This chapter presents a condensed overview of the incidence, etiology, presentation, and treatment options for medial and lateral scapular winging. Though relatively rare, undiagnosed scapular winging can have deleterious functional consequences. With timely and proper treatment, good outcomes have been reported.
20 Scapular Winging
I. General overview
Rare entity; incidence largely unknown due to underdiagnosis
Two main types of scapular winging (▶ Fig. 20.1 ):
Medial scapular winging:
Inferior pole of scapula translated medially and posteriorly off chest wall. Large scapular prominence can be seen on inspection.
Lateral scapular winging:
Inferior pole of scapula depressed and laterally shifted.
Caused by a dysfunction of the stabilizing muscles of the scapula, resulting in an imbalance of forces
Serratus anterior palsy as a result of long thoracic nerve injury is most common cause of scapular winging
Clinical symptoms include upper back and shoulder pain, and difficulty with overhead motion:
History of trauma could indicate acute muscular detachment.
Management ultimately guided by etiology of winging. Typically, nonoperative management initially for neuropraxic injuries, followed by surgical treatment if nonoperative management failed. Early surgical repair for acute muscular detachments. Trapezius palsy may benefit from early nerve procedures.
Originates from ribs 1–8
Responsible for scapular protraction, holding medial border of scapula against chest wall
Innervated by long thoracic nerve (C5–C7 nerve roots):
Originates from occiput and spinous processes of C7–T12
Three functional components: superior, middle, and inferior
Innervated by spinal accessory nerve.
Rhomboid major and rhomboid minor:
Rhomboid major originates from T2–T5 and inserts on medial border of scapula; rhomboid minor originates from C7–T1 and inserts on medial border of scapula just superior to rhomboid major insertion
Rhomboids work together with middle portion of trapezius in scapular retraction and medial scapular border elevation
Innervated by dorsal scapular nerve.
Originates from C1–C4 transverse processes and inserts onto medial border of scapula at the level of the scapular spine
Works to elevate scapula and medially rotate its inferior angle
Innervated by C3–C4, and dorsal scapular nerve.
Long thoracic nerve:
Innervates serratus anterior
Arises from anterior rami of C5–C7 nerve roots, running posterior to brachial plexus and axillary vessels
Susceptible to injury by direct trauma or stretch, particularly during sports participation, due to its superficial course
Can be damaged during removal of axillary lymph nodes during breast cancer surgery.
Spinal accessory nerve:
Innervates trapezius and sternocleidomastoid muscles
Cranial nerve XI: Exits skull and courses downward crossing internal jugular vein before sending branches to sternocleidomastoid and trapezius muscles.