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Unraveling the Mystery of Scapular Winging: From Origins to Solutions

Updated: Dec 5, 2023


Winged scapula, a relatively rare but debilitating condition, hinders the upper limb's functionality. It often arises from factors like trauma, medical procedures, or unidentified causes, leading to nerve impairment and paralysis of muscles like the serratus anterior, trapezius, or rhomboids(14).


This article delves into "Winged Scapula", addressing its clinical anatomy, origins, diagnosis, and therapeutic approaches. We'll also spotlight manual therapy techniques and specific exercises beneficial for managing and countering this condition. Essentially, a winged scapula manifests when the shoulder blade protrudes from the ribcage, altering its position and function(1). Such misalignment typically results from nerve damage affecting the aforementioned muscles, with medial winging often attributed to serratus anterior paralysis and lateral winging linked to trapezius and rhomboid paralysis(14).


Article Index:


Introduction

Examination & Diagnosis

Treatment & Exercise

Conclusion & References

 

Causes


Winged scapula can result from various causes, including:

  • Nerve damage: Injury to the long thoracic nerve, which innervates the serratus anterior muscle, can lead to a winged scapula (3). Similarly, injury to the spinal accessory or dorsal scapular nerve can result in trapezius or rhomboid paralysis, respectively (14).

  • Traumatic causes: Physical trauma to the shoulder or upper back region can damage nerves or muscles, leading to scapular winging (14).

  • Iatrogenic causes: Surgical procedures or other medical interventions can inadvertently damage nerves or muscles, contributing to winged scapula (14).

  • Idiopathic causes: In some cases, the cause of winged scapula may be unknown (14).


When left unaddressed, winged scapula can result in persistent pain, restricted movement, and diminished functionality, affecting everyday tasks and athletic performance (6). In most instances, serratus anterior paralysis resolves within 24 months. A 6–24 month period of conservative treatment is often suggested to provide time for natural healing. Patients might be considered for corrective surgery if there's no improvement after this period (14).


 

Clinical Anatomy, Neurology, and Biomechanics of Scapular Winging


The principal musculature responsible for scapular stabilization comprises the serratus anterior, trapezius, and rhomboid muscles (7). These muscles operate synergistically to preserve optimal scapular alignment and kinematics. The long thoracic nerve facilitates innervation of the serratus anterior, the trapezius receives neural input from the spinal accessory nerve, and the dorsal scapular nerve innervates the rhomboids (8).


Regarding biomechanics, these muscles play distinct yet complementary roles in scapular motion and stability. The serratus anterior is primarily responsible for protraction and upward rotation of the scapula, which is crucial for overhead arm movements (5). The trapezius, a large superficial muscle, consists of three parts—upper, middle, and lower fibers—that collectively contribute to scapular elevation, retraction, and depression, respectively (4). The rhomboids, conversely, function to retract and elevate the scapula, working in opposition to the serratus anterior (9). A balance between these muscles is vital for maintaining proper scapular biomechanics and preventing dysfunction, such as scapular winging.


 

Clinical Manifestations


Patients presenting with scapular winging may exhibit the following clinical features:

Protrusion of the medial border of the scapula: An outward displacement of the inner edge of the shoulder blade may be observed, indicating a potential muscular imbalance or nerve-related issue (1).


  1. Impaired shoulder abduction: A reduced ability to elevate the arm overhead, which may signify compromised function of the scapular stabilizing muscles or associated neurological structures (3).

  2. Pain or discomfort in the shoulder and upper back region: Sensations of pain or unease may be reported in the area surrounding the shoulder and upper thoracic spine, potentially as a result of abnormal scapular motion or stress on surrounding soft tissues (2).

  3. Weakness in the affected extremity: Diminished muscular strength in the involved arm could be indicative of impaired motor function related to nerve injury or muscle dysfunction associated with scapular winging (10).


 

Diagnostic Assessment


The diagnostic process for winged scapula usually entails a thorough physical evaluation, incorporating the following elements:


  • Muscle strength assessment: A systematic evaluation of the strength of the serratus anterior, trapezius, and rhomboid muscles, as well as other surrounding musculature, to identify any imbalances or weaknesses that may contribute to scapular winging (9).

  • Range of motion analysis: An examination of the active and passive range of motion of the shoulder joint to detect any limitations or deviations from normal movement patterns that may be associated with scapular dysfunction (9).

  • Observation of scapular movement: A close inspection of scapular kinematics during various functional tasks, such as arm elevation or reaching activities, to identify any abnormal motion or positioning that may signify winged scapula (9).


Shoulder Examination - Orthopaedic Testing

Video Introduction: "Welcome to our in-depth Shoulder Examination video, focused on orthopaedic testing. In this video, we will explore common causes of shoulder pain and demonstrate how to diagnose them using various orthopaedic examination techniques.

Throughout this video, we'll cover tests and assessments across various categories, including:

  1. Inspection and Active Range of Motion

  2. Rotator Cuff Anatomy and Tests (Full Can Test, Empty Can Test, External Rotators, and Internal Rotators)

  3. Impingement Tests (Empty Can, Neer's Test, and Hawkins-Kennedy Test)

  4. Serratus Anterior Test

  5. Biceps Tendinopathy Tests (Speed's Test and Yergason's Test)

  6. Frozen Shoulder Assessment

  7. Acromioclavicular Joint Tests (Step Off Deformity, Scarf Test, and Painful Arc)

  8. Shoulder Instability Tests (Sulcus Sign, Apprehension Test, and Relocation Test)

  9. SLAP Lesion Tests (Speed's Test, O'Brien Test, and Crank's Test)"


Imaging


In addition to the physical examination, imaging studies may be employed to investigate the underlying causes further or exclude alternative diagnoses:


  • Radiography (X-ray): X-ray imaging may be utilized to evaluate the bony structures of the shoulder girdle and identify any fractures, dislocations, or other osseous abnormalities that could contribute to scapular winging (10).

  • Magnetic resonance imaging (MRI): MRI can provide detailed visualization of the soft tissues surrounding the scapula, including muscles, ligaments, and nerves, potentially revealing any structural damage or inflammatory processes that may be associated with winged scapula (10).

  • Nerve conduction studies: These tests can help assess the integrity and functionality of the nerves that innervate the scapular stabilizing muscles, such as the long thoracic nerve, spinal accessory nerve, and dorsal scapular nerve, to detect any nerve injuries or impairments that may be implicated in scapular winging (10).


 

Differential Diagnosis


Various conditions that may present with similar symptoms or coexist alongside winged scapula include:

  • Rotator cuff injuries: Damage to the tendons and muscles that make up the rotator cuff complex can result in pain, weakness, and a restricted range of motion in the shoulder, which may be confused with scapular winging (11).

  • Shoulder impingement syndrome occurs when the rotator cuff's tendons or the subacromial bursa become compressed within the subacromial space, leading to pain and functional limitations that may resemble winged scapula (11).

  • Thoracic outlet syndrome: Compression of the neurovascular structures as they pass through the thoracic outlet can cause symptoms such as pain, weakness, and numbness in the shoulder, arm, and hand, potentially mimicking or occurring concurrently with scapular winging (11).

  • Glenohumeral joint instability: Laxity or instability in the shoulder joint can present with pain, restricted motion, and a sensation of the shoulder "giving way," which may be mistaken for winged scapula (12).

  • Scapulothoracic bursitis: Inflammation of the bursa between the scapula and the ribcage can cause pain and discomfort during scapular movement, potentially leading to confusion with scapular winging (13).


 

Manual Therapy and Exercise


Manual therapy can be advantageous in addressing winged scapula through a range of targeted techniques, focusing on the following structures:


  • Nerve entrapments: Manual therapy techniques, such as Motion Specific Release (MSR) mobilizations, can help alleviate nerve entrapments that may contribute to scapular winging, including the long thoracic, spinal accessory, and dorsal scapular nerves (14).


  • Soft tissue restrictions:

    • Myofascial Release: Soft tissue mobilization techniques can assist in releasing tension and adhesions in the muscles and fascia surrounding the scapula, such as the serratus anterior, trapezius, and rhomboid muscles, as well as the subscapular and pectoral regions (12).

    • Trigger Point Therapy: Manual pressure or dry needling can be applied to deactivate hyperirritable nodules, or trigger points, within the muscle fibers that may contribute to pain and dysfunction in winged scapula cases (15).


  • Osseous restrictions in the thoracic region:

    • Joint Mobilization: Specific joint mobilization techniques can be employed to address restrictions within the thoracic spine, sternoclavicular joint, and acromioclavicular joint, which may indirectly impact scapular positioning and movement (16).

    • Chiropractic Manipulation: High-velocity, low-amplitude (HVLA) thrust techniques can be utilized to adjust restricted spinal or rib articulations, potentially improving thoracic mobility and biomechanics related to scapular winging.


By addressing these various structures through manual therapy, clinicians can help alleviate contributing factors to winged scapula, promoting optimal scapular function and decreasing pain and discomfort.


 

Exercises


Including focused stretches and strength-building exercises can aid in managing and preventing winged scapula. This video tutorial will examine evidence-supported exercises and therapeutic approaches to alleviate winged scapula symptoms and strengthen the periscapular muscles. By integrating a comprehensive knowledge of the musculoskeletal anatomy and biomechanics at play, you will gain insight into how these exercises can enhance postural alignment, alleviate pain, and boost functional mobility.


Winged Scapula - Exercise and Treatment Video

In this video, we'll delve into the world of winged scapula, an unusual but impactful condition that significantly impacts upper limb function. Various factors, including trauma, medical procedures, or unidentified causes, can lead to nerve damage and paralysis of the serratus anterior, trapezius, or rhomboid muscles. Join exercise instructor Miki Burton RMT and Dr. Brian Abelson as they guide you through targeted exercises and demonstrate Motion Specific Release protocols to help you overcome this challenging condition.


 

Conclusion


In summary, the winged scapula is a rare but potentially debilitating condition that can significantly impact upper extremity function and quality of life. A thorough understanding of clinical anatomy, neurology, and biomechanics is essential for accurate diagnosis and effective treatment. With a comprehensive physical examination, appropriate imaging studies, and consideration of differential diagnoses, healthcare professionals can design tailored interventions to manage and prevent winged scapula.


Manual therapy, including myofascial release, joint mobilization, and chiropractic manipulation, can address underlying nerve entrapments, soft tissue restrictions, and osseous limitations in the thoracic region. Targeted stretches and strengthening exercises can promote optimal scapular function, reduce pain, and enhance functional mobility.


As with any musculoskeletal condition, it is essential to seek professional help if symptoms persist or worsen. Early intervention and a multidisciplinary approach to treatment can improve outcomes and help individuals with winged scapula regain a more active and pain-free lifestyle.


 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!


 

References:


  1. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1(1):1-11.

  2. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26(2):325-337.

  3. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res. 1999;(368):17-27.

  4. Kuhn JE, Plancher KD, Hawkins RJ. Scapular winging. J Am Acad Orthop Surg. 1995;3(6):319-325.

  5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003;11(2):142-151.

  6. Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 2009;39(2):90-104.

  7. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1(1):1-11.

  8. Kibler WB, Sciascia A. Evaluation and management of scapular dysfunction. Sports Med Arthrosc Rev. 2012;20(1):39-48.

  9. LaBan MM, Taylor RS, Weir SK. Scapular winging: a disorder of the long thoracic nerve producing scapular dyskinesis. Am J Phys Med Rehabil. 2004;83(3):213-216.

  10. Page P, Frank CC, Lardner R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Champaign, IL: Human Kinetics; 2010.

  11. Ajimsha MS, Binsu D, Chithra S. Effectiveness of myofascial release in the management of chronic low back pain in nursing professionals. J Bodyw Mov Ther. 2015;19(2):173-181.

  12. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012;20(6):364-372.

  13. Hartz CR, Linscheid RL, Gramse RR, Daube JR. The pronator teres syndrome: compressive neuropathy of the median nerve. J Bone Joint Surg Am. 1981;63(6):885-890.

  14. Dommerholt J, Fernandez-de-las-Penas C. Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. Edinburgh: Churchill Livingstone; 2013.

  15. Vicenzino B, Hing W, Rivett D, Hall T. Mobilisation with Movement: The Art and the Science. Chatswood, NSW: Elsevier Australia; 2011.

  16. Souza TA. Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms. 5th ed. Burlington, MA: Jones & Bartlett Learning; 2015.

  17. Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.


 

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