What is Winged Scapula or Scapular Winging?
Shoulder blade is also known as scapula. The scapula or the shoulder blade is the largest bone present in the shoulder. Several muscles are attached to scapula or the shoulder blade. Scapula or the shoulder blade slides along the rib cage and allows smooth movement of arm in all directions. The muscles attached to the scapula or the shoulder blade prevent dislocation and over sliding of the scapula and assist movements of the arm at the shoulder joint. These muscles act at all times together as a single unit for smooth movement of the arms. The injuries or paralysis of any of the muscles attached to scapula results in uncoordinated movements of the scapula. The scapula when angulates or turns away from chest wall is known as winged scapula or scapular winging. The bones of scapula become prominent and lie in angulation to back of the chest wall surface. The degree and direction of angulation depends on weak group of muscles, which is paralyzed.
About Winged Scapula or Scapular Winging:
- A winged scapula or scapular winging is a floating scapula mostly observed during movement of the arm and shoulder joint.
- The angulation of scapula is observed when one group of muscle is paralyzed and contraction of normal muscles pulls the scapula away from chest wall.
- In normal individual the contraction and relaxation of different group of muscles maintains the normal position of the scapula.
- A winged scapula or scapular winging usually arises due to weakness of the shoulder stabilizers, most notably the Serratus Anterior.
Causes of Winged Scapula or Scapular Winging
- The weakness or paralysis of the Serratus Anterior muscle causes the floating or uncoordinated movement of scapula resulting in scapula protruding out like a wing and thus called Winged Scapula or Scapular Winging.
- Winged Scapula or Scapular Winging is also seen in individual maintaining poor posture for prolonged period of time.
- The weakness results from damage or irritation of the Serratus Anterior muscle nerve.
- Damage to the long thoracic nerve leading to Winged Scapula or Scapular Winging can be caused by a blunt trauma or contusion of the shoulder. It can also be caused due to a viral illness or infection.
- Trauma and sports injury can cause damage of the nerve to Serratus anterior muscles. 1
- Nerve injury in rare cases is caused by Osteochondroma.2
- Long thoracic nerve injury is rarely seen following spinal surgery resulting in winged scapula or scapular winging.3
Symptoms of Winged Scapula or Scapular Winging
- A winged scapula or scapular winging generally becomes very obvious, as there is a clear protrusion of the shoulder blade in an outward direction.
- Individual suffering from winged scapula or scapular winging often complain of symptoms of mild to severe pain at rest and during upper arm movements.
- Scapular pain is spread over the shoulder blade and pain becomes worse when pressure is applied over the scapula.
- Symptoms of pain in Winged Scapula or Scapular Winging is also observed during change of position from lying down to sitting or sitting to standing when upper arm is used to support the movement.
Treatment for Winged Scapula or Scapular Winging
- Conservative Treatment for Winged Scapula or Scapular Winging- Application of ice may be helpful to reduce pain associated with Winged Scapula or Scapular Winging, although it is a very difficult endeavor as it is a very tough place to apply ice. Cold application works better than warm or heat treatment for Winged Scapula or Scapular Winging.
- Physical Therapy and Rehabilitation for Winged Scapula or Scapular Winging- Strengthening of weak muscle and retraining of normal predominant muscle can reduce the deformity and pain.
- Surgical Treatment- The long thoracic nerve is repositioned surgically if entrapped in scar tissue or pinched following injury or trauma.1
- Strengthening is definitely required for the Serratus Anterior Muscle.
Exercises for Winged Scapula or Scapular Winging
- Scapular Protraction Exercise for Winged Scapula or Scapular Winging: To do this exercise, start with end of a band in one hand placed at shoulder height and the elbow bent. Now, try and push the hands forward in the process straightening the elbow entirely as far as possible. Gradually return to the starting position.
- Serratus Press Exercise for Winged Scapula or Scapular Winging: To do this exercise, start in lying down position with a medicine ball in both hands and keeping the elbows straight. You need to ensure the elbow is kept straight throughout the exercise. Now, push the ball up by using only the shoulder girdle. Bring the shoulders down and repeat the same.
Diagnostic Tests to Evaluate Winged Scapula or Scapular Winging
- X-Ray is performed to rule out associated disease like fracture or cancer causing abnormal protrusion.
- CAT Scan and MRI of the Cervical and thoracic spine is performed to evaluate the cause of nerve injury leading to Winged Scapula or Scapular Winging. The study evaluates nerve injury in spinal canal or spinal foramina.
- The 3D wing CT analysis. 3D wing CT analysis is performed to evaluate precise scapular dyskinesis.4
- Isolated paralysis of the serratus anterior muscle: surgical release of the distal segment of the long thoracic nerve in 52 patients.
Le Nail LR1, Bacle G1, Marteau E1, Corcia P2, Favard L1, Laulan J3
Orthop Traumatol Surg Res. 2014 Jun;100(4Suppl):S243-8.
Static winging of the scapula caused by osteochondroma in adults: a case series.
Orth P1, Anagnostakos K, Fritsch E, Kohn D, Madry H.
J Med Case Rep. 2012 Oct 25;6:363. doi: 10.1186/1752-1947-6-363
- Isolated long thoracic nerve paralysis - a rare complication of anterior spinal surgery: a case report.
Ameri E, Behtash H, Omidi-Kashani F.
J Med Case Rep. 2009 Jun 23;3:7366. doi: 10.4076/1752-1947-3-7366.
- How to assess scapular dyskinesis precisely: 3-dimensional wing computer tomography--a new diagnostic modality.
Park JY1, Hwang JT, Kim KM, Makkar D, Moon SG, Han KJ.
J Shoulder Elbow Surg. 2013 Aug;22(8):1084-91.