4. The patient reports spontaneous severe pain near his right shoulder, unrelated to any trauma. Two weeks later, the shoulder protrudes in a winglike position on the upper back, made more apparent when the same side arm pushes against resistance. He has limited ability to lift that arm above his head.
Diagnosis: Winged scapula injury is due to dysfunction of the anterior serratus muscle, which is supplied by the injury-prone long thoracic nerve.
Damage can be caused by a contusion or blunt trauma of the shoulder, traction of the neck, and sometimes a viral illness. Paralysis of the serratus anterior muscle has been well documented among athletes and laborers. To identify an injury, the patient stands facing a wall from about two feet away and then pushes against the wall with flat palms at waist level. Conservative treatment is often recommended; if after 6-24 months if there is no recovery, patients become candidates for corrective surgery.
For more information, see “Scapular winging: anatomical review, diagnosis, and treatments.” Curr Rev Musculoskelet Med. 2008;1(1):1-11.
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For more on peripheral neuropathies, see “An easy approach to evaluating peripheral neuropathy.” J Fam Pract. 2006 October;55(10):853-861.
Photographs courtesy of Ashley Owens and Alexander Orban. They are included for illustration only and do not represent actual cases.