Long Thoracic Neuropathy: Next Step When Conservative Management Has Not Resolved Scapular Winging

This protocol applies to patients with long thoracic neuropathy whose scapular winging has persisted after completing a full initial course of conservative care. It defines the structured approach taken once that first-line period ends without achieving the expected recovery.

Prior Treatment — Goal Not Achieved

Previous Line: Conservative Management (9–12 Months)

The initial protocol consisted of conservative management over 9–12 months, incorporating physical therapy for range of motion, scapular stabilisation, rotator cuff stretching, and periscapular muscle strengthening, together with pain control and avoidance of precipitating activities. The target for this line was spontaneous resolution of scapular winging within that timeframe. When that goal is not met, this protocol is indicated.

Current Protocol — Partial Overview

For patients unresponsive to conservative measures, the current approach involves a surgical decompression procedure directed at the thoracic long thoracic nerve. The full procedural sequence, decision points, and criteria for this step are contained in the structured protocol.

Clinical Goal

The target outcome is complete or near-complete resolution of scapular winging, assessed using the Wrightington Winging Score.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jhsg.2022.11.006

For those with persistent winging beyond that period, we offer LTN neurolysis.
Given its relative ease and low morbidity, our practice is to decompress the thoracic LTN initially.
For those patients who are unresponsive to conservative measures, thoracic LTN neurolysis can then be considered.
By using the above approach, we have observed 60% complete or near-complete resolution of scapular winging, with significant improvement in their Wrightington Winging Score (unpublished data).

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