Scapular Winging: Should I Be Concerned?

Written By Jack Banister

If you've noticed a protruding shoulder blade that gives your back a wing-like appearance, you might be experiencing scapular winging. But should you be concerned? Let's delve into what scapular winging is, its causes, and what it means for your shoulder health.

What is Scapular Winging?

Scapular winging occurs when the shoulder blade (scapula) sticks out rather than lying flat against the back. This can be seen in movements such as raising your arm or pushing against a wall. The scapula plays a crucial role in shoulder mechanics, providing a stable base for arm movements. When it wings, this stability is potentially compromised and could affect shoulder function and predispose you to some aches and pains.

Anatomically, the scapula is connected to the rib cage by several muscles, including the serratus anterior, trapezius, and rhomboids. These muscles are controlled by nerves, and if these become compromised in any way, the scapula can lose its stable position, leading to winging [1][2].

What Causes Scapular Winging?

Scapular winging can result from factors mainly related to nerve or muscle compromise. Here’s a simplified look at the common causes:

1. Nerve Issues:

  • Long Thoracic Nerve: This nerve innervates the serratus anterior muscle, which helps keep your scapula in place flat against the rib cage and allows the scapula to move smoothly during arm movements, such as lifting the arm. When this nerve is damaged, which can occur due to repetitive strain, direct trauma, or certain surgical procedures, it can no longer effectively control the serratus anterior muscle, leading to the scapula winging out [1].

  • Spinal Accessory Nerve: This nerve controls the trapezius muscle, which is responsible for stabilising, elevating, retracting, and rotating the scapula. When the spinal accessory nerve is compromised, such as by surgery, injuries, or nerve entrapment, the trapezius muscle can become weak, leading to lateral scapular winging, where the outer edge of the scapula sticks out [2].

  • Dorsal Scapular Nerve: This nerve innervates the rhomboid muscles, which are critical for retracting and stabilising the scapula against the rib cage. When the dorsal scapular nerve is compromised, due to injury or entrapment, the rhomboid muscles may become weak and lose the ability to retract the scapula, causing it to wing out medially [3].

2. Surgical and Traumatic Causes:

  • Some surgeries, especially around the chest or neck, can impact the nerves that stabilise the scapula. For instance, during a radical mastectomy, the long thoracic nerve can be damaged, leading to dysfunction of the serratus anterior muscle. Similarly, neck surgeries can affect the spinal accessory nerve, impacting the trapezius muscle [1].

  • Direct injuries to the shoulder or upper body can also lead to nerve issues. Blunt trauma from an accident or sports injury can damage the nerves supplying the muscles around the scapula [4].

3. Repetitive Strain:

  • Activities and sports that involve repetitive overhead movements, like swimming, throwing sports, tennis, or certain jobs, can lead to fatigue and overuse of the muscles stabilising the scapula. Over time, this repetitive strain can damage the nerves, such as the long thoracic or spinal accessory nerve, leading to muscle weakness and scapular winging. Similarly, professions that require constant overhead activities, such as painters, carpenters, or electricians, can experience similar nerve and muscle strains, potentially resulting in scapular winging [5].

Should You Be Concerned About Scapular Winging?

It's natural to be concerned if you notice scapular winging, but it's important to know that misalignment doesn’t always lead to pain or significant dysfunction. The human body is incredibly complex and adaptable, so sometimes something may look uneven or unbalanced but might just be a result of many cumulative adaptations to your environment and daily activities.

Reasons Not to Worry:

  1. Many Asymptomatic Cases: Many people with scapular winging don't experience pain and studies show that while winging is sometimes associated with shoulder problems, it doesn’t always cause them. Many individuals that display signs of winging have no symptoms at all, indicating that the presence of scapular winging alone is not a definitive predictor of shoulder dysfunction or pain [6][7].

  2. Compensation by the Body: Your body often compensates for winging by using other muscles, which can help maintain shoulder function. For instance, the levator scapulae and the upper fibres of the trapezius can take over some of the stabilising roles, helping to maintain shoulder mechanics even when the primary stabilisers like the serratus anterior are compromised. Additionally, the latissimus dorsi can contribute to compensatory mechanisms to support shoulder function despite the presence of scapular winging [8].

Reasons for Concern:

  • Potential for Pain and Dysfunction: Scapular winging can sometimes cause shoulder pain and affect how your shoulder moves, especially if it changes the normal mechanics of your shoulder. Conditions like subacromial impingement can arise, where the altered scapular position compresses the rotator cuff tendons, causing pain and limiting movement [9].

  • Impact on Daily Activities: You might find it harder to lift your arm or do overhead tasks, which can significantly affect your daily life and work-related activities.

Treatment and Rehabilitation Protocols

If you are experiencing discomfort or functional deficits, conservative management such as manual therapy combined with targeted exercises has been shown to be effective [10]. Here’s an overview of some effective treatment and rehabilitation protocols cited in the literature:

Manual Therapy Techniques

  • Soft Tissue Mobilisation: Gentle manipulation of the muscles around the scapula to reduce tension and improve mobility. This technique targets the tight or overactive muscles, helping to alleviate pain and restore normal movement patterns. Soft tissue mobilisation can include massage, stretching, and other hands-on techniques to release muscle tension and improve blood flow [10].

  • Myofascial Release: Techniques to release tightness in the fascia, the connective tissue surrounding the muscles, to improve movement and reduce discomfort. Myofascial release involves applying sustained pressure to the myofascial connective tissue to eliminate pain and restore motion. This technique helps to break down adhesions and scar tissue, improving the overall flexibility and function of the shoulder [10].

  • Joint Mobilisation: Gentle techniques to improve the movement of the shoulder joint and surrounding structures. Joint mobilisation involves passive movements performed by a therapist to increase joint range of motion and reduce stiffness. This technique can help restore normal joint mechanics, decrease pain, and improve functional mobility [11].

  • Dry Needling: This technique involves inserting fine needles into the muscles around the scapula to relieve pain and improve function. Dry needling can help release muscle knots and trigger points, reducing muscle tension and enhancing mobility [12].

Exercises


1. Serratus Punches:

  • Purpose: Strengthen the serratus anterior muscle [12]

  • How to Do It: Stand with a resistance band anchored behind you. Punch forward, extending your arm and protracting the scapula. Repeat 10-15 times per side. Perform 2-3 sets with 30-60 seconds rest between sets. 

2. Wall Slides:

  • Purpose: Improve scapular retraction and shoulder stability.

  • How to Do It: Stand with your back against a wall, arms bent at 90 degrees. Slide your arms up and down the wall, keeping the scapula retracted. Repeat 10-15 times. Perform 2-3 sets with 30-60 seconds rest between sets [12]. 

3. Resistance Band Rows:

  • Purpose: Strengthen the rhomboids and trapezius [12].

  • How to Do It: Anchor a resistance band in front of you. Pull the band towards you, squeezing your shoulder blades together. Repeat 10-15 times. Perform 2-3 sets with 30-60 seconds rest between sets.

4. Scapular Push-Ups: 

  • Purpose: Strengthen the muscles around the scapula [12].

  • How to Do It: In a push-up position, perform push-ups focusing on moving the scapula without bending the elbows. Repeat 10-15 times. Perform 2-3 sets with 30-60 seconds rest between sets. 

In addition to these exercises, maintaining overall shoulder and upper back strength and flexibility is crucial. Incorporating a balanced workout routine that includes strength training, stretching, and functional movements can support long-term shoulder health and prevent recurrence of scapular winging

Conclusion

In summary, while scapular winging may appear concerning, it often does not affect the shoulder's functionality or result in aches and pains. The body's amazing ability to adapt allows for compensatory strategies that maintain good shoulder function without discomfort. However, to mitigate potential issues down the line, it is advisable to incorporate targeted exercises to restore scapular control and stability, regardless of whether you are experiencing shoulder pain or not. For personalised guidance, consider booking an appointment with one of our osteopaths who can educate you further, help you find the right exercises, and provide manual therapy to help speed up the process.

References

  1. Park SB, Ramage JL. Winging of the Scapula. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541005/

  2. Kibler WB, Sciascia A, Dome D. Evaluation of scapular dyskinesis in athletes. J Athl Train. 2012;47(5):516-524.

  3. Bury TF, McCluskey GM, Sciascia A. Scapular dyskinesis in the overhead athlete: current pathophysiologic concepts. Br J Sports Med. 2016;50(5):263-270.

  4. Struyf F, Nijs J, Mottram S, et al. Clinical assessment of the scapula: a review of the literature. Br J Sports Med. 2014;48(11):883-890.

  5. Saito H, Saito M, Yasuda K. Conservative treatment for winged scapula caused by isolated serratus anterior palsy: a case report and review of the literature. J Shoulder Elbow Surg. 2018;27(8)

  6. Burn MB, McCulloch PC, Lintner DM, Liberman SR, Harris JD. Prevalence and functional impact of dyskinesis in collegiate baseball players. J Shoulder Elbow Surg. 2016;25(6):935-940.

  7. Clausen MB, Bandholm T, Rathleff MS, et al. Diagnosing scapular dyskinesis in patients with subacromial impingement syndrome: interobserver reliability and validity of clinical tests. Orthop J Sports Med. 2016;4(2):2325967116628730.

  8. Comprehensive Capacity: an alternative to the kinesiopathological model for shoulder function. J Orthop Sports Phys Ther. 2020;50(4):208-217.

  9. Hickey D, Solvig V, Cavalheri V, Harrold M, McKenna L. Scapular dyskinesis increases the risk of shoulder pain in elite competitive swimmers: a prospective cohort study. Br J Sports Med. 2018;52(17):1089-1094.

  10. Larsen CM, Søgaard K, Petersen HH, et al. The effects of scapular function training on shoulder function, pain, and quality of life in patients with subacromial impingement syndrome: a randomized controlled trial. J Shoulder Elbow Surg. 2019;28(3):465-472.

  11. Littlewood C, Malliaras P, Mawhinney C. Self-managed loaded exercise versus usual physiotherapy treatment for rotator cuff tendinopathy: a pilot randomized controlled trial. Physiotherapy. 2017;103(2):195-201.

  12. McQuade KJ, Borstad JD, de Oliveira AS. Critical and theoretical perspective on scapular stabilization: what does it really mean, and are we on the right track? Phys Ther. 2016;96(8):1162-1169.

Jack Banister