What is Winged Scapula?
Winged scapula is a condition where the scapula bone appears to protrude from the back. In cases of winged scapula, the scapula is lifted or protrudes from the spine, where normally the scapula is on the chest wall and connected to the surrounding muscles.
Winged scapula can cause decreased muscle strength and limited flexion and abduction movements in the upper arm. This certainly affects the patient's daily activities, such as the ability to lift, pull, and push heavy objects, comb hair and brush teeth, or carry shopping bags.
These scapular muscles play a role in keeping the medial border of the scapula attached to the posterior thoracic wall, and denervation or paralysis of these muscles results in the medial border of the scapula being flared as it is lifted from the thoracic wall. In addition, the scapula can move medially or laterally along the posterior thoracic wall due to the contraction of the muscle pulling the scapula to one side without resistance from the other paralyzed scapular muscle. This distinction is known as a medial winged scapula (serratus anterior paralysis) or a lateral winged scapula (trapezius or rhomboid paralysis).
Causes of Winged Scapula
The most common cause of winged scapula is damage or disruption of the nerves to the serratus anterior muscle. The nerve that innervates this muscle is the long thoracic nerve. Injured nerves will cause the serratus anterior muscle to not function. Some patients may also complain of an inability to lift their head overhead. This dysfunction causes the medial border of the scapula to appear prominent. Damage to this nerve causes the winged appearance because the serratus anterior muscle attaches to the medial aspect of the scapula and holds it against the posterior ribs.
The scapula can also flare laterally due to damage to the trapezius or rhomboid muscles, which are innervated by the spinal accessory nerves and dorsal scapular nerve respectively. The scapula will move laterally due to decreased muscle strength caused by paralysis or weakness of the trapezium or rhomboid. This occurs because the function of the trapezius muscle is to elevate, retract, and rotate the shoulder blade.
| Medial winging | Lateral winging | Lateral winging | |
| Injured nerves | Long thoracic | Spinal accesorry | Dorsal scapular |
| Muscle weakness | Serratus anterior | Trapezius | Rhomboids |
| Physical examination | Arm flexion, push up on the wall | Arm abduction, external rotation against resistance | Arm extension from full flexion |
| Position of the scapula compared to normal | The entire scapula is displaced medially and superiorly. | The superior angle is more shifted laterally | The inferior angle is more displaced laterally |
Signs and Symptoms of Winged Scapula
Some signs and symptoms that appear in winged scapula are:
- Pain (not always present)
- Weakness when moving the scapula
- Difficulty lifting arms and objects
- Fatigue
- Inability to lift the shoulder due to weakness or pain
The Role of Physiotherapy in Winged Scapula
The core goal of physiotherapy management is to strengthen the weakened muscles, especially the serratus anterior and upper trapezius, to restore normal shoulder mobility. During the early stages of rehabilitation, exercises should be performed with the arm below 90° from the humeral elevation. This is done to prevent rotator cuff injuries. Some exercises that can be performed are:
- Press up against wall
This exercise can be done with or without a swiss ball by standing an arm's length away from a wall as shown in the picture. Lean against the wall, bend your arms and push away. Repeat 10 times. Aim for 3 sets of 10 reps.
- Serratus anterior punches
Serratus anterior punches are performed with theraband to strengthen the serratus anterior and rotator cuff muscles. This exercise is effective in increasing the range of motion and strength of the periscapular muscles. This strengthening exercise should be combined with stretching exercises of the antagonist muscle groups.
- Military-type push up
The serratus anterior muscle works more actively during military-type push-ups with scapular protraction. In addition to the serratus anterior, the upper trapezius muscle is one of the most important muscles in moving the scapula in various overhead activities. If these two muscles do not work together, this can cause other problems in the shoulder. When the contraction of the serratus anterior is weak or the contraction of the upper trapezius is too strong, this can cause the scapula to protrude instead of being attached to the ribs. If we want to have biomechanical rhythm, we must have coordination between the upper trapezius and serratus anterior muscles.
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Reference :
- Park SB, Ramage JL. Winging of the Scapula. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541005/
- Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008 Mar;1(1):1-11. doi: 10.1007/s12178-007-9000-5. PMID: 19468892; PMCID: PMC2684151.
- Ishaque F, Bilawal M. Physical Therapy Management of Scapular Winging. J. Baqai Med. Univ. Vol. 12, No. 2 – July – Dec. 2009
