Winged scapula in a man with new neck pain and shoulder weakness.

Unilateral scapular winging most commonly results from neuropathy of the long thoracic nerve that innervates the serratus anterior muscle (1, 2). We present a case illustrating a patient with a “winged scapula” on the left side (Fig. 1).

Fig. 1

Protrusion of the left scapula, illustrating scapular winging.

A winged scapula is the protrusion of the vertebral border of the scapula. The circuitous course of the long thoracic nerve predisposes it to injury or impingement. It may also rarely arise from a lesion of the accessory nerve or the dorsal nerve of the scapula, affecting the trapezius or rhomboids, respectively (1). Important etiologies causing nerve palsy include compression injury, trauma, vigorous exercise causing traction, or viral illnesses. At times the cause may be idiopathic (1, 3, 4). The condition is invariably missed on initial presentation due to lack of suspicion and rarity of presentation (3). Diagnosis is essentially clinical and should be considered in any patient presenting with shoulder pain or weakness, as delay in recognition may cause permanent disability (1, 3). In our case, inspection was positive for a subtle prominence of the medial border of the scapula with accentuation on abduction of arm.

A majority of patients respond to conservative treatments involving physical therapy and range of motion exercises (2, 3). If conservative treatment fails over the course of 6 months to 1 year, surgical intervention may be considered (2). Failure to respond or worsening of symptoms requires further investigations such as electromyography and MRI (3). Since the long thoracic nerve branches off of the brachial plexus, it is important to rule out cervical nerve impingement, specifically impingement of C5–C7. This can be a serious etiology of scapular winging which can produce progressive weakness and may require surgical intervention (3). MRI of the cervical spine is vital to define the nature, site, and degree of compression of the nerve roots contributing to the presentation of scapular winging (3).