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Winged Scapula

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Other Names

  • Winging of the scapula
  • Scapular Winging
  • Serratus Anterior Palsy
  • Trapeizus Palsy

Background

History

  • First described by Winslow in 1723[1]

Epidemiology

  • Rare clinical entity, incidence and prevalence unknown
  • Fardin et al: 15 cases in 7000 patients seen in EMG lab[2]
  • Ghormley: 1 case in 38,500 patients at Mayo Clinic[3]

Pathophysiology

  • Medial vs lateral is defined by direction of superomedial corner of the scapula
  • Medial winging
  • Lateral winging
  • Consequences
    • These muscle groups responsible for keeping the medial border of the scapula protracted against the posterior thorax
    • Denervation or paralysis leads to winging of the medial scapula

Etiology

  • Serratus Anterior Palsy
    • Most common: repetitive stretch injury represents >50% of cases (need citation)
    • Trauma (blunt trauma, depression of shoulder girlde, sudden twisting of neck or shoulder)
    • Atraumatic (infection, allergic, toxicology, muscular dystrophy)
    • Idiopathic
    • Surgical procedures (mastectomy, first rib resection, thoracotomy)
  • Trapezius Palsy
    • Traumatic (traction, MVC, direct trauma, heavy lifting, pentrating wounds)
    • Iatrogenic represents 71% of cases (cervical lymph node biopsy, cervical mass exision)[4]
    • Spontaneous or Idiopathic
  • Rhomboid Palsy
    • Trauma (entrapment, direct trauma, shoulder dislocation)

Pathoanatomy

Risk Factors

  • Sports (with documented cases)
    • Archery
    • Ballet
    • Baseball
    • Basketball
    • Weight lifting
    • Bowling
    • Football
    • Golf
    • Gymnastics
    • Hockey
    • Soccer
    • Tennis
    • Wrestling
    • Ballet[5]
  • Occupations (with documented cases)
    • Mechanic
    • Navy Airmen
    • Scaffolders
    • Welders
    • Carpenters
    • Laborers
    • Seamstress

Differential Diagnosis

Clinical Features

  • General: Physical Exam Shoulder
  • History
    • Careful review of medical history, trauma, occupation, sports, etc
    • Patient will report difficulty elevating the arm and lifting objects
    • Vague, non specific shoulder pain and fatigue
    • Subjective shoulder instability
  • Physical Exam
    • Serratus anterior palsy: inferior-medial scapula elevates, protrudes posteriorly-medially
    • Trapezius palsy: superior-medial scapula drops, protrudes posteriorly-laterally
      • Atrophy/wasting of the ipsilateral trapezius
    • Abduction limited
    • Weakness with forward flexion, abduction
  • Special Tests

Evaluation

  • The diagnosis is primarily clinical

Radiographs

Ultrasound

  • Neuromuscular ultrasound may be used to determine if muscular or neurologic pathology is present

EMG/NCS

  • Electromyography and nerve conduction studies allow for determination of the specific damaged nerve.
  • Will demonstrate:
    • Resting denervation potentials
    • Decreased motor unit recruitment
    • Polyphasic motor unit potentials during volitional activity
  • Unclear if improvement on serial EMG over time correlates with improved clinical outcome[6]

Classification

Management

Prognosis

  • Possible to recovery most or all function, typically between 1 and 24 months
  • Mild deficits, asymptomatic winging may persist after functional recovery[7]
  • Up to 25% of patients will maintain scapular winging after conservative therapy and be surgical candidates[8]

Nonoperative

  • First line treatment
  • Activity modifcation, avoiding overhead activities or painful activities
  • NSAIDS
  • Physical Therapy
    • Avoid excessive stretching
  • Consider bracing
    • Scapular Brace for serratus anterior palsy
    • Shoulder Orthosis for trapezius palsy

Operative

  • Indications
    • Failure of conservative therapy (typically 6-24 months)
  • Technique (serratus anterior)
    • Scapulothoracic arthrodesis (fusion)
    • Scapulopexy (fascial graft without fusion)
    • Dynamic muscle transfer (using head of pec major)
  • Technique (trapezius)
    • Neurolysis
    • Eden-Lange muscle transfer procedure (levator scap & rhomboid)
  • Technique (rhomboids)
    • Scapulopexy
    • Neurolysis
    • Scapulothoracic arthrodesis

Rehab and Return to Play

Rehab

  • Watson and Schenkman protocol for long thoracic nerve injury[9]
  • Acute stage
    • Denervation of the serratus anterior causes pain
    • Goals of treatment include pain reduction and ROM exercise
    • Activity modification to limit further injury to the shoulder.
  • Intermediate stage
    • Pain has subsided and the nerve is beginning to heal
    • Maintain full ROM, passive stretching prevent contracture of muscles due to the loss of serratus anterior activity.
  • Late stage
    • The serratus anterior becomes progressively stronger, shoulder mechanics improve.
    • To improve strength and overhead work, strengthening exercise of all shoulder girdle muscles
    • Avoidance of overstretching the serratus anterior should be continued.

Return to Play

  • Needs to be updated

Complications

See Also

References

  1. ↑ Winslow M. Panckouke: Chez; 1723. Sur quelques mouvements extraordinaires des omoplates et des bras, et sur une nouvelle espece de muscles
  2. ↑ Fardin P, Negrin P, Dainese R. The isolate paralysis of the serratus anterior muscle: clinical and electromyographical follow-up of 10 cases. Electromyogr Clin Neurophysiol 1978;18:379–86.
  3. ↑ Overpeck DO, Ghormley RK. Paralysis of the serratus magnus muscle caused by lesion of the long thoracic nerve. JAMA 1940;114:1994–6.
  4. ↑ Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907–11.
  5. ↑ White SM, Witten CM. Long thoracic nerve palsy in a professional ballet dancer. Am J Sports Med 1993;21:6326–628.
  6. ↑ Martin, Ryan M., and David E. Fish. "Scapular winging: anatomical review, diagnosis, and treatments." Current reviews in musculoskeletal medicine 1.1 (2008): 1-11.
  7. ↑ Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M. Serratus anterior paralysis in the young athlete. J Bone Joint Surg 1979;61:825–32.
  8. ↑ Fery A. Results of treatment of anterior serratus paralysis. In: Post M, Morrey BF, Hawkins RJ, editors. Surgery of the shoulder. St. Louis: Mosby Year Book;1990. p. 325–9.
  9. ↑ Watson CJ, Schenkman M. Physical therapy management of isolated serratus anterior muscle paralysis. Phys Ther 1995;75:194–202.
  10. ↑ Kauppila LI, Vastamaki M. Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest 1996;109:31–4.
Created by:
Connor Farrell on 4 August 2019 15:51:29
Last edited:
1 October 2022 19:14:07
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