Scapular Winging
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Direct answer
Scapular winging is abnormal prominence of the scapula, most often its medial border, away from the chest wall, and the commonest cause is long thoracic nerve palsy. Paralysis of serratus anterior produces medial winging that is most obvious on forward flexion of the arm. Spinal accessory nerve palsy, which weakens trapezius, causes a drooping, rotated scapula instead, and the wall push-up test helps separate the two.
What you must remember
- Stabilisers: serratus anterior holds the scapula against the chest wall, supplied by the long thoracic nerve from C5 to C7, while trapezius is supplied by the spinal accessory nerve and cervical branches.
- Long thoracic nerve palsy: causes medial border winging, worst on forward flexion or on pushing against resistance.
- Spinal accessory palsy: weakens trapezius, so the shoulder droops, the scapula rotates and elevation of the arm above shoulder height is lost.
- Wall push-up test: the patient pushes against a wall, which accentuates medial winging in serratus anterior palsy.
- Causes of long thoracic palsy: brachial neuritis, traction injury and surgery, with many cases having no obvious trigger.
- Electrodiagnosis: nerve conduction studies and EMG confirm the lesion and its extent, and exclude a cervical or thoracic cause.
- Management: most long thoracic palsies recover over months, so physiotherapy comes first, with tendon transfer or scapulothoracic fusion reserved for persisting disability.
Comparing the two common palsies
Both palsies produce an abnormal scapula, but the muscle paralysed and the pattern of winging differ, and the difference is what examiners ask about. The table compares the features that separate the two.
| Feature | Long thoracic nerve | Spinal accessory nerve |
|---|---|---|
| Muscle paralysed | Serratus anterior | Trapezius |
| Winging pattern | Medial border lifts off the chest wall | Drooping, rotated scapula with weak elevation |
| Worst movement | Forward flexion and pushing against a wall | Shrugging and abduction above shoulder height |
| Typical clue | Wall push-up test accentuates winging | Shoulder sags and the arm cannot be raised fully |
The clinical pattern guides the diagnosis, but electrodiagnosis confirms the nerve. A lesion that looks like scapular winging may also come from a muscle or a bony cause, so a careful examination of the neck and shoulder is always needed. In the viva, the expected sequence is to name the muscle, state the nerve that supplies it, and then describe the test that makes the deformity visible.
Where the exam tries to catch you
Scapular winging questions are usually won by naming the palsy from the pattern of deformity and the muscle weakness.
- Trap: attributing all scapular winging to the long thoracic nerve. Correct: spinal accessory palsy produces a drooping, rotated scapula with less classic medial winging, so the pattern matters.
- Trap: operating early for a long thoracic nerve palsy. Correct: most recover over months, so observation and physiotherapy come first unless the picture is severe and persistent.
- Trap: using the wall push-up test to diagnose trapezius palsy. Correct: the test accentuates serratus weakness, while trapezius is assessed by shrugging and elevating the arm against resistance.
Frequently asked questions
Which nerve is injured in medial scapular winging?
The long thoracic nerve is injured in medial scapular winging, because it supplies serratus anterior. Paralysis of this muscle lets the medial border of the scapula lift away from the chest wall. Winging is most obvious on forward flexion of the arm.
What is the wall push-up test used for in scapular winging?
The wall push-up test is used to accentuate medial scapular winging when serratus anterior is weak. The patient pushes the hands against a wall, and the winging becomes more visible. It helps confirm long thoracic nerve palsy during clinical examination.
Which muscle is paralysed in long thoracic nerve palsy?
Serratus anterior is paralysed in long thoracic nerve palsy, because the long thoracic nerve supplies it. Loss of this muscle causes medial scapular winging and weakness in forward flexion of the arm. Electrodiagnosis is used to confirm the lesion.
Does long thoracic nerve palsy usually need surgery?
Long thoracic nerve palsy does not usually need surgery, because many cases recover over several months with physiotherapy. Surgery such as tendon transfer or scapulothoracic fusion is reserved for persistent and disabling palsy. Management depends on the severity and duration of the deficit.