Winged shoulder blade

What it is

Serratus anterior holds the shoulder blade flat against the ribcage and rotates it upward as the arm rises. When it fails, the inner border of the blade lifts away - winging - and overhead reach becomes weak and uncomfortable.

There are two very different causes. Long thoracic nerve injury produces true paralysis with dramatic winging and a recovery measured in many months to two years. Simple weakness and poor recruitment produce milder winging that responds to strengthening in weeks. Both look similar at a glance and behave completely differently.

What it feels like

• A shoulder blade that sticks out, most obvious pushing against a wall
• Weakness lifting the arm overhead
• Aching around the shoulder blade and the back of the shoulder
• Difficulty with pressing and reaching forward
• A visible asymmetry noticed by someone else before the person notices it

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Serratus anterior weakness

The muscle is rarely trained directly and is easy to substitute out of most exercises. Simple weakness and poor recruitment is the commonest cause of mild winging and the most treatable.

Long thoracic nerve injury

The nerve supplying serratus runs a long superficial course and is vulnerable to traction, direct blows, carrying heavy loads on the shoulder and viral illness. Injury produces true paralysis with obvious winging.

Parsonage-Turner syndrome

A brachial plexus inflammation, often following a viral illness or vaccination, producing sudden severe shoulder pain followed by weakness and winging. It is under-recognised and it has a distinctive story.

Trapezius weakness from spinal accessory nerve injury

A different pattern of winging, usually following neck surgery such as lymph node biopsy. The blade drops and wings laterally rather than medially.

Poor thoracic posture

A rounded thoracic spine changes the surface the blade has to sit on and can produce an appearance of winging without any muscle failure.

Repetitive overhead or heavy carrying activity

Traction on the long thoracic nerve from repeated overhead work or carrying heavy loads on the shoulder is a recognised mechanism.

Shoulder pain producing altered recruitment

Any painful shoulder changes how the scapular muscles fire. Winging can be a consequence of a shoulder problem rather than its cause.

Sports with heavy overhead or throwing demand

Volleyball, tennis, swimming and throwing all place high demand on scapular control and are common settings for it to appear.

Not testing which muscle is failing

Medial and lateral winging have different causes and different treatments. Assuming serratus without testing is a common reason a programme fails.

Who tends to get it

• Anyone with a recent viral illness followed by severe shoulder pain and weakness
• People who carry heavy loads on the shoulder
• Overhead athletes - volleyball, swimming, tennis, throwing
• Anyone who has had neck surgery, for the trapezius version
• People with poorly trained scapular muscles, which is most people

What makes it worse, and what settles it

The qFIT routine for this

Ready-made routineShoulder Relief & Overhead Range

qFIT already has this one built. It runs massage first, then stretching, then strength — the order that works on a body that is already sore — and every activity in it carries the reason it is there.

The button below opens your Checklist with this routine already selected, so instead of your whole list you land on just its Categories, Targets and Exercises, each with its checkbox, ready to tick as you work through them.

Have more than one problem? Tick yours under My Problems on My Profile and your Checklist's Routine list gains Recommended for my problems — every routine for the problems you picked, merged into one. Your picks stay private; that filter is the only thing they feed.

Get it checked if…

Sudden winging after trauma or a viral illness suggests nerve palsy - refer, recovery takes 12-24 months

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

Winging from simple weakness improves over eight to twelve weeks of targeted strengthening. Long thoracic nerve palsy recovers spontaneously in the majority but takes many months to two years, and the strengthening in the meantime maintains everything around it. Parsonage-Turner syndrome follows its own course with a similar timeline. Getting the cause identified early is what makes the difference between reasonable expectations and frustration.

Prevalence basis: Clinical examination series

Others the same routine covers

These share the Shoulder Relief & Overhead Range routine, so the work is the same. If one of them also sounds like you, that is a reason to expect more from it, not less.

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.