' compliance/satisfaction with brace as measured by personal interview during follow-up.

Results: Muscle strength increased by one grade with brace application; patients who maintained compliance (n = 6) recovered their brace-free shoulder flexion strength and/or had reduced pain at the last follow-up (1 to 7 months after brace). All patients reported a subjective feeling of increased shoulder flexion strength and decreased pain with brace application.

Conclusion: The scapula winger's brace is a useful tool for physiatrists in the management of scapular winging secondary to long thoracic nerve palsy. Additional studies are needed to confirm the conclusion that the device's benefits derive from proprioceptive feedback that prevents muscle overuse or over-stretch and from its transfer of contralateral shoulder protraction force to the affected scapula.

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Cited by (44)

Treatment of neurogenic scapular winging: a systematic review on outcomes after nonsurgical management and tendon transfer surgery
2023, Journal of Shoulder and Elbow Surgery
Scapular winging is a rare condition of the shoulder girdle that presents challenging treatment decisions for clinicians. To inform clinical practice, clinicians need guidance on what the best treatment decision is for their patients, and such recommendations should be based on the total evidence available. Therefore, the purpose of this review was to systematically review the evidence regarding nonsurgical management and tendon transfer surgery of patients with neurologic scapular winging due to serratus anterior (SA) or trapezius (TP) palsy.
PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier were searched up to April 5, 2022, for studies reporting on clinical outcomes after nonsurgical management and tendon transfer surgery of scapular winging due to weakness of the SA or TP muscle. The Integrated quality Criteria for Review Of Multiple Study (ICROMS) tool was used to classify the quality of the studies. Primary outcomes were the fraction of patients with spontaneous recovery after nonsurgical management and improvement in shoulder function, pain scores, and shoulder scores after tendon transfer surgery. Data were pooled if data on the same outcome were available for at least 3 studies, using random-effects meta-analysis.
Twenty-three (10 moderate-quality [MQ] and 13 low-quality) studies were included. Six studies (3 MQ; 234 shoulders) reported on outcomes after nonsurgical management of SA palsy, whereas 12 (6 MQ; 221 shoulders) and 6 studies (1 MQ; 80 shoulders) evaluated the outcomes of tendon transfer for SA or TP palsy (1 study addressed both). Spontaneous recovery of scapular winging with nonsurgical management varied between 21% and 78% across studies after a median follow-up of 72 months. For surgical management of SA palsy, pooling data in a meta-analysis showed that patients on average improved by 47° (95% confidence interval [CI]: 34-61, P ≤ .001) in active forward flexion, had lower visual analog scale scores for pain (mean difference [MD]: −3.0, 95% CI: −4.9 to −1.0, P = .003), and had substantial improvements in American Shoulder and Elbow Surgeons (MD: 24, 95% CI: 9-39, P = .002) and Constant scores (MD: 45, 95% CI: 39-51, P ≤ .001). Patients with TP palsy on average improved by 36° (95% CI: 21-51, P ≤ .001) in active forward flexion after tendon transfer. Statistical pooling was not possible for other outcome measures as insufficient data were available.
A substantial part of nonsurgically managed patients with scapular winging seem to have persistent complaints, which should be part of the information provided to patients. Data pooling demonstrated significant improvements in shoulder function, pain scores, and shoulder scores after tendon transfer surgery, but higher quality evidence is needed to allow for more robust recommendations and guide clinical decision-making on when to perform such functional surgery.
Scapular Winging
2018, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation
Scapular winging indicates a prominence of the vertebral border of the scapula. There is an association with numerous medical conditions or injuries that ultimately affect glenohumeral and scapulothoracic biomechanics.
Scapular winging more recently has been classified anatomically, based on whether the etiology of the lesion is related to nerve, muscle, bone, or joint disease. Most commonly, injuries to the long thoracic nerve and the spinal accessory nerve, with weakness of serratus anterior and trapezius muscles, respectively, have been associated with scapular winging.
The anatomy of the upper back and shoulder girdle is reviewed with emphasis on innervation, muscle connections, and function. The physical examination of the region emphasizes review of posture, muscle atrophy, muscle spasm, and glenohumeral and scapulothoracic motion. The different patterns of scapulothoracic movement aid in the differential diagnosis of scapular winging.
Functional limitations depend not only on the cause of scapular winging, but also on the severity of weakness, pain, and glenohumeral and scapulothoracic dysfunction. Activities of daily living, recreational, and social activities can be adversely affected and lead to development of chronic pain and secondary impingement syndromes. Diagnostic studies including plain radiographs, advanced imaging, and electro diagnosis are discussed. Treatment includes use of pain control, activity modification, physical therapy, physical modalities, and immobilization with various braces and orthotics. Surgical options are discussed for patients who fail to respond to conservative treatment.
Isolated serratus palsy etiology influences its long-term outcome
2017, Journal of Shoulder and Elbow Surgery
The cause of isolated serratus palsy is multifactorial, but evaluation of the mechanism of the injury indicates that the lesion to the long thoracic nerve is mechanical in origin in most cases. What is unknown, however, is how etiology influences its long-term outcome. We believed that overuse injuries may recover sooner and better than acute traumatic, infectious, or inflammatory injuries.
We determined the presumed etiology of isolated serratus palsy in 92 patients treated by brace or observation only and compared it with its long-term outcome after a mean follow-up of 18.1 years (range, 2.1-26.9) by measuring pain, range of motion, and winging of the scapula.
Trauma preceded 22 (24%) of the cases, exertion 37 (40%), infection 14 (15%), and surgery/anesthesia 10 (11%). In 9 (10%) cases, no etiologic factor was evident. Serratus palsy preceded by infection recovered better than did cases with no infection, and those with palsy preceded by surgery/anesthesia had a poorer outcome than did those with no surgery (axilla, chest, or any other areas) or anesthesia. Those palsies caused by acute trauma or acute or chronic overuse/exertion had the same recovery course.
Etiology of isolated serratus palsy influenced long-term outcome less than we had expected. It seems, however, that palsies caused by infection recover better and those caused by surgery wherever in the body recover most poorly.
Scapulothoracic Pathology
2017, Orthopaedic Physical Therapy Secrets: Third Edition
Nerve Problems Related to the Shoulder
2016, Rockwood and Matsen’s The Shoulder
Scapula alata: Description of a physical therapy program and its effectiveness measured by a shoulder-specific quality-of-life measurement
2015, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
As the serratus anterior function gradually recovered, the exercises progressed through increased endurance, repetitions, and resistance. In step with beginning function of the musculus serratus anterior and incipient improved scapular stability and kinesis, kinetic chain components including diagonal patterns were integrated into the exercise program to achieve increased muscle activity in the lower trapezius and the serratus anterior muscles5,6 and preferably exercises with minimal activity in the upper trapezius muscle.5,15,25,27 In time, with restored neuromuscular conditions and regained activity of the serratus anterior muscle, the exercises were gradually progressed, becoming more functional and eventually including plyometric exercises.17
To date, there are no published outcomes-based treatment programs to guide clinicians when managing patients with scapula alata. The purposes of this study were to describe a physical therapy program in patients with scapula alata and to evaluate its effect using a shoulder-specific quality-of-life measurement.
In this case series and retrospective study, 22 patients (11 female patients) with a median age of 34 years (interquartile range, 28-44 years), diagnosed with scapula alata caused by injury to the long thoracic nerve, were successively referred as outpatients to a physical therapy program at a university hospital. The program included (1) physical examination, (2) thoracic brace treatment, and (3) muscular rehabilitation. The treatment frequency and duration were determined individually. The effect was evaluated by a shoulder-specific quality-of-life questionnaire, the Western Ontario Rotator Cuff (WORC) Index. The WORC Index is grouped into 5 domains: physical symptoms, sport/leisure time, work, lifestyle, and emotional health.
The results showed a highly significant improvement (P < .001) from pretest to post-test as measured by all 5 domains in the WORC Index.
This study described in detail a physical therapy program; the program showed significant benefit. Further research is needed before recommending the program as a potential treatment option.

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^☆: The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of Army or the US Government.

^☆☆: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

^★: This is a US government work. There are no restrictions on its use.

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ArticleScapula winger's brace: A case series on the management of long thoracic nerve palsy☆,☆☆,★

Abstract

An anatomical study of the role of the long thoracic nerve and the related scapular bursae in the pathogenesis of local paralysis of the serratus anterior muscle

Anat Rec

Long thoracic neuropathy from athletic activity

Arch Phys Med Rehabil

Long thoracic nerve palsy in a professional ballet dancer

Am J Sports Med

Neuralgic amyotrophy: the shoulder-girdle syndrome

Lancet

Some neurological complications of serum therapy

BMJ

C7 radiculopathy: importance of scapular winging in clinical diagnosis

J Neurol Neurosurg Psychiatry

C7 radiculopathy: importance of scapular winging in clinical diagnosis

J Neurol Neurosurg Psychiatry

Radiation-induced long thoracic nerve palsy

Cancer

Familial long thoracic nerve palsy: a manifestation of brachial plexus neuropathy

Neurology

Electrodiagnosis in diseases of nerve and muscle: principles and practice

Scapular winging in cervical spondylotic myelopathy

Clin Neurol

Article
Scapula winger's brace: A case series on the management of long thoracic nerve palsy☆,☆☆,★