Winged Scapula
What is a winged scapula?
A winged scapula is a condition in which the shoulder blade (scapula) protrudes abnormally from the back, creating a visible ridge or "wing" — particularly noticeable when the arm is raised forward or when performing a push-up. In a normally functioning shoulder, the scapula lies flat against the ribcage and moves smoothly in coordination with the arm. When the muscles that anchor the scapula to the thorax are weakened or the nerves supplying them are compromised, the scapula loses this stability and lifts away from the chest wall.
The visual appearance can be striking and is often what prompts people to seek help. The good news is that winged scapula responds well to physiotherapy in most cases — and understanding the specific cause is the first step to effective treatment.
What causes a winged scapula?
The cause determines both the prognosis and the treatment approach, so it is worth distinguishing between the two main categories.
The most common cause is weakness or inhibition of the serratus anterior muscle, which normally acts like a strap holding the medial border of the scapula against the ribcage. Serratus anterior weakness produces medial winging — where the inner border of the shoulder blade lifts away — and is typically caused by long thoracic nerve palsy (injury to the nerve supplying serratus anterior), overuse injuries in overhead athletes, or following surgery to the chest or axilla. Long thoracic nerve injuries can occur from direct trauma, prolonged compression (carrying a heavy backpack), viral illness, or traction injuries during sport or surgical procedures. Recovery depends on the degree of nerve injury — neuropraxia (temporary conduction block) recovers well with time and physiotherapy, while more significant nerve damage has a more variable prognosis.
Less commonly, trapezius muscle weakness — from spinal accessory nerve injury — produces lateral winging, where the upper outer portion of the scapula lifts away. This pattern is associated with neck dissection surgery, traumatic nerve injury, or radiation therapy to the neck and upper chest.
A third category worth acknowledging is voluntary or habitual winging — where the scapula protrudes due to postural habits, muscle imbalance or hypermobility rather than nerve injury. This responds very well to targeted physiotherapy and is often seen in adolescents and young adults, particularly those who are flexible or have Ehlers-Danlos Syndrome or generalised hypermobility.
What are the symptoms?
The visible protrusion of the shoulder blade is the defining feature. Associated symptoms vary depending on the underlying cause and severity, and may include shoulder pain, weakness when lifting the arm, difficulty reaching overhead or forward, fatigue with sustained arm activities, and aching around the shoulder blade and upper back. Some patients notice their posture has changed — the affected shoulder appearing lower, more rounded, or sitting differently to the other side.
In nerve-related winged scapula, there may also be pain or altered sensation along the course of the affected nerve.
How is it diagnosed?
Diagnosis is primarily clinical. A physiotherapist will assess the degree and pattern of winging, the strength of serratus anterior, trapezius and other periscapular muscles, and the neurological status of the long thoracic and spinal accessory nerves. The pattern of winging — medial versus lateral, and whether it is present at rest or only with movement — provides important diagnostic information.
Where nerve injury is suspected, nerve conduction studies and electromyography (EMG) may be requested to assess the degree of nerve damage and guide prognosis. MRI or ultrasound of the shoulder can rule out structural causes of similar-appearing symptoms.
How can physiotherapy help?
The physiotherapy approach depends significantly on the underlying cause.
For nerve-related winged scapula — particularly long thoracic nerve palsy — the initial phase focuses on protecting the recovering nerve, maintaining range of motion, and preventing secondary complications from abnormal scapular positioning including shoulder impingement and rotator cuff irritation. As nerve function returns, progressive serratus anterior reactivation and strengthening is introduced in a very careful, graded way — overloading a recovering nerve can impede recovery. Taping techniques that help position the scapula while the serratus recovers function can provide useful short-term support.
For postural, muscular or hypermobility-related winging, the approach is more directly corrective — serratus anterior strengthening through progressive push-up variations and protraction exercises, lower trapezius strengthening to control scapular upward rotation, and thoracic spine mobility work to optimise the platform on which the scapula sits. Real time ultrasound can assist in retraining serratus anterior activation in patients who are struggling to isolate and engage the muscle effectively.
For overhead athletes — swimmers, throwers, gymnasts and racquet sport players — rehabilitation also addresses sport-specific movement patterns and the biomechanical factors that may have contributed to the overuse component of the injury. Clinical Pilates is a valuable tool in rehabilitation, particularly for developing the dynamic scapular control needed for functional upper limb activities.
For patients with hypermobility or Ehlers-Danlos Syndrome, the rehabilitation approach acknowledges the systemic context — building active muscular stability around a shoulder that lacks normal passive restraint requires a more comprehensive and sustained program than equivalent work in a non-hypermobile patient.
Our physiotherapists Bethany Kippen, Emma Cameron and Yulia Khasyanova all have experience in shoulder and scapular rehabilitation. Yulia's specialist background in hypermobility and connective tissue disorders is particularly relevant for patients with hypermobility-related winging. All are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
A winged scapula is a condition in which the shoulder blade (scapula) protrudes abnormally from the back, creating a visible ridge or "wing" — particularly noticeable when the arm is raised forward or when performing a push-up. In a normally functioning shoulder, the scapula lies flat against the ribcage and moves smoothly in coordination with the arm. When the muscles that anchor the scapula to the thorax are weakened or the nerves supplying them are compromised, the scapula loses this stability and lifts away from the chest wall.
The visual appearance can be striking and is often what prompts people to seek help. The good news is that winged scapula responds well to physiotherapy in most cases — and understanding the specific cause is the first step to effective treatment.
What causes a winged scapula?
The cause determines both the prognosis and the treatment approach, so it is worth distinguishing between the two main categories.
The most common cause is weakness or inhibition of the serratus anterior muscle, which normally acts like a strap holding the medial border of the scapula against the ribcage. Serratus anterior weakness produces medial winging — where the inner border of the shoulder blade lifts away — and is typically caused by long thoracic nerve palsy (injury to the nerve supplying serratus anterior), overuse injuries in overhead athletes, or following surgery to the chest or axilla. Long thoracic nerve injuries can occur from direct trauma, prolonged compression (carrying a heavy backpack), viral illness, or traction injuries during sport or surgical procedures. Recovery depends on the degree of nerve injury — neuropraxia (temporary conduction block) recovers well with time and physiotherapy, while more significant nerve damage has a more variable prognosis.
Less commonly, trapezius muscle weakness — from spinal accessory nerve injury — produces lateral winging, where the upper outer portion of the scapula lifts away. This pattern is associated with neck dissection surgery, traumatic nerve injury, or radiation therapy to the neck and upper chest.
A third category worth acknowledging is voluntary or habitual winging — where the scapula protrudes due to postural habits, muscle imbalance or hypermobility rather than nerve injury. This responds very well to targeted physiotherapy and is often seen in adolescents and young adults, particularly those who are flexible or have Ehlers-Danlos Syndrome or generalised hypermobility.
What are the symptoms?
The visible protrusion of the shoulder blade is the defining feature. Associated symptoms vary depending on the underlying cause and severity, and may include shoulder pain, weakness when lifting the arm, difficulty reaching overhead or forward, fatigue with sustained arm activities, and aching around the shoulder blade and upper back. Some patients notice their posture has changed — the affected shoulder appearing lower, more rounded, or sitting differently to the other side.
In nerve-related winged scapula, there may also be pain or altered sensation along the course of the affected nerve.
How is it diagnosed?
Diagnosis is primarily clinical. A physiotherapist will assess the degree and pattern of winging, the strength of serratus anterior, trapezius and other periscapular muscles, and the neurological status of the long thoracic and spinal accessory nerves. The pattern of winging — medial versus lateral, and whether it is present at rest or only with movement — provides important diagnostic information.
Where nerve injury is suspected, nerve conduction studies and electromyography (EMG) may be requested to assess the degree of nerve damage and guide prognosis. MRI or ultrasound of the shoulder can rule out structural causes of similar-appearing symptoms.
How can physiotherapy help?
The physiotherapy approach depends significantly on the underlying cause.
For nerve-related winged scapula — particularly long thoracic nerve palsy — the initial phase focuses on protecting the recovering nerve, maintaining range of motion, and preventing secondary complications from abnormal scapular positioning including shoulder impingement and rotator cuff irritation. As nerve function returns, progressive serratus anterior reactivation and strengthening is introduced in a very careful, graded way — overloading a recovering nerve can impede recovery. Taping techniques that help position the scapula while the serratus recovers function can provide useful short-term support.
For postural, muscular or hypermobility-related winging, the approach is more directly corrective — serratus anterior strengthening through progressive push-up variations and protraction exercises, lower trapezius strengthening to control scapular upward rotation, and thoracic spine mobility work to optimise the platform on which the scapula sits. Real time ultrasound can assist in retraining serratus anterior activation in patients who are struggling to isolate and engage the muscle effectively.
For overhead athletes — swimmers, throwers, gymnasts and racquet sport players — rehabilitation also addresses sport-specific movement patterns and the biomechanical factors that may have contributed to the overuse component of the injury. Clinical Pilates is a valuable tool in rehabilitation, particularly for developing the dynamic scapular control needed for functional upper limb activities.
For patients with hypermobility or Ehlers-Danlos Syndrome, the rehabilitation approach acknowledges the systemic context — building active muscular stability around a shoulder that lacks normal passive restraint requires a more comprehensive and sustained program than equivalent work in a non-hypermobile patient.
Our physiotherapists Bethany Kippen, Emma Cameron and Yulia Khasyanova all have experience in shoulder and scapular rehabilitation. Yulia's specialist background in hypermobility and connective tissue disorders is particularly relevant for patients with hypermobility-related winging. All are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
