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Special Test

Scapular Winging Test

Scapular Winging is a clinical syndrome that is caused by a loss of the normal scapular stability that make the inferior border of scapula moves medially or laterally.

To evaluate the Scapular Winging, you should perform the Scapular Winging Test or as it called Wall Push-up Test.

Medial Scapular Winging is seen in:

  1. Serratus anterior muscle weakness.
  2. Long thoracic nerve dysfunction.

While Lateral Scapular Winging is seen in:

  1. Trapezius muscle weakness.
  2. Spinal accessory nerve (CN XI) dysfunction.

The Long thoracic nerve can get directly injured during thoracic surgery (first rib resection, introduction of chest drain etc.) or in case of direct trauma of the chest wall. Indirect injury can happen when the arm is overstretched in elevation. When there is no injury in the history, virus infection may be the reason of the nerve lesion.

See Also: Rotator Cuff of the Shoulder

How would you test for winging of the scapula?

The patient stands arms’ length from a wall. The patient is then asked to do a “wall push-up” 15 to 20 times. Any weakness of the scapular muscles or winging usually shows up with 5 to 10 push-ups. For stronger or younger people, a normal pushup on the floor shows similar scapular changes, usually with fewer repetitions.

Goldbeck and Davies have taken this test further in what they describe as a closed kinetic chain upper extremity stability test. In Scapular Winging Test, two markers (e.g., tape) are placed 91 cm (36 inches) apart. Patients assume the push-up position with one hand on each marker. When the examiner says “go,” the subject moves one hand to touch the other, returns it to the original position, and then does the same with the other hand, repeating the motions for 15 seconds.

Females use a modified push-up position (on knees instead of feet). The examiner counts the number of touches or crossovers made in the allotted time. The test is repeated three times, and the average is the test score. This test is designed primarily for young, active patients.

Scapular Winging test
Winged Scapula Test

What does a positive Scapular Winging Test mean?

Winged Scapula Test is positive if the inferior border of the scapula migrates medially which is called Medial Scapular Winging .

If the inferior boarder of the scapula migrates laterally then it’s called Lateral Scapular Winging.

Primary scapular winging implies that the winging is the result of muscle weakness of one of the scapular muscle stabilizers. This, in turn, disrupts the normal muscle force couple balance of the scapulothoracic complex. Secondary scapular winging implies that the normal movement of the scapula is altered because of pathology in the glenohumeral joint.

Dynamic scapular winging (i.e., winging with movement) may be caused by a lesion of the long thoracic nerve affecting serratus anterior, trapezius palsy (spinal accessory nerve), rhomboid weakness, multidirectional instability, voluntary action, or a painful shoulder resulting in splinting of the glenohumeral joint, which in turn causes reverse scapulohumeral rhythm.

Related Anatomy

Scapula:

Scapula is a flat bone that spans from the second rib to the seventh rib and serves as an attachment for 17 muscles. It is anteverted on chest wall approximately 30 degrees relative to the body.

Long thoracic Nerve:

Long thoracic Nerve is the first branch of the C5-C6-C7 roots of the Brachial Plexus, it’s the motor nerve to the serratus anterior muscle. It’s 24 cm in length from origin to the serratus anterior muscle, which makes it susceptible to mechanical injury.

See Also: Brachial Plexus Anatomy

Serratus anterior Muscle:

  • It’s a broad and flat sheet of muscle that originates from the 1-9 ribs and insert into the costal surface of the medial border of the scapula.
  • Its function is preventing winging of the scapula.
  • Serratus anterior Muscle is innervated by the Long thoracic Nerve.
Medial Scapular Winging 1
Serratus anterior muscle and Long thoracic nerve Anatomy

Trapezius Muscle

  • The trapezius muscle is the most superficial back muscle. It is a flat triangular muscle that runs from the superior nuchal line and external occipital protuberance of the occipital bone to the spinous process of T12 and is the largest muscle attachment in the body.
  • Its insertion can be traced from the entire superior aspect of the spine of the scapula, the medial aspect of the acromion, and the posterior aspect of the lateral third of the clavicle.

This muscle traditionally is divided into middle, upper, and lower parts, according to anatomy and function:

  1. The middle part originates from C7 and forms the cervicothoracic part of the muscle.
  2. The lower part, attaching to the apex of the scapular spine, is relatively thin.
  3. The upper part is very thin, and yet it has the most mechanical and clinical importance to the cervical spine.
  • The innervation for the trapezius comes from the accessory nerve (CN XI) and fibers from the anterior (ventral) rami of the third and fourth cervical spinal nerves.
  • The different parts of this muscle provide a variety of actions on the shoulder girdle, including elevation and retraction of the scapula.
  • When the shoulder girdle is fixed, the trapezius can produce ipsilateral side bending and contralateral rotation of the head and neck.
  • Working together, the trapezius muscles can produce symmetric extension of the neck and head.
  • In addition, the trapezius muscle can produce scapular adduction (all three parts), and upward rotation of the scapula (primarily the superior and inferior parts).
Trapezius muscle anatomy
Trapezius Muscle Anatomy

Scapular Winging Syndrome

This syndrome is characterized by an inability to elevate and/ or lower the arm without the scapula winging or its inferior angle tilting. This syndrome results from a weakness and adaptive shortness of the serratus anterior, with accompanying shortness of the pectoralis minor and scapulohumeral muscles.

Intervention should focus on stretching the pectoralis minor to correct the tilting and serratus anterior for strengthening and retraining.

Reference

  • Campbel’s Operative Orthopaedics 13th Book
  • Department of Orthopaedics, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250, 16th St, 7th Floor, Tower Bld, Rm 745, Santa Monica, CA 90404 USA
  • Goldbeck TG, Davies GJ. Test-retest reliability of the closed kinetic chain–upper extremity stability test: a clinical field test. J Sports Rehab. 2000;9:35–43.
  • Tucci HT, Martins J, de Carvalho Sposito G, et al. Closed kinetic chain upper extremity stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC Musculoskelet Disord. 2014;15:1–9. Pubmed
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