Scapular Winging

Original Editors - Derick Glenn

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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 or lateral borders of the scapula protrudes from back, like wings. The main reasons for this condition are musculoskeletal- and neurological-related.Winging of scapula disturbs scapulohumeral rhythm; contributes to loss of power and limited flexion and abduction of the upper extremity and can be a source of considerable pain. This 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 one’s hair and teeth and carrying grocery bags.

Figure.1 Neurological Scapular Winging

Figure.2 Musculoskeletal Scapular Winging

Clinically Relevant Anatomy

Figure.3 Scapula - Posterior View

The anatomic structures involved in the winged scapula are:

Bones

• Scapula

Muscles

• Trapezius
• Serratus Anterior
• Rhomboids
• Levator Scapulae
• Pectoralis Minor
• Latissimus Dorsi

Nerves

• Spinal Accessory Nerve
• Dorsal Scapular Nerve
• Thoracicus Longus / Long Thoracic Nerve
• Brachial Plexus

Structures involving the musculoskeletal winged scapula: 

• Trapezius
• Serratus Anterior
• Rhomboids - Rhomboids Major
• Levator Scapulae
• Pectoralis Minor
• Latissimus Dorsi

Structures involving the neurological winged scapula: 

• Trapezius (Pars Descendens)
• Serratus Anterior
• Rhomboids
• Spinal Accessory Nerve
• Dorsal Scapular Nerve
• Thoracicus Longus / Long Thoracic Nerve
• Brachial Plexus

Etiology

Scapular winging is rare. Out of which, incidence of scapular winging due to trapezius paralysis is very sparse and difficult to assess. Whereas serratus anterior paralysis due to iatrogenic injury has shown to be the most common reason for scapular winging. Broadly, the etiology of winging are:

• Serratus Anterior Palsy
• Trapezius Palsy
• Rhomboid Palsy

Epidemiology

The causes of all these leading winged scapula are: 

Traumatic

• Acute Traumas, for example a direct shock on the shoulder during a car accident with a sudden traction on the arm. It has also seen 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.
• Micro Traumas, repeated stretching of the neck in later flexion as in tennis (N. Thoracicus longus) or by wearing a heavy backpack (N. Accessories).Occupational injuries in individuals working as car mechanics, navy airmen, scaffolders, welders, carpenters, laborers, and a seamstress has also reported.

Post-infection

Influenza infection, tonsillitis-bronchitis, poliomyelitis, etc.

Iatrogenic Injury

• As result of post-surgical complications, like a chest tube placement. Mastectomies for breast cancer that involve resection of the axillary lymph nodes are at higher risk as the long thoracic nerve lies near the axillae. Neck dissection may lead to injury to the spinal accessory nerve causing trapezius paralysis.

• Allergic-drug reactions, drug overdose, toxic exposure (herbicides and tetanus antitoxin)
• Consequence of Chiropractic Manipulation
• Use of a Single Axillary Crutch

Congenital

• Muscular Dystrophy-Fascioscapulohumeral Dystrophy

Spontaneous

• Idiopathic as in the case of Parsonage-Turner Syndrome.

Clinical Presentation

• Pain: A severe or excruciating pain, often keeping them awake are mainly caused by a neurological trauma or neuritis. However, winged scapula due to muscular cause are not painful; some may experience moderate pain. Pain can be the result of the strain and spasm of overcompensating periscapular muscles which could be dull-aching and heaviness feeling.
• Difficulty with elevating the arm above the head and lifting object. Patients couldn't flex their shoulder above 120°.
• Fatigue was a significant characteristic.
• On physical exam,
  1. Serratus anterior palsy: Health care providers should be able to recognize deformation of the back due to a protrusion of the medial portion of the scapula, which is not anchored against the rib cage.
  2. Trapezius palsy: An asymmetrical neckline with drooping of the effected shoulder. This may be accompanied with lateral displacement and winging of the scapula.
  3. Rhomboids palsy: It produces a very subtle winging of the scapula, with the scapula laterally translated and the inferior angle rotated laterally
• Clinical test that providers can use to assess patients are:
  1. Serratus anterior palsy: Have the patient face a wall and stand with the affected arm out in front of their body, parallel to the floor. The patient should then be instructed to push against the wall with the palm of their hand on the affected side. A protrusion of the medial portion of the scapula should then be apparent showing serratus anterior palsy. 
     
  2. Trapezius palsy: Typically, winging is minimal so can be easily missed. It is accentuated during arm abduction, with the scapula moving upwards with the superior angle more lateral to the midline than the inferior angle. Winging may disappear during forward flexion of the arm due to the action of the serratus anterior muscle.
     
  3. Rhomboids 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. Weakness of the rhomboids can be tested by having the patient try to bring his or her scapulae together medially, or by having the patient push his or her elbows backwards against resistance with hands on hips. Difficulty with either task suggests weakness of the rhomboids, but this may be masked by trapezius hypertrophy.

	Medial winging	Lateral winging
Injured nerve	Long thoracic	Spinal accessory	Dorsal scapular
Muscle palsy	Serratus anterior	Trapezius	Rhomboids
Physical exam	Arm flexion; push-up motion against a wall	Arm abduction; external rotation against resistance	Arm extension from full flexion
Position of the scapula compared to normal	Entire scapula displaced more medial and superior	Superior angle more laterally displaced	Inferior angle more laterally displaced

Diagnostic Procedures

• Scapular winging can be diagnosed by practitioner with a proper history and physical examination.
• Electrodiagnostic testing can help to establish the underlying neuromuscular pathology.
• Neuromuscular ultrasound can be used to establish the muscular pathology and the neurologic causes of the muscle pathology. 

Differential Diagnosis

• Rotator Cuff Disorders
• Frozen Shoulder
• Over-stressed Trapezius
• Glenohumeral Instability
• Thoracic Outlet Syndrome
• Cervical Spondylosis
• Acromioclavicular Disorder

Management

Currently, no treatment method is considered to be the first line for the resolution of scapular winging. As discussed prior, the recommended treatment for initial treatment is pain control and physical therapy. If treatment is not initiated early on in the progression of the condition, patients can develop subsequent issues such as adhesive capsulitis (or frozen shoulder), subacromial impingement, and other pathogenesis involving the brachial plexus.

Medical Management

There are 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 
• Scapuloplexy
  

Physical Therapy Management

Physiotherapy treatment depends upon the etiology of the scapular winging.

Serratus Anterior Palsy

• Upon diagnosis, patients should be advised to avoid overhead use of the effected extremity and to avoid activities that cause pain .
• Range of motion (ROM) exercises in the supine position should also be prescribed. 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.
• Special consideration should be taken not to stretch the serratus anterior muscle, as stretching the denervated muscle can impair the time to and extent of functional recovery.
• A scapular brace may accomplish both tasks of keeping the scapula placed against the thorax and preventing stretching of the serratus anterior muscle, and has been shown to be a generally effective treatment option for compliant individuals. However, the brace tends to be poorly tolerated leading to poor compliance and less functional recovery.
• Watson and Schenkman have identified three stages of long thoracic nerve injury and appropriate treatment at each stage.
  • In the acute stage, denervation of the serratus anterior causes pain, and goals of treatment include pain reduction and ROM exercise. Activity modification of the patient is also important to limit further injury to the shoulder.
  • In the intermediate stage, the pain has subsided and the nerve is beginning to heal. 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.
  • In the third or late stage, the serratus anterior becomes progressively stronger and shoulder mechanics improve. To improve strength and overhead work, strengthening exercise of all shoulder girdle muscles, including the trapezius, should be implemented and avoidance of overstretching the serratus anterior should be continued.

Trapezius Palsy

• Functional recovery of the trapezius muscle due to spinal accessory nerve injury does not consistently benefit from conservative management such as physical therapy, transcutaneous nerve stimulation, external support, chiropractic, NSAIDS, and narcotic analgesics.
• A shoulder orthosis has been developed for trapezius muscle paralysis and has been used somewhat successfully in radical neck dissection patients. Within 3 months of using the orthosis, 72% of patients were pain free, had improved shoulder girdle muscle function, and increased endurance and function due to loss of pain. However, active abduction only improved by 5–20°.
• The preferred method of treatment for healthy and active patients with isolated chronic trapezius palsy secondary to spinal accessory nerve injury is the Eden-Lange muscle transfer procedure.

Rhomboids Palsy

• Injury to the dorsal scapular nerve or the rhomboid muscles is usually treated conservatively with cervical spine stabilization (collar or cervical traction), muscle relaxants, anti-inflammatories, and physical therapy.
• Strengthening of the trapezius is the primary objective of physical therapy, as the middle portion of the trapezius can compensate for rhomboid weakness or paralysis.

Revalidation Program

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. 

• 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.
  • Myofeedback

• 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 external rotation
  • 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
  • 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 
• Serratus anterior palsy is the most common cause of scapular winging.
• 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. 
  

Resources

This 3 minute video is a good summary of the movement of the scapula bone.