WINGED SCAPULA: CAUSES, SYMPTOMS, DIAGNOSIS AND TREATMENT
Medically Reviewed by Dr. Sony Sherpa (MBBS) - September 8, 2023
Scapular Winging or Winged Scapula is a medical disorder caused when the muscles that stabilize the area between the shoulder blades become weak or paralyzed. This condition leads to the protrusion of the shoulder blade to form a deformity that resembles the shape of a wing. This condition can impact a person's quality of life, with symptoms ranging from mild back discomfort to severe pain. Scapular winging can also affect the range of motion for activities such as pulling, pushing, and lifting objects.
Causes of Winged Scapula
Scapular Winging can result from dysfunction of the nerves and muscles in the shoulder blade region. Another cause is trauma or injuries to the nerves and muscle structures in this area. The etiology of this condition includes the following:
Nerve damage
Damage to nerves of the shoulder blade region can be traumatic (due to injuries) or non-traumatic. Traumatic injuries are caused by:
- Major blunt or sharp traumas to the neck and torso region
- Repeated micro-traumas from daily activities such as cleaning overhead structures, gardening, and mopping
- Sports injuries, such as from shot put, bowling, and weight-lifting
- Compression of the nerves by tight clothing or bag straps
- Iatrogenic sharp traumas, such as during treatment of Pneumothorax or shoulder surgeries
- Surgeries such as Mastectomy
- Tumors or other growths in the shoulder area
Non-traumatic injuries include viral nerve damage such as Polio or Influenza, toxin exposures, allergic reactions, congenital conditions such as Muscular Dystrophy, and genetic conditions affecting the musculoskeletal or neural system.
Damage to the long thoracic nerve often results in winging of the medial (inner) border of the scapula. Damage to the spinal accessory nerve causes scapular winging of the outer (lateral) border of the scapula. Dorsal scapular nerve damage can also contribute to this condition.
If you experience tingling sensations in your arm or occasional weakness in your shoulders, this may be a sign of nerve problems that increase your susceptibility to scapular winging.
Muscular weakness or imbalance
Pathologies involving the Serratus Anterior, Trapezius, or Rhomboid muscles can cause scapular winging. Serratus Anterior weakness or paralysis is the most common cause of a winged scapula. Muscular Dystrophy, congenital muscle weakness, tearing of muscle fibers due to trauma, and drug-induced myopathies are some causes of scapular winging.
Symptoms and Diagnosis
Winged scapula manifests with various symptoms and signs. People with winged scapula complain of discomfort and fatigue in the shoulder blade region. Often, dull aching pain or sharp shooting pain accompanies the inability to lift the arms above a certain point and difficulty reaching behind the back. The pain can be in your shoulder region and may extend to the upper arms or further down. Fatigue is another common complaint. This results in a reduction in daily activities and a decrease in quality of life.
The diagnosis of winged scapula is confirmed by clinical tests. The healthcare provider will ask you to face the wall and push against the wall with your arms parallel to the ground. In case of Serratus Anterior muscle involvement, this clinical test makes the winged scapula more prominent. Winged scapula due to a Trapezius muscle problem is diagnosed by raising the arms to form a ‘T shape’ with your body. Similarly, a winged scapula due to a Rhomboid muscle problem is diagnosed by extending the arm from a fully flexed position.
The healthcare provider may also order an electrodiagnostic test or neuromuscular ultrasound to confirm the exact cause of the condition. This helps with treating the underlying cause of your scapular winging. Other techniques used to assess winged scapula include electromyography (EMG) and nerve conduction studies. These methods are highly accurate and can pinpoint the specific nerve affected in the condition, as well as identify the precise location of the nerve damage. This is achieved by recording the electrical activity generated by muscles and assessing the speed at which nerve impulses travel through a particular nerve.
Common Risk Factors
Certain risk factors increase the likelihood of developing a winged scapula. Intense activities and sports involving rapid movements of the torso or upper limb can contribute to scapular winging. Weight-lifters, athletes, construction workers, and dancers are prone to winging of the scapula. In addition, previous injuries to your shoulder region or surgeries in this part of your body can also make you more susceptible.
Treatment Options
In most cases, your doctor will recommend techniques to strengthen the shoulder blade muscles and physical therapy. This includes range of motion exercises and muscle strengthening exercises, which improve shoulder girdle function.
You can get relief from your symptoms through pain relief medication, anti-inflammatories, and muscle relaxants. Non-steroidal pain medication and more potent pain medication are used for symptomatic relief. Another pillar of treatment includes external support devices. External support devices or orthoses (devices that you can wear) and braces/collars/traction devices.
It is important to identify and treat the underlying causes of scapular winging. This includes avoiding certain physical activities that may have caused the condition, such as sports, gardening, cleaning, and heavy overhead exercises. Mobility modification helps to reduce further damage to this area.
In severe or chronic cases, surgical treatment can be considered. Choices include split pectoralis major transfer, Eden-Lange muscle transfer, intercostal nerve transfer, tendon transfer, and Scapulopexy.
Coping Strategies and Lifestyle Tips
By modifying your lifestyle, you can reduce your symptoms and also prevent debilitating sequelae of scapular winging. You need to avoid heavy weight-lifting and long-term repetitive actions, including swimming, digging, and reaching overhead structures.
You have to be mindful of your posture and adopt coping mechanisms. Avoid sleeping with your arms stretched away from the body, popularly known as abduction, such as when you make a snow angel, use comfortable bedding, and avoid sitting in positions with the arm overhead for extended periods.
Low to moderate-intensity exercises preceded by adequate stretching can help to strengthen your muscles. Coping with muscle weakness and fatigue can be difficult without these exercises. The push-up plus (PUP) exercise has been shown to strengthen your Serratus Anterior muscle. You can also do exercises to strengthen your Rhomboid muscle and Trapezius muscle.
Prevention
You can reduce the likelihood of developing winged scapula by taking certain precautions. It is essential to properly stretch and warm-up adequately before engaging in rigorous athletic activities. You can also do prophylactic shoulder girdle strengthening exercises. These exercises should be done regularly and show a beneficial effect over time.
If you experience any pain in the shoulder blades or notice any protrusion in that area, avoid activities that put pressure on the shoulder and maintain a healthy weight. Seek advice from a certified doctor. Early treatment of this condition can prevent complications and long-term issues such as brachial plexus injuries, a frozen shoulder, and subacromial impingement.
Living with Winged Scapula
If you have a winged scapula, you need to develop a support system to help with your symptoms. Your family and friends can help you with rigorous activities involving the shoulder blade muscles. You can also notify your condition at work so they can facilitate your needs. You can utilize physiotherapy facilities and support groups to form a coping strategy.
It is essential to have a holistic approach and maintain your physical and mental well-being.
Conclusion
A winged scapula is a deformity of the shoulder blades resulting from neural or musculoskeletal problems. Serratus anterior muscle and long thoracic nerve damage are commonly implicated in this condition. Trauma to the shoulder blade region is the main cause.
Pain and fatigue of the shoulder and limited arm mobility, along with a clinically induced or grossly visible deformity of the shoulder blade, leads to a diagnosis of winged scapula. Physiotherapy and supportive medication or orthosis form the main pillars of treatment for this condition. If you experience any symptoms of a winged scapula, seek professional medical advice as soon as possible to get treatment and prevent serious complications.
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