Winged Scapula: Symptoms, Types, Causes and Treatment

A winged scapula is more than just a visible shoulder blade sticking out—it’s a sign of underlying muscle or nerve issues that can impact daily activities, shoulder function, and overall quality of life. In this comprehensive guide, we’ll break down the symptoms, types, causes, and treatments of winged scapula, making use of state-of-the-art research and clinical insights. Whether you’re a patient, clinician, or simply curious, this article will help demystify this condition.

Symptoms of Winged Scapula

A winged scapula announces itself in striking ways, but the underlying signs go beyond appearance. Recognizing these symptoms early is crucial for proper diagnosis and tailored treatment.

Symptom	Description	Impact on Patient	Source(s)
Visible Winging	Scapula protrudes from back, especially during arm movement	Cosmetic, Uncomfortable	1 2 3 4
Shoulder Pain	Aching, sharp, or persistent pain near the shoulder blade	Limits daily activities	2 3 4 8
Weakness	Difficulty lifting or moving arm above shoulder level	Functional limitation	2 3 6 8
Reduced ROM	Limited range of shoulder motion (abduction, flexion)	Activity restriction	2 3 7 9

Table 1: Key Symptoms

Visible Winging

The hallmark of this condition is the prominent protrusion of the scapula away from the rib cage, most noticeable when pushing against resistance or lifting the arm forward or sideways. This “winged” appearance can be alarming, but it’s often painless in mild cases 1 2.

Pain and Discomfort

Many patients experience persistent or activity-related pain around the shoulder or upper back. This can be dull or sharp and often worsens with movement or after repetitive use 2 3 4 8. Some also report discomfort when resting the back against hard surfaces.

Weakness and Loss of Function

Weakness, particularly when trying to lift the arm above shoulder level or push against resistance, is common. This loss of strength can make daily tasks—like reaching, lifting, or even dressing—challenging 2 3 6 8.

Reduced Range of Motion

Patients often find their shoulder movement is restricted, especially in abduction (raising the arm to the side) or flexion (lifting arm forward). This limitation is due to the loss of scapular stability, which is essential for smooth shoulder motion 2 3 7 9.

Types of Winged Scapula

The winged scapula is not a singular entity—different anatomical and clinical patterns exist. Understanding these types is fundamental for diagnosis and management.

Type	Defining Feature	Typical Cause	Source(s)
Dynamic	Appears with movement	Neuromuscular disorder	1 4 6
Static	Present at rest	Structural deformity	1
Medial Winging	Scapula’s inner border lifts	Serratus anterior/long thoracic nerve	3 6 8 9
Lateral Winging	Outer scapular edge lifts	Trapezius/accessory nerve	4 6 8 9
Rare Variants	Atypical winging patterns	Rhomboid/dorsal scapular nerve	5 7

Table 2: Classification of Winged Scapula

Dynamic vs. Static Winging

• Dynamic winging only appears with arm movement or resistance, usually due to neuromuscular disorders affecting muscle control 1 4 6.
• Static winging is visible even at rest, often the result of fixed deformities in the shoulder girdle, spine, or ribs 1.

Medial vs. Lateral Winging

• Medial winging: The inner (vertebral) border of the scapula juts out, often due to paralysis of the serratus anterior muscle, typically from long thoracic nerve injury 3 6 8 9.
• Lateral winging: The outer (lateral) edge of the scapula is prominent, associated with paralysis of the trapezius muscle from accessory nerve dysfunction 4 6 8 9.

Rare and Atypical Types

• Rhomboid paralysis (dorsal scapular nerve): Results in subtle or atypical winging, sometimes confused with other causes 5 7.
• Combined neuropathies: Some patients may exhibit unique patterns due to involvement of multiple nerves (e.g., dorsal scapular and suprascapular nerves) 5.
• Structural or muscular causes: Less frequently, direct muscle rupture or congenital bone/joint abnormalities can lead to distinctive static or dynamic winging 1 3 8.

Causes of Winged Scapula

The reasons behind a winged scapula are diverse, ranging from nerve injuries to rare muscular defects. Identifying the precise cause is key to effective treatment.

Cause Category	Specific Cause/Mechanism	Example/Notes	Source(s)
Nerve Injury	Long thoracic, accessory, dorsal scapular	Trauma, surgery, neuropathy	2 3 4 5 6 7 8 9 11 12
Muscle Pathology	Rupture, dystrophy, overuse	Serratus anterior, trapezius	3 4 8
Structural	Bone/joint deformity	Congenital or acquired	1
Idiopathic	Unknown/uncertain etiology	Neuralgic amyotrophy, idiopathic	2 4 6

Table 3: Main Causes of Winged Scapula

Nerve Injuries

This is the most common cause. Key nerves include:

• Long thoracic nerve: Supplies the serratus anterior; injury leads to medial winging 2 3 4 6 8 9 11 12. Causes include:

  • Trauma (e.g., sports, accidents)
  • Surgical complications (e.g., thoracic, neck operations)
  • Repetitive stretch injuries (overhead activities)
  • Compression (sometimes in the scalene muscles) 12
  • Neuralgic amyotrophy (Parsonage-Turner syndrome) 2 4

• Spinal accessory nerve: Supplies the trapezius; injury causes lateral winging 4 6 8 9. Causes include:

  • Neck trauma or surgery
  • Space-occupying lesions
  • Idiopathic processes

• Dorsal scapular nerve: Supplies the rhomboids; rare cause of winging, often due to acute trauma or nerve lesion 5 7.

• Suprascapular nerve: Rarely contributes to atypical winging when combined with other neuropathies 5.

Muscle Pathology

• Serratus anterior rupture: Though uncommon, direct muscle tears from trauma or overuse can mimic nerve-related winging 3 8.
• Trapezius or rhomboid tears: Acute traumatic detachment of these muscles is rare but possible 8.
• Muscular dystrophies: Fascioscapulohumeral muscular dystrophy (FSHD) can cause chronic, progressive winging 4.

Structural Abnormalities

Static winging can arise from congenital or acquired deformities of the bones (scapula, ribs, spine) or joints, though much less common than neuromuscular causes 1.

Idiopathic/Unknown Causes

In some cases, no clear cause is found. Idiopathic neuralgic amyotrophy—an inflammatory neuropathy—can present with acute pain and subsequent winging 2 4 6.

Treatment of Winged Scapula

Management of winged scapula depends on its cause, severity, and impact on daily life. Many patients improve with conservative measures, but persistent or severe cases may require surgical intervention.

Treatment Type	Example/Approach	Indication/Outcome	Source(s)
Conservative	Physiotherapy, bracing, rest	Most nerve injuries, mild cases	2 3 4 6 8
Surgical	Muscle/tendon transfer, nerve transfer, neurolysis	Severe or persistent cases	9 10 11 12 13
Observation	Watchful waiting	Idiopathic neuropraxia	2 4 6
Rehabilitation	Specific exercises	All cases for functional recovery	3 5 8

Table 4: Treatment Options

Conservative Management

• Physical Therapy: Tailored exercises to strengthen compensating muscles, improve scapular stability, and restore range of motion are first-line for most cases, especially those due to nerve injury 2 3 4 6 8.
• Bracing: Temporary support may help alleviate discomfort and prevent further injury while nerves recover 6 12.
• Rest and Activity Modification: Reducing aggravating activities can promote healing, particularly in traumatic or overuse cases 2 3.

Most cases of long thoracic nerve injury (serratus anterior palsy) recover spontaneously within 6–24 months, so initial treatment is conservative 2 4 6.

Surgical Management

Surgery is considered when conservative measures fail after 6–24 months, or if there’s no evidence of nerve recovery:

• Muscle/Tendon Transfers:
  • Pectoralis Major Transfer: Replaces lost serratus anterior function 10 13.
  • Eden-Lange Procedure: Transfers the levator scapulae and rhomboid muscles, mainly for trapezius paralysis 10.
• Nerve Transfers: Newer techniques involve rerouting healthy nerves (e.g., thoracodorsal to long thoracic) to restore muscle function 11.
• Neurolysis: Surgical decompression of entrapped nerves (e.g., supraclavicular neurolysis of the long thoracic nerve) can correct winging in select cases 12.

Outcomes from surgical procedures are generally positive in well-selected patients, with improved shoulder function and reduced winging 10 11 13.

Observation and Prognosis

• Observation: For idiopathic or mild cases, watchful waiting with serial evaluation is appropriate 2 4 6.
• Prognosis: Long thoracic nerve injuries have a good prognosis, with up to two years for full recovery. Accessory nerve injuries (trapezius palsy) are less likely to recover fully and may require surgical correction 4 6.

Rehabilitation

Rehabilitation is central to all treatment pathways, focusing on restoring movement, strength, and function. Even after surgery, post-operative therapy is vital for optimal outcomes 3 5 8.

Conclusion

Winged scapula is a complex, multifaceted condition—sometimes dramatic in appearance, always important in function. Understanding its symptoms, types, causes, and treatments is crucial to effective management and patient recovery.

Key Points:

• Symptoms: Prominent scapular protrusion, pain, weakness, and reduced shoulder movement are classic signs 1 2 3 4 6 8 9.
• Types: Winging can be dynamic or static, medial or lateral, depending on the muscles and nerves involved 1 3 4 6 8 9.
• Causes: Most commonly due to nerve injuries (long thoracic, accessory), but can also arise from muscle tears, dystrophies, or structural problems 2 3 4 5 6 7 8 9 11 12.
• Treatment: Conservative care (physiotherapy, rest) is first-line; surgery is reserved for persistent or severe cases, with generally good outcomes 2 3 4 6 8 9 10 11 12 13.

Early recognition, accurate diagnosis, and tailored treatment—often with patience and persistence—are the foundations for restoring function and comfort to those affected by this unique shoulder condition.