The scapula (also known as the shoulder blade), is a triangular bone that serves as a joining force between the clavicle and the humerus. Several muscles are located in the area of the shoulder girdle, including rotator cuff muscles, nerve networks such as the brachial plexus, and upper arm muscles. The blood supply to the scapula is often impaired in neurological conditions such as cerebrovascular accidents or strokes and other brain hemorrhages – the muscles are responsible for stabilizing the shoulder joint, as well as for providing arm movement.
When one or more of the muscle-tendon units no longer work in unison, it causes a break in scapular movement and may lead to scapular dyskinesis (abnormal movement). This type of condition is relatively common. In severe cases of nerve or muscle damage, winged scapula may occur. A winged scapula can at times be quite easy to diagnose since the scapula is protruding out and away from the back. At other times, however, the diagnosis may be more subtle and difficult to make.
A winged scapula can be a primary diagnosis when caused by a nerve or muscle injury; alternatively, it can be a secondary diagnosis when it becomes a symptom of another shoulder condition. A winged scapula is marked by the shoulder blade protruding out on the back instead of lying flat.
Scapular dyskinesis, where the shoulder blade moves abnormally, is common and is usually due to mild muscle imbalances. Winged scapula on the other hand, while more disabling, is fortunately quite rare and is due to more severe injury to the muscles that control the scapula or to the nerves that supply the muscles. ‘Winging’ is typically treated non-surgically as it can frequently resolve or heal with time, but when it persists, surgery may be needed to restore shoulder function.
Causes & Symptoms of Winged Scapula
There are a total of three types of scapular winging conditions, such as the following described below:
Serratus anterior muscle dysfunction
The long thoracic nerve innervates the serratus anterior muscle. Injury to this nerve, in turn, causes weakness of the serratus anterior muscle, which can manifest clinically as a winged scapula. Long thoracic nerve injury can occur acutely from a blow to the shoulder, or with activities involving chronic repetitive traction on the nerve. Symptoms may include diffuse shoulder or neck pain which worsens with overhead activities.
The spinal accessory nerve innervates the trapezius muscle. Injury to the spinal accessory nerve can occur with trapezius trauma or shoulder dislocation. Certain previous surgeries, including radical neck dissection, carotid endarterectomy, and cervical node biopsy are additional sources of injury. Patients typically have generalized shoulder pain and weakness. The shoulders may even appear asymmetrical. The affected shoulder appears to sag, and the patient is unable to shrug the shoulder toward the ear. Associated weakness of forwarding arm elevation is common. With a chronic injury, atrophy of the trapezius may occur.
Rhomboid muscle dysfunction
The dorsal scapular nerve innervates the rhomboid major and minor muscles. Dorsal scapular nerve entrapment is an uncommon and frequently under-recognized cause of neck and shoulder pain. The winged scapula may be subtle, and the symptoms are easily mistaken for other problems. Causes may include repetitive overhead activity and trauma such as anterior shoulder dislocation or whiplash neck injury.
Some of the most common symptoms linked to a winged scapula (or other scapular disorders) include:
- Pain and tenderness around the scapula, especially on the top and inner border.
- Fatigue with repetitive activities, especially overhead movements.
- Limited range of motion (you may be unable to raise your arm above shoulder height).
- A “crunch” or “snapping” sound with shoulder movement.
- Noticeable “winging” of the scapula.
- Weakness in the affected arm. Your arm may feel tired when you try to use it on a regular daily basis.
Who gets Winged Scapula?
Many risk factors associated with scapular injuries include the following:
- Sports involving overhead activity – Sports (such as football, tennis, volleyball, and swimming) may increase the chance of dislocating your scapula. Athletes who participate in these sports apply immense force across their shoulders during hitting and throwing and are at a higher risk of developing this condition.
- Loose joints – Having loose joints near the scapula may increase the chance of experiencing a winged scapula due to the weakening.
- Increasing in throwing velocity – Increasing your velocity when throwing something (for instance, pitching with much more force during a baseball match) can put more stress on your shoulder, thus leading to an increased risk of scapular winging.
- Previous shoulder injuries – If you have dealt with shoulder injuries in the past, you may have a higher percentage of scapular injury recurrence.
- Kyphosis – Kyphosis is excessive, forward rounding of the back. Age-related kyphosis is often due to weakness in the spinal bones that causes them to compress or crack. Developing this condition may also increase your risk of a winged scapula.
How does it affect you? How serious is it?
Most patients living with a winged scapula aren’t required to undergo surgery. However, if conservative treatment fails to recover your condition, surgery is required. The most common surgical treatments for scapular winging are nerve and muscle transfers. These surgeries involve taking all or part of a nerve or muscle and moving it to another part of the body. Nerve and muscle transfers for scapular winging typically focus on the shoulder, back, or chest. Another option is called static stabilization.
This specific procedure involves using a sling to attach the scapula to either the ribs or the vertebral spinous processes, which are bony arts that stick out of your vertebrae. There is a risk that the sling will stretch out over time, causing the winged scapula to return. Lastly, your doctor may recommend a procedure called scapulothoracic fusion if all other treatments fail to succeed.
This involves attaching the scapula directly to the ribs. You may not be able to lift your arms after this surgery has been done. It can also cause permanent bone fractures and lung problems. Your doctor may only suggest this type of surgical procedure if there are no more alternatives.
Recommended Treatment & Rehabilitation
With many possible causes and clinical presentations, the incidence and prevalence of scapular winging is unknown as it is often misdiagnosed. Common misdiagnoses include rotator cuff tendinopathy, shoulder instability, cervical radiculopathy, acromioclavicular joint disorders, and nerve disorders. Electromyography (EMG) testing is the only definitive for serratus anterior, trapezius, rhomboid, and levator scapulae dysfunction that may contribute to scapular winging, however the extent of nerve damage or recovery potential cannot be identified unless serial EMG tests are performed.
Additionally, it is important to understand that patients presenting with symptomatic winging may not show EMG dysfunction, thus clinical findings are equally as important. Identifying scapular dyskinesis and the muscle length and strength relationships involved is key to a proper diagnosis of scapular syndromes. More importantly, early identification of a winged scapula as a component of shoulder dysfunction is important for maximizing outcomes and minimizing continued pain or secondary injury to the shoulder.
After a diagnosis for a winged scapula has been done, a physiotherapist will work with you to design a specific treatment program to speed your recovery. It will include exercises and treatments that you can perform at home. Physiotherapy will help you safely return to your regular lifestyle and activities. Therefore, your therapist will work with you to:
- Reduce your pain – Your physiotherapist may use different types of treatments and technologies to control and reduce your pain and symptoms. These may include ice, heat, diathermy, ultrasound, laser treatment, electrical stimulation, taping, exercises, and other treatments.
- Improve your motion – Your physiotherapist will choose specific activities and treatments to help restore normal movement in the shoulder, neck, and spine. These might begin with passive motions that your therapist performs for you to slowly move your arm, shoulder, neck, scapula, and progress to active exercises and stretches that you perform yourself.
- Improve your flexibility – He or she will teach you how to gently stretch your shoulder, neck, and arms where your winged scapula is present. Your physiotherapist may apply hands-on techniques, such as massage and trigger-point release, to help loosen and stretch your muscles.
- Improve your strength – Specific exercises will aid healing at each stage of recovery. Your therapist will choose and teach you the best exercises and equipment to steadily restore your strength and agility. He / she will choose the right treatments and activities to help you heal, return to your healthy lifestyle, and reach your goals faster than you are likely to do on your own.
- Return to activities – Your physiotherapist will discuss your goals with you. They will work with you to set your job, sport, and homelife recovery goals. Your treatment program will help you reach those types of goals in the safest, fastest, and most effective way possible.
- Prevent future injury – Your therapist can recommend a home exercise program to help prevent future injury. These exercises will help to strengthen and stretch the muscles around your shoulder and arm. They may include strength and flexibility exercises for the muscles of the neck, shoulder, arm, and scapula.
The exercises mentioned below will help boost your recovery from a winged scapula:
Shoulder rotation robot
Stand with your back against a wall, fingers pointing down toward the ground, and elbows slightly bent. Next, keeping your upper arm and elbow pressing into the wall, start to lift your right fingers and forearm away from the wall as you rotate them up. Try to get the back of your hand to the wall, fingers pointed up, and pause, pressing both hands into the wall. As you rotate your right arm back down to the starting position, lift your left arm up, swapping positions. Continue to move, taking one hand up as the other moves down and pausing in between. Repeat this exercise 3-4 times a day.
Overhead wall rollout
Stand leaning against a wall with an ab-wheel in your hands, while you protract your scapulae. Then, slowly roll the ab-wheel up the wall and ensure you are shrugging your shoulders to elevate your scapulae as your arms rise up, while keeping tension in your core to avoid lumbar extension. Roll back down slowly and with control and return to the initial position. Repeat this method 2-3 times a day.
Supine serratus activator
Lie on your back with your upper arms on the ground by your sides and flex your elbows, pointing your fingers toward the ceiling. Drive your elbows into the ground at about 50% strength and hold. Maintaining this contraction, try to bring the medial border of your scapulae up as if you are trying to pull them into your body and open your chest. Hold for 5 seconds, then repeat 2-3 times a day.
Alternative & Homeopathic Treatment
A winged scapula isn’t always preventable; however, you can be able to reduce your risk by doing the following natural treatments:
- Avoiding repetitive shoulder or arm movements by resting.
- Maintaining correct posture.
- Using an ergonomic chair or pillow for assistance.
- Applying a non-steroidal anti-inflammatory cream onto the affected area to reduce inflammation or swelling if needed.
- Using shoulder-friendly ergonomic bags.
- Having warm baths or applying heat packs on your back to increase blood circulation.