What is the recommended evaluation and management for a patient with a painful, more prominent right scapula suggestive of scapular winging?

Evaluation and Management of Painful Scapular Prominence Suggestive of Scapular Winging

Begin with plain radiographs (AP, lateral, and scapular Y views) to rule out fracture or bony pathology, followed by clinical examination to identify the specific nerve palsy pattern, then proceed to MRI if structural lesions are suspected or electromyography (EMG) to confirm nerve injury. 1

Initial Diagnostic Approach

Radiographic Evaluation

• Obtain standard shoulder radiographs first including anteroposterior views in internal and external rotation plus an axillary or scapular Y view to exclude fracture, tumor, or other bony abnormalities that could cause scapular prominence 1
• Radiography is the preferred initial screening modality for acute shoulder pain and effectively demonstrates many forms of shoulder pathology 1
• The scapula's complex osteology and overlying ribs can obscure pathology on conventional radiography, so multiple views are essential 1

Clinical Examination Specifics

• Identify the winging pattern: Medial border prominence suggests serratus anterior weakness (long thoracic nerve palsy), while superior/lateral prominence suggests trapezius weakness (spinal accessory nerve palsy) 2, 3
• Assess active forward flexion and external rotation range of motion, as these are significantly impaired in scapular winging 4
• Evaluate for associated shoulder weakness and pain severity using standardized measures 4
• Look for asymmetric scapular position at rest and abnormal scapular motion during arm elevation 5

Advanced Imaging Indications

When to Order MRI

• MRI without contrast is indicated if radiographs are normal but you suspect a structural cause such as soft tissue tumor (lipoma in subscapularis muscle can cause scapular malposition), rotator cuff pathology, or other soft tissue abnormalities 5
• MRI provides superior soft tissue contrast and can identify masses on the ventral surface of the scapula that may cause abnormal scapular positioning 5

When to Order EMG/Nerve Conduction Studies

• Obtain EMG confirmation when clinical examination suggests nerve palsy to definitively identify long thoracic nerve or spinal accessory nerve injury before proceeding with treatment 4
• EMG is essential for confirming the diagnosis and guiding treatment decisions, particularly if surgical intervention is being considered 4

Management Algorithm

Conservative Management (First-Line)

• Most cases resolve with nonsurgical management and should be attempted for at least 6-12 months before considering surgery 3
• Physical therapy focusing on scapular stabilization exercises and pain control 3
• This approach is appropriate for the majority of patients with scapular winging 3

Surgical Intervention Criteria

• Consider surgery only after persistent symptoms despite adequate nonsurgical management (typically 6-12 months of conservative treatment) 3
• Pectoralis major tendon transfer is effective for chronic long thoracic nerve palsy, improving pain (VAS from 7.7 to 3.0), function (ASES score from 28 to 67), and range of motion (forward flexion from 112° to 149°) 4
• Combined muscle transfers (pectoralis major for serratus anterior, plus levator scapulae and rhomboid transfers for trapezius) are needed when both long thoracic and spinal accessory nerves are affected 6

Critical Pitfalls to Avoid

• Do not miss posterior shoulder dislocation: Axillary or scapular Y views are vital as dislocations are routinely misclassified on AP views alone 7
• Do not overlook soft tissue tumors: Lipomas in the subscapularis muscle have been reported as a rare but treatable cause of scapular malposition 5
• Do not delay EMG confirmation: Electromyographic confirmation is essential before committing to surgical intervention for presumed nerve palsy 4
• Do not rush to surgery: Early diagnosis followed by conservative management is important, as most cases resolve without surgery 3
• Do not assume single nerve involvement: Combined palsy of spinal accessory and long thoracic nerves can occur, with secondary traction injury to the long thoracic nerve from the unsupported scapula 6