Notes on Winged Scapula, Weakness and Postural Asymmetry
True winging of the scapula is a rare condition that results form paralysis of the long thoracic nerve or damage to the serratus anterior muscle. But the observation of winged scapula is a regular part of many physical therapy assessments and treatment plans. Viewed as a larger problem of postural weakness, it becomes the focus of treatment. Also, many therapists see what appears to be scapular winging, or other skeletal asymmetries, and believe that this asymmetry is the "cause'" of pain and dysfunction. As many, many PTs, and other health professionals, come from a so-called "weakness model" of pain, they will prescribe exercise as a means to reduce pain. I do realize that my niche physical therapy/myofascial release private practice receives a rather skewed community of referrals, as I tend to see those whom traditional therapeutic approaches (physical therapy, massage therapy, chiropractic, injections, medications, surgery, etc.) have not been effective.
If weakness is the underlying issue, ask yourself "does weakness hurt?". The answer should be "never", unless a weak muscle is worked to full fatigue (rare). So why does the therapeutic community prescribe strengthening as a means to address pain? Studies have shown that movement has a positive effect on pain conditions, so exercise does satisfy this need. But it is the movement component that creates the change, not the fact that the person is stronger. The approach that myofascial release, and other fine manual therapies, follows is to address the tightness that may be interfering with pain-free movement. Reduce or remove the tightness and pain is no longer a problem.
Physical therapy, including the larger medical model, often observe a winged scapula and other postural asymmetries and see a problem, one that must be "fixed". These are only a few of many areas that traditional physical therapy gets it wrong, in my opinion.
Research shows us that in one study (1 and 2), 98.4% of us have a lateral spinal curve, or a scoliosis. Rib deformity is an unavoidable result of any rotatory changes (scoliosis) in the spinal column. The first diagram shown below demonstrates how the posterior thorax will change with the presence of scoliosis. Note the rib hump on the right hand side. The diagram below shows the typical progression of deformity as the spine rotates. Notice how the rib cage develops a posterior hump on one side. If there was no spinal rotation and scoliosis present, the rib cage would be equal on both sides and the scapula would ride on top of the rib cage in a symmetrical fashion. But with rib deformities, the scapulas are forced into different positions. The second diagram shows a potential scenario for scapular placement when scoliosis is present. Due the forced migration of the right scapular to a new position, the right side will appear winged. It is the underlying landscape that has been altered and it has NOTHING to do with weakness.
Another aspect of scoliosis to think about is the client who complains that no matter how much chest region strengthening they do, one side of the pectoral region remains much smaller in relation to the opposite side. Rib asymmetry, which most of us have to some degree, will force one side of the anterior chest wall to appear less developed. In most cases, exercise will never “even things out”.
Are we, as manual and myofascial release therapists, able to reduce or correct skeletal asymmetries? I believe we can, to some extent. I have had the experience of working with clients over the course of a number of years who have had documented improvement in the scoliosis via X-rays. These were not strictly controlled case studies and I am fully aware that other factors could have played a role. There is one published case study, which I am aware, that documents a positive improvement in scoliosis via myofascial release:
http://www.lebauerpt.com/uploads/1/3/9/4/1394925/jbmt_-_mfr_scoliosis_published_final.pdf
The upshot of this article is that postural asymmetry is not abnormal, in most cases. 98.4% will have such asymmetries. Expand your search, do not be misled.
For now,
Walt Fritz, PT