Scapula winging

What is scapula winging?

The scapula is the anatomical term for the shoulder blade. Scapula winging describes the position of the shoulder blade sticking outwards as opposed to being flat against the ribcage. A winging scapula that is left untreated can lead to more debilitating shoulder injury like a rotator cuff tear. Doing scapula push ups will exercise the muscles that prevent scapula winging.

The normal biomechanical position of the shoulder blade should always be rested flat against the ribcage regardless of the position of the arm. The shoulder blade slides upwards, downwards, forwards, backwards as well as rotating clockwise or anti-clockwise as the arm moves, but it should not come away from the ribcage as seen in the right shoulder blade in the picture below.

Source: emedicine.medscape.com

The following video shows how a winging scapula looks like when the shoulder is moving. Look at how much the bottom tip of the left scapula sticks out compared to the right (normal) scapula.

Scapula instability causes shoulder injuries

It is important that the above mechanics occur as the stability of the scapular is an essential facet to the proper function of the shoulder complex. An analogy would be a bicycle. There are many parts that are put together to allow the bicycle to move as it is pedaled. If the chain of the bicycle is loose, not only it creates noise but it also the cyclist will have to pedal harder to reach the same speed, making it inefficient. Eventually other parts will be worn out faster than normal. Similarly, if the muscle that holds the shoulder blade against the ribcage does not work properly, causing scapular winging, inappropriate activation from other muscle groups will compensate resulting in overuse and pain in these muscles. This will lead to a cycle of pain in the muscles and poor biomechanics in the shoulder, subsequently leading to problems such as shoulder muscle (rotator cuff) impingements or tears.

Serratus Anterior Muscle

The primary muscle that stabilizes the scapula to the ribcage is the Serratus Anterior. Other muscles that offer support to that role are the middle and lower trapezius. Hence any weaknesses in these muscles due to injury, disease process or lesion in the nerve supply can result in winging. In cases where the nerve supply is intact, specific exercises targeting at the Serratus Anterior and middle and lower trapezius can be performed to rehabilitate the specific muscles affected.

Exercise

Shoulder push-ups is a good way to train the serratus anterior muscles. The idea is to push your chest away and towards the ground by moving your shoulders and not from the elbows. This exercise is demonstrated in the video below. An easier way to perform this exercise is to lean against the wall with your hands instead of on the floor.

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Comments

davidlbh
Do you have good results with people having weak anterior serratus doing the exercise as described in the youtube. Thank you.
chyetuan
Yes definitely. Weak serratus anterior muscles can be strengthen effectively with this exercise.
However, If the exercise is too difficult for the muscles, compensation by other muscles takes place and the exercise will not be effective.
Sometimes the serratus anterior may be too weak to perform the above push ups well. So the alternative is to make it easier for the muscles by doing a wall push-ups or simply go on your knees like in a kneel instead of on to your toes.
davidlbh
My understanding of anterior serratus is a shoulder protractor and upward rotation movement. In the video it looks like a shoulder retractor.
chyetuan
yes you are absolutely right, the serratus anterior muscle protracts the shoulder and helps in upward rotation.
What you see in the video is the serratus anterior working through its full range of the muscle. The shoulder is retracted as the starting position and using the serratus anterior to push up (protract the shoulder) against gravity and body weight. Therefore the serratus anterior has to work against resistence which is how it gains strength.
Similarly, a biceps curl exercise to strengthen the biceps through its full range has to start from an elbow extended and then bend the elbow through range.
davidlbh
Hi Chyetuan,
Thank you for your reply. I have not done the exercise described in youtube myself and i will give it a try to feel it for myself. I believe that you are awared that ant. serratus is a tonic (stabilizing) muscle unlike biceps muscle which is a phasic (mover) muscle. Training of these 2 types of muscles should be different i presumed. Maybe i'm wrong. Some may benefits from the exercise. Thanks.
David Lee
chyetuan
Dear David,
Yes the serratus anterior stabilises the ribcage and also acts as a synergist to allow other muscles to work. The exercise shown in the video allows for isolation of the serratus anterior. For people with scapula winging or deficiency in serratus anterior activation, they need to relearn the activation pattern to prevent compensatory movement patterns. Once the muscle can contract properly, functional loading of the muscle should be added with focus on tonic activation.
Thanks for your comments. Hopefully, the discussion will make things clearer to our reader.
davidlbh
Hi Chyetuan, this is indeed interesting. Years ago, when i did my first human dissection, i witnessed the continuous of the rhomboid and anterior serratus muscle fibers. They should call rhomboid-serratus muscle. The fibers intermingle and difficult to separate at the medial border of the scapular. Just imagine, rhomboid and ant. serratus are like 2 slings, both meet at medial border of scapular. When both muscles contract, bringing the medial border of the scapular closer to the ribcage, thereby reducing the winging and achieving better stabilization of the scapular.
The exercise shown in the youtube might have ant. serratus activation but have little carry over towards stabilization.
I hope this is a healthy exchange of views and ideas.
chyetuan
Hi David, this is a very healthy discussion indeed. Both the rhomboids and serratus anterior stabilises the scapula. In terms of function, they work differently; As we know, rhomboids retracts and serratus protracts the scapula. During functional activities like wearing a shirt where you have to put your hand through the sleeves or when reaching out to grab something, the scapula needs to slide forwards along the contour of the ribcage. Serratus anterior will be the muscle that allows that to happen while keeping the scapula close to the ribs. Rhomboids can contract to stabilise the scapula too but it needs to perform an eccentric contraction to allow the scapula to protract forwards.
The muscle fibres might intermingle at their attachment site but because of the different vector of pull, both rhomboids and serratus anterior work differently to stabilise the scapula at different scapula position.
Hope this clears up the fuctional anatomy of rhomboids and serratus anterior.
davidlbh
Hi Chyetuan, i would like to comment a bit on functional anatomy. It is not about just looking at the fiber orientation and how it moves. Some muscles provides neurofeedback to allow other muscles to operate much more efficiently. Tonic muscle works more like that.
As for wearing a shirt in your example, anterior serratus is poorly activated. Anterior serratus need to be in closed kinetic chain to be efficiently activated. Example, hands on wall or floor to push to allow activation. You can try it yourself by putting a hand on ant. serratus while wearing a shirt in your example. More likely the ant. serratus is poorly activated. As for rhombiod muscle, it is not through eccentric contraction to stabilize the shoulder. You must have seen winging of scapular even with rhomboid in eccentric activation as one protracts the scapular. It is through co-activation of the rhomboid and serratus to stop the winging of scapular.
I would like to meet you someday and do an exchange if you want. Thank you for sharing your views.
chyetuan
Hi David, I agree with you. both serratus and rhomboids have to co-contract to prevent winging. Serratus anterior does work best in close chain activities but they are also a prime muscle action in open chain activities like reaching out to grab something or throwing a punch by extending your reach(scapular protraction); and as a stabiliser to prevent winging in overhead activities like reaching upwards. In other words, it is a global stabiliser. Much like how glut medius stabilises the pelvis in walking and also do hip abduction in open chain.
I've seen many examples of winging with protraction of the scapula regardless of rhomboids activation simply because of serratus anterior deficiancy. They often show winging when wearing their shirt.
If you like, drop by at our Parkway Parade clinic and i can share with you other exercises to train the serratus anterior as a tonic stabilisers. Cheers.
kriskiley
Yes but how do we learn or get trained on the activation pattern so to prevent the compensating muscle from working cause they are causing me great pain.
chyetuan
step 1: learn to isolate the activation
the exercise shown in the video or the alternative described in my first reply to davidlbh will help you learn to strengthen the serratus anterior muscles or start to activate the muscles.
step 2: combine activation of serratus anterior with movement
Once these muscles can start firing properly, then movements like lifting the arm forwards and upwards while consciously contracting the serratus anterior helps to train it to stabilise and prevent winging. Compensation happens the moment serratus anterior fail to stabilise the scapula, and that's when the movement should stop and restart the process.
step 3: increase range of movement with stabilisation
As your serratus anterior get stronger, the range of arm movement can increase with better stabilisation of the scapula.