summary Scapular winging is a dysfunction involving the stabilizing muscles of the scapula resulting in imbalance and abnormal motion of the scapula. Diagnosis is made clinically with the presence of excessive medializing scapular retraction (medial winging) or excessive lateralizing scapular protraction (lateral winging). Treatment is generally observation, physical therapy and activity modification or operative depending on etiology of winging and presence of identifiable neurological lesion. Epidemiology Anatomic location Types of scapular winging defined by the direction of the superomedial corner of the scapula medial scapular winging login to view 8 more bullets lateral scapular winging login to view 6 more bullets Anatomy Scapulothoracic articulation not a true joint attached to thorax via ligaments at the acromioclavicular (AC) joint suction mechanism created by serratus anterior and subscapularis holds scapula closely to thorax allows scapular movement against the posterior rib cage contributes to glenohumeral joint positioning and mechanics Stabilizing muscles scapula serves as attachment site for 17 muscles function to stabilize scapula to the thorax, provide power to the upper limb and synchronize glenohumeral motion serratus anterior originates from ribs 1-8 and inserts on anteromedial border of scapula login to view 1 more bullet primary motion is scapular protraction (anterior and lateral motion) innervated by long thoracic nerve login to view 1 more bullet blood supply login to view 2 more bullets three parts with different functions login to view 3 more bullets trapezius originates from medial third superior nuchal line, external occipital protuberance, nuchal ligament and C7-T12 spinous processes inserts on lateral third clavicle, acromion and scapular spine primary motion is upward rotation and elevation of the scapula innervated by spinal accessory nerve login to view 1 more bullet three parts with different functions login to view 3 more bullets rhomboid major and rhomboid minor rhomboid major originates from T2-T5 spinous processes and inserts onto medial scapular border, just below insertion of rhomboid minor rhomboid minor originates from C7 and T1 spinous processes and inserts onto medial scapular border, near base of scapular spine primary motion is scapular retraction innervated by dorsal scapular nerve levator scapulae originates from C1-C4 transverse processes and inserts onto medial border of scapula at the level of the scapular spine primary motion is elevation of the scapula and downward rotation to tilt the glenoid cavity inferiorly innervated by C3-C4 cervical plexus with contributions from dorsal scapular nerve Nerves long thoracic nerve arises from ventral rami of C5, C6 and C7 anatomic variations login to view 2 more bullets travels posterior to the axillary vessels and brachial plexus runs superficially to the serratus anterior, giving branches to each slip crow's foot login to view 1 more bullet spinal accessory nerve (cranial nerve XI) spinal and cranial portions join to form the accessory trunk accessory trunk traverses the jugular foramen, crosses laterally over the internal jugular vein to innervate the sternocleidomastoid enters posterior triangle of the neck to innervate the trapezius Medial Scapular Winging Pathophysiology deficit in serratus anterior function due to injury to the muscle itself or to the long thoracic nerve mechanical traumatic avulsion of the serratus anterior displaced fractures of the inferior pole of the scapula neurologic traction nerve injury login to view 6 more bullets compressive nerve injury login to view 9 more bullets direct nerve injury login to view 6 more bullets neuralgic amyotrophy (brachial neuritis) login to view 2 more bullets Presentation vague, nonspecific shoulder girdle pain and fatigue base of neck, scapula and deltoid muscle spasms weakness when lifting away from body and overhead activity discomfort sitting against a chair may have neurologic symptoms due to traction on brachial plexus subjective shoulder instability failure of the scapula to provide a stable platform for rotation of the glenohumeral joint Evaluation physical examination inferior medial scapula elevates and protrudes posteriorly and medially login to view 1 more bullet abduction often limited to 90° or less weakness of forward arm flexion and abduction wasting of anterior scalene triangle login to view 1 more bullet scapular compression test login to view 2 more bullets diagnostic studies electromyography login to view 1 more bullet Treatment nonoperative observation, physical therapy and activity modification login to view 10 more bullets operative early repair of serratus anterior avulsion login to view 2 more bullets neurolysis of the long thoracic nerve login to view 8 more bullets muscle transfer: split pectoralis major transfer login to view 16 more bullets nerve transfer login to view 7 more bullets scapulothoracic fusion login to view 16 more bullets Lateral Scapular Winging Pathophysiology deficit in trapezius function due to injury to the spinal accessory nerve (CN XI) neurologic iatrogenic login to view 4 more bullets traumatic login to view 5 more bullets Presentation similar to medial scapular winging vague, nonspecific shoulder girdle pain and fatigue muscle spasms weakness with overhead activity discomfort sitting against a chair may have neurologic symptoms from traction on the brachial plexus subjective shoulder instability failure of the scapula to provide a stable platform for rotation of the glenohumeral joint shoulder impingement inferior translation of the coracoacromial arch as scapula depresses secondary to loss of trapezius Evaluation physical examination superior medial scapula drops downward and protrudes posterior and lateral login to view 1 more bullet shoulder girdle appears depressed or drooping asymmetry or visible atrophy of the ipsilateral trapezius weakness of forward arm flexion and abduction scapular stabilization login to view 1 more bullet diagnostic studies electromyography login to view 1 more bullet Treatment nonoperative observation, physical therapy and activity modification login to view 5 more bullets operative exploration of the spinal accessory nerve, neurolysis, repair login to view 4 more bullets muscle transfer: levator scapulae, rhomboid major and rhomboid minor login to view 5 more bullets scapulothoracic fusion login to view 1 more bullet