Original Editors - Derick Glenn
- 1 Definition/Description
- 2 Clinically Relevant Anatomy
- 3 Video
- 4 Epidemiology /Etiology
- 5 Characteristics/Clinical Presentation
- 6 Diagnostic Procedures
- 7 Medical Management
- 8 Physical Therapy Management
- 9 Clinical Bottom Line
- 10 References
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.
Clinically Relevant Anatomy
The anatomic structures involved in the winged scapula are:
- M. trapezius
- M. serratus anterior
- M. Rhomboids
- M.levator scapulae
- M. Pectoralis minor
- M.latissimus dorsi
- N.thoracicus longus
- Brachial plexus
Structures involving the musculoskeletal winged scapula:
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:
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:
• 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
• From birth
• The result of post-surgical complications, like a chest tube placement
• Idiopathic as in the case of Parsonage-Turner Syndrome
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.
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.
Clinical presentation for the musculoskeletal winged scapula
There are three types of scapular motion deviation:
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.
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.
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:
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.
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.
- 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.
- 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.
- 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.
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.
These treatments are:
- Split pectoralis major transfer
- Modified version of the Eden-Lange procedure
Physical Therapy Management
- Conscious muscle activation of scapular muscles:
- 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.
- Automate of the scapular muscle control:
- 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:
- Push-up with a plus (additional protraction of the scapula)
- Elevation in the scapular flat in exorotation
- Elbow push-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
- It can arise often after an acute trauma or micro-trauma
- 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.
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