Scapular winging secondary to serratus anterior dysfunction: analysis of clinical presentations and etiology in a consecutive series of 96 patients

J Shoulder Elbow Surg. 2021 Oct;30(10):2336-2343. doi: 10.1016/j.jse.2021.02.012. Epub 2021 Mar 4.


Background: This study aimed to establish the relative incidence of etiologies causing serratus anterior (SA) dysfunction in patients with proven abnormality on needle electromyography.

Methods: This was a retrospective review of patients with scapular winging secondary to SA dysfunction. Each patient underwent a detailed clinical, radiological, and neurophysiological assessment to arrive at the precise etiological diagnosis. Patients with atypical clinical features were referred for a neurologist's assessment. Hematological and genetic testing were requested at the discretion of the neurologist. A scapular winging severity score based on clinical signs was devised to aid clinical grading.

Results: Between 2014 and 2020, a consecutive series of 108 patients with suspected SA dysfunction were assessed, of whom 96 met the inclusion criteria. There were 34 females and 62 males, with a mean age of 38 years (range, 15-77 years). Winging affected the right scapulae in 69 patients, the left scapulae in 17 patients, and was bilateral in 10 patients. This was caused by a myopathic disorder in 12 (12%) patients. Eighty-four (88%) patients had a long thoracic nerve lesion, caused by cervical pathology (2), iatrogenic injury (2), trauma (33), and neuralgic amyotrophy (NA) (47). Among those with NA, winging resolved spontaneously within 3 years of onset in 22 patients (mean duration, 16 months; range, 3-36 months). No patients recovered fully if their duration of winging lasted longer than 3 years. Patients with palsy secondary to NA tended to have a worse severity of winging than those due to a traumatic cause (P = .04).

Conclusion: NA accounted for approximately half of the patients with SA dysfunction; therefore, it is essential to also consider the differentials of myopathy, trauma, iatrogenic injury, and spinal pathology. We recommend the judicious employment of ancillary tests and a low threshold of referral to a neurologist, in order to arrive at the exact diagnosis to accurately guide patient treatment.

Keywords: Parsonage-Turner syndrome; Serratus anterior; brachial neuritis; dyskinesis; facioscapulohumeral dystrophy; muscular dystrophy; neuralgic amyotrophy; scapular winging.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Electromyography
  • Female
  • Humans
  • Male
  • Middle Aged
  • Muscle, Skeletal*
  • Paralysis
  • Retrospective Studies
  • Scapula* / diagnostic imaging
  • Young Adult