A Woman with Non-Traumatic Scapular Winging: A Case Report

Case Diagnosis: Idiopathic Winged Scapula

Case Description or Program Description: A 70 year old woman presented to an orthopedic clinic with a few months of right shoulder pain and instability, worse with right upper extremity overhead motions without any known inciting event. On physical exam, shoulder external rotation was limited to 40 degrees but otherwise range-of-motion was intact. Exam also elicited 5/5 motor strength in the extremity and negative empty can, Neer’s, and Hawkins tests. The patient had medial scapular winging that was not caught on initial evaluation and was discovered by outpatient physical therapy later on. After 8 weeks of outpatient physical therapy, the patient had decreased pain but continued instability with overhead motions. An EMG study was ordered to assess for neurological causes of the patient’s weakness and instability.

Setting: Outpatient Physiatry Clinic

Assessment/Results: EMG showed acute/subacute denervation, 3+ fibrillation potentials, positive sharp waves, and reduced recruitment in the right serratus anterior muscle. Findings of the study were consistent with a right long thoracic mononeuropathy with evidence of active and ongoing denervation.

Discussion (relevance): Long thoracic neuropathies are possible in atraumatic cases without history of muscular dystrophy; however, patient’s classically present after trauma. In this rare case, symptoms presented insidiously without any preceding trauma or known muscular disorder. In patient presentations with atraumatic history, clinicians may not look for scapular winging on physical exam, thus resulting in delayed diagnosis. Careful initial physical exam screening and prompt EMG evaluation are key for timely diagnosis of idiopathic scapular winging. Early identification allows for physicians and therapy staff to tailor the rehabilitation plan to the patient’s specific needs in order to prevent chronic disability and improve functional outcomes.

Conclusions: Understanding idiopathic presentations of scapular winging is crucial for clinicians to accurately diagnose and effectively manage patients early, ensuring appropriate interventions and optimal outcomes.