From the Guidelines
Scapular winging in a healthy 18-year-old boy with cervicogenic discomfort is most likely due to serratus anterior weakness, typically caused by long thoracic nerve dysfunction, and initial workup should include a thorough physical examination and cervical spine examination to evaluate for cervical pathology contributing to nerve compression. The etiology of scapular winging can be attributed to various factors, including mechanical pain associated with facet joints, intervertebral discs, muscles, or fascia, as well as neuropathic pain from a herniated disc or osteophyte 1. Key points to consider in the workup include:
- A thorough physical examination focusing on scapular movement during arm elevation and wall push-ups to assess for medial scapular border prominence
- Cervical spine examination to evaluate for cervical pathology contributing to nerve compression
- Ordering cervical spine X-rays to rule out structural abnormalities
- Considering electromyography (EMG) and nerve conduction studies to confirm nerve involvement, as neuropathic symptoms should be clarified by examination to exclude myelopathy or plexopathy 1 Initial management includes:
- Physical therapy focusing on scapular stabilization exercises 3 times weekly for 6-8 weeks, including serratus anterior strengthening (wall slides, push-up plus), trapezius strengthening, and postural correction
- Anti-inflammatory medications like ibuprofen 400-600mg three times daily with food for 1-2 weeks may help reduce inflammation Most cases resolve with conservative management within 3-6 months, but persistent symptoms beyond 6 months may require orthopedic or neurology consultation, and it is essential to consider the patient’s medical history to accurately guide imaging 1.
From the Research
Etiology of Scapular Winging
- Scapular winging is a rare and debilitating disorder that can result from various underlying etiologies, including injuries to the long thoracic nerve or spinal accessory nerve, leading to neuromuscular imbalance in the scapulothoracic stabilizing muscles 2, 3, 4.
- The condition can also be caused by traumatic, iatrogenic, and idiopathic processes that result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles 3.
- Structural causes, such as osteochondroma, can also contribute to scapular winging, although they are not frequently considered in the differential diagnosis 5.
Workup for Scapular Winging
- Diagnosis of scapular winging can be made through visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula, and trapezius and rhomboid paralysis resulting in lateral winging 3.
- A comprehensive physical examination, including appreciation of scapulothoracic anatomy, is essential for accurate diagnosis and detection 4.
- Electromyography and nerve conduction studies can also be used to aid in diagnosis 6.
- A thorough patient history and physical examination of the scapula and associated studies are necessary to make the correct diagnosis of scapular winging and avoid misdiagnosis with other shoulder or spine abnormalities 6.
Considerations for Cervicogenic Discomfort
- Scapular winging can present with diffuse neck, shoulder girdle, and upper back pain, which may be debilitating and associated with abduction and overhead activities 4.
- Cervicogenic discomfort can be a contributing factor to scapular winging, and a thorough evaluation of the cervical spine and surrounding structures is necessary to determine the underlying cause of the condition 6.