What is scapular winging?

Scapular winging is an uncommon nerve condition, causing pain and occasionally weakness in the shoulder. It involves injury to the long thoracic nerve in the back near the shoulder blade. The long thoracic nerve runs from the neck along the chest wall to the serratus anterior muscle. The nerve can be stretched, due to a fall on the shoulder while the neck bends toward the other shoulder or due to repetitive injury; it may also occur without injury or due to a viral illness. Injury to this nerve results in weakness of the serratus anterior muscle, causing the shoulder blade (scapula) to pull away from the chest wall with attempted shoulder movement, called winging. The scapula is the base from which the shoulder functions. With winging, the shoulder works off a weak base, making shoulder function weak as well.

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What causes scapular winging?

• Viral illness
• Repetitive stretch injury
• Fall onto shoulder with the head and neck stretched away from the shoulder

What increases the risk of scapular winging?

• Contact sports
• Sports that require overhead throwing-type activity, such as baseball, volleyball or tennis
• Poor physical conditioning (strength and flexibility)

What are the symptoms of scapular winging?

• Pain and discomfort (burning or dull ache) that is poorly localized (not confined to one location), often in the back of the shoulder or shoulder blade
• Heaviness or fatigue of the arm
• Loss of power of the shoulder
• Difficulty raising the arm above shoulder level
• Pain in the back when sitting in a chair with a high back due to the scapula hitting the back of the chair
• Bump in the back of the shoulder (the scapula) that is more obvious when trying to do push-ups or reach forward overhead

How is scapular winging treated?

Non-operative treatment: Initial treatment consists of rest from the offending activity and nonsteroidal anti-inflammatory medications to help reduce inflammation and pain. The nerve usually spontaneously recovers, although this may take up to 12-24 months. Performing shoulder range-of-motion exercises while waiting
for nerve recovery is of paramount importance. Referral to a physical therapist or an athletic trainer may be recommended for further treatment, including ultrasound and other modalities.

Operative treatment: If this conservative treatment is not successful, surgery may be necessary to replace the lost function of the serratus anterior muscle with the function of another muscle. This surgery is considered a salvage operation; it is not meant to allow the athlete to return to sports, just to allow pain-free activities of daily living.

What are the complications of treatment?

Possible complications of operative treatment include:

• Surgical complications not specifically associated with scapular winging, such as pain, bleeding (uncommon), infection (<1percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.

When can you return to your sport/activity?

There is usually complete spontaneous recovery within 18 months. Rarely surgery is necessary, and may not allow the athlete to return to sports.

How can scapular winging be prevented?

• Appropriately warm up and stretch before practice or competition
• Maintain appropriate conditioning:
  • Shoulder flexibility
  • Muscle strength and endurance