What is a Winged Scapula?

The scapula, or shoulder blade, is the largest bone of the shoulder and has a complex set of muscles attached to it. When functioning properly, the scapula and surrounding muscles stabilize the arm and allow it to move freely.

A winged scapula occurs when these muscles weaken and fail to hold the scapula close against the back of the rib cage. This condition often results in the medial portion of the scapula protruding, leading to what is known as medial scapular winging, where the medial border of the scapula sticks outwards and upwards, causing the shoulder blade to resemble a wing.

Winging of the scapula can result from underlying neuromuscular pathology affecting the muscles or nerves that stabilize the scapula, such as injury to the long thoracic nerve or dysfunction of the serratus anterior muscle.

Anatomy and Physiology of the Scapula

The scapula, commonly known as the shoulder blade, is a flat, triangular bone that forms the foundation of the shoulder girdle. It plays a vital role in connecting the upper extremity to the trunk and enabling a wide range of shoulder movements. The shoulder blade is surrounded by several key muscles, including the serratus anterior, trapezius, rhomboid muscles, and levator scapulae. Each of these muscles contributes to the stability and mobility of the shoulder joint.

The serratus anterior muscle, which is innervated by the long thoracic nerve, is essential for scapular protraction and upward rotation—movements that allow you to lift your arm above your head and reach forward. Weakness or paralysis of the serratus anterior, often due to long thoracic nerve injury, can lead to scapular winging, where the medial border of the scapula protrudes away from the rib cage. The trapezius muscle, supplied by the spinal accessory nerve, assists in retracting, elevating, and depressing the scapula, while the rhomboid muscles, innervated by the dorsal scapular nerve, help retract and stabilize the scapula against the chest wall. The levator scapulae also plays a supporting role in elevating the shoulder blade.

Understanding the intricate anatomy and physiology of the scapula and its supporting muscles and nerves is crucial for diagnosing and managing conditions like scapular winging. When any of these components are compromised, it can disrupt the delicate balance of the shoulder girdle, leading to pain, limited movement, and functional impairment.

What Causes a Winged Scapula: The Role of the Long Thoracic Nerve

A winged scapula is caused by a weak muscle that is supposed to stabilize your shoulder blade. Usually, a direct injury of the muscle or the nerves around the shoulder blade can bring it on. Winged scapula can also be caused by traumatic injury to the nerves or muscles, such as blunt trauma, upper-limb stretching, or other trauma-related events. While blunt trauma is the most common cause of winged scapula, it may also be caused by repetitive shoulder motion.

Since this condition affects the nerves, there are some non-traumatic injuries that can cause winged scapula. These include, but are not limited to:

• Viral illnesses

• Allergic reactions

• Toxin exposure

• Pre-existing medical conditions

Winged scapula caused by nerve injuries may involve the long thoracic nerve, spinal accessory nerve injury (which can result in lateral winging due to trapezius muscle dysfunction), or damage to nerves near the axillary lymph nodes, especially after surgical procedures in the axillary region. Muscular pathology, such as weakness or paralysis of the stabilizing muscles like the serratus anterior, trapezius, or rhomboids, can also result in scapular winging.

Winged Scapula Symptoms and the Serratus Anterior Muscle

Winged scapula symptoms usually begin with overarching pain in the shoulder that is difficult to identify. Depending on the type of nerves or muscles involved, a winged scapula may be asymptomatic.

Some common symptoms of a winged scapula are:

• Shoulder Pain

• Weakness and fatigue

• Deformity of the shoulder, including medial winging (protrusion of the medial border of the scapula due to serratus anterior dysfunction) and lateral winging (resulting from trapezius muscle dysfunction)

• Muscle spasms

• Instability of the shoulder

• Limited range of motion

The inferior angle of the scapula may become more prominent or visible in cases of scapular winging, which can be an important clinical sign during assessment.

Effective treatment of winged scapula can lead to significant pain reduction for patients.

How is a Winged Scapula Diagnosed?

In order to diagnose a winged scapula, your Resurgens shoulder physician will first discuss with you your medical history, lifestyle, and how the condition began. Then they will perform a thorough physical examination to assess your range of motion, level of pain, and to identify any signs of scapular winging. The examination is brief and causes only minor discomfort.

Your physician will then order diagnostic imaging such as x-rays or MRI scans to rule out other potential shoulder conditions. They may also perform electrodiagnostic testing, including nerve conduction studies, to evaluate nerve function. Additionally, neuromuscular ultrasound can be used to help identify muscular and nerve pathology related to scapular winging. Then, they will talk to you about your treatment options and create a custom treatment plan to fit your needs.

Winged Scapula Treatment

There are several types of surgical and non-surgical winged scapula treatment. There is no single first-line treatment method; the choice of treatment depends on the underlying cause. While most winged scapula cases can be treated with non-surgical methods, severe cases may require surgical intervention.

In severe or refractory cases, muscle transfer procedures and bone joint surg are considered to restore scapular stability and shoulder function.

Non-Surgical Treatment: Physical Therapy Options

There are many non-surgical options for winged scapula treatment, such as:

• Anti-inflammatories to help manage pain

• Immobilization with a brace or sling

• RICE therapy

Physical therapy is also important, as it focuses on improving forward flexion and arm abduction by strengthening the shoulder muscles.

Surgical Treatment

Your doctor will only recommend winged scapula surgery if your injury isn’t responding to non-surgical treatment methods. Surgical treatment for winging scapula or scapula winging is considered when conservative measures fail. The surgery may involve muscle transfer procedures, such as pectoralis major transfer, to restore scapular stability in cases of serratus anterior palsy or serratus anterior paralysis. These procedures can include transferring the sternal head of the pectoralis major or other shoulder muscles to compensate for serratus anterior muscle palsy. Injury to the long thoracic nerve lies at the root of many cases, as this nerve supplies the serratus anterior muscle. Trapezius muscle paralysis, often due to spinal accessory nerve injury, may require different surgical approaches, sometimes involving the trapezius muscles. The glenohumeral joint and soft tissues must be carefully evaluated before surgery. The brachial plexus is another neural structure that can be involved in scapular winging. Surgery may also involve taking nerve or muscle tissue and grafting it to a different part of the body, or static stabilization, where the scapula is attached to the ribs or vertebrae.

Rehabilitation and Recovery

Rehabilitation and recovery from scapular winging focus on restoring strength, stability, and function to the affected shoulder blade and surrounding muscles. Physical therapy is the cornerstone of treatment, with a physical therapist designing a personalized program to target the specific muscles involved in scapular winging. Through a combination of strengthening exercises, stretching, and manual therapy, patients can improve the function of the serratus anterior, trapezius, and other scapular muscles, helping to correct abnormal movement patterns and reduce pain.

In cases where scapular winging is caused by nerve compression or underlying muscle pathology, addressing these issues is essential for successful recovery. Physical therapists may incorporate modalities to manage pain and inflammation, as well as techniques to enhance neuromuscular control and promote proper scapular movement. If conservative management is not effective, surgical treatment may be considered to repair damaged nerves or transfer muscles to restore scapular stability. After surgery, a structured rehabilitation program is critical to ensure optimal healing, regain range of motion, and prevent recurrence.

A comprehensive approach to rehabilitation not only focuses on the affected arm and shoulder blade but also educates patients on posture, activity modification, and strategies to avoid further injury. With commitment to physical therapy and guidance from healthcare professionals, most individuals can achieve significant improvement in shoulder function and quality of life.

Prevention and Maintenance

Preventing scapular winging involves a proactive approach to shoulder health, emphasizing proper posture, regular exercise, and injury prevention. Maintaining good posture, while keeping the shoulders back and down, helps support the shoulder girdle and reduces unnecessary strain on the scapular muscles. Incorporating exercises such as shoulder blade squeezes, scapular push-ups, and gentle shoulder rolls into your routine can strengthen the muscles that stabilize the shoulder blade, including the serratus anterior and trapezius.

It’s also important to avoid activities that may cause blunt trauma or excessive strain to the shoulder, such as heavy lifting or high-impact sports, especially if you have a history of shoulder problems. Certain groups, such as breast cancer patients who have undergone axillary lymph node dissection or individuals with a history of neck dissection, are at increased risk for scapular winging due to potential nerve injury. These individuals should take extra precautions to protect their shoulder girdle and consult a physical therapist if they notice any changes in shoulder movement or appearance.

Regular check-ups with a physical therapist or healthcare provider can help identify early signs of muscle imbalance or nerve issues, allowing for timely intervention. By staying active, practicing good posture, and seeking professional guidance when needed, you can help maintain healthy shoulder blades and reduce the risk of developing scapular winging.

Every winged scapula case is different, so we customize a treatment plan for each patient. If you are experiencing debilitating pain in your shoulder, make an appointment with a Resurgens shoulder physician today.