What is Winging of the Scapula?
A winged scapula is a condition where one side of the shoulder blade seems to stick out from the back. As the name suggests, it can look like a wing. This unusual position of the shoulder blade can cause various physical issues like pain, reduced strength, and interruptions in your range of motion. The movements most commonly affected are abduction (moving a part away from the central line of the body) and flexion (bending a joint) in the affected arm.
What Causes Winging of the Scapula?
A winged scapula, which is a condition where the shoulder blade sticks out, is often caused by damage or issues with the function of a muscle called the serratus anterior. This muscle is controlled by the long thoracic nerve. If this nerve gets damaged or squeezed, it can cause problems with the serratus anterior muscle. Some people with this condition might have trouble lifting their arm above their head.
This issue causes the inner edge of the shoulder blade to stick out, making it look like a wing. This happens because the serratus anterior muscle, which attaches to the inner edge of the shoulder blade, isn’t able to hold the shoulder blade against the back of the rib cage, causing it to stick out.
Less commonly, damage to two other muscles – the trapezius and rhomboid muscles – can cause the shoulder blade to stick out. These muscles are controlled by the spinal accessory nerves and the dorsal scapular nerve, respectively. In this case, the shoulder blade moves sideways because the strength of these muscles is less due to paralysis or weakness. The trapezius muscle helps to lift, pull back, and turn the shoulder blade.
Risk Factors and Frequency for Winging of the Scapula
Scapular winging is a condition that can occur in women who have had chest surgery, including breast cancer patients who have underwent a radical mastectomy. The reason for this is that during this process, the long thoracic nerve, which is near the axillary lymph nodes, may get injured. This risk is higher in surgeries that involve removal of axillary lymph nodes.
Another common cause of this issue is paralysis of the trapezius muscle, which might happen during neck surgery due to injury to the spinal accessory nerve. There are many documented cases of serratus anterior muscle paralysis, often found in sportspeople and certain occupational groups.
- Scapular winging often affects women who’ve had chest surgeries like radical mastectomy.
- The issue arises when the long thoracic nerve gets damaged because it resides near the axillary lymph nodes which are sometimes removed in such surgeries.
- Trapezius muscle paralysis, as a result of neck surgery that can injure the spinal accessory nerve, is another common cause.
- Paralysis of the serratus anterior muscle is commonly reported amongst sportspeople and certain professions like car mechanics, carpenters and laborers.
Signs and Symptoms of Winging of the Scapula
Winged scapula is a condition that usually presents with pain and weakness in movements involving the scapula, or shoulder blade. Common symptoms include difficulty raising the arm above the head and lifting objects. It’s also important to note that the symptoms can vary due to different causes of a winged scapula. In some cases, pain may not be present at all, while fatigue might be a significant feature.
During a physical exam, medical practitioners look for a noticeable distortion of the back, caused by a bony part of the scapula sticking out. This happens because the scapula isn’t properly attached to the rib cage. This muscle issue affects the shoulder blade’s ability to rotate upwards, move away from the body (abduction), and elevate, especially if there’s weakness or pain.
A practical way to assess the presence of a winged scapula involves a simple physical test: The patient faces a wall, extends the affected arm in front of the body parallel to the floor, and then pushes against the wall with the palm of their hand. This action typically makes the bony protrusion of the scapula visible.
It’s worth noting that in some cases, the winged scapula may not be immediately visible. It could take several weeks for the condition to become clearly visible.
Testing for Winging of the Scapula
If you have a condition known as “scapular winging,” where your shoulder blade sticks out and doesn’t move normally, your doctor can typically diagnose it by asking about your symptoms and doing a physical check-up. If more details are needed, they can use other methods like electrodiagnostic testing, which can identify any underlying issues with your nerves and muscles.
An alternative testing method is neuromuscular ultrasound. This uses soundwaves to produce images of your muscles and nerves, helping your doctor identify any issues that might be causing scapular winging. Not only is this test painless, but it also doesn’t expose you to any radiation, making it a safe option for everyone.
Your doctor may also use tests like electromyography and nerve conduction studies, which are more specific for evaluating scapular winging. Electromyography measures the electrical activity in your muscles when they contract, whereas nerve conduction studies test the speed of electrical signals traveling through your nerves. These tests can be great at pinpointing the exact nerve involved and location of any damage.
A significant aspect of using these evaluation methods is that it allows early diagnosis and treatment. This is crucial in preventing more severe shoulder issues that could potentially develop from untreated scapular winging.
Treatment Options for Winging of the Scapula
A “winged scapula,” a condition where the shoulder blade sticks out abnormally, is usually managed through non-surgical methods like pain management and physical therapy. Physical therapy helps keep your shoulder mobile and may prevent complications such as “adhesive capsulitis,” a condition that restricts shoulder movement due to inflammation. Most people with this problem who start treatment early recover fully. In many cases, your body can compensate for the weak or paralyzed front shoulder muscle (serratus anterior) that often causes the condition, by using the trapezius muscle in your upper back and neck. However, recovery can take months or even years, and if there’s no improvement within this time, full recovery may not happen.
There are surgical options for treating a winged scapula, including procedures where the shoulder blade is attached to some of the ribs to prevent improper movement and the winged appearance. Another option is a muscle transfer, where a part of the chest muscle (pectoralis major) is moved to the lower tip of the shoulder blade. But this isn’t the best option for athletes or those who do heavy physical work.
While therapies can often help if the front shoulder muscle is weak or paralyzed, they’re usually less successful if there’s a problem with the trapezius muscle. While exercises may help with pain in this case, they won’t fix the neck asymmetry that can occur. Surgical exploration and potentially repairing the nerves show better results. For young, healthy people, moving some of the back and neck muscles to the shoulder blade has been effective. Lastly, some patients may benefit from injections of a drug called botulinum toxin, but this is a temporary solution and can be expensive over time.
What else can Winging of the Scapula be?
When someone has symptoms such as pain, weakness, or discomfort in the upper body, it may not be immediately clear what’s causing these issues. The symptoms are similar to those of several different conditions:
- Rotator cuff disorders, which can naturally limit arm motion and strength
- Glenohumeral instability, which could make the shoulder feel unstable
- Peripheral nerve disorders, which can cause a variety of symptoms
- Cervical spine disease, which can affect areas around the neck and shoulders
- Thoracic outlet syndrome, a condition affecting the space between the collarbone and the first rib
- Acromioclavicular disorders, which involve the joint at the top of the shoulder
However, the actual cause could be scapular winging, a condition where the shoulder blade sticks out. In cases of scapular winging, the scapula (or shoulder blade) is unstable, not the glenohumeral joint, which is often the case in these other conditions. So, the discomforts of other diagnoses might confuse and overlap with scapular winging symptoms, and it’s essential to rule out these other conditions.
What to expect with Winging of the Scapula
At present, there’s no go-to treatment for scapular winging, a condition where the shoulder blade sticks out. The current approach includes managing pain and physical therapy. These strategies are best applied early on to prevent worsening of the condition.
If treatment is not started early, patients might deal with more problems down the line. These include frozen shoulder (or adhesive capsulitis), a condition that severely restricts shoulder mobility, subacromial impingement, a situation where the shoulder muscles are compressed, and other issues related to the brachial plexus, a network of nerves that send signals from your spine to your shoulder, arm and hand.
Possible Complications When Diagnosed with Winging of the Scapula
Sometimes, an injury to a nerve called the “long thoracic nerve” can cause a condition known as “scapular winging.” The scapula, or shoulder blade, sticks out instead of lying flat against the back of the chest. Consider this condition like a branch on a tree being damaged; it can affect the other branches around it. The nerves and structures nearby can also be affected.
The long thoracic nerve comes from a “nerve network” called the brachial plexus. This network starts at the lower part of the neck (the cervical nerve roots) and the upper part of the back (the thoracic nerve root). If the brachial plexus gets damaged, it can cause problems in the arms and the trunk of the body.
The long thoracic nerve is like an offshoot or a smaller branch of the brachial plexus. Research has shown that if the brachial plexus is damaged during surgery, it can have alarming consequences. The loss of function can be devastating, leading to the wasting away (atrophy) of the muscles that the damaged nerves connect to.
Key Points:
- Scapular winging happens when the long thoracic nerve gets injured.
- This nerve is part of a network called the brachial plexus, starting from the lower neck to the upper back.
- If the brachial plexus is damaged, it can lead to problems in the arms and the body’s trunk.
- Damage to the long thoracic nerve and brachial plexus during surgery can lead to muscle wasting.
Preventing Winging of the Scapula
As with many health conditions, the most effective approach to scapular winging, which is a condition where the shoulder blade sticks out, is prevention and early treatment once the symptoms appear. In some cases, this condition may last for up to two years. While most people with this condition eventually get better, about a quarter of them may continue to experience pain afterwards.
