Curr Rev Musculoskelet Med (2008) 1:111

DOI 10.1007/s12178-007-9000-5

Scapular winging: anatomical review, diagnosis, and treatments

Ryan M. Martin David E. Fish

Published online: 2 November 2007

Humana Press 2007

Abstract Scapular winging is a rare debilitating condi- living, such as brushing ones hair and teeth and carrying
tion that leads to limited functional activity of the upper grocery bags [1]. Cosmetically, some patients may be
extremity. It is the result of numerous causes, including distressed by pronounced winging [2]. Disrupting scapu-
traumatic, iatrogenic, and idiopathic processes that most lohumeral rhythm, scapular winging contributes to loss of
often result in nerve injury and paralysis of either the power and limited flexion and abduction of the upper
serratus anterior, trapezius, or rhomboid muscles. Diagno- extremity and can be a source of considerable pain [38]. A
sis is easily made upon visible inspection of the scapula, condition due to a number of etiologies, most cases are due
with serratus anterior paralysis resulting in medial winging to lesions of the long thoracic and spinal accessory nerves
of the scapula. This is in contrast to the lateral winging that innervate the serratus anterior and trapezius muscles,
generated by trapezius and rhomboid paralysis. Most cases respectively. Rarely, it may also be due to a lesion to the
of serratus anterior paralysis spontaneously resolve within dorsal scapular nerve that innervates the rhomboid mus-
24 months, while conservative treatment of trapezius cles. These scapular muscles (Fig. 1) contribute to keeping
paralysis is less effective. A conservative course of treat- the medial border of the scapula protracted against the
ment is usually followed for rhomboid paralysis. To allow posterior thoracic wall, and denervation or paralysis of any
time for spontaneous recovery, a 624 month course of of these muscles results in the winging of the medial border
conservative treatment is often recommended, after which of the scapula as it lifts off the thoracic wall. In addition,
if there is no recovery, patients become candidates for the scapula may translate medially or laterally along the
corrective surgery. posterior thoracic wall due to unopposed muscle contrac-
tion of the other functioning scapular muscles, a distinction
Keywords Scapular winging
Serratus anterior
known as medial (serratus anterior paralysis) or lateral
Trapezius
Rhomboid
Long thoracic nerve (trapezius or rhomboid paralysis) winging (Table 1).
Scapular winging may present in a variety of clinical
contexts, and may be due to traumatic- or sports-related
Introduction injury [2, 4, 5, 822], iatrogenic injury [1, 2, 12, 15, 16, 19,
2327], or spontaneous in nature [68, 11, 2730]. Here we
Scapular winging is a rare, but potentially debilitating discuss incidence and demographics, pertinent anatomy,
condition that can affect the ability to lift, pull, and push the nature of the injury, diagnostic tests, and treatment
heavy objects, as well as to perform daily activities of options for scapular winging due to serratus anterior,
trapezius, and rhomboid muscle paralysis.

R. M. Martin
D. E. Fish (&)

Department of Orthopaedics, Physical Medicine and Incidence/Demographics
Rehabilitation, David Geffen School of Medicine at UCLA,
1250, 16th St, 7th Floor, Tower Bld, Rm 745, Santa Monica, CA
90404, USA Scapular winging due to serratus anterior palsy is a rare
e-mail: dfish@mednet.ucla.edu lesion. Fardin et al. [29] reported an incidence of 15 cases
2 Curr Rev Musculoskelet Med (2008) 1:111

Fig. 1 Anatomical relationship

of the serratus anterior,
trapezius, and rhomboid
muscles around the scapula,
with the rhomboids just deep to
the trapezius. Modified from
Ref. [44, p. 52, Fig. 2.43]

Table 1 Neurogenic causes of scapular winging and the physical exam

Medial winging Lateral winging

Injured nerve Long thoracic Spinal accessory Dorsal scapular

Muscle palsy Serratus anterior Trapezius Rhomboids
Physical exam Arm flexion; push-up Arm abduction; external Arm extension from
motion against a wall rotation against resistance full flexion
Position of the scapula Entire scapula displaced more Superior angle more Inferior angle more laterally
compared to normal medial and superior laterally displaced displaced

in 7,000 patients seen in their electromyographical labo- surgery has led to newer techniques that have reduced the
ratory. Overpeck and Ghormley [31] found only one case incidence of trapezius palsy since its peak in the 1950s [7].
of serratus anterior paralysis in 38,500 patients observed at There are no published reports in the English language
the Mayo Clinic, while Remak [32] diagnosed three cases literature stating the incidence of scapular winging due to
of serratus anterior paralysis in a series of 12,000 neuro- rhomboid paralysis. Indeed, there are only anecdotal
logical examinations. Gregg et al. [4] claims serratus statements describing rhomboid paralysis as rare and its
anterior paralysis to be a fairly common entity, functional effects as even rarer [33, 34].
observing 10 cases in 3 years amongst the practice of 20 Paralysis of the serratus anterior muscle has been well
orthopedists in the University of Pennsylvania hospital documented amongst professional and amateur athletes of
system, although no rate of incidence could be established a variety of sports, including archery, ballet, baseball,
as the total number of patients examined was not reported. basketball, body building/weight lifting, bowling, football,
Incidence of scapular winging due to trapezius paralysis is golf, gymnastics, hockey, soccer, tennis, and wrestling [4,
rare and difficult to assess. Awareness of the possibility of 6, 11, 13, 28, 35, 36]. Athletic injuries have also been
iatrogenic injury to the spinal accessory nerve during neck attributable to trapezius [7, 37] and rhomboid paralysis [20,
Curr Rev Musculoskelet Med (2008) 1:111 3

21, 38, 39]. Occupational injuries causing serratus anterior

paralysis have been reported in the literature in individuals
working as car mechanics, navy airmen, scaffolders,
welders, carpenters, laborers, and a seamstress [11, 4043].

Pertinent anatomy and biomechanics

Serratus anterior

The serratus anterior is a broad flattened sheet of muscle

originating from the first nine ribs and passes posteriorly
around the thoracic wall before inserting into the costal
surface of the medial border of the scapula [44]. The ser-
ratus anterior has three functional components [4, 8]. The
superior component originates from the first and second
ribs and inserts into the superior medial angle of the
scapula [4, 8]. This component serves as the anchor that
allows the scapula to rotate when the arm is lifted overhead
[4]. The middle component of the serratus anterior origi-
nates from the third, fourth, and fifth ribs and inserts on the
vertebral border of the scapula, serving to protract the
scapula [4, 8]. The inferior component originates from the Fig. 2 Course of the long thoracic nerve to its innervations of the
sixth to ninth ribs and inserts on the inferior angle of the serratus anterior muscle. Proposed vulnerable sites for injury include
scapula [4, 8]. This third portion serves to protract the compression of the nerve between the clavicle and first rib and
traction within the nerves fascial sheath [72, Fig. 1]
scapula and rotate the inferior angle upward and laterally
[4]. As a whole, the main function of the serratus anterior is
to protract and rotate the scapula, keeping it closely [7, 44]. The primary insertion is along the spine of the
opposed to the thoracic wall and optimizing the position of scapula [7, 44]. Separated into three components, the
the glenoid for maximum efficiency for upper extremity superior portion elevates the scapula and rotates the lateral
motion [4, 8, 44]. angle upwardly, the middle portion adducts and retracts,
The serratus anterior is solely innervated by the long and the inferior portion depresses the scapula and rotates
thoracic nerve, originating from the anterior rami of the the inferior angle laterally [7, 12]. The trapezius is solely
fifth, sixth, and seventh cervical nerves [4, 8, 44]. Branches innervated by the spinal accessory nerve, or cranial nerve
from the fifth and sixth cervical nerves pass anteriorly XI, which crosses the posterior cervical triangle superfi-
through the scalenus medius muscle before joining the cially before diving vertically along the deep surface of the
seventh cervical nerve branch that coursed anteriorly to the trapezius [7, 44].
scalenus medius [4, 8, 45]. The long thoracic nerve then
dives deep to the brachial plexus and the clavicle to pass
over the first rib [4, 8]. Here, the nerve enters a fascial Rhomboids
sheath [45, 46] and continues to descend along the lateral
aspect of the thoracic wall to innervate the serratus anterior Just deep to the trapezius, the two rhomboid muscles work
muscle (Fig. 2) [4, 8]. An average of 24 cm in length [27], together to retract and elevate the scapula and rotate its
it is this long and winding course that is postulated to make lateral border downward [5, 22, 44, 47, 48]. The smaller
the nerve susceptible to mechanical injury. rhomboid minor is a cyndrical muscle that finds its origin
in the ligamentum nuchae of the neck and the spinous
processes of the seventh cervical and first thoracic verte-
Trapezius brae [44, 47]. It projects downward and laterally to the
medial border of the scapula at the base of the scapular
The trapezius muscle, like the serratus anterior, serves to spine [44, 47]. The larger and more inferior rhomboid
elevate, retract, and rotate the scapula [7]. The muscle major originates from the spinous processes of the second
originates from the skull and the spinous processes of the through fifth thoracic vertebrae and inserts on the medial
first cervical vertebra through the 12th thoracic vertebra border of the scapula, from the insertion of the rhomboid
4 Curr Rev Musculoskelet Med (2008) 1:111

minor to the inferior angle of the scapula [44, 47]. Both conduction through the long thoracic nerve [32]. This
rhomboid muscles are innervated by the dorsal scapular hypothesis is unlikely, though, as the nerve to the unaf-
nerve, with its fibers predominantly derived from the C5 fected rhomboids also passes through the scalenus medius
nerve root with minor contributions from C4 or C6 [22, 44, muscle and the seventh cervical branch passes anterior to
49, 50]. Like some of the fibers of the long thoracic nerve, the muscle, bypassing the proposed causative spasm [4, 9,
the dorsal scapular nerve penetrates the scalenus medius 11]. Later, Gregg et al. [4] purposed a traction injury to the
muscle, before heading to the levator scapulae, giving off long thoracic nerve, showing in a cadaver study that they
innervating fibers to the muscle [44, 49]. The nerve then could double the length of the nerve by rotating, flexing,
may pass deep to or pierce the levator scapulae muscle and tilting the head laterally away from the involved
before diving under the brachial plexus and running to the shoulder and then raising the ipsilateral arm overhead.
anterior surface of the rhomboid muscles [22, 34, 44, 49]. They hypothesized that sudden or recurrent irritating trac-
tion force may cause serratus anterior paralysis. Foo and
Swan [11] were not convinced, though, citing that since the
Etiology nerve is long, it must be capable of a reasonable amount of
stretch, supported by the fact that traction injuries to the
Serratus anterior palsy brachial plexus are not always accompanied by long tho-
racic nerve injury. Gozna and Harris [9] showed in their
The commonest cause of scapular winging is serratus cadaver study that a forceful downward pull on the arm
anterior paralysis, a dysfunction attributed to traumatic could pinch the nerve between the second rib and the
[2, 4, 8, 9, 11], non-traumatic [6, 8, 11, 28, 41, 5153], scapula and concluded this to be the site of traumatic palsy
and idiopathic [6, 8, 11, 2830] lesions of the long of the serratus anterior. However, there is evidence that
thoracic nerve. Reported causes of non-traumatic injury under such extreme force, damage to the long thoracic
to the long thoracic nerve include viral illness (influenza nerve should be accompanied by damage to the brachial
[11]; tonsillitis-bronchitis [6, 28]; poliomyelitis [6]), plexus and axillary vessels as well [4]. More recent work
allergic-drug reactions [28], drug overdose [11], toxic on cadavers suggests that injury may take place as the
exposure (herbicides and tetanus antitoxin [28]), muscu- nerve exits the fascial sheath that encompasses it, either in
lar dystrophy-fascioscapulohumeral dystrophy [41, 54 the form of a traction injury [46] or in a bow-stringing
56], C7 radiculopathy [52], and aortic coarctation [6]. effect [45].
Most trauma-induced long thoracic nerve injury are
neurapraxias as a result of blunt trauma [4, 8, 9, 11], such
as sudden depression of the shoulder girdle [9] or unusual Trapezius palsy
twisting of the neck and shoulder [4]. Trauma may also be
due to repetitive movements, as seen in athletics [4, 13] and Paralysis to the trapezius muscle, like serratus anterior
house-hold activities such as hedge-clipping [11], digging paralysis, is primarily neurogenic, but from injuries to the
[11], car washing [57], or prolonged lying in bed with the spinal accessory nerve. The superficial course of the nerve
arms abducted and propping up the head to read [7]. In makes it susceptible to closed traction lesions in assault
addition, long thoracic nerve palsy may be due to direct cases [16], motor vehicle accidents [12, 15], and direct
mechanical pressure by an inflamed and enlarged subcor- trauma to the posterior cervical region [15]. Other direct
acoid or subscapular bursa along the pathway of the nerve traumas to the spinal accessory nerve include heavy lift-
[58]. Long thoracic nerve injury may also be iatrogenic as ing [14, 60], biting to the posterior cervical triangle [10],
consequence of chiropractic manipulation [26], the use of a penetrating wounds to the area [14, 17, 19], and other
single axillary crutch [59], mastectomies with axillary node forms of blunt trauma to the posterior cervical triangle
dissection [1, 25], scalenotomies [1], surgical treatment of [12, 14, 15]. By far, the most common cause of spinal
spontaneous pneumothorax [1], and post-general anesthesia accessory nerve palsy is iatrogenic, primarily sustained
for various clinical reasons [1, 2]. Electrical shock may during surgeries for cervical lymph node biopsy [14, 16,
also cause long thoracic nerve palsy [40]. 19, 27] and cervical mass excision [12, 1416, 24, 27]. In
Although the association between serratus anterior a series of 83 consecutive patients with accessory nerve
paralysis and trauma is well established, there is no con- injury, Donner and Kline [14] reported 71% of cases to be
sensus of exactly how trauma injures the long thoracic iatrogenic and 24% of cases to be trauma related. In a
nerve. Initial hypotheses were linked to the observation that similar study, Williams et al. [16] reported 58% of 43
the fifth and sixth cervical branches of the long thoracic patients with accessory nerve injury to be iatrogenic.
nerve pass through the substance of the scalenus medius Spontaneous or idiopathic trapezius paralysis has also
muscle, suggesting that spasms of this muscle could block been reported [7, 27].
Curr Rev Musculoskelet Med (2008) 1:111 5

Rhomboid palsy middle and posterior deltoid, and acromegalic arthropathy

of the shoulder [4, 5, 62].
Similarly, rhomboid paralysis tends to be primarily neu-
rogenic in nature, involving the dorsal scapular nerve. An
entrapment injury is the most common cause of injury Clinical picture and diagnosis
reported in the literature [22, 39, 48, 49], although the site
of entrapment is not well known. Unlike the long thoracic History
nerve, there is some strong evidence that the dorsal
scapular nerve can become entrapped in the scalenus Purported by Wiater and Bigliani [7] and Wiater and Flatow
medius muscle as some have suggested [22, 48, 49]. De- [8], the physician evaluation should include a detailed his-
song et al. [49] reported very high rates of symptom tory including questions regarding hand dominance,
resolution after decompressing the dorsal scapular nerve occupation, hobbies, and current and previous level of
by transecting the scalenus anterior and medius muscles function, answers to which will dictate the use of conserva-
and suggested that dorsal scapular entrapment is simply an tive or surgical treatment. In cases of traumatic etiology, the
atypical presentation of thoracic outlet syndrome. Similar exact mechanism of injury should be elucidated, along with a
findings have not been reported elsewhere. Ravindran et history of surgery of the neck, shoulder, thorax, or axilla, and
al. [39] reported an unusual case of suprascapular and recent illness and immunizations [7, 8]. Key features of the
dorsal scapular nerve entrapment in two siblings, both of physical exam relating to winging due to serratus anterior,
whom were competitive volleyball players who developed trapezius, or rhomboid palsy is outlined in Table 1.
identical symptoms in their dominant shoulder. There were
six other siblings who did not play volleyball and did
not have the condition, leading Ravindran et al. to suggest Serratus anterior palsy
a familial anatomical peculiarity predisposing toward
nerve entrapment. However, no site of entrapment was The typical patient suffering from serratus anterior palsy
suggested. will present with pain around the affected shoulder (usually
In addition to entrapment syndromes, direct injury to the the right side), which either arises spontaneously or linked
nerve has been reported to cause rhomboid paralysis. Saeed to some traumatic event [4, 11]. This pain may radiate
et al. [5] reported a case of an individual who developed down the arm and to the scapula [3]. Pain in the shoulder is
shoulder pain and weakness several days after a motor usually localized to the rhomboid and levator scapulae
vehicle accident, most likely due to a severe C5 root lesion muscles due to spasm secondary to unopposed contraction
or avulsion. In addition, anterior shoulder dislocation can in the absence of serratus anterior tone [8]. In addition,
also cause direct injury to the dorsal scapular nerve, as patients will typically complain of shoulder weakness [8],
reported in a Judo player who developed extreme insta- while athletes may complain of reduced performance [4].
bility of the glenohumeral joint, resulting in six Severe pain should raise suspicion of a neuritis, such as
dislocations in 2 weeks [21]. A C5 radiculopathy has also ParsonageTurner syndrome [8]. In one series of 14
been suggested as a causative factor [34]. Finally, muscle patients with traumatic lesions, pain was localized to the
injury during overhead athletics has been implicated as lower pole of the scapula immediately after injury and was
well, as the deceleration of the scapula during the follow- described as having a burning quality [9]. The authors of
through motion of a pitcher or volleyball player can strain that study consider this to be a strong diagnostic clue and
and injure the rhomboids [20]. advocate asking all patients with shoulder weakness after
sustaining an injury specifically if they have such a burning
pain. Typically, the pain usually resolves spontaneously
Other etiologies over the next several weeks, but the patient is left with a
winged scapula that is noticed by others or is occasionally
Although primarily due to serratus anterior palsy, and less felt while sitting in a chair [4, 11].
frequently trapezius and rhomboid palsy, these are not the Upon physical examination, classical or medial scapular
only conditions that present with scapular winging. winging is usually evident at rest, with the medial and
Rhomboid and trapezius muscle rupture [61] and other inferior borders closer to the spine and lifted superiorly
direct injuries to scapulothoracic muscles [62] can also when compared to the normal side [4, 63]. Scapular winging
cause scapular winging. Structural abnormalities can also can be accentuated when the patient is asked to forward flex
present similarly and include rotator cuff pathology, his arms to the horizontal (Fig. 3) and/or push on a wall in a
shoulder instability, mal-united acromial fractures, aseptic push-up motion [4, 8, 63]. In this position, the vertebral
necrosis of the humeral head, fibrotic shortening of the border of the scapula lifts further from the thoracic wall due
6 Curr Rev Musculoskelet Med (2008) 1:111

and upon prolonged exertion [7, 15]. Pain can be quite

debilitating and can be the result of the strain and spasm of
overcompensating periscapular muscles [7, 12, 15].
Patients may complain of a dull ache and heaviness around
the shoulder [12, 15] and may describe the feeling as
having a brick on the shoulder [15]. Trapezius paralysis
and subsequent deficient rotation of the scapula may also
cause pain associated with subacromioclavicular impinge-
ment [7, 12, 15]. Consistently, patients are limited in all
overhead activities [7, 12, 15].
Physical examination elicits an asymmetrical neckline
with drooping of the effected shoulder. This may be
accompanied with lateral displacement and winging of the
scapula [12, 15, 16]. Typically, winging is minimal and is
accentuated during arm abduction, with the scapula moving
Fig. 3 Winging of the right scapula due to serratus anterior palsy, upwards with the superior angle more lateral to the midline
accentuated by active flexion of the arms. In addition to the medial than the inferior angle [5]. Winging may disappear during
border lifting off the posterior thoracic wall, note the medial and forward flexion of the arm due to the action of the serratus
superior translation of the right scapula when compared to the normal
left side [83, Fig. A]
anterior muscle [5]. Difficulty in abducting the arm is a
consistent finding, and in one series of patients, the
majority could only abduct to 8090 [16]. Chan et al. [64]
to the loss of serratus anterior scapular protraction. Gregg suggest an additional test for accessory nerve palsy,
et al. [4] point out that prominent scapular winging may not requiring the patient to externally rotate the shoulder
be evident until several weeks after an acute lesion in order against a force provided by the examiners hand. Any
for the trapezius to stretch out far enough. In addition, medial winging of the scapula is indicative of accessory
because the scapula cannot be stabilized against the thorax, nerve palsy (Fig. 4).
forward flexion of the arm past the horizontal may be limited Identification of trapezius palsy is not straight forward,
or impossible [4, 8, 63]. In a series of 14 patients suffering and like serratus anterior paralysis, is easily misdiagnosed.
from painful scapular winging, Warner and Navarro [63] Wiater and Bigliani [7] summarize conditions with signs
found that none of the patients could flex their shoulder and symptoms that are similar to trapezius palsy and
above 120, with an average forward flexion of 97. Gregg include paralysis of the rhomboid and serratus anterior
et al. [4] found that patients with complete serratus anterior muscles, herniated nucleus pulposus, scoliosis, progressive
paralysis could not abduct their arms beyond 110. Repro- neuromuscular disease, scapular osteochondroma, fracture
ducibly, manual stabilization of the scapula against the mal-union, stroke, herpes zoster infection, and
thorax by the physician can alleviate shoulder discomfort
and can allow for shoulder flexion above 150 [63].
As summarized nicely by Wiater and Flatow [8], more
common diseases may mimic serratus anterior palsy and
lead to initial misdiagnosis. They cite examples of rotator
cuff tear, fracture malunion, trapezius palsy, glenohumeral
instability, impingement, acromioclavicular joint disease,
biceps tendonitis, neurologic disorders, suprascapular
nerve entrapment, scoliosis, and scapular osteochondroma.
In previous reports, such misdiagnoses have led to 17
surgical procedures to be performed on five patients
without improvement of symptoms [63] and a diagnostic
delay in 10 of 14 patients [9].

Trapezius palsy
Fig. 4 A patient with pronounced winging of the left scapula during
active external rotation against resistance, typical of trapezius palsy.
Typical presentation includes stiffness, pain, and weakness Note the lateral displacement of the scapula with the superior angle
of the shoulder girdle, especially with overhead activity more lateral to the midline than the inferior angle [64, Fig. 4A]
Curr Rev Musculoskelet Med (2008) 1:111 7

glenohumeral instability. Other misdiagnoses include tho- shows resting denervation potentials, decreased motor unit
racic outlet syndrome, subacromial impingement, and pain recruitment and polyphasic motor unit potentials during
about the shoulder [15]. volitional activity [4, 5, 13, 21, 22, 26, 28, 29, 34, 35, 37,
39, 40, 42, 43, 48, 53, 59, 65, 66]. Although diagnostically
helpful in determining muscle involvement and detecting
Rhomboid palsy improvement and reinnervation, the initial degree of
denervation cannot be used to predict the extent of recov-
The typical patient will present with pain down the medial ery [28, 66]. Improvement over time on serial
aspect of the scapula [5, 34, 65], with pain sometimes electromyographic examination may [35] or may not [66]
radiating down the arm to the C5 and C6 dermatomes [48, correlate with clinical outcome. Nerve conduction studies
49, 65]. The patient may also suggest a feeling of abnormal of the long thoracic nerve may also be helpful in deter-
shoulder motion [22] or traction [49] when raising the mining the severity of the lesion [30, 67].
effected arm. In the only published cohort of patients with Plain radiographs of the neck, chest, shoulder, and
dorsal scapular nerve palsy, Desong et al. [49] reported thoracic inlet are rarely diagnostic, but should be obtained
discomfort of the neck, back, and shoulder to be the main to rule out structural abnormalities such as mal-united or
complaint of 36 patients. In addition, neck pain was often greenstick fractures [7, 8, 11, 61, 68]. Computed tomog-
aggravated by changes in the weather, and insomnia was raphy (CT) and magnetic resonant imaging (MRI) are
common due to shoulder discomfort [49]. Symptoms were rarely needed, but may be useful to rule out other diag-
unilateral in 34 of 36 patients, and there was a prepon- noses, such as neurofibromatous-related injury [37], disk
derance of females, 28 in all [49]. disease and radiculopathy [52], and mass lesions [7, 8].
Upon examination, rhomboid palsy produces a very
subtle winging of the scapula, with the scapula laterally
translated and the inferior angle rotated laterally [5, 34, Treatment
38]. Winging may be accentuated by having the patient
extend his or her arm from a fully flexed position, during Serratus anterior palsy
which the inferior angle of the scapula is pulled laterally
and dorsally off the thoracic wall [5, 34]. If allowed to Isolated serratus anterior palsy responds well to conserva-
progress, atrophy of the rhomboids may be evident [5, 21, tive treatment, with most cases functionally resolving
39]. Weakness of the rhomboids can be tested by having within 124 months [3, 4, 9, 11, 13, 24, 25, 28, 35, 57, 63,
the patient try to bring his or her scapulas together medially 69]. Mild deficits in endurance functioning and asymp-
[22], or by having the patient push his or her elbows tomatic scapular winging may persist after functional
backwards against resistance with hands on hips [34, 47]. recovery [4, 11]. Patients may also learn to compensate for
Difficulty with either task suggests weakness of the persistent serratus anterior paralysis by using the trapezius
rhomboids, but this may be masked by trapezius hyper- muscle [28]. Paralysis as a result of trauma tends to lead to
trophy [21]. a poorer prognosis [1, 4, 28, 66]. To allow time for spon-
Due to the rhomboids anatomical position deep to the taneous recovery, several authors have advocated the use of
trapezius muscle and the subtleness of the scapular wing- conservative treatment for the first 624 months after
ing, rhomboid paralysis is a difficult diagnosis. In the symptoms begin. If adequate recovery has not been made
cohort of Desong et al. [49], 25 out of 36 patients were by then, paralysis can be considered permanent and
initially misdiagnosed with conditions such as neurosis, patients become candidates for corrective surgery [4, 11].
over-stressed trapezius, cervical spondylosis, and shoulder Upon diagnosis, patients should be advised to avoid over-
periarthritis. This difficulty has led some authors to suggest head use of the effected extremity and to avoid activities
dorsal scapular nerve palsy to be an under-diagnosed cause that cause pain [4, 28, 63, 69, 70]. Range of motion (ROM)
of shoulder pain [22, 50, 65]. exercises in the supine position should also be prescribed.
In the supine position, the weight of the body prevents
winging by compressing the scapula against the thorax and
Diagnostic tests allows for full shoulder range of motion [3, 25, 28]. Special
consideration should be taken not to stretch the serratus
Currently, electromyographic testing is the only definitive anterior muscle, as stretching the denervated muscle can
diagnostic test for serratus anterior, trapezius, and rhom- impair the time to and extent of functional recovery [3, 28].
boid muscle paralysis, and is essential for determining A scapular brace (Fig. 5) may accomplish both tasks of
which muscle is involved and to what degree of denerva- keeping the scapula placed against the thorax and pre-
tion [29, 35, 37, 66]. Electromyographic testing typically venting stretching of the serratus anterior muscle, and has
8 Curr Rev Musculoskelet Med (2008) 1:111

loss of total elevation, pseudarthrosis, and pulmonary

complications [8, 5456, 73]. As such, it is generally
considered a salvage operation after failure of other sur-
gical procedures [8, 73], or reserved for patients with
generalized shoulder weakness such as facioscapulohu-
meral dystrophy [54, 55, 74]. The second category, static
stabilization, uses a fascial graft or sling to tether the
scapula to the ribs or vertebral spinous processes. However,
this procedure has fallen out of favor due to the recurrence
of scapular winging as the fascial grafts stretch out with
time [8]. The third and most popular procedure is a
dynamic muscle transfer in which the sternal head of the
pectoralis major is transferred to the inferior angle of the
scapula extended or reinforced by a fascial auto graft [6, 8,
9, 40, 41, 63, 69, 75]. This procedure has shown consis-
tently positive results with improved function, resolution of
Fig. 5 A treatment option for scapular winging due to serratus winging, and relief of pain. Transfer of the pectoralis major
anterior or trapezius muscle paralysis, the wingers brace is designed may not be recommended for individuals looking to return
to manually press the scapula against the posterior thoracic wall,
to strenuous labor or contact sports, as these activities,
preventing stretching of the paralyzed muscle and providing limited
functional recovery [71, Figs. 1 and 2] along with lifting greater than 20 pounds, should be avoi-
ded a minimum of 612 months post-operatively [63, 69,
75]. Recently, surgical neurolysis or nerve transfer to the
been shown to be a generally effective treatment option for long thoracic nerve has shown early promising results, with
compliant individuals [3, 63, 71]. However, the brace tends patients expressing near complete relief of pre-operative
to be poorly tolerated leading to poor compliance and less symptoms [18, 76, 77]. As such, initial nerve exploration
functional recovery [37, 63, 69, 72]. In addition, Goodman may be a favorable option before a muscle transfer is
et al. [28] advocate the use of a restraint that limits performed.
abduction of the arm to only 30, forcefully preventing
overuse of the serratus anterior.
Watson and Schenkman [70] have identified three stages Trapezius palsy
of long thoracic nerve injury and appropriate treatment at
each stage. In the acute stage, denervation of the serratus In contrast to the serratus anterior, functional recovery of
anterior causes pain, and goals of treatment include pain the trapezius muscle due to spinal accessory nerve injury
reduction and ROM exercise. Activity modification of the does not consistently benefit from conservative manage-
patient is also important to limit further injury to the ment [7, 10, 12, 1416, 78]. In one series of conservatively
shoulder. In the intermediate stage, the pain has subsided treated patients, only pain from frozen shoulder syndrome
and the nerve is beginning to heal. To maintain full ROM, was relieved by an exercise program, while pain from
passive stretching of the rhomboids, levator scapulae, and muscle spasm, radiculitis, impingement, and asymmetry of
pectoralis minor is used to prevent contracture of these the neckline persisted [12]. Conservative treatments known
muscles due to the loss of serratus anterior activity. In the to have failed include physical therapy, transcutaneous
third or late stage, the serratus anterior becomes progres- nerve stimulation, external support, chiropracty, NSAIDS,
sively stronger and shoulder mechanics improve. To and narcotic analgesics [12, 15]. Several authors propose
improve strength and overhead work, strengthening exer- conservative treatment of neuropraxic lesions to the spinal
cise of all shoulder girdle muscles, including the trapezius, accessory nerve for a minimum of 1 year [7, 37]. If inad-
should be implemented and avoidance of overstretching the equate functional recovery is seen at this time, additional
serratus anterior should be continued. conservative treatment is unlikely to be beneficial and
Serratus anterior paralysis and scapular winging will surgery is indicated [7, 37]. Failure of conservative treat-
persist in approximately 25% of patients treated conser- ment is largely due to the inability of physical therapy to
vatively and such patients are candidates for surgical adequately strengthen adjacent muscle groups enough to
reconstruction [6]. Summarized by Wiater and Flatow [8], compensate for the cross-sectional area and direction of
the surgical procedures to correct scapular winging fall pull of the trapezius [7, 12, 15]. A shoulder orthosis
within three categories. The first category, scapulothoracic (Fig. 5) has been developed for trapezius muscle paralysis
fusion, eliminates scapular winging, but often results in and has been used somewhat successfully in radical neck
Curr Rev Musculoskelet Med (2008) 1:111 9

dissection patients [78]. Within 3 months of using the 49, 65]. Strengthening of the trapezius is the primary
orthosis, 72% of patients were pain free, had improved objective of physical therapy, as the middle portion of the
shoulder girdle muscle function, and increased endurance trapezius can compensate for rhomboid weakness or
and function due to loss of pain [78]. However, active paralysis [34]. Local steroid block for muscle tenderness
abduction only improved by 520 [78]. may also be useful for a minority of patients. Desong et al.
Surgical exploration and nerve repair, such as neuroly- [49] treated 18 patients with local steroid injection for neck
sis, end-to-end suturing, or nerve grafting, has produced tenderness. Of these, the symptoms of 6 patients were
variable outcomes, but appear to be generally beneficial relieved, 4 managed some relief but became refractory to
[1417, 19, 60, 7982]. In the largest series of 111 surgical treatment, while 8 patients experienced no treatment effect
repairs of the spinal accessory nerve, neurolysis resulted in at all. In cases of muscle strain, such as after an athletic
mostly excellent results, while end-to-end suture repair injury, massage is an effective treatment [20].
resulted in slightly better outcomes than graft repair [19]. Surgical procedures may be warranted in severe cases
Modest recovery was seen after neurotization and dismal that are unresponsive to conservative treatment. One option
prognoses were seen after nerve burial into the muscle [19]. is a fascial sling operation where two fascia lata grafts are
Although recovery was the norm, persistent winging of the used to connect the lower medial border of the scapula to
scapula and lack of full abduction was common, as was an the spinal muscles and the inferior angle of the scapula to
asymmetrical neckline with a drooping shoulder on the the latissimus dorsi [33, 34]. This anchors the scapula to
affected side [19]. In a recent review of the literature, the posterior thoracic wall, eliminating winging. However,
authors have reported good or excellent results in approx- there is concern that the fascia lata grafts may stretch or fail
imately two-thirds of patients treated with nerve surgery with time [34]. Another option is neurolysis or decom-
[27]. pression, a procedure most authors suggest to be used only
The preferred method of treatment for healthy and as a last resort [22, 48, 65]. Desong et al. [49] reported
active patients with isolated chronic trapezius palsy sec- effective relief of symptoms for 14 out of 22 patients up to
ondary to spinal accessory nerve injury is the Eden-Lange 1.5 years after undergoing decompression surgery in the
muscle transfer procedure [7, 12, 15, 80]. A dynamic anterior neck. Another three patients who had undergone
muscle transfer, the procedure involves the lateral transfer the surgery were able to control their symptoms with
of the insertion sites of the levator scapulae and rhomboid periodic local lidocaine blocks [49]. Desong et al. advocate
muscles along the scapula. This maneuver redirects the weekly local lidocaine blocks for 46 weeks after diag-
force vectors of these muscles and allows them to stabilize nosis, after which if the patients symptoms are
the scapula and support the shoulder girdle, substituting the unresponsive, decompression surgery is warranted.
denervated trapezius [7, 12, 15, 80]. The Eden-Lange
surgery results in mostly good to excellent outcomes, with
adequate relief of pain and functional overhead movement Conclusions
[7, 12, 15, 80]. However, there are some limitations. Te-
boul et al. [27] report two predictive factors of poor Although rare, scapular winging is a debilitating condition
outcome, including patient age over 50 years and a spinal that limits functional activity of the upper extremity.
accessory nerve lesion caused by radical neck dissection, Scapular winging is diagnosed easily by visible inspection
penetrating injury, or spontaneous palsy. Romero and of the scapula, but its etiology is often more illusive.
Gerber [80] reported poorer outcomes in the presence of an Medial winging due to serratus anterior paralysis is
additional serratus anterior palsy or weak rhomboid mus- accentuated when patients are asked to forward flex their
cle. In such a case, scapulothoracic fusion may be the arms to the horizontal and push on a wall in a push-up
preferred surgical procedure [7]. Some authors recommend motion. In contrast, trapezius paralysis results in exagger-
the Eden-Lange procedure only in the case of spontaneous ated lateral winging upon active abduction. The lateral
palsy of the trapezius, failed nerve repair, or a duration of winging of rhomboid paralysis is subtle, but may be
1220 months have elapsed post-injury [7, 27]. accentuated by extending the arm from the fully flexed
position. Electromyographical testing of all scapulotho-
racic muscles is essential for correct diagnosis. Scapular
Rhomboid palsy winging should initially be treated conservatively, allowing
time for spontaneous recovery. Early spinal accessory
Injury to the dorsal scapular nerve or the rhomboid muscles nerve exploration is warranted in cases of trapezius paral-
is usually treated conservatively with cervical spine sta- ysis, while decompression of the dorsal scapular nerve may
bilization (collar or cervical traction), muscle relaxants, be advisable after conservative treatment has failed. Ser-
anti-inflammatories, and physical therapy [20, 22, 34, 48, ratus anterior paralysis should be treated conservatively for
10 Curr Rev Musculoskelet Med (2008) 1:111

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