the contents by NLM or the National Institutes of Health. Biting palsy of the accessory nerve. Paralysis of the serratus anterior muscle has been well documented amongst professional and amateur athletes of a variety of sports, including archery, ballet, baseball, basketball, body building/weight lifting, bowling, football, golf, gymnastics, hockey, soccer, tennis, and wrestling [4, 6, 11, 13, 28, 35, 36]. [. The trapezius is solely innervated by the spinal accessory nerve, or cranial nerve XI, which crosses the posterior cervical triangle superficially before diving vertically along the deep surface of the trapezius [7, 44]. Makin G, Brown WF, Ebers GC. However, there are some limitations. [39] reported an unusual case of suprascapular and dorsal scapular nerve entrapment in two siblings, both of whom were competitive volleyball players who developed identical symptoms in their dominant shoulder. Warner JJP, Navarro RA. Indeed, there are only anecdotal statements describing rhomboid paralysis as rare and its functional effects as even rarer [33, 34]. [. Medial winging due to serratus anterior paralysis is accentuated when patients are asked to forward flex their arms to the horizontal and push on a wall in a push-up motion. Here we discuss incidence and demographics, pertinent anatomy, the nature of the injury, diagnostic tests, and treatment options for scapular winging due to serratus anterior, trapezius, and rhomboid muscle paralysis. Disa JJ, Wang B, Dellon AL. 4). Reading time: 4 minutes. Because a nerve root in the neck is just the end of a wire that serves entire areas of the upper body, sypmtoms can appear in various places. Clinically Oriented Anatomy (7th ed.). [27] report two predictive factors of poor outcome, including patient age over 50years and a spinal accessory nerve lesion caused by radical neck dissection, penetrating injury, or spontaneous palsy. You wouldnt hang a tire swing from the top of a sapling. Some authors recommend the Eden-Lange procedure only in the case of spontaneous palsy of the trapezius, failed nerve repair, or a duration of 1220months have elapsed post-injury [7, 27]. Pinched nerve - Diagnosis and treatment - Mayo Clinic Unlike some statements that merely sound sensible, this turns out to be true for the vast majority of cases we see at RNI. Long thoracic nerve injury. It pierces the scalenus medius muscle and descends between the levator scapulae on one side and serratus posterior superior and scalenus posterior muscles on the other side. [4] point out that prominent scapular winging may not be evident until several weeks after an acute lesion in order for the trapezius to stretch out far enough. Dorsal scapular nerve: Origin, course and function | Kenhub Read more. Register now Atlas of Human Anatomy (7th ed.). Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Transfer of the pectoralis major may not be recommended for individuals looking to return to strenuous labor or contact sports, as these activities, along with lifting greater than 20pounds, should be avoided a minimum of 612months post-operatively [63, 69, 75]. Schultz JS, Leonard JA. How to Do It: Stand up nice and straight, keeping the shoulders down and back. 2. The levator scapulae length and tension can be assessed by placing the patient in supine, stabilizing the ipsilateral scapula, and contralateraly side bend and rotate the head. The rhomboids serve to pull the scapula posteriorly medially towards the vertebral column , while the levator . Split pectoralis major transfer for serratus anterior palsy. Levator scapulae muscle - Wikipedia These scapular muscles (Fig. Bigliani LU, Perez-Sanz JR, Wolfe IN. Functional electrical stimulation and spinal cord injury. The wooden bow begins as a relatively straight piece of wood. Scapulothoracic arthrodesis in facioscapulohumeral dystrophy. Winging of the right scapula due to serratus anterior palsy, accentuated by active flexion of the arms. However, unlike the large muscles that are meant to do this job, it is not attached to a strong part of the spine. Many conditions affect this area of your spine, including neck pain, arthritis, degenerative bone and disk disease, and stenosis. Severe pain should raise suspicion of a neuritis, such as ParsonageTurner syndrome [8]. Its named after Atlas, of Greek mythology, who held the world on his shoulders. Phillips LH. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. In the intermediate stage, the pain has subsided and the nerve is beginning to heal. It carries messages between your brain and the muscles mentioned above. Specifically, the C4 nerve enervates the levator scapulae, trapezius and rhomboid muscles. It attaches to the three neck vertebrae immediately below the skull, far up and away from the shoulders. Surgical procedures may be warranted in severe cases that are unresponsive to conservative treatment. I would honestly say that Kenhub cut my study time in half. 5) has been developed for trapezius muscle paralysis and has been used somewhat successfully in radical neck dissection patients [78]. In addition, anterior shoulder dislocation can also cause direct injury to the dorsal scapular nerve, as reported in a Judo player who developed extreme instability of the glenohumeral joint, resulting in six dislocations in 2weeks [21]. Acquired winged scapula in a patient with systemic lupus erythematous. Kizilay A, Kalcioglu MT, Saydem L, Ersoy Y. Long tract symptoms, where spinal cord compression in the neck causes symptoms in lower parts of the body, with leg weakness, sensory level, and/or bladder problems. Cosmetically, some patients may be distressed by pronounced winging [2]. The .gov means its official. Neurapraxia is least severe and involves focal damage of the myelin fibers around the axon,. Gordana Sendi MD In addition, because the scapula cannot be stabilized against the thorax, forward flexion of the arm past the horizontal may be limited or impossible [4, 8, 63]. How is levator scapulae pain related to stiff neck & how to relieve the Ravindran etal. Tight Neck? Effective Levator Scapulae Stretch (Video) - Back Intelligence Long thoracic neuropathy from athletic activity. Trigger Point Injections (TPI): What They Are & Procedure The most common reason for this procedure is cervical disk degeneration. Teboul etal. There are only three good reasons to perform surgery to relieve neurological problems in the neck, and youll notice that two of them are only for cases where conservative therapy has already failed: In any of these cases, the thoroughness of the diagnosis a patient receives at RNI will leave no doubt about the nature of the problem and the need for surgery. Shoulder and elbow overuse injuries in sports. In addition, neck pain was often aggravated by changes in the weather, and insomnia was common due to shoulder discomfort [49]. Levator Scapulae - The Definitive Guide | Biology Dictionary In addition, patients report limited range of motion in their shoulders and sharp or aching pain along the medial border of the scapula that can radiate to the lateral aspect of the upper limb. Get instant access to this gallery, plus: Introduction to the musculoskeletal system, Nerves, vessels and lymphatics of the abdomen, Nerves, vessels and lymphatics of the pelvis, Infratemporal region and pterygopalatine fossa, Meninges, ventricular system and subarachnoid space, Rhomboid major, rhomboid minor and levator scapulae muscle. The levator scapulae is innervated by cervical nerve (C3-C4) and dorsal scapular nerve (C5). Treasure Island (FL): StatPearls Publishing; 2021 Jan-. A scapular brace (Fig. Familial long thoracic nerve palsy: a manifestation of bracial plexus neuropathy. Patient outcome after surgical management of an accessory nerve injury. Most aren't serious. Olarte M, Adams D. Accessory nerve palsy. Surgical treatment of a long thoracic nerve palsy. Winging may be accentuated by having the patient extend his or her arm from a fully flexed position, during which the inferior angle of the scapula is pulled laterally and dorsally off the thoracic wall [5, 34]. Functionally, however, it is considered to be a muscle of scapular motion along with the rhomboids, serratus anterior, serratus posterior superior and inferior muscles. Scapulothoracic articulation: anatomy, biomechanics, pathophysiology, management. To increase the stretch further, the left hand can be brought up to the back of the head to gently pull down a little more. Exercises to maintain ROM is important to limit contracture of periscapular muscles, but special care must be taken not to stretch the paralyzed muscle. Frontera: essentials of physical medicine and rehabilitation, 1st ed. sharing sensitive information, make sure youre on a federal Overview What are trigger point injections? 2. In the largest series of 111 surgical repairs of the spinal accessory nerve, neurolysis resulted in mostly excellent results, while end-to-end suture repair resulted in slightly better outcomes than graft repair [19]. Most cases of cervical radiculopathy go away with nonsurgical treatment. There were six other siblings who did not play volleyball and did not have the condition, leading Ravindran etal. For the purposes of this discussion, conservative therapy includes medications and, crucially, physical therapy by P.T.s who are expert in neuro-physiology. In previous reports, such misdiagnoses have led to 17 surgical procedures to be performed on five patients without improvement of symptoms [63] and a diagnostic delay in 10 of 14 patients [9]. Occasionally, it may arise from the superior trunk of the brachial plexus. A treatment option for scapular winging due to serratus anterior or trapezius muscle paralysis, the wingers brace is designed to manually press the scapula against the posterior thoracic wall, preventing stretching of the paralyzed muscle and providing limited functional recovery [71, Figs. Surgical exploration and nerve repair, such as neurolysis, end-to-end suturing, or nerve grafting, has produced variable outcomes, but appear to be generally beneficial [1417, 19, 60, 7982]. Saeed MA, Gatens PF, Singh SS. Hawkins RJ, Willis RB, Litchfield RB. The muscle that holds up the weight of the shoulders when others can't is called the levator scapula, seen in red in the diagrams. Marin R. Scapula wingers brace: a case series of the management of long thoracic nerve palsy. As a whole, the main function of the serratus anterior is to protract and rotate the scapula, keeping it closely opposed to the thoracic wall and optimizing the position of the glenoid for maximum efficiency for upper extremity motion [4, 8, 44]. Always seek the advice of a qualified health provider with any questions you may have regarding a medical condition. Levator scapulae is a long and slender muscle that anatomically belongs to the superficial layer of extrinsic muscles of the back. Williams WW, Donell ST, Twymann RS, Birch R. The posterior triangle and the painful shoulder. The treatment of winged-scapula. Function. Martin JT. In addition to entrapment syndromes, direct injury to the nerve has been reported to cause rhomboid paralysis. At RNI we help patients avoid surgery for pinched nerve neck pain by aggressive Physical Therapy to correct a posture problem that continues to put strain on the neck and cervical nerve roots. Vinson EN. Spontaneous or idiopathic trapezius paralysis has also been reported [7, 27]. Paralysis to the trapezius muscle, like serratus anterior paralysis, is primarily neurogenic, but from injuries to the spinal accessory nerve. Difficulty with either task suggests weakness of the rhomboids, but this may be masked by trapezius hypertrophy [21]. Inclusion in an NLM database does not imply endorsement of, or agreement with, Levator originates from the Latin word levare which means "to raise" and scapula is Latin for "shoulder.". [16] reported 58% of 43 patients with accessory nerve injury to be iatrogenic. Trauma may also be due to repetitive movements, as seen in athletics [4, 13] and house-hold activities such as hedge-clipping [11], digging [11], car washing [57], or prolonged lying in bed with the arms abducted and propping up the head to read [7]. The authors of that study consider this to be a strong diagnostic clue and advocate asking all patients with shoulder weakness after sustaining an injury specifically if they have such a burning pain. . The general strategy is to strengthen the muscles of the shoulders and upper back to reverse the rounding and return the upper spine to an upright posture. [2] Associated structure The dorsal scapular artery (DSA) follows the DSN to provide blood to the trapezius, levator scapulae, and rhomboid muscles. The smaller rhomboid minor is a cyndrical muscle that finds its origin in the ligamentum nuchae of the neck and the spinous processes of the seventh cervical and first thoracic vertebrae [44, 47]. Patients may complain of a dull ache and heaviness around the shoulder [12, 15] and may describe the feeling as having a brick on the shoulder [15]. Correction of scapular winging by supraclavicular neurolysis of the long thoracic nerve. The levator scapulae is a slender: 910 skeletal muscle situated at the back and side of the neck. [44, p. 52, Fig. Serratus anterior paralysis and scapular winging will persist in approximately 25% of patients treated conservatively and such patients are candidates for surgical reconstruction [6]. In one series of 14 patients with traumatic lesions, pain was localized to the lower pole of the scapula immediately after injury and was described as having a burning quality [9]. [49] reported discomfort of the neck, back, and shoulder to be the main complaint of 36 patients. Due to the rhomboids anatomical position deep to the trapezius muscle and the subtleness of the scapular winging, rhomboid paralysis is a difficult diagnosis. Dorsal Scapular Nerve Syndrome Treatment and Causes Kinesio tapes can help with the healing process during and after physical activity, like playing a sport or exercising. Cervical Radiculopathy (Pinched Nerve) Cervical radiculopathy (also known as "pinched nerve") is a condition that results in radiating pain, weakness and/or numbness caused by compression of any of the nerve roots in your neck. Strengthening exercises should be incorporated gradually and only after reinnervation of the muscle is evident. For these reasons we suggest to any patient with pinched nerve neck pain or other spine-related pain that they see a neurologist before talking to a surgeon. Dorsal scapular nerve, from C5 to rhomboid and levator scapula muscles; responsible for elevation and stabilization of the scapula. Available from: Vuvi H. Nguyen, Hao (Howe) Liu, Armando Rosales, Rustin Reeves, "A Cadaveric Investigation of the Dorsal Scapular Nerve", Anatomy Research International, vol. [49] treated 18 patients with local steroid injection for neck tenderness. Dorsal scapular nerve: want to learn more about it? This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. The levator scapulae is a muscle of the upper neck and back. Purported by Wiater and Bigliani [7] and Wiater and Flatow [8], the physician evaluation should include a detailed history including questions regarding hand dominance, occupation, hobbies, and current and previous level of function, answers to which will dictate the use of conservative or surgical treatment. But that is essentially what is happening here. A collar helps support and immobilize your neck. Extracranial spinal accessory nerve injury. The Neurology of Hypermobility, Role of Hypermobility in Headache and Migraine, The Gut-Brain-Hypermobility Connection with Autoimmunity. To maintain full ROM, passive stretching of the rhomboids, levator scapulae, and pectoralis minor is used to prevent contracture of these muscles due to the loss of serratus anterior activity. If your symptoms warrant, you should see a physician (orthopaedic surgeon or . Stretches and Exercises for Neck Pain and Dizziness First, as the name suggests, it helps to elevate your shoulder and rotating the scapula downwards. Sports and performing arts medicine. A pinched nerve occurs when too much pressure is applied to a nerve by surrounding tissues, such as bones, cartilage, muscles or tendons. Scapular winging is a rare, but potentially debilitating condition that can affect the ability to lift, pull, and push heavy objects, as well as to perform daily activities of living, such as brushing ones hair and teeth and carrying grocery bags [1]. Similarly, rhomboid paralysis tends to be primarily neurogenic in nature, involving the dorsal scapular nerve. To learn everything about the nervous system in a fun and engaging way, try out nervous system quizzes and diagrams!. This muscle gets really tight with bad posture during desk work. In one series of conservatively treated patients, only pain from frozen shoulder syndrome was relieved by an exercise program, while pain from muscle spasm, radiculitis, impingement, and asymmetry of the neckline persisted [12]. Scapular winging: anatomical review, diagnosis, and treatments Reproducibly, manual stabilization of the scapula against the thorax by the physician can alleviate shoulder discomfort and can allow for shoulder flexion above 150 [63]. [28] advocate the use of a restraint that limits abduction of the arm to only 30, forcefully preventing overuse of the serratus anterior. Long . Levator Scapulae Stretch. Like some of the fibers of the long thoracic nerve, the dorsal scapular nerve penetrates the scalenus medius muscle, before heading to the levator scapulae, giving off innervating fibers to the muscle [44, 49]. government site. Scapular winging can be accentuated when the patient is asked to forward flex his arms to the horizontal (Fig. In the supine position, the weight of the body prevents winging by compressing the scapula against the thorax and allows for full shoulder range of motion [3, 25, 28]. As a library, NLM provides access to scientific literature. The fibers on the outside of the bundle are the first to suffer any impingement. Bertelli JA, Chizoni MF. Scapular winging should initially be treated conservatively, allowing time for spontaneous recovery. A dynamic muscle transfer, the procedure involves the lateral transfer of the insertion sites of the levator scapulae and rhomboid muscles along the scapula. This crowding will cause problems over time on its own, but if the disc begins to bulge or herneate, the crowding becomes acute very quickly with pain and other symptoms. [49] reported effective relief of symptoms for 14 out of 22 patients up to 1.5years after undergoing decompression surgery in the anterior neck. A condition due to a number of etiologies, most cases are due to lesions of the long thoracic and spinal accessory nerves that innervate the serratus anterior and trapezius muscles, respectively. 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. Levator Scapula Stretch (fig.13) To stretch the right side: Place right hand behind head with elbow pointing upwards. Due to being the sole motor supply to the rhomboid muscles, an injury to the dorsal scapular nerve affects their function. In such a case, scapulothoracic fusion may be the preferred surgical procedure [7]. Electrical shock may also cause long thoracic nerve palsy [40]. Fardin P, Negrin P, Dainese R. The isolate paralysis of the serratus anterior muscle: clinical and electromyographical follow-up of 10 cases. Edinburgh: Elsevier Churchill Livingstone. there is some strong evidence that the dorsal scapular nerve can become entrapped in the scalenus medius muscle as some have suggested [22, 48, 49]. 1. It then runs across the medial scapular region, along the anterior border of the rhomboid muscles. They hypothesized that sudden or recurrent irritating traction force may cause serratus anterior paralysis. 1. The entrapment is often located at the middle scalene muscle, because the nerve often pierces this muscle. 3) and/or push on a wall in a push-up motion [4, 8, 63]. This pain may radiate down the arm and to the scapula [3]. In: Pappas AM, editor. Donner TR, Kline DG. Cervical Radiculopathy (Pinched Nerve) - Cleveland Clinic Perlmutter GS, Leffert RD. Typical presentation includes stiffness, pain, and weakness of the shoulder girdle, especially with overhead activity and upon prolonged exertion [7, 15]. The levator scapulae muscle is at the side and back of your neck. They stimulate muscle movement in your neck, shoulder, arm and hand, and provide sensation. Levator Scapula Muscle and Its Role in Pain and Posture - Verywell Health . Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. Trigger Point Injections for Neck Pain: How Well Do They Work? - Healthline The whammys are starting to add up, here. National Library of Medicine The typical patient suffering from serratus anterior palsy will present with pain around the affected shoulder (usually the right side), which either arises spontaneously or linked to some traumatic event [4, 11]. Dorsal scapular nerve, from C5 to rhomboid and levator scapula muscles; responsible for elevation and stabilization of the scapula. Both nonsurgical treatment options and surgery are available to treat many of the conditions that affect the cervical spine. In the acute stage, denervation of the serratus anterior causes pain, and goals of treatment include pain reduction and ROM exercise. Disorders of the shoulder: diagnosis and management. Modified from Ref. Treatment of winged scapula by pectoralis major transfer. 2.43], Neurogenic causes of scapular winging and the physical exam. Duncan MA, Lotze MT, Gerber LH, Rosenberg SA. This specially made elastic tape can be applied to muscles and joints to decrease pain or swelling, and restore motion. Department of Orthopaedics, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250, 16th St, 7th Floor, Tower Bld, Rm 745, Santa Monica, CA 90404 USA. Current Reviews in Musculoskeletal Medicine, Arm flexion; push-up motion against a wall, Arm abduction; external rotation against resistance, Position of the scapula compared to normal, Entire scapula displaced more medial and superior. Know Your Back. In a series of 14 patients suffering from painful scapular winging, Warner and Navarro [63] found that none of the patients could flex their shoulder above 120, with an average forward flexion of 97. Incidence. . It is in a good position to pull straight up on the shoulder blade, and so this task falls to it when the shoulders are out of position. The levator scapulae muscles are superficial extrinsic muscles of the back that primarily function to elevate the scapulae. and grab your free ultimate anatomy study guide! Although recovery was the norm, persistent winging of the scapula and lack of full abduction was common, as was an asymmetrical neckline with a drooping shoulder on the affected side [19]. The middle component of the serratus anterior originates from the third, fourth, and fifth ribs and inserts on the vertebral border of the scapula, serving to protract the scapula [4, 8]. Desong etal. Accessibility . Akuthota V, Chou JH, Drake DF, Nadler SF, Toledo SD. The levator scapulae muscle is one of the more common muscles that has myofascial pain symptoms. The levator scap influences both neck motion and upper back posture. [49] reported very high rates of symptom resolution after decompressing the dorsal scapular nerve by transecting the scalenus anterior and medius muscles and suggested that dorsal scapular entrapment is simply an atypical presentation of thoracic outlet syndrome. The commonest cause of scapular winging is serratus anterior paralysis, a dysfunction attributed to traumatic [2, 4, 8, 9, 11], non-traumatic [6, 8, 11, 28, 41, 5153], and idiopathic [6, 8, 11, 2830] lesions of the long thoracic nerve.