Virtual Care Sports Medicine Examination Guide
May 3, 2020
Virtual Care Sports Medicine Examination Patient Guide
May 10, 2020

Scapular Winging

Scapular Winging

Anatomy:

Scapulothoracic Joint1

  • The articulation between the scapula and the thorax
  • Not a true joint – “sliding joint” – between medial border of the scapula and ribs 2-7
  • Function is to allow scapular motion against the rib cage
  • The scapula is an attachment point for 17 different muscles; including the serratus anterior, rhomboids and the trapezius

Movement2:

  • The scapula can move in the following ways:
  • (1) Protraction/retraction (abduction, adduction), (2) Elevation/depression, (3) medial and lateral rotation (see figure 1)
    Figure 1: Scapular Movements and muscles involved

Image from https://www.earthslab.com/wp-content/uploads/2017/06/060717_0239_Movementsof1.jpg

Definitions:Of note, the scapula aids with shoulder abduction in the following way3:

  • Shoulder Abduction: First 30° of movement is at glenohumeral joint.
  • Beyond 30°, the scapula engages with a 2:1 ratio of glenohumeral to scapulothoracic movement

Scapular dyskinesis2: deviation in normal resting position of the scapula during shoulder movement.

Medial winging4: On exam, the inferior medial scapula elevates and protrudes posteriorly and medially (see figure 2). This can be caused by an injury to the serratus anterior muscle or to the long thoracic nerve.

Figure 2 – Medial winging right shoulder

Image from https://www.orthobullets.com/shoulder-and-elbow/3062/scapular-winging

Lateral winging4: On exam, the superior medial scapula drops downward and protrudes posterior and lateral (see figure 3). This can be due to a deficit in the trapezius muscle as a result of injury to the spinal accessory nerve.

Figure 3 – Lateral winging right shoulder

Image from https://www.orthobullets.com/shoulder-and-elbow/3062/scapular-winging

Differential Diagnosis5:

Neurogenic:

  • Entrapment of the following neurological structures:
    • Suprascapular nerve
    • Dorsal scapular nerve
    • Long thoracic nerve
    • Spinal accessory nerve
    • Superior trunk of brachial plexus

Muscular:

  • Injury or palsy to the following muscles
    • Serratus anterior
    • Trapezius
    • Rhomboid

Bone:

  • Thoracic Kyphosis
  • Clavicle fracture (nonunion or shortened mal-union)
  • Acromioclavicular, sternoclavicular, or glenohumeral joint instability
  • Glenohumeral osteoarthritis

Other:

  • Hyper-laxity syndromes
  • Shoulder impingement
  • Adhesive capsulitis
  • Shoulder labral tear
  • Fascioscapulohumeral dystrophy

Scapular Exam:

Note: The differential diagnosis for scapular winging is broad and a complete shoulder examination should be completed along with the following scapular exam.

Inspection:

Inspect scapulae bilaterally for symmetry, atrophy, and for evidence of medial or lateral winging (see above for descriptions). At this stage, check for crepitation of the superior medial scapula during passive range of motion.

Step 1: Assessing for scapular dyskinesia

The Kibler classification6 can be used by asking the patient to abduct and adduct the shoulder (rate of 45 degrees/second) and watching their scapular motion:

The classification is as follows:

Type 1: At rest: Inferior medial border prominent dorsally

During motion: inferior angle tilts dorsally and the acromion tilts ventrally over the top of the thorax

Type 2: At rest: Entire medial border is prominent dorsally

During motion: Medial border tilts dorsally off the thorax

Type 3: At rest: Superior border elevated and the scapula is anteriorly displaced

During motion: Shoulder shrug initiates movement without winging of the scapula

Type 4: Symmetric scapulothoracic movement

Figure 4 – Kibler Classification

Image from Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556.

Note: Intra-rater and inter-rater reliability for this test are k = 0.5 and k = 0.4 respectively, and as such, clinical utility is lower than for the tests below.5

Lateral Scapular Slide Test (LSST)7:

This test is an objective measure for shoulder dyskinesia.

How to perform: measure side to side difference of the distance from the inferior angle of the scapula to the adjacent spinous process in 3 different positions (shown below). A side to side difference of >1.5cm is considered pathological.

Figure 5 – Three positions of LSST

Image from Curtis, Thomas, and James R. Roush. “The lateral scapular slide test: A reliability study of males with and without shoulder pathology.” North American journal of sports physical therapy: NAJSPT 1.3 (2006): 140.

 

Scapular Dyskinesis Test (SDT)8:

How to perform: Patient is given 2 dumbbells of 3lbs each (if patient weighs 150lb or less) or 5lbs (if patient weighs over 150lb). Patient does bilateral flexion and bilateral abduction 5 times each. Make sure shoulders are in thumbs up position during both flexion and abduction. Test is positive if winging or dysrhythmia is present on observation.

Inter-Rater Reliability ranges from 0.48-0.61.

Figure 6 – Scapular dyskinesis test

Image from McClure, Philip, et al. “A clinical method for identifying scapular dyskinesis, part 1: reliability.” Journal of athletic training 44.2 (2009): 160-164.

The limitations with the LSST and SDT tests is that the prevalence of scapular dyskinesia can be 33% in asymptomatic non-overhead athletes and 61% in asymptomatic overhead athletes. While they are useful in determining if there is scapular dyskinesia, the Scapular Assistance Test and Scapular Reposition Test (below) can be used to determine if scapular dyskinesia is contributing to symptoms.9

Step 2: Assessing if scapular dyskinesia is contributing to patient symptoms

Scapular Assistance Test (SAT)10:

How to perform: Fixate clavicle and scapular spine with one hand and place other hand inferior angle of the scapula with other hand (as shown below). Ask patient to abduct the shoulder and assist the scapular movement (upward rotation of scapula). A positive test is if the patient has decreased pain during abduction.

Figure 7 – Scapular assist test

Image from McClure, Philip, Elliot Greenberg, and Stephen Kareha. “Evaluation and management of scapular dysfunction.” Sports medicine and arthroscopy review 20.1 (2012): 39-48.

Scapular Retraction (Rotation) Test (SRT)10:

How to perform: Fixate clavicle and scapular spine with one hand and with the forearm of the same hand, press the patient’s scapula against the chest wall. Now perform the empty can test. A positive test is if the patient has decreased pain during empty can testing.

A positive test on either the SAT or SRT indicates weakness of the scapular stabilizers including the lower trapezius and the serratus anterior.

Figure 8 – Scapular Retraction Test


Image from McClure, Philip, Elliot Greenberg, and Stephen Kareha. “Evaluation and management of scapular dysfunction.” Sports medicine and arthroscopy review 20.1 (2012): 39-48.

Step 3: Scapular neurological exam to assess for nerve entrapments11

Long Thoracic Nerve

If the patient has medial winging, perform testing for the long thoracic nerve. Ask the patient to perform a push-up movement against the wall. Displacement of the scapula medially and superiorly (medial winging) that is more pronounced with this maneuver is consistent with long thoracic nerve entrapment.

Spinal Accessory Nerve

If the patient has lateral winging, ask the patient to abduct or externally rotate their arm against resistance. In patients with spinal accessory nerve entrapment, the superior angle of their scapula will be displaced laterally with this movement. Alternatively, lateral winging can be appreciated on descent from full abduction on the affected side.

Dorsal Scapular Nerve

In patients with lateral winging, assess the dorsal scapular nerve. Ask the patient to flex their shoulder to 180 degrees. Now ask the patient to slowly extend their shoulder and examine the scapula during this motion.   A positive test for nerve entrapment is if the inferior angle of the scapula becomes more laterally displaced on the affected side (lateral winging).

Imaging/Investigations5:

Scapular winging is a clinical diagnosis. Investigations can be done to identify the etiology of winging.

Initial workup can include the following (based on differential):

  • Chest X-ray – rule out accessory ribs
  • C-spine/shoulder/scapula x-ray – rule out fracture (mal-union), osteochondroma, cervical spine disease
  • Ultrasound or MRI of the shoulder to rule out shoulder pathology as indicated
  • NCS/EMG – to distinguish neuromuscular causes of scapular winging (remember to specifically ask for evaluation of the spinal accessory nerve and the long thoracic nerve)
  • *Confirmation of neurological exam can be done with dynamic ultrasound testing. This must be done in the hands of a sonographer who is well versed in scapular ultrasound techniques.

Management:

Medial Winging

Conservative Management Principles5

  • Most cases of scapular winging are caused by a neuropraxic injury. The vast majority of cases will spontaneously resolve with full shoulder range of motion and resolution of winging by 2 years
    • Observation for a minimum of 6 months is recommended before consideration of surgery (most authors recommend observation for 12-24 months)
  • Sling immobilization may be useful acutely, however, long term use is not recommended as it can increased stiffness in the shoulder.
  • Rest, ice and analgesia acutely after injury.
  • Strengthening and stretching program for the serratus anterior muscle
  • Taping may be beneficial as an adjunct for those who have an abnormal posture at baseline or for those who have a positive SRT test.10

Operative Management12

  • Indicated for
    • Incomplete recovery with conservative management for at least 6 months (12-24 months for low demand athletes)
    • Scapular winging caused by penetrating injury or iatrogenic causes
  • Techniques
    • Early repair of serratus anterior avulsion
    • Neurolysis of long thoracic nerve
    • Muscle transfer
    • Nerve Transfer
    • Scapulothoracic Fusion
      • Not first line surgical option – done primarily for pain relief if other surgical options have been unsuccessful

Lateral winging

Conservative Management Principles5

  • The role of conservative management for lateral winging is controversial. This is because most of these injuries are secondary to iatrogenic nerve injuries that would benefit from surgical intervention.12
  • Conservative management for lateral winging follows the same principles as that of medial winging
  • Candidates for conservative management12
    • Elderly/sedentary patients
    • Patients without an identifiable cause

Surgical Management12

  • Techniques
    • Exploration of the spinal accessory nerve and neurolysis repair
    • Muscle Transfer
    • Scapulothoracic Fusion

Author Dr. Mustafa Mohamedali (May 9, 2020 PR AF)

References

  1. https://www.orthobullets.com/shoulder-and-elbow/3035/scapulothoracic-joint

 

  1. Kibler, W. Ben, and Aaron D. Sciascia. “Disorders of the Scapula and Their Role in Shoulder Injury.”

 

  1. Panagiotopoulos, Andreas Christos, and Ian Martyn Crowther. “Scapular Dyskinesia, the forgotten culprit of shoulder pain and how to rehabilitate.” SICOT-J5 (2019).

 

  1. McClure, Philip, Elliot Greenberg, and Stephen Kareha. “Evaluation and management of scapular dysfunction.” Sports medicine and arthroscopy review1 (2012): 39-48.

 

  1. Meininger, Alexander K., Benedict F. Figuerres, and Benjamin A. Goldberg. “Scapular winging: an update.” JAAOS-Journal of the American Academy of Orthopaedic Surgeons8 (2011): 453-462.

 

  1. Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556.

 

  1. Curtis, Thomas, and James R. Roush. “The lateral scapular slide test: A reliability study of males with and without shoulder pathology.” North American journal of sports physical therapy: NAJSPT3 (2006): 140.

 

  1. McClure, Philip, et al. “A clinical method for identifying scapular dyskinesis, part 1: reliability.” Journal of athletic training2 (2009): 160-164.

 

  1. Burn, Matthew B., et al. “Prevalence of scapular dyskinesis in overhead and nonoverhead athletes: a systematic review.” Orthopaedic journal of sports medicine 4.2 (2016): 2325967115627608.

 

  1. McClure, Philip, Elliot Greenberg, and Stephen Kareha. “Evaluation and management of scapular dysfunction.” Sports medicine and arthroscopy review 20.1 (2012): 39-48.

 

  1. Martin, Ryan M., and David E. Fish. “Scapular winging: anatomical review, diagnosis, and treatments.” Current reviews in musculoskeletal medicine1 (2008): 1-11.

 

  1. https://www.orthobullets.com/sports/3062/scapular-winging

Images

Figure 1: https://www.earthslab.com/wp-content/uploads/2017/06/060717_0239_Movementsof1.jpg

 

Figure 2 + 3: https://www.orthobullets.com/shoulder-and-elbow/3062/scapular-winging

 

Figure 4: Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556.

 

Figure 5: Curtis, Thomas, and James R. Roush. “The lateral scapular slide test: A reliability study of males with and without shoulder pathology.” North American journal of sports physical therapy: NAJSPT 1.3 (2006): 140.

 

Figure 6: McClure, Philip, et al. “A clinical method for identifying scapular dyskinesis, part 1: reliability.” Journal of athletic training 44.2 (2009): 160-164.

 

Figure 7 + 8 McClure, Philip, Elliot Greenberg, and Stephen Kareha. “Evaluation and management of scapular dysfunction.” Sports medicine and arthroscopy review 20.1 (2012): 39-48.