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Winged scapula

From Physiopedia

Original Editors - Derick Glenn

Top Contributors -

Derick Glenn and Daphne Jackson

Contents

Definition/Description

The term ‘winged scapula’ (also scapula alata) is used when the muscles of the scapula are too weak or paralyzed, resulting in a limited ability to stabilize the scapula. As a result, the medial border of the scapula protrudes, like wings. The main reasons for this condition are musculoskeletal- and neurological-related.[1][2]  

Neurological:
[3]



Musculoskeletal:
[4]

Clinically Relevant Anatomy


The anatomic structures involved in the winged scapula are:

  • Scapula
  • M. trapezius
  • M. serratus anterior
  • Mm.romboideï
  • M.levator scapulae
  • M. Pectoralis minor
  • M.latissimus dorsi
  • N.accessorius
  • N.thoracicus longus
  • Brachial plexus

Epidemiology /Etiology


Structures involving the musculoskeletal winged scapula:[5] 
M.trapezius, M.serratus anterior, M.rhomboideus major, Mm.rhomboideï, M.levator scapulae, M.pectoralis minor, M.latissimus dorsi
Structures involving the neurological winged scapula:[6] 
M.trapezius (pars descendens), M.serratus anterior, M.rhomboidei, N.accessories, N.thoracicus longus, Plexus brachialis.

The causes of both species of winged scapula are:[7][8][9] 
• Acute traumas, for example a direct shock on the shoulder during a car accident with a sudden traction on the arm.
• Micro traumas, repeated stretching of the neck in later flexion as in tennis (N. Thoracicus longus) or by wearing a heavy backpack (N. Accessories)
• Post-infection, for example an influenza infection
• Injections
• From birth
• The result of post-surgical complications, like a chest tube placement[10] 
• Idiopathic as in the case of the syndrome of Parsonage and Turner
Most of these patients describe a sever or excruciating pain, often keeping them awake. Most of the painful scapula alata are caused by a neurological trauma. But a winged scapula is not always painful, this is often with a muscular scapula alata. Other patients feel a moderate pain and some are experiencing no pain at all.[11]  

Any infringement of the plexus brachialis, N.accessorius or N. Thoracicus longus is susceptible to provoke the winging of the scapula. The causes are multiple and new ones are frequently discovered.[12] 

Characteristics/Clinical Presentation

  • Clinical presentation for the musculoskeletal winged scapula:
    There are three types of scapular motion deviation:[13] 

Type 1:
A visible angulus inferior and a pronounced anterior tilt of the scapula can be observed.
The causes for this type are: shortening of the M.pectoralis minor, shortening of the posterior joint-capsule and muscular unbalance of the M.Trapezius pars ascendens and the M.serratus anterior.
[14]

Type 2:
A visible margo medialis and an intern rotation of scapula can be observed.
The causes are: shortening of the posterior joint-capsule, shortening of the M.latissimus dorsi and muscular unbalance of the M.trapezius and the M.serratus anterior.

[15]

Type 3:
A visible angulus inferior and a downward rotation of scapula can be notified.
The causes are: shortening of the M.levator scapulae and muscular unbalance of the M.trapezius pars descendens and ascendens.

  • Clinical presentation for the neurological winged scapula:
    There are two types of scapular motion deviation:[16] 

Type 1:
The characteristics of type 1 are a separated scapula of the thorax, elevation of scapula and the margo medialis comes closer to the spinal line. These causes are related to damage of the N.thoracicus longus and an insufficiency of the M.serratus anterior.

Type 2:
The characteristics of type 2 are a separated scapula of the thorax, lowering of the scapula and spreading of the margo medialis against the spinal line. The causes are damage to the N.accessorius and insufficiency of the M.trapezius pars descendens.




Differential Diagnosis



Diagnostic Procedures

  • The therapist offers an isometric resistance against a scapular elevation in midrange of motion. With a type 1 the angulus inferior becomes visible. Then the therapist asks the patient to execute a protraction, afterwards he repeats the resistance-test. If the scapular posture deviation increases or stays the same, the conclusion would be: a dysfunction of the M. Serratus anterior. If it decreases then we have a dysfunction of the M. Trapezius pars ascendens.[17] 
    • The humerus is passively placed into endorotation behind the back. The capsular tension will bring the scapula to the front. It’s also a test to conclude a shortening of the M. Latissimus dorsi.[18] 
    • When the patient lifts his arm we see a charged excessive acromion, now we can explain that there is an excessive activity of the M. Trapezius pars ascendens and a low activity of the M. Trapezius pars descendens. This phenomenon is called the ‘shrug-phenomenon’.[19] 

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Examination

add text here related to physical examination and assessment

Medical Management

There’re surgical treatments with patients being very satisfied about the result. But some studies prefer a non-operative treatment especially in case of older patients who are sedentary and with minimal symptoms.[20] 

These treatments are:
• Split pectoralis major transfer[21][22] 
• Modified version of the Eden-Lange procedure[23] 
• Scapuloplexy[24]


Physical Therapy Management

In the revalidation we have to give attention to diverse monitoring parameters. Timing, muscle activity, muscular balance, endurance and power of the scapular muscles are important in the revalidation program.[25] 

Revalidation program:
Conscious muscle activation of scapular muscles:[26] 
 Correction scapular position with tactile feedback on the level of the angulus inferior and ask the patient to move the scapula downwards and inwards.
 Scapulothoracal feedback of muscle control with feedback on the level of the sternum
 The patient put his fingers on the processus coracoideus, after this the patient moves his scapula backwards (medio-cranial) with his fingers on the processus coracoideus.
 Myofeedback

  • Automate of the scapular muscle control:[27] 
     Rhythmic stabilisation in lateral position, hand supported on 90° anteflexion
     Rhythmic stabilisation in stand, hand supports on the ball against the wall
     Rhythmic stabilisation in prone, the shoulder girdle in retraction, shoulder in exorotation
     Rhythmic stabilisation in prone, shoulder girdle in protraction, arm in submaximal elevation
  • Dynamic scapulothoracal muscle training:[28] 
     Push-up with a plus (additional protraction of the scapula)
     Elevation in the scapular flat in exorotation
     Elbow push-up
     Press-up
     Low rowing
     Horizontal abduction
     Retroflexion against resistance
     Serratus punch upright, prone and fitter
     Dynamic hug
     ‘Elbow in the back pocket’-exercise 

Clinical Bottom Line

  • Winged scapula can have a neurological or a musculoskeletal cause[29][30] 
    • It can arise often after an acute trauma or micro-trauma[31] 
    • We can give some physical exercises for the scapula. First conscious muscles activation of the scapula, then automate exercises for the scapula muscles and at last dynamic exercises for the muscles of the scapula.[32] 

Recent Related Research (from Pubmed)

References

  1. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  2. (10) Grethe Aalkjӕr, Lisbeth Rejsenhus. Scapula alata or winging scapula. 2006, 1-7.fckLREvidence levels :A2
  3. http://en.wikipedia.org/wiki/Winged_scapula
  4. http://www.maitrise-orthop.com/viewPage_us.do?id=1010
  5. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  6. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  7. (3) C.L. Foo, M. Swann. Isolated paralysis of the serratus anterior, a case report of 20 cases. The journal of bone and joint surgery 1983 (65-B), 552-556.fckLREvidence levels: 3
  8. (10) Grethe Aalkjӕr, Lisbeth Rejsenhus. Scapula alata or winging scapula. 2006, 1-7.fckLREvidence levels :A2
  9. (11) B. Forthomme, F.C. Wang, J.M. Crielaard, J.L. Croisier. Scapula alata : facteurs musculaires et neurologiques. Épaule neurologique et médecine de réeducation 2009, 21-24.fckLREvidence levels : E
  10. (1) W.U. Hassan, N.P. Keaney. Winging of the scapula: an unusual complication of chest tube placement. Journal of accident and Emergency Medicine 1994 (12), 156-157.fckLREvidence levels: A2
  11. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  12. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  13. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  14. http://www.maitrise-orthop.com/viewPage_us.do?id=1010
  15. http://medischcontact.artsennet.nl/Nieuws-26/Tijdschriftartikel/87135/Afstaand-schouderblad-na-neurotrauma.htm
  16. (8) M.N. Thaury, R. Pallise, M. Chammas. Paralysies du trapeze et du dentelé antérieur: presentation Clinique, traitement kinésithérapique. Épaule neurologique et médecine de réeducation 2009, 68-71.fckLREvidence levels : E
  17. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  18. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  19. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  20. (7) Sandro Giannini, MD; Cesare Faldini, MD; Stavroula Pagkrati, MD; Gianluca Grandi, MD;Vitantonio Digennaro, MD; Deianira Luciani, MD; and Luciano Merlini, MD. Fixation of winged scapula in facioscapulahumeral muscular dystrophy. Clinical Medicine and research 2007 (5), 155-162.fckLREvidence levels: A2
  21. (5) Gregory J. Galano, MD, Louis U. Bigliani, MD, Christopher S. Ahmad, MD, and William N. Levine, MD. Surgical treatment of winged scapula. Clinical Orthopaedics and related research 2008 (466), 652-660. Received vovember 27, 2007; accepted November 27, 2007; published online January 8, 2008.fckLREvidence levels: A2
  22. (6) John Iceton, W.R. Harris. Treatment of winged scapula by pectoralis major transfer. The journal of bone and joint surgery 1987 (69-B), 108-110.fckLREvidence levels: A2
  23. (5) Gregory J. Galano, MD, Louis U. Bigliani, MD, Christopher S. Ahmad, MD, and William N. Levine, MD. Surgical treatment of winged scapula. Clinical Orthopaedics and related research 2008 (466), 652-660. Received vovember 27, 2007; accepted November 27, 2007; published online January 8, 2008.fckLREvidence levels: A2
  24. (7) Sandro Giannini, MD; Cesare Faldini, MD; Stavroula Pagkrati, MD; Gianluca Grandi, MD;Vitantonio Digennaro, MD; Deianira Luciani, MD; and Luciano Merlini, MD. Fixation of winged scapula in facioscapulahumeral muscular dystrophy. Clinical Medicine and research 2007 (5), 155-162.fckLREvidence levels: A2
  25. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  26. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  27. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  28. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  29. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  30. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F
  31. (4) Dr Jacques Vanderstraeten, médecin généraliste et du sport. Scapula alata. La revue de la Médecine Générale 2010 (269), 32-33.fckLREvidence levels : A1
  32. (9) Ann Cools, Marc Walravens. Oefentherapie bij schouderaandoening. 2005, 104-135. VUB-BIB.fckLREvidence levels : F


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