Atypical Electrodiagnostic Findings in Scapular Winging Secondary to
Multiple Neuropathies: A Case Series
Mitul Kapadia MD, MS3, Oluseum Olufade MD2, Gilbert Siu DO PhD2, Theera Vachranukunkiet, MD1, C.R. Sridhara MD1,2,3
1
MossRehab, Elkins Park, PA, 2Temple University Hospital, Philadelphia, PA
3
Jefferson University Hospital, Philadelphia, PA
ABSTRACT
Nerve / Sites
Setting: Electrodiagnostic laboratory at tertiary care rehabilitation center
Patients: Four patients, two males and two females, with mean age of 46 years (range 21-68 years) with scapular
winging.
Background: Scapular winging is an easily diagnosed condition seen by visible inspection. Causes of scapular winging
usually involve one nerve (long thoracic, spinal accessory or dorsal scapular nerve), resulting in either lateral or medial
scapular winging. We present a series of four patients for electrodiagnostic evaluation with atypical scapular winging.
Assessment & Results: One patient presented with right shoulder pain after a flu-like illness and electrodiagnostic
studies revealed an axon-loss neuropathy involving the right upper and middle spinal accessory nerve branches and dorsal
scapular nerve. The second patient presented with right arm weakness after a fall with a traumatic brain injury and was
found to have isolated neurapraxic block with preservation of axons involving the upper and lower spinal accessory nerve
branches and long thoracic nerve. The third patient presented with right arm weakness and pain after thyroidectomy and
was found to have axon-loss neuropathy involving the upper and middle spinal accessory nerve branches and long thoracic
nerve. The fourth patient presented with right shoulder weakness after a fall/injury and was found to have axon-loss
neuropathy involving the all three branches of spinal accessory nerve, long thoracic nerve and a C5 radiculopathy.
Discussion: Unilateral scapular winging with similar clinical presentation can result from various neuropathic etiologies.
Electrodiagnostic findings in these four cases revealed multiple neuropathies involving two or three nerves that cause
winging of the scapula. Etiology in two of the four patients was trauma, one patient with Parsonage Turner Syndrome and
one patient due to surgery related to carcinoma.
Conclusions: Although uncommon, this case series provides examples of multiple nerve involvement in scapular winging
and the importance of electrodiagnostic studies for evaluating involvement of the specific nerves.
Keywords: Scapula winging; Dorsal scapular neuropathy; Spinal accessory neuropathy; Long thoracic neuropathy
Rec. Site
Lat
Amp Rel Amp
ms
mV
%
EMG Table
Area
mVms
R Spinal Accessory - Trapezius
1. Neck
Upper Trap
3.05
1.7
100
6.5
2. Neck
Mid Trap
4.25
0.4
20.9
1.1
3. Neck
Lower Trap
7.00
2.3
134
16.8
Upper Trap
2.70
6.5
100
51.3
2. Neck
Mid Trap
3.30
4.8
74
27.4
3. Neck
Lower Trap
5.55
2.7
42.2
19.8
Thorax
2.85
1.0
2.1
Thorax
3.10
1.2
1.9
R. Rhomboid
Maj C5
R. Serr Ant
C5, 6,7
R. Trapezius
(M) C3, 4
L Spinal Accessory - Trapezius
1. Neck
Spontaneous
MUAP
Recruitment
IA
H.F.
Dur.
PPP
Pattern
N
None
1+
2+
Mild Red
N
None
N
N
Mild Red
N
CRD's
N
2+
N
L Long Thoracic - Upper Ext
1. Neck
R Long Thoracic - Upper Ext
1. Neck
Patient #1. Pertinent electrodiagnostic results showing axon-loss neuropathy involving the right upper and
middle spinal accessory nerve branches and dorsal scapular nerve .
Nerve / Sites
Rec. Site
L Spinal Accessory - Trapezius
Neck (X1 - X2)
Neck (X3 - X4)
Neck (X5 - X6)
R Spinal Accessory - Trapezius
Neck (X1 - X2)
Neck (X3 - X4)
Neck (X5 - X6)
Nerve / Sites
Lat
ms
Upper Trap
Mid Trap
Lower Trap
2.25
2.75
5.15
Upper Trap
Mid Trap
Lower Trap
Rec. Site
2.05
2.10
3.30
Resp
L Long Thoracic - Serratus Ant
Neck
Ser Ant
R Long Thoracic - Serratus Ant
Neck
Ser Ant
No
Amp
mV
Rel Amp
%
11.4
6.7
2.5
100
58.8
21.9
6.3
7.8
0.3
Lat
ms
Area
mVms
MUAP
Recruitment
neous
92.6
48.5
16.8
100
124
4.88
Amp
mV
EMG Table Sponta
48.9
66.9
0.8
Rel Amp
%
Area
mVms
4.70
2.0
100
20.8
4.00
0.1
100
2.6
R. Rhomboid
Maj C5
R. Serr Ant
C5, 6,7
R. Trapezius
(M) C3, 4
IA
Dur.
PPP
Pattern
N
N
N
N
N
N
N
N
N
N
N
N
DISCUSSION
Most cases of scapular winging described in the literature results in neuropathy of single nerve, most
commonly the long thoracic nerve, and have a clearly discernable presentation. However, scapular
winging due to multiple nerve and muscle involvement is rarely reported. In this study, we present a
series of cases of unilateral scapular winging which presented with indistinct presentations. The initial
cause of scapular winging in these cases was either trauma, remote trauma with possible Parsonage
Turner Syndrome or surgery related to carcinoma. Physical examination findings varied in each patient,
but proved inconclusive in elucidating the precise neuropathic etiology. Although a scapular winging is a
clinical diagnosis, the electrodiagnostic evaluation helped to clarify the unusual multiple neuropathies
involved in the atypical presentations of these cases. The neuropathies in each of these cases involved two
or three nerves varying from spinal accessory nerve branches, dorsal scapular nerve, long thoracic nerve
and C5 radiculopathy. These multiple neuropathies lead to weakness in multiple scapular muscles and
disruption of scapular motion (Figure 3). It is this multiple nerve etiology of the scapular winging that led
to indistinguishable presentations and illustrates precisely the value of electrodiagnostic evaluation in
discerning etiology of scapular winging.
Without electrodiagnostic verification of these scapular winging cases, successful rehabilitation and
treatment for scapular winging would have been difficult due to the multiple nerves involved. Therefore,
in these patients, rehabilitation was prescribed to target at least two muscle groups with scapular
stabilization.
Patient #2. Pertinent electrodiagnostic results showing right isolated neurapraxic block with preservation of
axons involving the upper and lower spinal accessory nerve branches and long thoracic nerve.
Nerve / Sites
Figure 1
Figure 2
CASE SERIES DESCRIPTION
The first patient is a 68 year-old female with a history of a traumatic brain injury who presented with severe right shoulder
pain shortly after having an acute flu-like respiratory infection. Physical examination revealed marked atrophy of the right
shoulder girdle with medial winging of the scapula at rest with glenoid depression or clockwise rotation (Figure 1).
The second patient is a 36 year-old male who presented with right arm weakness after a fall down a number of stairs that
resulted in a traumatic brain injury. Physical examination revealed atrophy of his right shoulder girdle muscles. The right
scapula was depressed and laterally rotated with medial winging exacerbated with forward flexion (Figure 2). Muscle
strength was diminished in the right upper and lower trapezius and serratus anterior.
The third patient is a 21year-old male who presented with right upper arm weakness and pain following a total
thyroidectomy for multifocal papillary thyroid cancer. Subsequently, the patient underwent right extended comprehensive
cervical lymphadenectomy. Physical examination revealed right scapular winging both with activation of the serratus
anterior and the middle trapezius. Muscle strength was diminished in the right serratus anterior and trapezius.
The fourth patient is a 60 year old female who presented with right shoulder weakness and pain after a fall in which she
fell on her outstretched right hand while she had heavy books with her and also another local trauma to shoulder. Physical
examination revealed significant depression of the right scapula, winging of the right scapula with the inferior angle more
medial than the glenoid, and atrophy of all sections of the trapezius. She had decreased strength on manual muscle testing
of all sections of the right trapezius (upper, middle, and lower) along with the serratus anterior.
Rec. Site
Lat
ms
R Spinal Accessory - Trapezius (3 Ch)
1. Neck
Upper Trap
2. Neck
Mid Trap
3. Neck
Lower Trap
L Spinal Accessory - Trapezius (3 Ch)
1. Neck
Upper Trap
2. Neck
Mid Trap
3. Neck
Lower Trap
L Long Thoracic - Upper Ext
1. Neck
Ser Ant
R Long Thoracic - Upper Ext
1. Neck
Ser Ant
Amp Rel Amp Area
mV
%
mVms
1.65
2.05
3.40
1.1
2.1
1.7
100
181
147
11.9
19.3
16.7
1.90
2.30
3.35
10.4
10.2
2.6
100
98.6
25.4
65.9
66.5
12.2
3.45
4.9
100
45.5
4.15
1.2
100
5.0
EMG
Table
R. Serr Ant
C5,6,7
R. Trapezius
(U) C3,4
R. Trapezius
(M) C3,4
R. Trapezius
(L) C3,4
R. Deltoid
C5,6
Spontaneous
MUAP
Recruitment
IA
Fib
PSW
Dur.
PPP
Pattern
Increase
1+
1+
N
N
Mild Red
Increase
2+
3+
N
N
Discrete
Increase
1+
1+
N
N
Discrete
Increase
1+
1+
N
N
Mod Red
N
None
None
N
N
N
Patient #3. Pertinent electrodiagnostic results showing right axon-loss neuropathy involving the upper and
middle spinal accessory nerve branches and long thoracic nerve..
Nerve / Sites
Rec. Site
Lat
ms
R Spinal Accessory - Trapezius (3 Ch)
1. Neck
Upper Trap
2. Neck
Mid Trap
3. Neck
Lower Trap
L Spinal Accessory - Trapezius (3 Ch)
1. Neck
Upper Trap
2. Neck
Mid Trap
3. Neck
Lower Trap
L Long Thoracic - Upper Ext
1. Neck
Ser Ant
R Long Thoracic - Upper Ext
1. Neck
Ser Ant
Amp Rel Amp Area
mV
%
mVms
2.25
3.50
4.40
1.0
0.5
1.5
100
51.2
148
7.3
3.0
5.1
1.70
2.90
3.55
6.4
7.5
5.8
100
117
90.9
50.8
51.7
39.6
4.45
3.2
100
20.6
4.15
1.3
100
10.7
Spon
MUAP
IA
AMP
Dur
PPP
Pattern
R. Serr Ant C5,6,7
N
N
1+
2+
Discrete
R. Deltoid C5,6
N
N
N
1+
N
R. Trapezius (U) C3,4
N
N
N
1+
Mod Red
EMG Table
Recruitment
R. Trapezius (L) C3,4
N
1-/N
1-/N
1+
Mild Red
R. SCM
N
1-/N
1-/N
1+
Mild Red
Patient #4. Pertinent electrodiagnostic results showing right axon-loss neuropathy involving the all three
branches of spinal accessory nerve, long thoracic nerves and a C5 radiculopathy.
Figure 3. A schematic diagram of the scapula demonstrating different muscle involvements in scapular winging.
CONCLUSION
Even though scapular winging involving a single nerve is a rare debilitating condition, having multiple
nerves involved is uncommon and atypical with need for complex rehabilitation planning. This case
series highlights the importance of electrodiagnostic studies for evaluating multiple specific nerves
involved in scapular winging that would generally have been overlooked.
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2. Schreiber AL, Abramov R, Fried GW, Herbison GJ. Expanding the differential of shoulder pain: Parsonage-Turner syndrome. J Am
Osteopath Assoc. 2009 Aug;109(8):415-22.
3. Akgun K, Aktas I, Terzi Y. Winged scapula caused by a dorsal scapular nerve lesion: a case report. Arch Phys Med Rehabil. 2008
Oct;89(10):2017-20.
4. Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop Relat Res. 1999 Nov;(368):5-16.