What is the diagnosis and treatment for winging of the scapula?

Scapular Winging: Diagnosis and Treatment

Scapular winging requires physical therapy focused on strengthening the rotator cuff and scapular stabilizers as first-line treatment, with surgical intervention reserved for cases without spontaneous recovery after 6-24 months of conservative management. 1

Diagnosis

Clinical Examination

• Observe the scapula during arm elevation to identify abnormal movement patterns—the scapula should normally rotate upward and tilt posteriorly during this motion 1
• Distinguish between medial winging (caused by serratus anterior paralysis) versus lateral winging (caused by trapezius or rhomboid paralysis), as this determines the underlying nerve injury 2
• Assess for coexisting rotator cuff weakness, which frequently accompanies scapular winging 1
• In patients with head and neck cancer treatment history, specifically evaluate for spinal accessory nerve injury 1

Diagnostic Studies

• Plain radiographs should be obtained initially to exclude structural causes such as osteochondroma or scapular fractures 3
• CT imaging is indicated when scapular fractures are suspected based on clinical presentation or radiographic findings 1
• MRI should be performed to evaluate associated rotator cuff pathology or other soft tissue abnormalities 1
• Electroneuromyography helps confirm nerve injury and differentiate between serratus anterior, trapezius, or rhomboid muscle involvement 4

Treatment Approach

Conservative Management (First-Line)

• Initiate physical therapy emphasizing strengthening of the rotator cuff and scapular stabilizers 1
• Focus on restoring proper shoulder mechanics and spine positioning 1
• Include range of motion exercises to prevent adhesive capsulitis 1
• For serratus anterior weakness specifically, perform wall push-ups with emphasis on scapular protraction 1
• Continue conservative treatment for 6-24 months to allow time for spontaneous recovery, particularly in serratus anterior paralysis where most cases resolve within 24 months 2

Surgical Intervention

Surgery is indicated when conservative treatment fails after 6-24 months or when nerve procedures are no longer feasible. 4

For Serratus Anterior Palsy:

• Acute cases: Consider nerve surgery including neurolysis, nerve transfers, or nerve grafts 4
• Chronic cases: Perform tendon transfers using the sternal or clavicular head of the pectoralis major, which produces excellent results with high patient satisfaction 4

For Trapezius Palsy:

• Conservative treatment is less effective than for serratus anterior paralysis 2
• Surgical option: Elhassan triple transfer using the levator scapulae, rhomboid minor, and rhomboid major muscles 1, 4

For Rhomboid Paralysis:

• Conservative treatment is typically followed, as surgical intervention is less commonly required 2

Important Clinical Pitfalls

• Do not miss trapezius palsy, which is frequently overlooked but requires different management than serratus anterior paralysis 4
• Consider neuromuscular diseases such as limb-girdle muscular dystrophy in the differential diagnosis, as these may present with scapular winging 1
• Structural causes like osteochondroma must be excluded with imaging, as they require surgical resection rather than conservative management 3
• Refer patients to specialized centers immediately if spontaneous recovery does not occur, as appropriate surgical timing is critical for optimal outcomes 4