Scapular winging is a condition characterized by the abnormal protrusion of the shoulder blade (scapula) from the back of the body. This atypical positioning makes the bone appear wing-like, especially during movement. It signals a disruption in the muscles and nerves responsible for stabilizing the shoulder girdle. When the scapula cannot sit flat against the rib cage, it impairs normal shoulder function, limiting mobility, reducing power, and causing pain. Addressing this issue requires a targeted approach, typically guided by physical therapy, to restore necessary strength and coordination.
Defining Scapular Winging and Its Causes
Scapular winging is categorized into two main types based on the direction of abnormal movement. Medial winging is the most common, occurring when the inner edge of the shoulder blade lifts away from the rib cage. This is linked to weakness or paralysis of the Serratus Anterior muscle, which is supplied by the Long Thoracic Nerve. Injury to this nerve, often resulting from trauma, repetitive strain, or viral illness, is the primary cause of medial winging.
Lateral winging involves the scapula’s lower angle protruding outward and backward, typically due to weakness in the Trapezius or Rhomboid muscles. Trapezius weakness results from damage to the Spinal Accessory Nerve, while Rhomboid weakness is associated with the Dorsal Scapular Nerve. In both types, the underlying issue is the failure of the affected muscle to anchor the scapula securely against the thorax.
Diagnostic Process and Professional Intervention
Seeking professional evaluation from a physical therapist or physician is the first step to confirm the diagnosis and determine the specific cause. The clinician begins with dynamic observation, watching how the scapula moves during various arm actions, such as raising the arm or performing a wall push-up. The wall push-up test is particularly useful for identifying medial winging, as Serratus Anterior weakness is most apparent when pushing against resistance.
The next phase involves manual muscle testing (MMT) to grade the strength of stabilizing muscles, including the Serratus Anterior, Trapezius, and Rhomboids. If nerve injury is suspected, the clinician may recommend advanced testing. Electrodiagnostic studies, such as electromyography (EMG) and Nerve Conduction Studies (NCS), assess the health of the Long Thoracic, Spinal Accessory, and Dorsal Scapular nerves. These tests confirm a neurological cause and guide the prognosis for the tailored physical therapy regimen.
Core Physical Therapy and Strengthening Regimens
The primary treatment is a structured physical therapy program focused on restoring muscle function. This regimen starts with foundational stability and improving postural awareness. Patients learn to consciously position the scapula correctly against the chest wall. Simple exercises, like gentle scapular retractions (squeezes), help activate deep stabilizing muscles without excessive strain.
The next phase introduces targeted strengthening to rebuild muscle power. For medial winging, the Wall Push-Up Plus is foundational for the Serratus Anterior, emphasizing pushing away from the wall until the shoulder blades protract fully. Strengthening the Rhomboids and Trapezius involves exercises like resistance band rows and prone “T” and “Y” raises. These movements require low weight and high repetition to build muscular endurance for long-term stability.
Physical therapy also addresses flexibility and soft tissue restrictions that pull the scapula out of alignment. Muscles on the front of the body, such as the pectorals and anterior deltoids, often become tight and contribute to the problem. Specific stretching exercises lengthen these tight structures, allowing the scapula to sit in a more neutral position. This combined approach re-establishes the proper scapulohumeral rhythm, which is the coordinated movement between the shoulder blade and the arm.
Addressing Severe or Persistent Cases
Most cases of scapular winging caused by nerve issues resolve spontaneously within six to twenty-four months. However, severe or chronic instances may not respond to conservative physical therapy. If a patient shows no functional improvement after this extended period, further medical intervention is necessary. Non-surgical options include custom-fabricated orthotic bracing to provide temporary static stabilization of the scapula.
If nerve recovery is unlikely, surgical procedures restore dynamic shoulder function. Options include nerve decompression or nerve grafting to repair damaged nerves, such as the Long Thoracic Nerve. When the muscle is permanently paralyzed, muscle transfer procedures substitute for lost function; for example, a Pectoralis Major transfer replaces a paralyzed Serratus Anterior. In rare, chronic cases, a scapulothoracic arthrodesis may be considered, which surgically fuses the scapula to the ribs or vertebrae for permanent static stability.