Scapular Winging

with Rehab

ExitCare ImageScapular winging syndrome is also known as serratus anterior palsy or long thoracic nerve injury. The condition is an uncommon injury to the nervous system. The condition is caused by injury to the long thoracic nerve that runs through the neck and shoulder. Injury to the shoulder, such as a fall or repetitive stress on the shoulder causes the nerve to become stretched. Occasionally the injury is the result of an infection of the nerve. Damage to the long thoracic nerve results in weakness of the serratus anterior muscle. The serratus anterior muscle is responsible for controlling the shoulder blade (scapula). Weakness in this muscle results in a instability (winging) of the scapula.

SYMPTOMS

  • Pain and weakness in the shoulder (usually the back of the shoulder) that is often diffuse or unable to localize.

  • Loss of or decrease in shoulder function.

  • Upper back pain while sitting, due to the scapula pressing on the back of the chair.

  • Visible deformity in the back of the shoulder.

CAUSES

Scapular winging is caused by stretching of the long thoracic nerve. Common mechanisms of injury include:

  • Viral illness.

  • Repetitive and/or stressful use of the shoulder.

  • Falling onto the shoulder with the head and neck stretched away from the shoulder.

RISK INCREASES WITH:

  • Contact sports (football, rugby, lacrosse, or soccer).

  • Activities involving overhead arm movement (baseball, volleyball, or racquet sports).

  • Poor strength and flexibility.

PREVENTION

  • Warm up and stretch properly before activity.

  • Allow for adequate recovery between workouts.

  • Maintain physical fitness:

  • Strength, flexibility, and endurance.

  • Cardiovascular fitness.

  • Learn and use proper technique. When possible, have a coach correct improper technique.

PROGNOSIS

Scapular winging normally resolves spontaneously within 18 months. In rare circumstances surgery is recommended.

RELATED COMPLICATIONS

  • Permanent nerve damage, including pain, numbness, tingle, or weakness.

  • Shoulder weakness.

  • Recurrent shoulder pain.

  • Inability to compete in athletics.

TREATMENT

Treatment initially involves resting from any activities that aggravate your symptoms. The use of ice and medication may help reduce pain and inflammation. The use of strengthening and stretching exercises may help reduce pain with activity, specifically shoulder exercises that improve range of motion. These exercises may be performed at home or with referral to a therapist. If symptoms persist for greater than 6 months despite non-surgical (conservative) treatment, then surgery may be recommended. Surgery is only used for the most serious cases and the purpose is to regain function, not to allow an athlete to return to sports.

MEDICATION

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication for 7 days before surgery.

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

HEAT AND COLD

  • Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or massage the area with a piece of ice (ice massage).

  • Heat treatment may be used prior to performing the stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or soak the injury in warm water.

SEEK MEDICAL CARE IF:

  • Treatment seems to offer no benefit, or the condition worsens.

  • Any medications produce adverse side effects.

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Scapular Winging (Serratus Anterior Palsy, Long Thoracic Nerve Injury)

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

ExitCare Image ROM - Pendulum

  • Bend at the waist so that your right / left arm falls away from your body. Support yourself with your opposite hand on a solid surface, such as a table or a countertop.

  • Your right / left arm should be perpendicular to the ground. If it is not perpendicular, you need to lean over farther. Relax the muscles in your right / left arm and shoulder as much as possible.

  • Gently sway your hips and trunk so they move your right / left arm without any use of your right / left shoulder muscles.

  • Progress your movements so that your right / left arm moves side to side, then forward and backward, and finally, both clockwise and counterclockwise.

  • Complete __________ repetitions in each direction. Many people use this exercise to relieve discomfort in their shoulder as well as to gain range of motion.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Flexion, Seated

  • Sit in a firm chair so that your right / left forearm can rest on a table or on a table or countertop. Your right / left elbow should rest below the height of your shoulder so that your shoulder feels supported and not tense or uncomfortable.

  • Keeping your right / left shoulder relaxed, lean forward at your waist, allowing your right / left hand to slide forward. Bend forward until you feel a moderate stretch in your shoulder, but before you feel an increase in your pain.

  • Hold __________ seconds. Slowly return to your starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Flexion, Standing

  • Stand with good posture. With an underhand grip on your right / left and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder-width apart.

  • Keeping your right / left elbow straight and shoulder muscles relaxed, push the stick with your opposite hand to raise your right / left arm in front of your body and then overhead. Raise your arm until you feel a stretch in your right / left shoulder, but before you have increased shoulder pain.

  • Avoid shrugging your right / left shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine. Hold __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Abduction, Supine

  • Stand with good posture. With an underhand grip on your right / left and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder-width apart.

  • Keeping your right / left elbow straight and shoulder muscles relaxed, push the stick with your opposite hand to raise your right / left arm out to the side of your body and then overhead. Raise your arm until you feel a stretch in your right / left shoulder, but before you have increased shoulder pain.

  • Avoid shrugging your right / left shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine. Hold __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image ROM – Flexion, Active-Assisted

  • Lie on your back. You may bend your knees for comfort.

  • Grasp a broomstick or cane so your hands are about shoulder-width apart. Your right / left hand should grip the end of the stick/cane so that your hand is positioned "thumbs-up," as if you were about to shake hands.

  • Using your healthy arm to lead, raise your right / left arm overhead until you feel a gentle stretch in your shoulder. Hold __________ seconds.

  • Use the stick/cane to assist in returning your right / left arm to its starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTHENING EXERCISES - Scapular Winging (Serratus Anterior Palsy, Long Thoracic Nerve Injury)

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress with the resistance and repetition exercises only as your caregiver advises.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

  • During your recovery, avoid activity or exercises which involve actions that place your injured hand or elbow above your head or behind your back or head. These positions stress the tissues which are trying to heal.

ExitCare Image STRENGTH - Scapular Depression and Adduction

  • With good posture, sit on a firm chair. Supported your arms in front of you with pillows, arm rests or a table top. Have your elbows in line with the sides of your body.

  • Gently draw your shoulder blades down and toward your mid-back spine. Gradually increase the tension without tensing the muscles along the top of your shoulders and the back of your neck.

  • Hold for __________ seconds. Slowly release the tension and relax your muscles completely before completing the next repetition.

  • After you have practiced this exercise, remove the arm support and complete it in standing as well as sitting.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Standing

  • Stand arms-length away from a wall. Place your hands on the wall, keeping your elbows straight.

  • Begin by dropping your shoulder blades down and toward your mid-back spine.

  • To strengthen your protractors, keep your shoulder blades down, but slide them forward on your rib cage. It will feel as if you are lifting the back of your rib cage away from the wall. This is a subtle motion and can be challenging to complete. Ask your clinician for further instruction if you are not sure you are doing the exercise correctly.

  • Hold for __________ seconds. Slowly return to the starting position, resting the muscles completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Supine

  • Lie on your back on a firm surface. Extend your right / left arm straight into the air while holding a __________ weight in your hand.

  • Keeping your head and back in place, lift your shoulder off the floor.

  • Hold __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Quadruped

  • Get onto your hands and knees with your shoulders directly over your hands (or as close as you comfortably can be).

  • Keeping your elbows locked, lift the back of your rib cage up into your shoulder blades so your mid-back rounds-out. Keep your neck muscles relaxed.

  • Hold this position for __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH – Scapular Depressors

  • Keeping your feet on the floor, lift your bottom from the seat and lock your elbows.

  • Keeping your elbows straight, allow gravity to pull your body weight down. Your shoulders will rise toward your ears.

  • Raise your body against gravity by drawing your shoulder blades down your back, shortening the distance between your shoulders and ears. Although your feet should always maintain contact with the floor, your feet should progressively support less body weight as you get stronger.

  • Hold __________ seconds. In a controlled and slow manner, lower your body weight to begin the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Extensors, Prone

  • Lie on your stomach on a firm surface so that your right / left arm overhangs the edge. Rest your forehead on your opposite forearm. With your thumb facing away from your body and your elbow straight, hold a __________ weight in your hand.

  • Squeeze your right / left shoulder blade to your mid-back spine and then slowly raise your arm behind you to the height of the bed.

  • Hold for __________ seconds. Slowly reverse the directions and return to the starting position, controlling the weight as you lower your arm.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Horizontal Abductors

Choose one of the two oppositions to complete this exercise.

Prone: lying on stomach:

  • Lie on your stomach on a firm surface so that your right / left arm overhangs the edge. Rest your forehead on your opposite forearm. With your palm facing the floor and your elbow straight, hold a __________ weight in your hand.

  • Squeeze your right / left shoulder blade to your mid-back spine and then slowly raise your arm to the height of the bed.

  • Hold for __________ seconds. Slowly reverse the directions and return to the starting position, controlling the weight as you lower your arm.

Repeat __________ times. Complete this exercise __________ times per day.

Standing:

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • Grasp an end of the band/tubing in each hand and have your palms face each other. Straighten your elbows and lift your hands straight in front of you at shoulder height. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeeze your shoulder blades together. Keeping your elbows locked and your hands at shoulder-height, bring your hands out to your side.

  • Hold __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Retractors

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing in each hand. Straighten your elbows and lift your hands straight in front of you at shoulder height. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, draw your elbows back as you bend them. Keep your upper arm lifted away from your body throughout the exercise.

  • Hold __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Extensors

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a thumbs-up grip, grasp an end of the band/tubing in each hand. Straighten your elbows and lift your hands straight in front of you at shoulder height. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, pull your hands down to the sides of your thighs. Do not allow your hands to go behind you.

  • Hold for __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Retractors and External Rotators

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing in each hand. Bend your elbows 90 degrees and lift your elbows to shoulder height at your sides. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, rotate your shoulder so that your upper arm and elbow remain stationary, but your fists travel upward to head-height.

  • Hold __________ for seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Retractors and External Rotators, Rowing

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing in each hand. Straighten your elbows and lift your hands straight in front of you at shoulder height. Step back away from the secured end of band/tubing until it becomes tense.

  • Step 1: Squeeze your shoulder blades together. Bending your elbows, draw your hands to your chest as if you are rowing a boat. At the end of this motion, your hands and elbow should be at shoulder-height and your elbows should be out to your sides.

  • Step 2: Rotate your shoulder to raise your hands above your head. Your forearms should be vertical and your upper-arms should be horizontal.

  • Hold for __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Retractors and Elevators

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a thumbs-up grip, grasp an end of the band/tubing in each hand. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, straighten your elbows and lift your hands straight over your head.

  • Hold for __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.