Sep-Oct 2017 – “Long Thoracic Nerve: understanding and identifying a palsy”

An orthopaedic physiotherapist will assess the shoulder numerous times in their career and yet each assessment is unique resulting in different outcomes and treatments approaches. For example, the contribution of the serratus anterior muscle with its innervation and its impact on the shoulder is rather significant yet the amount of research on this area is limited. If we look into the evidence available, there appears to be a lack of articles which clearly focus on this region while providing clear data on its effect on the mechanics of the shoulder complex.


Report from Chair

It’s been a privilege to serve this executive for you. I am very pleased with the direction of the Division and to have been a part of establishing collaborative relationships, building our strategic plan, and with that increasing our transparency and revisiting our governance, and lastly renewing our annual symposium. I encourage you all to continue to provide us feedback, as I know you are all passionate and we rely on your opinion to ensure your membership remains valuable. Keep this momentum. Stronger, together. Always forward, forward always.


Original Submission

Upper Fibres of Serratus Anterior – The Hidden Powerhouse – Part 1
The serratus anterior muscle is recognized as the primary stabilizer of the scapulothoracic articulation, providing a solid base of support for upper extremity function. It has an important role in normal scapulohumeral rhythm during arm elevation because it provides the pivotal force required for upward scapular rotation and protraction (abduction). It also contributes to the stability of the scapula by maintaining the medial border of the scapula against the chest wall.

Upper branch(s)of the long thoracic nerve -the hidden powerhouse – Part 2
As described in part one of this paper, the serratus anterior does have three distinct parts. They differ in size, location and orientation on the chest wall. Although not yet fully understood, the function of each part of this muscle is likely both independent and integrated with the use of the entire muscle, depending on the task requirements. Three parts in one muscle; working together, yet independently, to provide a complex and co-coordinated blend of stability and mobility on the chest wall. It would be logical to assume that if there are three separate parts to the serratus anterior muscle, there would need to be at least three separate branches from the long thoracic nerve, supplying each part with an independent nerve supply.


Case Study

Long thoracic nerve palsy (LTNP) results in the inability to use the serratus anterior muscle. Weakness or palsy of serratus anterior (SA) will cause winging of the scapula. Orthopaedic textbooks show us many examples of the winging scapula, and the winging appears to be obvious – the hallmark sign of a LTNP.


Clinical Tidbits

The Difficulty Factor
Having lived with long thoracic nerve palsy for five years, I have had a great deal of time to think. Yes, that sounds dangerous – but It has resulted in hundreds of “ah ha!” moments, when I would finally figure out why something feels or behaves as it does. My unique perspective has been an ongoing challenge. I am constantly bouncing back and forth between a clinician point of view, and a patient point of view. I am documenting, reading and researching and I have started to participate as a consultant in the assessment and management of this problem. This has helped a great deal in reconciling my conflicting mind-set.

Excerpts from: Long Thoracic Nerve Palsy
An educational and exercise resource for patients and therapists.
I had a difficult time adjusting to my new, very different life. As a physiotherapist, I had a great deal of experience assisting patients with their difficult life transitions, but there is no way I could have anticipated how I would feel when faced with a significant transition in my own life. I am no longer able to work as an “active” physiotherapist but I have always been passionate about my profession and the importance of an active lifestyle.


Featured Articles

Serratus anterior or pectoralis minor: Which muscle has the upper hand during protraction exercises?

Birgit Castelein a.*, Barbara Cagnie a, Thierry Parlevliet b, Ann Cools a


The influence of induced shoulder muscle pain on rotator cuff and scapulothoracic muscle actuvity during elevation of the arm

Birgit Castelein, MSc, PTa,*, Ann Cools, PhD, PTa, Thierry Parlevliet, MDb, Barbara Cagnie, PhD, PTa