A 30-year-old man presented to our clinic with right winging scapula, shoulder pain, decreased range of motion, and weak muscle strength, following acromioplasty and clavicular osteotomy after traumatic injury. A carbon fiber scapulothoracic orthosis was designed and laminated in our clinic to reduce scapular winging, alleviate pain, and increase active range of motion of the shoulder. ( J Prosthet Orthot . 2008;20:14–18.)
The scapula is the largest bone of the shoulder complex and has the greatest number of muscles attached to it. The scapula forms the mobile base from which the free upper limb acts.1
Winging of the scapula is defined as a prominence of the medial or vertebral border of the scapula. The winged scapula may also be rotated or displaced medially or laterally.2 Winging of the scapula is often seen subsequent to an injury which involves the brachial plexus, an isolated paralysis of the serratus anterior, or a symptom of fascioscapulo humeral muscular dystrophy.3
The position of the winged scapula depends on the specific nerve injury and the resulting pattern of muscle paralysis.3
An injury to the long thoracic nerve causes paralysis of the serratus anterior. The scapula assumes a high position with the upper medial corner rotated laterally and the inferior angle medially. Injury to the spinal accessory nerve causes paralysis of trapezius muscle. In this scenario the scapula assumes a lower position with lateral rotation of the inferior angle and medial rotation of the upper corner. An injury to the dorsal scapular nerve causes paralysis of the levator scapular and rhomboid muscles. The resultant winging is mild and similar to that caused by the paralysis of the trapezius.3
The most common cause of winging scapula is paralysis of the serratus anterior muscle. Fiddian and King,2 presented a detailed classification of several types of winging due to various causes.
Biceps brachii, as a strong antagonist of the serratus anterior, is a leading factor in the production of classic "winging of scapula."4 The weight of the forearm and hand is transmitted through the biceps and coracobrachialis muscles to the coracoid process and supraglenoid tubercle, pulling the scapula to cause the winging.4 The disappearance of winging by the motion of flexion of forearm is evidence that the biceps muscle, rather than the deltoid, is responsible for this deformity. 4
Like other muscle palsies, the isolated serratus anterior palsy can be divided into two stages: 1) acute paralysis stage with possible recovery and 2) later permanent palsy stage. In the acute paralysis stage the goal of the orthotic treatment is to position the muscle in complete relaxation, eliminating the action of the antagonistic muscles, and thereby favoring recovery5 through restoring the tonicity of the paralyzed muscle. For the permanent serratus palsy stage, the orthotic treatment: a) must allow complete use of the arm, b) must stabilize the winged scapula in its normal position against the chest wall, and c) must prevent scapular rotation.5
Goodman et al6 reported traumatic etiology of long thoracic nerve palsy to carry a poorer prognosis than lesions due to toxic, infectious, allergic, or idiopathic causes. The authors also found that a delay in initiating therapeutic measures resulted in poorer outcome. The authors recommended a serratus restraint strap to limit shoulder abduction and flexion to 30° to be worn for a minimum of 4 to 6 weeks of the onset of the long thoracic nerve palsy.
The standard physical therapy treatment for serratus anterior palsy consists of modalities and manual therapy for pain control and to aid healing, therapeutic exercises to strengthen the shoulder girdle, range of motion exercises to stretch tight structures, neuromuscular reeducation using functional electrical stimulation, and bracing. The purpose of the brace is to place the scapula in a good anatomical position as well as to prevent the overstretching and repeated weakening of the serratus anterior that occur with the winging while the muscle is being strengthened. The braces currently available are prefabricated out of canvas or light fabric with Velcro straps. These braces have been proven ineffective, as they do not provide the compression and stability needed in the scapula to prevent winging and excessive rotation.7
The primary methods for the treatment of winging scapula are surgical stabilization of the scapula and orthotic stabilization of the scapula. Surgical correction is either by scapulodesis or muscle transfer. In scapulodesis, the scapula is fixed to the thoracic wall with screws, wires, or plates with or without bone graft to produce a solid fusion. Muscle transfer offers dynamic control and potential for nearly normal scapulothoracic movement.8
Atasoy and Majd3 surgically stabilized the scapula by drilling holes through the medial border of the scapula and using a graft of fascia lata muscle to tie down the scapula through the drilled holes to the underlying ribs.
For isolated paralysis of serratus anterior muscle, Iceton and Harris8 and Connor et al9 reported that transfer of the sternal part of the pectoralis major muscle to the lower pole of the scapula, closely replace the normal function of serratus anterior muscle. Iceton and Harris8 recommended scapulodesis for cases where paralysis of serratus anterior is accompanied by the paresis of other muscles.
Marin10 presented orthotic treatment with a scapular winger's brace for a series of 14 patients with long thoracic nerve palsy. The brace is made of a thick leather rectangular scapular pad, attached to two loops to form a figure-8. The inferior edge of the scapular pad is fastened to a waist belt with a strap, to prevent superior migration.
Horwitz and Tocantins4 designed an adjustable elbow rest made of light metal attached to a pelvic band. The elbow rest forces the humeral head upward and backward.
Wolf5 designed a metal brace with two metal cups supporting both affected and unaffected scapulae. Both metal cups are connected by three metal springs. The lowest spring loops around both the axillae and ends anteriorly in two spoons placed in infraclavicular fossae.
Johnson and Kendall11 designed a simpler version of Wolf's5 orthosis. They contoured a 5/8th inch spring steel bar into a brace. The ends of the bar were connected to two metal discs and rest on either side of the sternum below the sternal notch. A padded steel cup was attached to the posterior section of the bar to support the affected scapula.
Alsancak, Altinkaynak, and Kinik12 presented a case study of a patient with bilateral scapular winging due to bilateral facioscapulo humeral dystrophy. The authors designed a scapulothoracic fixation orthosis to prevent protraction, elevation, and rotation of the affected scapula. The orthosis is designed as a low density polyethylene jacket with anterior opening. Two scapular cups, indented within the jacket, allowed scapulothoracic fixation. The authors found their design to be superior both in terms of range of motion and muscle strength achieved, compared with the orthoses presented by Marin,10 and Johnson and Kendall.11
The patient is a 30-year-old man who states that on November 28, 2004, he was working at a supermarket when a box full of cans fell on his right shoulder. The patient underwent 4 months of physical therapy and pain medication with no improvement in pain. The patient then underwent arthroscopic surgery on May 30, 2005, for a distal clavicle excision and had 6 months of physical therapy and cortisone injections. The pain in the right shoulder and arm continued unabated. The patient was then referred to a pain clinic where he had injections in the neck, but had no improvement. The patient underwent another arthroscopy on January 1, 2006, with no improvement in pain. The patient was evaluated by one of the authors (Lissette Dozier, PT) on February 06, 2006. The patient reported constant 10/10 pain in the shoulder that radiated to the neck, numbness of the arm with occasional cramping, and tingling sensation under the arm. He also reported swelling of the shoulder and hand, and at times, the hand becoming extremely hot. The patient was unable to lie down on his back because the pressure of the arm caused unbearable pain. The patient reported that he was unable to sleep more than 3 hrs at night and only after taking Norco. The most recent electromyography study revealed involvement of long thoracic and suprascapular nerves. The patient was referred to Rehabilitation Institute of Chicago (RIC) for orthotic management in September 2006 ( Figure 1 ). At the initial evaluation a fiberglass (Delta-Lite conformable 4" fiberglass casting tape, BSN Medical, Inc. Charlotte, NC) impression was taken with the patient standing. A manually applied compression was applied to the right scapula as tolerated by the subject. A plaster mold was created ( Fig. 2 , Figure 3 ). The RIC team designed and laminated a Scapulothoracic orthosis. The patient has been wearing the brace three times a day for 2 to 3 hrs at a time. He is also using it while performing therapeutic exercises during the therapy sessions. He reports that he has increased range of motion and slightly less pain while wearing the brace ( Figure 4 , Figure 5 ). The patient continues to experience high levels of pain in the acromioclavicular joint from the clavicle impingement when he elevates the arm above 108°. The physical therapist (Lissette Dozier) has noted that the patient can do more exercises with the arm while wearing the orthosis, and is continuing to gain strength because of the use of the orthosis.
Instead of a single continuous polyethylene body jacket, such as that of Alsancak, Altinkaynak, and Kinik,12 this article presents an Orthosis with separate anterior and posterior carbon fiber-laminated panels that are attached to each other through adjustable Velcro straps on the sides ( Figure 5 , Figure 6 ). This gives the wearer total freedom to control the amount of Anterior–Posterior pressure. In addition to the lateral straps the two panels are also connected by an adjustable superior strap that traverses obliquely across the upper trapezius and clavicle of the affected side. This superior strap serves three functions: 1) it provides a depressing force on the elevated scapula, 2) the obliquity of the strap creates a derotational force on the rotated scapula, and 3) prevents inferior migration of the orthosis due to gravity and the tightening of the other four straps. The proposed orthosis is less bulky ( Figure 7 ) and provides improved adjustability compared with a single continuous jacket presented by Alsancak, Altinkaynak, and Kinik. 12
The initial fitting consisted of a polyethylene terephthalate copolymer (PETg) test orthosis. The trimlines were established and patient tested the fit and function for 4 weeks. Upon recheck, the trimlines were transferred to the positive mold. These trimlines were defined on the positive mold by adding plaster splinting to roll the edges to alleviate pressure in final laminated shells. The final orthosis was designed as a carbon lamination to provide rigid structure with minimal weight. The lay up for the lamination was as follows:
The carbon was buffed, hand sanded with wet/dry 800 grit paper, and sealed with clearcoat spray acrylic (Krylon).
Table 1 compares the active range of motion before and after the orthotic intervention. The flexion and abduction measurements were obtained with a goniometer. The internal and external rotation measurements were based on functional movement patterns. For internal rotation, the patient was asked to reach behind his back as far as he could go superiorly with the tip of his thumb, and the landmark was obtained and recorded. For external rotation, he reached behind his head as far as he could go inferiorly with the tip of his third (middle) finger. The data show a significant improvement in the active range of motion achieved after the orthotic intervention.
Table 2 compares the manual muscle testing using a dynamometer, before and after the orthotic intervention.
The results indicate 81% to 86% increase in active range of motion, and between 25% to 400% increase in muscle strength.
The combination of physical therapy and the orthotic management had a substantial improvement both in the range of motion and muscle strength. The patient still continues to gain strength. The orthosis has had a negligible affect on pain alleviation.
During the latest evaluation on January 8, 2007, the Physical Therapist (Lissette Dozier) has observed a 30% decrease in the scapular winging, and increased recruitment of the scapular musculature, and the patient reported his arm felt stronger.
Research studies need to be conducted to determine the best physical therapy treatment approach combined with the use of a well-designed and effective orthosis for winging of the scapula due to serratus anterior paralysis.
Disclosure: The authors declare no conflict of interest.
Correspondence to: Donald McGovern, CPO, FAAOP, Rehabilitation Institute of Chicago, 345 E. Superior Street, Chicago, IL 60611; e-mail:
DONALD MCGOVERN, CPO, FAAOP, is affiliated with Rehabilitation Institute of Chicago, Chicago, Illinois.
SYED RAHMAN, PhD, is an Orthotic Resident at Rehabilitation Institute of Chicago, Chicago, Illinois.
MICHAEL LAVEZZO, CO, is a Prosthetic Resident at Rehabilitation Institute of Chicago, Chicago, Illinois.
LISSETTE DOZIER, PT, is affiliated with Physical Therapy Chicago, Chicago, Illinois.