Recommended Treatment of Scapular Winging

The shoulder is one of the most complex joints in the human body. It involves the arm bone, the collar bone, and the shoulder blade all moving together in proper unison. When the shoulder blade, or scapula, does not move properly or sits on the rib cage incorrectly it can cause pain, weakness, and poor range of motion. Scapular winging is a rare, under reported disorder that involves the shoulder blade sitting incorrectly on the rib cage. It is named winging because the side and bottom of the shoulder blade sticks out and resembles a bird wing when at rest, that is exaggerated by movement. Scapular winging can be caused by damage to the long thoracic nerve or the spinal accessory nerve, which control the shoulder blade stabilizing muscles: the serratus anterior muscle and the trapezius muscle. Injuries can include extreme nerve stretching, blunt injuries, or certain neurological diseases, such as Polio or Lyme disease.

When diagnosing a patient with scapular winging, a thorough history must first be taken as the suspected cause of the scapular winging determines the treatment path. If there is penetrating trauma to the nerve, but the nerve remains somewhat intact, it is recommended to wait to see if the nerve recovers. Most winging due to nerve damage recovers on its own in six to nine months. If there is not obvious recovery, then a referral to physical therapy is in order. Nonsurgical treatment should continue for up to 24 months before considering surgery, which consists of physical therapy for improved range of motion, decreased pain and increased muscle strength and function.

If there fails to be progress after 24 months, surgery is indicated. To compensate for the serratus anterior muscle, a graft of the pectoralis major tendon is moved to the lower border of the shoulder blade to improve the winging (which also requires a piece of hamstring for the attachment). To compensate for upper trapezius some of the shoulder blade muscles, specifically the rhomboid minor and levator scapulae, along with a piece of the shoulder bone are moved to the upper portion of the shoulder blade. While fairly invasive, both of these procedures show outcomes ranging from 71 to 100 per cent recovery.

References: Lee, S. M.D. et al. Scapular Winging: Evaluation and Treatment. The Journal of Bone and Joint Surgery. October 21, 2015. Vol. 97-A, No. 20. Pp. 1708-1716.

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