The Steadman-Hawkins Clinic

Most patients with scapular winging caused by blunt trauma or unknown causes will usually recover without surgery within a year. Since nerves recover by regenerating themselves one millimeter at a time and the long thoracic and spinal accessory nerves are very long, the healing process is a lengthy one. If there has been no recovery of function of the serratus anterior or trapezius after a year’s time, improvement is unlikely to occur without surgery.

Conservative (non-surgical) treatment includes:

avoidance of any activities (such as lifting) that might traumatize or stretch the nerve as it recovers.
Some physicians recommend bracing, but there is no clear consensus that this is beneficial. Many patients find braces uncomfortable and cannot tolerate the compression across the shoulder.

Operative Treatment
There are several surgical options available to patients whose scapular winging has not improved and is still painful after a year of conservative treatment.

A tendon transfer involving the pectoralis (chest) muscle may restore function in the case of long thoracic nerve palsy in which the serratus anterior does not function properly. (illus.). In this procedure, the lower portion of the muscle is transferred along the chest wall and placed through the scapula so that it can pull the scapula forward when it contracts, thus duplicating the function of the serratus anterior.(illus) Using a tendon graft from the side of the leg, the surgeon normally lengthens this part of the pectoralis since it is usually too short for a direct transfer.
Transfer of the rhomboid and levator muscles is the procedure of choice when the trapezius malfunctions because of spinal accessory nerve palsy. In this disorder, the scapula cannot rotate and is positioned lower than normal on the affected side. During corrective surgery, the surgeon raises the scapula to the proper level, and attaches the rhomboid and levator muscles to it.This will assist scapular rotation during arm motion. These muscles are now positioned to move the scapula and effectively substitute for the trapezius function.
Fusion of the scapula (for severe winging of the shoulder) There are certain rare neurological conditions such as fascioscapular humeral muscular dystrophy which require a fusion of the scapula so that it does not move on the chest wall. Failed surgery for winging may also be an indication for scapular fusion. In this procedure wires are placed around the ribs to secure a bone graft between them and the scapula, holding the scapula in place while it gradually fuses to the ribs. In six weeks’ time solid fusion has usually occurred, resulting in a reduction of symptoms. Raising the arm overhead as well as out to the side is usually possible by this time. Shoulder rotation is preserved since the shoulder moves not only through the scapula on the chest wall, but also by rotation of the ball in the socket