Scapular winging, often called a winged scapula, is a condition where the shoulder blade protrudes noticeably from the back instead of lying flat against the chest wall. This abnormal posture can cause pain, weakness, and significant difficulty with common activities like lifting the arm or wearing a backpack. Fortunately, for the majority of people experiencing this issue, correction and substantial functional improvement are achievable through targeted medical intervention.
Identifying the Underlying Cause
The first step toward fixing scapular winging involves precisely determining what caused the muscular dysfunction. Scapular winging is nearly always a result of nerve damage, which leads to paralysis or weakness in the muscles that stabilize the shoulder blade.
Medial winging, the most common type, is caused by damage to the long thoracic nerve, which supplies the serratus anterior muscle. This muscle is responsible for keeping the shoulder blade anchored to the rib cage, and its failure causes the inner edge of the scapula to stick out, especially when pushing the arm forward.
Lateral winging is less common and results from injury to the spinal accessory nerve or the dorsal scapular nerve. The spinal accessory nerve controls the trapezius muscle, while the dorsal scapular nerve controls the rhomboid muscles.
Injuries to these nerves can occur from blunt trauma, repetitive motion, or surgical procedures near the shoulder or neck. Non-traumatic causes include viral illnesses or various inflammatory conditions. Identifying the specific nerve injury, often through electrodiagnostic studies like electromyography, guides the entire treatment plan.
Non-Surgical Correction Methods
Conservative management is the initial and most successful treatment, especially when the nerve damage is not severe or the injury is recent. Physical therapy aims to restore strength and proper movement patterns to the shoulder complex.
Physical therapy begins with targeted exercises designed to re-activate the weakened muscles, such as the serratus anterior and lower trapezius. For serratus anterior dysfunction, exercises like the “push-up plus” and wall slides are used to specifically train the muscle to protract and stabilize the scapula against the rib cage. These movements teach the brain how to properly engage the stabilizing muscles.
Manual therapy techniques, including soft tissue mobilization and joint manipulation, may be used to address surrounding muscular tightness and improve overall shoulder mechanics. Posture correction is also a focus, as poor posture can exacerbate the winging and place undue strain on the recovering nerves and muscles. Temporary external supports, such as specialized braces or kinesiology tape, can be used to help hold the scapula in a more stable position during the early phases of recovery, reducing strain and pain. For cases of nerve damage, observation and physical therapy are typically continued for at least six months, allowing the nerve time to regenerate and heal spontaneously.
When Surgery Becomes Necessary
Surgical intervention is typically reserved for cases where conservative treatment has failed to restore function after six to twelve months, or for severe injuries like nerve lacerations. The choice of procedure depends on the specific nerve injured and the severity of the muscle paralysis.
Nerve decompression involves releasing pressure on the nerve by removing scar tissue or adjacent structures. If the nerve is damaged but capable of repair, a nerve graft or nerve transfer procedure may be performed to bridge the gap or reroute a healthy nerve to the paralyzed muscle.
When nerve recovery is unlikely, the primary surgical approach is a muscle transfer, which replaces the function of the paralyzed muscle with a nearby working muscle. For serratus anterior palsy, a common technique is the split pectoralis major transfer, where a portion of the chest muscle is detached and rerouted to the scapula to provide dynamic stabilization. For trapezius palsy, the Eden-Lange procedure is often used, which transfers other upper back muscles, such as the rhomboids, to reconstruct the trapezius’s function.
A more drastic measure, scapulothoracic fusion, involves attaching the scapula directly to the ribs using hardware. This procedure is considered a last resort, typically for chronic, severe cases that have failed other treatments, as it sacrifices some shoulder range of motion for static stability.
Recovery Expectations and Prognosis
Recovery is highly variable, depending on the underlying cause and extent of nerve damage. For non-surgical cases involving nerve injury, recovery can be a slow process, often taking anywhere from six months to two years for the nerve to fully regenerate and for muscle strength to return.
Younger patients and those whose winging is caused by non-traumatic factors, such as a viral illness, generally have a better prognosis for spontaneous recovery. Functional improvement is often achieved sooner than full anatomical correction, meaning the shoulder may work well even if a slight protrusion remains.
Following muscle transfer surgery, patients usually recover the ability to perform daily activities within six months, with full strength and functional recovery continuing for up to a year. Full pre-injury performance is not always guaranteed, especially in chronic cases where muscle atrophy has occurred. Consistent adherence to the rehabilitation program remains the most significant factor influencing a successful long-term outcome.