What is the best management approach for winging of the scapula?

Management of Scapular Winging

The optimal management of scapular winging requires accurate diagnosis of the underlying cause followed by targeted treatment, with conservative management being the first-line approach for most cases, particularly those involving nerve injury where spontaneous recovery is expected within 6-24 months.

Diagnosis

Clinical Assessment

• Observe the scapula during rest and movement to determine the pattern of winging:
  • Medial winging: Suggests serratus anterior dysfunction (most common)
  • Lateral winging: Indicates trapezius or rhomboid muscle dysfunction
• Perform specific tests:
  • "Push on wall" test: Positive in serratus anterior weakness
  • Arm elevation: Observe for abnormal scapular movement
  • Assess for pain, weakness, and limited range of motion

Imaging

• Plain radiographs: Initial imaging to rule out structural causes 1
• CT: Best for characterizing scapular fractures and bony abnormalities 1
• MRI: Preferred for soft tissue evaluation, including muscle tears 1
• Electroneuromyography (EMG): Essential for confirming neurogenic causes and determining the extent of nerve injury 2, 3

Treatment Algorithm

1. Conservative Management (First-Line)

• Duration: 6-24 months to allow for spontaneous recovery 4
• Components:
  • Physical therapy focusing on:
    • Scapular stabilizer strengthening (serratus anterior, trapezius, rhomboids)
    • Rotator cuff strengthening
    • Correction of scapular dyskinesis
  • Pain management:
    • NSAIDs or acetaminophen for symptomatic relief
  • Activity modification:
    • Avoid aggravating activities
    • Rest from overhead movements

2. Surgical Management (If No Recovery After Conservative Treatment)

• For Serratus Anterior Palsy:

  • Nerve procedures (for acute cases <12 months):
    • Neurolysis
    • Nerve transfers
    • Nerve grafts
  • Tendon transfers (for chronic cases >12-24 months):
    • Pectoralis major transfer (sternal or clavicular head) 2

• For Trapezius Palsy:

  • Tendon transfers:
    • Elhassan triple transfer (preferred method) 2
    • Levator scapulae transfer
    • Rhomboid transfer

• For Rhomboid Palsy:

  • Typically managed conservatively as surgical options are limited 4, 3

Special Considerations

Etiology-Specific Approaches

1. Neurogenic causes (most common):

   • Long thoracic nerve injury (serratus anterior): Allow 24 months for spontaneous recovery 4
   • Spinal accessory nerve injury (trapezius): Less likely to recover with conservative treatment 4
   • Dorsal scapular nerve injury (rhomboids): Specific rehabilitation protocol recommended 3

2. Traumatic muscle tears:

   • Conservative management with physical therapy is often sufficient 5
   • Surgical repair may be considered for complete tears with significant functional impairment

3. Structural causes:

   • Osteochondromas or other bony abnormalities require surgical resection 6
   • Scapular fractures may need surgical fixation if significantly displaced 1

Rehabilitation Pearls

• Focus on correcting the entire kinetic chain, not just the affected muscle
• Address scapular dyskinesis which can contribute to impingement and rotator cuff injury 1
• Progressive return to activity only after achieving pain-free motion and strength

Prognosis

• Most cases of serratus anterior palsy resolve spontaneously within 24 months
• Trapezius palsy has poorer outcomes with conservative treatment
• Rhomboid palsy may have residual symptoms despite rehabilitation 3
• Surgical interventions for chronic cases show high satisfaction rates when performed by specialized centers 2

Pitfalls to Avoid

• Misdiagnosis: Scapular winging is often misdiagnosed initially
• Delayed referral: Patients should be referred to specialized centers if no improvement is seen
• Overlooking structural causes: Always consider osteochondromas and other bony abnormalities
• Inadequate follow-up: Regular reassessment is necessary to determine if surgical intervention is needed

Remember that early diagnosis and appropriate management are crucial for optimal outcomes in patients with scapular winging.