This case series reports eight patients with chronic scapulothoracic winging from serratus anterior dysfunction refractory to conservative care. It examines how often these patients are misdiagnosed and describes a modified pectoralis major transfer using small incisions and hamstring autograft.
When a shoulder patient has vague posterior pain, limited elevation, and prior failed surgery for instability or impingement, look at the scapula. Serratus anterior dysfunction produces medial winging with a prominent inferior scapular tip and loss of protraction, and it convincingly mimics both instability and impingement through scapulothoracic biomechanics.
The practical mental model: an unstable scapula fails to provide a stable glenoid platform (mimicking instability) and tilts the coracoacromial arch downward (mimicking impingement). The scapular stabilization test is your bedside diagnostic anchor. If manually pinning the scapula to the chest wall relieves pain and restores elevation, the scapula is the problem, not the glenohumeral joint.
Do not let a negative EMG dissuade you. Only 9 of 14 patients had confirmatory long thoracic nerve palsy despite obvious winging. Try bracing and periscapular strengthening first, reserving pectoralis major transfer for chronic refractory cases.
This case series reports eight patients with chronic scapulothoracic winging from serratus anterior dysfunction refractory to conservative care. It examines how often these patients are misdiagnosed and describes a modified pectoralis major transfer using small incisions and hamstring autograft.
When a shoulder patient has vague posterior pain, limited elevation, and prior failed surgery for instability or impingement, look at the scapula. Serratus anterior dysfunction produces medial winging with a prominent inferior scapular tip and loss of protraction, and it convincingly mimics both instability and impingement through scapulothoracic biomechanics.
The practical mental model: an unstable scapula fails to provide a stable glenoid platform (mimicking instability) and tilts the coracoacromial arch downward (mimicking impingement). The scapular stabilization test is your bedside diagnostic anchor. If manually pinning the scapula to the chest wall relieves pain and restores elevation, the scapula is the problem, not the glenohumeral joint.
Do not let a negative EMG dissuade you. Only 9 of 14 patients had confirmatory long thoracic nerve palsy despite obvious winging. Try bracing and periscapular strengthening first, reserving pectoralis major transfer for chronic refractory cases.