Scapular Winging

Summer Yack SPTA

Hand, Upper Extremity and Shoulder PT
Salt Lake Orthopaedic Clinic
1160 East 3900 South, Suite 4050
Salt Lake City, UT 84124

Objectives

Review the mechanics and anatomy of the scapula

Discuss the primary and secondary causes of scapular

winging
Discuss the clinical presentation of scapular winging
Review the components of PT management associated with

primary scapular winging

Briefly discuss the surgical options available for scapular

winging

What is Scapular Winging?

Very rare disorder

Incidence isnt known due to

under diagnosis
Most commonly categorized as

medial or lateral winging

Delayed diagnosis may lead to

adhesive capsulitis, subacromial

impingement, thoracic outlet
syndrome, brachial plexopathy,
and periscapular muscle spasm

Scapula

Overlays the second to seventh ribs

on the posterior thorax

At rest, scapula is rotated 30

anterior on chest wall, 20 forward in

the sagittal plane, the inferior angle
is tilted 3 upward
Attachment site for 17 muscles
Scapular muscles function to

stabilize the scapula to the thorax,

provide power to the upper limb and
help to synchronize glenohumeral
motion

Scapular Movement

3 axis of movement
1. -Elevation: Upper Trapezius,

Levator Scapulae, Rhomboids

-Depression: Lower
Trapezius, Latissimus Dorsi,
Subclavius, Pectoralis Minor
2. -Protraction: Serratus

Anterior, Pectoralis Minor

-Retraction:
Rhomboids, Middle Trapezius
3. Rotation

Rotation

Upward/Lateral Rotation:
Upper Trapezius
Serratus Anterior
Lower Trapezius
Downward/Medial Rotation:
Levator Scapulae
Rhomboids
Pectoralis Minor

Serratus Anterior

Origin: First nine ribs

Insertion: Medial border of

the scapula
Upper portion: Upward

rotation
Middle portion: Protraction
Lower portion: Upward

rotation and protraction

Long Thoracic Nerve

5th and 6th Nerve Roots-

Proximal nerve behind Middle

Scalene muscle, innervates the
upper portion
7th Nerve Root- Passes behind

the brachial plexus, innervates

the middle and lower portions
Averages 21.9 cm in length
Superficial course makes it

susceptible to injury

Trapezius

Origin: External occipital protuberance,

medial 1/3 of nuchal line, spines of 7

cervical and 12 thoracic vertebrae
3 different insertions
Superior fibers: Posterior clavicle
Medial fibers: Medial aspect of the

acromion
Inferior fibers: Spine of the scapula
Superior and inferior fibers elevate and

assist in upward rotation

Middle fibers stabilize the scapula

during movement

Spinal Accessory Nerve

Cranial Nerve XI
Only cranial nerve to enter

and exit the skull

Associated with 5 to 10

lymph nodes
Superficial nature place

nerve at risk during surgical

dissection of the posterior
triangle of the neck

Rhomboids

Deep to the trapezius

Rhomboid Minor
Origin: Ligamentum nuchae and

spinous processes of C7 and T1

Insertion: Scapular spine
Rhomboid Major
Origin: Spinous processes of T2-T5
Insertion: Medial scapula to the

inferior angle
Retract, elevate and assist in

downward rotation

Levator Scapulae

Origin: First four cervical

vertebrae
Insertion: Medial border of

the scapula
Elevates the scapula and

assists in downward
rotation

Dorsal Scapular Nerve

C5 nerve root
Arises from the brachial

plexus
Innervates the Rhomboids

and Levator Scapulae

Causes of Scapular
Winging
Primary Scapular Winging: Dysfunction in 1 or

more of the scapulothoracic stabilizers causing a

muscle imbalance in scapular alignment
Secondary Scapular Winging: Scapular winging in

association with other pathologies (subacromial

bursitis, glenohumeral joint disorders, etc.)

Serratus Anterior Muscle

Palsy
Most common cause of primary scapular winging
Paralysis of Serratus Anterior after compression, traction or laceration

of the long thoracic nerve

Common causes: Automobile accidents, falls from height, sports

injuries (collision athletes)

Iatrogenic causes include compression injury from positioning during

surgery, surgical disruption occurring during cervical decompression,

mastectomy, first rib resection, etc.
Sites of compression: Middle Scalene muscles, between the clavicle

and second rib and inferior angle of the scapula

Trapezius Muscle Palsy

Paralysis of Trapezius after spinal accessory nerve injury

Superficial course in the posterior triangle of the neck

places the nerve at risk

Most common cause: iatrogenic injury to nerve during

cervical lymph node biopsy or mass excision

Other causes: falls from height, motor vehicle accidents,

blunt trauma (assault or direct blow), penetrating

gunshot wounds, stabbings, and bite injuries

Rhomboid Muscle Palsy

Less common than Trapezius muscle palsy

May cause winging due to dorsal scapular nerve injury
Symptoms: shoulder and upper arm pain that may get

confused with thoracic outlet syndrome

Common cause: entrapment of dorsal scapular nerve

beneath a hypertrophic Middle Scalene muscle

May occur with motor vehicle accidents or heavy weight

lifting

Fascioscapulohumeral
Dystrophy (FSHD)
Autosomal dominant genetic neuromuscular dystrophy
Predominantly affects the face, shoulder girdle, and upper limb

muscles
Severe scapular winging due to weakness in the Trapezius,

Levator Scapulae, and Rhomboids with preserved strength in the

Deltoid and Rotator cuff
Symptoms: shoulder girdle pain, scapular instability, weakness in

shoulder abduction and flexion

Genetic testing required to diagnose

Secondary Causes

Abnormal scapulothoracic motion as a result of

glenohumeral joint pathology

Painful intraarticular conditions of the glenohumeral joint

cause patients to compensate for lost motion with the

scapulothoracic articulation
Scapular stabilizers (Serratus Anterior and Trapezius) fatigue

under these increased demands

Causes include subacromial bursitis, adhesive capsulitis,

rotator cuff tears, shoulder instability

Patient Evaluation

Typically report difficulty

with ADLs or overhead

tasks, shoulder & upper
back pain, muscle weakness
Periscapular pain may be

the result of muscle

cramping compensating for
isolated weakness in
Serratus Anterior or
Trapezius muscle palsy

Physical exam: Undress patients

shoulders and back to waistline.

Assess from behind, carefully
inspecting for shoulder
asymmetry
Palpate the scapula assessing

tenderness, crepitus, or snapping

Isolated MMT should also be

completed
Winging may be immediately

obvious or it may require 5-10

reps before fatigue sets in

Clinical Presentation

Serratus Anterior muscle palsy =

Trapezius muscle palsy= Lateral

Medial winging

winging

Complain of shoulder pain

Complain of debilitating pain, dull

radiating down arm and shoulder

weakness
Accentuates with forward flexion

and/or completing a push up on a

wall

ache and heaviness around the

shoulder
Difficulty with abduction and

shrugging shoulders. May see

trapezius asymmetry

Rhomboid palsy= Subtle lateral

winging
Complain of discomfort of the
neck, back and shoulder
Accentuates with shoulder
extension from fully flexed
position

Diagnostic Testing

Plain radiographs of the chest, cervical spine, shoulder and

scapula, may help identify cervical spine disease, shoulder

disorders, fracture malunions, or osteochondromas
Further testing may be needed. CT- Osteochondromas MRI-

Cervical disk disease, shoulder instability or rotator cuff tears

Nerve conduction velocity and EMG confirm evaluation

findings and distinguish neuromuscular causes of scapular

winging
May need specific orders to evaluate spinal accessory nerves

and long thoracic nerve

Management

Most cases result of neurapraxic injury- resolves within 6-12 months

Immediately begin nonsurgical therapy to maintain shoulder motion and

prevent stiffness
If winging occurs with no previous trauma or surgery: complete PT for 12

to 24 months observing nerve recovery

Initially: activity modification, analgesics and NSAIDS. Limit overhead

activities and aggravating activities

PT: ROM exercises, stretch and strengthen scapular stabilizers, cervical

muscles and rotator cuff. Provide HEP

Complete ROM exercises in supine
May use a sling for pain control initially

PT Management

Serratus Anterior Palsy

Most cases functionally resolve within 24 months
Complete conservative treatment for 6-24 months
Avoid lengthening of the Serratus Anterior muscle
Scapular bracing
Pain reduction and ROM initially
Passive stretching of the Rhomboids, Levator Scapulae,

and Pectoralis Minor

Strengthening of all periscapular muscles.

PT Management

Trapezius muscle palsy

Mixed results with

conservative
management
Recommended to

complete PT for a
minimum of 1 year
Goal of PT: Strengthen

adjacent muscle groups

to compensate for the
Trapezius

Rhomboid muscle palsy

Goal of PT:

Strengthening the
Middle fibers of the
Trapezius

Surgical Intervention

Iatrogenic or penetrating trauma to the

long thoracic or spinal accessory

nerves will require neurolysis or nerve
grafting
Intraoperative nerve stimulation may

be needed to determine between

complete or partial lesions
Good prognosis= Surgery within 20

months
Poor prognosis= Association with

radical neck dissections, age > 50

years old and treatment delay > 20
months

Winging resulting from spontaneous

neuromuscular palsy, traction injury or

contusion that doesnt resolve in 12-24
months may need a dynamic muscle
transfer
Chronic Serratus Anterior palsy is

addressed with transfer of the sternal

head of Pectoralis Major to the inferior
angle of the scapula
Trapezius muscle palsy resistant to

nonsurgical treatment or nerve

exploration is managed with the EdenLange dynamic muscle transfer
Allows stabilizing muscles to act together

for the 3 components of the trapezius

References

Meininger, Alexander K., MD, Benedict F.

Figuerees, MD, and Benjamin A. Goldberg, MD.

"Scapular Winging: An Update." Journal of the
American Academy of Orthopaedic Surgeons 19.8
(2011): 453-62. Print.
Martin, Ryan M., and David E. Fish. Scapular

Winging: Anatomical Review, Diagnosis, and

Treatments. Current Reviews in Musculoskeletal
Medicine 1.1 (2008): 111. PMC. Web. 24 Sept.
2016.