A winged scapula is a shoulder blade that lifts away from the chest wall instead of moving smoothly against it. It may show at rest or only when the arm moves. Some people also have weakness, fatigue, pain or difficulty reaching overhead. The appearance is a finding rather than a diagnosis. Knowing which muscle, nerve or other structure is involved is what decides whether exercise, observation or an operation is likely to help.1, 2
Doctors also call it scapular winging. A shoulder blade that sticks out slightly, on both sides and without weakness, can simply be part of how a person is built. Persistent winging on one side, especially with weakness or pain, deserves a proper assessment.
In this guide: Causes · Assessment · Treatment · Surgery · Recovery · Link with thoracic outlet syndrome · Getting an opinion
Why the shoulder blade can stick out
The shoulder blade (scapula) has no joint holding it to the ribs. Muscles keep it in place and steer it as the arm moves. When one of those muscles is weak, or something changes the shape of the shoulder or chest wall, the blade can lift away from the ribs. The two causes doctors look for first both involve a nerve.
Long thoracic nerve and serratus anterior
The serratus anterior lies on the side of the chest wall and attaches to the underside of the shoulder blade. It holds the blade flat against the ribs and rotates it as the arm rises. Its nerve, the long thoracic nerve, runs a long course down the side of the chest. When the muscle weakens, the inner edge of the shoulder blade usually lifts away from the back, often most clearly when pushing against a wall or raising the arm forward.1, 2
A common cause is neuralgic amyotrophy (also called Parsonage–Turner syndrome): an inflammatory nerve condition that typically starts with sudden, severe shoulder pain, followed days or weeks later by weakness as the pain settles. Other causes include injury, strain from repeated or heavy shoulder use, surgery near the nerve’s path and, less often, compression along the nerve’s course.14 In one large clinical and electrical-testing series, long thoracic nerve problems were the most frequent cause of one-sided winging, and most of them were linked to neuralgic amyotrophy.1
Spinal accessory nerve and trapezius
The trapezius is the large, superficial muscle across the top of the shoulder and upper back. It holds the shoulder up and helps control the blade when the arm is lifted to the side. Its nerve, the spinal accessory nerve, runs close to the skin in the side of the neck, where it can be injured, most often during operations such as lymph node biopsy.4
Weakness of the trapezius typically lets the shoulder droop and the shoulder blade drift downward and outward, with difficulty lifting the arm sideways. It is often painful. In a large surgical series, most people were referred because of painful loss of shoulder function, and many were referred late.4 Very rarely, the nerve is compressed higher up, near the base of the skull. That is an uncommon possibility to consider in selected patients, not the usual explanation for a winged scapula.11
Other causes
Winging can also come from weakness of the rhomboid muscles, from muscle diseases such as facioscapulohumeral muscular dystrophy, from neck or brachial plexus nerve problems, from shoulder injuries, or from bone growths and other structural changes. Some young people can wing a shoulder blade voluntarily. These causes need different care, which is why the pattern alone is not enough.1, 2
Doctors also distinguish winging from scapular dyskinesis: a change in how the shoulder blade moves that often accompanies shoulder pain or instability without any nerve damage. It is usually treated with targeted rehabilitation, together with the shoulder problem behind it.3
How the cause is found
An assessment aims to answer three questions: which muscle is weak, why, and whether it is recovering.
History and examination. The doctor asks how the problem started (sudden pain followed by weakness points in a different direction from weakness after neck surgery), how it has changed, what the arm can and cannot do, and whether anything similar has happened before or runs in the family. The examination watches the shoulder blade during several movements, tests individual muscles and looks for wasting and other neurological signs. It covers the shoulder and neck, not only the visible blade.1, 2
Electromyography (EMG) and nerve conduction studies. These tests show whether a nerve or the muscle itself is affected, and how severely. For winging, the right muscles must be tested: a routine arm study may not answer the question. Results are most useful when the timing and the person doing the test fit the problem. They support a diagnosis; they do not predict on their own how well an operation will work.1
Imaging. Scans are chosen for the suspected cause: for example, to look at the neck, the shoulder, a possible bone growth or the muscles themselves. Muscle ultrasound is being studied as a complement to EMG. There is no single scan that every person with winging needs.9
Timing. Seek prompt assessment for new or worsening weakness, especially after an operation on the neck, chest or shoulder. A nerve that may have been cut is best recognized early, while repair is still an option. When recovery is expected, as often in neuralgic amyotrophy, a period of watching with regular reassessment is part of good care rather than a delay.4, 5
Treatment depends on the cause
Most people with winging start with non-surgical care. That means understanding the diagnosis, managing pain, easing off heavy or overhead work for a while, and rehabilitation planned around the affected muscle. A physiotherapist can strengthen the muscles that still work, improve shoulder control and keep the joint moving while the nerve recovers. A program designed for a shoulder injury is not the same as one for a muscle that has lost its nerve supply, so it helps to start after the diagnosis is clear.3, 6
Many nerve problems improve over months. In a long-term follow-up of people with isolated serratus palsy who were simply observed, winging resolved in most of them, on average about 16 months after it began, and movement recovered in most. Pain persisted more often than the visible winging, which is a reminder that appearance, pain and strength can recover differently. Recovery estimates vary widely across studies.5, 6
Reassessment matters as much as the first visit. If strength is not returning as expected, or the diagnosis changes, the plan should change too.
When surgery may be discussed
Surgery is considered when a specific problem is established and non-surgical care is unlikely to be enough, such as a nerve that was cut or is not recovering, or a lasting weakness that limits the shoulder. “Winged scapula surgery” covers several different operations with different aims:6, 14
| Operation | What it aims to do |
|---|---|
| Nerve release (neurolysis or decompression) | Free a nerve from tissue pressing on it, in selected patients where that is the identified problem |
| Nerve repair, grafting or nerve transfer | Restore a pathway for nerve signals after an injury, when timing and the muscle’s condition allow |
| Tendon or muscle transfer | Move a working muscle to take over the job of the weak one when the original nerve will not recover |
| Fixing the shoulder blade to the ribs (scapulothoracic fusion) | Stabilize the blade in selected situations, such as some muscle diseases or after other treatment has failed, at the cost of some movement |
These are not interchangeable. A nerve release does not repair a nerve that has been divided, and a tendon transfer does not bring the original nerve back. Transfers also differ by muscle: the operations used for serratus weakness and for trapezius weakness are not the same.
The published evidence is mostly small series from specialist centres. In one series, 29 people with isolated serratus palsy that had not improved with non-surgical care underwent release of the long thoracic nerve, and winging improved in most of them. In a long-term study of tendon transfer for serratus palsy, the gain in shoulder function lasted for many years, though it settled below its early peak. These results describe selected patients in particular centres; they do not provide one success rate for winged scapula surgery.7, 8
Before agreeing to an operation, it is reasonable to ask which muscle and nerve the operation addresses, what it is expected to improve, what it will not change, the main risks, and how long rehabilitation takes.
Recovery and what to expect
Recovery from nerve problems and from operations is usually measured in months. Appearance, pain, strength and the ability to work overhead can improve at different speeds and to different degrees, so it helps to agree on the goals that matter most to you. Rehabilitation continues after any operation, and follow-up should check function as well as how the shoulder blade looks.5, 6, 8
Is winged scapula related to thoracic outlet syndrome?
Sometimes the two overlap. Thoracic outlet syndrome (TOS) affects nerves or vessels passing between the neck and the arm, and some people with neurogenic TOS also have changes in how the shoulder blade moves. A study of people having TOS surgery found an association between winging before surgery and the long thoracic nerve running through one of the neck muscles.10 A drooping shoulder from trapezius weakness has also been reported alongside thoracic outlet symptoms in a small number of patients.15
Winging does not, however, diagnose TOS, and most winging has other causes. If you have arm tingling, numbness or weakness as well as winging, the assessment should consider both, and the guide to thoracic outlet syndrome diagnosis explains how that part is tested.
Getting an opinion
Dr. Kamran Aghayev is a neurosurgeon in Istanbul. His published work includes a clinical series of operations for neurogenic thoracic outlet syndrome and a co-authored anatomical study of surgical access to the brachial plexus, the network of nerves that supplies the shoulder and arm.12, 13 Read more about Dr. Aghayev’s background and publications.
If you have persistent winging or shoulder weakness and would like an opinion, contact the clinic to ask whether your case falls within Dr. Aghayev’s practice. Describe how the problem started, what you can no longer do with the arm, and the treatment you have had. Existing clinical reports and nerve-test or imaging results, if you have them, help the clinic advise on an appropriate appointment. New or worsening weakness should be assessed where you are rather than waiting for travel.
You can request an online consultation or book an appointment in Istanbul.
References
1. Seror et al. Unilateral winged scapula: clinical and electrodiagnostic experience with 128 cases, with special attention to long thoracic nerve palsy. Muscle & Nerve, 2018. Referral series over 25 years.
2. Ng and Wu. Scapular winging secondary to serratus anterior dysfunction: analysis of clinical presentations and etiology in a consecutive series of 96 patients. Journal of Shoulder and Elbow Surgery, 2021. Consecutive specialist series.
3. Kibler et al. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the “Scapular Summit”. British Journal of Sports Medicine, 2013. Expert consensus.
4. Camp and Birch. Injuries to the spinal accessory nerve: a lesson to surgeons. Journal of Bone and Joint Surgery (British volume), 2011. Series of 111 patients.
5. Pikkarainen et al. The natural course of serratus palsy at 2 to 31 years. Clinical Orthopaedics and Related Research, 2013. 37 patients followed without surgery.
6. Geurkink et al. Treatment of neurogenic scapular winging: a systematic review on outcomes after nonsurgical management and tendon transfer surgery. Journal of Shoulder and Elbow Surgery, 2023. Systematic review of low- to moderate-quality studies.
7. Ng et al. Neurolysis of the long thoracic nerve for scapular winging due to isolated serratus anterior palsy: early and midterm results in 29 patients. Journal of Hand and Microsurgery, 2024. Retrospective series.
8. Geurkink et al. Long-term outcomes of pectoralis major transfer for scapular winging due to long thoracic nerve palsy: results after a median follow-up of 17 years. JSES International, 2024. Small long-term cohort.
9. Rardin et al. Combined use of EMG and muscle ultrasound for the evaluation of scapular winging. Muscle & Nerve, 2026. Small retrospective study.
10. El Haj et al. The association of long thoracic nerve variants with medial scapular winging in thoracic outlet syndrome: a clinical and anatomical study. Journal of Hand Surgery, 2026; online 2025. Association within a surgical TOS cohort.
11. Mitchell et al. “Winged” Eagle’s syndrome: neurophysiological findings in a rare cause of spinal accessory nerve palsy. Journal of Neurosurgery: Case Lessons, 2023. Two patients.
12. Aghayev. Safety and efficacy of posterior upper rib excision and decompression technique for surgical treatment of neurogenic thoracic outlet syndrome. World Neurosurgery, 2023. Retrospective series.
13. Akaslan et al. Surgical anatomy of the posterior intermuscular approach to the brachial plexus. Hand, 2021; online 2020. Cadaver study; Dr. Aghayev is a co-author.
14. Wu and Ng. Long thoracic nerve palsy: when is decompression indicated. Journal of Hand Surgery Global Online, 2023. Clinical review.
15. Al-Shekhlee and Katirji. Spinal accessory neuropathy, droopy shoulder, and thoracic outlet syndrome. Muscle & Nerve, 2003. Two patients.
