Scapular winging: anatomical review, diagnosis, and treatments

Curr Rev Musculoskelet Med (2008) 1:1–11 DOI 10.1007/s12178-007-9000-5

Scapular winging: anatomical review, diagnosis, and treatments
Ryan M. Martin Æ David E. Fish

Published online: 2 November 2007 Ó Humana Press 2007

Abstract Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes,including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis.Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients becomecandidates for corrective surgery. Keywords Scapular winging Á Serratus anterior Á Trapezius Á Rhomboid Á Long thoracic nerve

Introduction Scapular winging is a rare, but potentially debilitating condition that can affect the ability to lift, pull, and push heavy objects, as well as to perform daily activities of

living, such as brushing one’s hair and teeth and carrying grocery bags [1].Cosmetically, some patients may be distressed by pronounced winging [2]. Disrupting scapulohumeral rhythm, scapular winging contributes to loss of power and limited flexion and abduction of the upper extremity and can be a source of considerable pain [3–8]. A condition due to a number of etiologies, most cases are due to lesions of the long thoracic and spinal accessory nerves that innervate the serratusanterior and trapezius muscles, respectively. Rarely, it may also be due to a lesion to the dorsal scapular nerve that innervates the rhomboid muscles. These scapular muscles (Fig. 1) contribute to keeping the medial border of the scapula protracted against the posterior thoracic wall, and denervation or paralysis of any of these muscles results in the winging of the medial border of the scapula asit lifts off the thoracic wall. In addition, the scapula may translate medially or laterally along the posterior thoracic wall due to unopposed muscle contraction of the other functioning scapular muscles, a distinction known as medial (serratus anterior paralysis) or lateral (trapezius or rhomboid paralysis) winging (Table 1). Scapular winging may present in a variety of clinical contexts, andmay be due to traumatic- or sports-related injury [2, 4, 5, 8–22], iatrogenic injury [1, 2, 12, 15, 16, 19, 23–27], or spontaneous in nature [6–8, 11, 27–30]. Here we discuss incidence and demographics, pertinent anatomy, the nature of the injury, diagnostic tests, and treatment options for scapular winging due to serratus anterior, trapezius, and rhomboid muscle paralysis.

R. M. Martin Á D. E.Fish (&) Department of Orthopaedics, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250, 16th St, 7th Floor, Tower Bld, Rm 745, Santa Monica, CA 90404, USA e-mail: dfish@mednet.ucla.edu

Incidence/Demographics Scapular winging due to serratus anterior palsy is a rare lesion. Fardin et al. [29] reported an incidence of 15 cases

2 Fig. 1 Anatomical relationshipof the serratus anterior, trapezius, and rhomboid muscles around the scapula, with the rhomboids just deep to the trapezius. Modified from Ref. [44, p. 52, Fig. 2.43]

Curr Rev Musculoskelet Med (2008) 1:1–11

Table 1 Neurogenic causes of scapular winging and the physical exam Medial winging Injured nerve Muscle palsy Physical exam Position of the scapula compared to normal Long thoracic...