Long Thoracic Nerve injury and burning pain in shoulder...

[mikepa]

When I was in the Army (1992), I started having some burning pain in my left shoulder/trap area after long hiking (with ruck sack) training sessions. I spent a lot of time (almost 4 years) trying to determine what the problem was and after a series of tests, EMG's, etc, they determined it was a long thoracic nerve injury. I've been dealing with this pain ever since, but it has recently (the last year or so) become much worse, consistent and just plain painful. I'm an avid hiker and mountain climber (both with backpacks) and it is severely limiting my time in the wild. The pain begins much earlier into my hikes than it used to and has become much more excruciating and long lasting. Is there a solution to this either surgical or otherwise....If I could manage the pain, I'd be happy to even just do that....Any help would be greatly appreciated...

Mike

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[alophysio]

Hi Mike,

Long thoracic nerve originates in the brachial plexus...therefore, you need an assessment from someone who can see if you neck and thorax are working properly. Often it could be a joint problem, overactive muscles or a muscle imbalance etc.

The pain may be from the Long Thoracic Nerve but has anyone answered the question of why??

Also, could you be more specific as to where your pain is - perhaps deownload a bodychart from google images and use MS Paint to colour in where your pain is...perhaps those who said it is the long thor n have got it wrong!

Cheers!

[Dr Damien]

Dear Mikepa

It is interesting that the only time you get this pain is when you are mountain climbing with your rucksack, from your description it seems it is onesided...If EMG results suggest its a long thoracic nerve injury then maybe it is?????...however true nerve injuries (especially motor ones as chronic as yours) should present with some weakness, in this case perhaps a winged scapula...do you have that?

I am in agreement with alophysio and to add alophysios point, it sounds like a compression problem, perhaps along the course of this nerve, neck or first rib? This I can imagine would be the case if you have to carry a rucksack as heavy as you mention in some instances two...climbing mountains...

fill us in with more details

cheers

[charlize29]

Injury to the long thoracic nerve although not common may occur from repetitive microtrauma with heavy effort above shoulder height, pressure on the nerve from packpacking and vigorous upper limb activities. If pain,weakness and winging of the scapula ensue, this is not a good sign. Recovery time mya take up to 2 years. So if i were you, elimination of the precipitating factor is a must which is your hiking and backpacking. In this case, you should focus more on your health over your passion as this will take toil later on in your life if you don't stop temporarily.

By the way, here's a link that would somehow help you understand why this happens among backpackers:

http://www.ncbi.nlm.nih.gov/pmc/arti...00238-0091.pdf

CHEERS!!
Charlize29

[SigMik]

Dear Mike,

there seems to be a few issues that needs to be clarified before we can try to be of any help.

Damien and Charlize already pointed out that if its a clinically true long thoracic nerve injury (LTN), then you should have a winged scapula when moving your affected arm forwards or out from your side. Get someone to observe your shoulder blades, it should be quite obvious. If not, try the same movement while holding a 5 kg/11 lbs weight. Or get on the floor and do a proper pushup while someone observes you. I've seen a few of these, when I worked as a physio in the military up here in the north , both cases triggered with heavy military rucksacks and both recovered completely without any intervention within 3 months. We say that normally these kind of nerve injuries, neuropraxia injuries, grows about 1-3 mm. a day with a generally good prognosis. Charlize points out that recovery might take up to 2 years, and I would add to this that poor recovery within 6 months will predict poor recovery also after 1 year.

Another thing that itch in my air, is that you say that "after a series of test, EMG's, etc" they determined LTN injury. What kind of series of tests? What does etc involve? Who were they? My understanding is that EMG's will seldom pick up neuropraxia (the mildest out of three on a nerve injury scale), even nerve conduction tests can be negative.

From the area you describe your pain (left shoulder/trap area) and the nature of your pain, I'd be REALLY interested in a thorough physical examination of your cervical (neck) spine, and with a focus on your left C5-6 and especially your left C6-7 facet joint. Carrying a ruck sack would transmit forces through muscles from your shoulder blade that attaches directly to this area, producing a compression within the joint. Needle injection studies have shown that a problem with these joints can refer pain into the area you describe and could be referred to as "secondary hyperalgesia", in other words, the source of your pain is different from where you feel your pain due to central pain modulation processes...

Very precise thumb pressures (posteroanterior mobilisations - PA's) to especially the left side of your neck at the C5-6 and C6-7 with different inclinations (also obviously compare with other side and the above and below vertebraes) aiming to reproduce the exact pain you are familiar with could provide evidence to this. Preferably it could be done WITH your ruck sack on to make it as close to your pain situation as possible. But wouldn't surprise me if the pains are reproducible with PA's even in sitting or when you lie on your front.

I stand shoulder to shoulder with Alophysio and Damien in suggesting that you should really get someone to look at your neck. Personally, based on the limited information given, I'd boldly say that long thoracic nerve injury sounds LESS likely. It's easy to disprove me on this; get someone to observe what happens to your shoulder blade while doing those movements as suggested. A minor difference between the shoulder blades could be caused by muscle imbalance/side preferential issues. We're not talking about a maybe or maybe not in case of a winging scapula caused by LTN injury, it should be hit-you-in-the-face obvious for the observer.

This buffy dude does a very good job in showing us how a damage to the LTN should look like:
YouTube - Long thoracic nerve damage.

Looking forward to hearing from you again.

Kind regards,
Sigurd Mikkelsen

[mikepa]

You can view the page at http://www.physiobob.com/forum/conte...in-shoulder...

[neurospast]

Hello, Mike,
not nice to have that problem. Unfortunately you might have to look some further since a lot of these symptoms are mimicked (e.g. T.O.S)and diagnosed with long thoracic nerve injury. Personally I would lokk into your posture. I am pretty sure you have protracted shoulders thus limiting the movement in general of the shoulder girdle and thus asking for problems. Also protraction of the head and neck symptoms would suggest other problems contributing to the problems you sense.
So; 1 be sure about the diagnose. 2 Get your posture right (tight pecs? I'm pretty sure because majority of army or ex army people like to work out in the gym and creating a disbalance between the muscle groups which are responsible for force and other groups which are responsible for positioning joints). 3 Get a back pack which is good for you thus the right size, lying close to your back. tighten the shoulder straps and strap between the 2 shoulder straps enough while avoiding to protract shoulders. 4 get a good movement and postural assessment!!!!

[tammsmith53]

It is best to get yourself properly diagnosed. With the advanced technology in modern science, there are several options that can be looked into. One of them is known as Reconstructive Nerve Surgery, which encompasses several different treatments. I recommend Jersey Shore University Medical Center for their expert faculty and specialized services for Reconstructive Nerve Surgery.