Pterygoid blades: causes, diagnosis and treatment methods

The term “pterygoid scapula” is used when the medial (inner) edge of the scapula protrudes (departs) from the chest and becomes like a wing. This occurs when the scapula muscles are too weakened, causing them to have limited ability to stabilize the scapula. The causes of this condition may be neurological deficits and damage to the musculoskeletal system.

Causes of pterygoid scapula

Pterygoid scapula occurs due to weakness of the adductor muscles that bring the shoulder blades together - the trapezius and rhomboid. With one edge they are attached to the spinous processes of the vertebrae, and with the other - to different parts of the bone. The trapezius muscle goes to the top, and the rhomboid muscle goes to the bottom. Under their influence, it approaches the spine and performs movement (rotation) around the sagittal axis.

If the serratus anterior muscle is weakened, then the corners stick out, because muscle fibers are attached to the dorsal and medial part of the bone. The serratus muscle brings the inferior angle to the spine. If this muscle group loses tone or its structure is disrupted, then the scapula takes an abnormal position.

The cause of muscle dysfunction is dysfunction:

• innervation - the dorsal nerve is located close to the surface of the body and its damage leads to pathology;
• blood supply - a violation of transport in the cervical arteries, which ensures the trophic process of tissues, causes the syndrome.

Pterygoid scapula can occur in both childhood and adulthood. Pathology is divided into:

• congenital;
• acquired.

Typically, a birth defect can be noticed immediately after the baby is born. Congenital pterygoid scapula syndrome results from:

• genetic abnormality of connective, nervous or muscle tissue;
• disturbances of intrauterine anlage and development of tissues and organs.

A child can acquire the syndrome as a result of:

• birth trauma;
• poor posture caused by ergonomic furniture (high chair and low table), improper distribution of load (wearing a heavy backpack or bag on one shoulder), improper lighting of the workplace;
• weakness of the muscle corset due to physical inactivity, muscle pathology (atony, dystrophy, hypotrophy);
• spinal or head injuries.

The photo shows how the shoulder blades stick out in a child with scoliosis.

The cause of pterygoid scapula in adults most often lies in:

• injuries, ruptures, muscle strains, dislocation of the shoulder joint;
• disease or damage to the spine;
• complication of a systemic disease - autoimmune and allergic origin (15% of cases), infectious (15-25% of cases), inflammatory (myositis, neuritis);
• a tumor compressing a nerve or blood vessel;
• surgical intervention - surgery on the spine, chest, rib, mammary gland (30% of cases).

The photo shows a winged scapula, the cause of which is spinal surgery.

The process of development of the musculoskeletal system ends by the age of 20-22. Therefore, the child is more susceptible to pathology due to the immaturity of the system. An adult suffers from excessive physical exertion caused by working conditions or intense sports.

In women, the disease occurs 3-6 times more often than in men. The reason is in the physiological characteristics of the structure of the muscular and skeletal system. For example, today a backpack is popular not only among schoolchildren. It has become an integral part of the image of young people of both sexes. Uncomfortable shoes, high heels, a handbag over the shoulder, wearing compressive clothing and underwear lead to complications of childhood spinal pathology.

As a result of prolonged exposure to damaging factors, scoliosis develops, the scapula protrudes, and the function of internal organs is impaired. The anomaly can accompany orthopedic diseases - kyphoscoliosis, rupture of the acromial clavicular joint, rupture of the serratus anterior muscle. Deformity is a typical manifestation of muscular dystrophy. The same syndrome is observed in amyotrophic lateral sclerosis and poliomyelitis (in children).

Physiological features of the disease

Winged scapula syndrome most often occurs in young men (the ratio to women is 2:1, and according to some reports 11:1). The reason is that active adult males are prone to injury. The shoulder girdle suffers during heavy lifting, strength training and contact sports. The clinical picture of the disease is manifested by a number of symptoms:

• pain, sharp, burning, bursting, aggravated by movement;
• radiating pain to the arm, collarbone or frontal chest, under the rib;
• decreased range of active movements in the shoulder girdle;
• decrease in shoulder muscle mass;
• weakness in the limb.

Acute pain rarely lasts more than 2 weeks. Most often, it subsides after 2-3 hours and becomes dull, aching, which is caused by the reaction of the nerve endings of the muscle. In children, the pathology occurs without acute pain.

At the initial stage of the pathology, one shoulder blade protrudes more than the other, but gradually the pathological process also affects the second one (noted in 5% of cases). With scoliosis, as a rule, there is a bilateral process.

Cases of the disease occur in any age group. It can affect both newborns and adults up to 85 years of age.

Main symptoms

Often, men at a young age suffer from pterygoid scapula disease.

This disease manifests itself suddenly: early in the morning or at night. First of all, a person begins to feel severe pain, which can radiate to the limb. Because of these sensations, active movements are significantly limited. Over time, the pain goes away, but after a month the muscle mass of the shoulder girdle decreases significantly and weakness in the arm (or arms, if both shoulder blades are affected) increases.

Although rare, all muscles of the shoulder, forearm, and hand can be involved during the pathological process.

Most often, damage occurs on only one side, but over time, displacement of the second scapula begins.

Diagnostic methods

The physical examination method helps to make the correct diagnosis. You can do the test yourself, at home. To do this, you need to stand facing the wall, at arm's length, and rest your hands on the wall. If there is an anomaly, the shoulder blades take on a wing-like appearance.

For differential diagnosis, the instrumental method is used:

• radiography to visualize the location of the bone;
• MRI and CT, to assess the condition of the nerve and muscle lesions, identify tumors;
• electromyography, to identify pathology of muscle groups - serratus and rhomboid;
• electroneurography, to detect disturbances in signal transmission through nerve tissue;
• angiography to assess the function and condition of the vascular bed.

To exclude a diagnosis with similar symptoms and clarify the cause of the lesion, laboratory tests are prescribed:

• clinical blood test;
• detection of antinuclear bodies in blood serum;
• biochemical analysis (if an infectious cause is suspected).

The x-ray shows how the shoulder blades stick out. Photo of a child with pathology.

A physiological test is also performed. The patient himself or with the help of an assistant should raise his arm to shoulder level. When raising the arm, the scapula protrudes, the bone has a wing-like appearance, and movements in the joint are difficult or impossible.

Treatment

There are surgical treatment methods that give good results. At the same time, some studies indicate that if we have an elderly patient who has minimal symptoms and leads a sedentary lifestyle, then we should limit ourselves to conservative treatment.

Physical therapy

When assessing a patient's function, we must pay attention to various parameters. In particular, when designing a rehabilitation program, we must consider the timing, strength, balance and endurance of the scapula muscles.

The rehabilitation program may include:

• Examples of working with voluntary activation of the scapula muscles: Correcting the position of the scapula by providing tactile feedback from the level of the lower angle - ask the patient to move the scapula down and inward.
• The patient places his fingers on the coracoid process, after which he needs to move the scapula medially and upward (the fingers must remain on the coracoid process).

What to do and how to treat?

Conservative treatment is usually symptomatic. Drugs that relieve pain are prescribed:

• analgesics;
• NSAIDs;
• glucocorticoids (in case of an autoimmune cause of the lesion).

Comprehensive treatment helps to get rid of imbalances:

• physiotherapy;
• physiotherapy.

If your shoulder blades are protruding, a vertebrologist will tell you how to correct your back. Gentle manual techniques have virtually no contraindications and will help to effectively correct the deformity, stop the progression of the disease and get rid of symptoms.

Special gymnastics helps strengthen the pectoral, dorsal and subscapularis muscles, and restore range of motion in the joint. If your shoulder blade protrudes, exercises must be done regularly. The doctor will individually select a set of exercises, intensity and duration of exercise.

In case of severe pathology, the use of orthopedic products – a corset, a fixator – is justified. Wearing it will help stop the development of muscle dysfunction and prevent joint instability. Treatment is a long process, especially in adults. To eliminate the disease, therapy must be started as early as possible, while the development of the skeletal system continues.

Long-term treatment is not a guarantee of recovery. In particularly advanced cases, surgical intervention may be required:

• neurolysis of the long thoracic nerve (dissection);
• innervation of the serratus anterior muscle (suturing);
• fixation of the scapula by tendon transfer;
• scapulothoracic arthrodesis.

However, most operations lead to disability due to limited movement in the joint. The doctor prescribes surgery after a certain period of time, because... With proper treatment, functional recovery is possible in 1-2 years.

Despite the apparent simplicity of therapy, it is not recommended to treat the disease on your own. Self-medication can cause complications and significantly worsen the condition.

Let's summarize:

1. For good and high-quality shoulder function, good control of the scapula and shoulder is necessary, which is carried out through the work of the serratus anterior muscle;
2. If you suspect the development of pterygoid blades, perform a simple test by standing against a wall and pressing your hands on the wall;
3. If a problem exists, use three exercises to stimulate the muscle well;
4. Always choose exercises according to your level of training, do not try to immediately perform a technically difficult option. The muscles will still work well.

And as Hippocrates said: “The doctor treats diseases, but nature heals!” Health and high sporting achievements to all!!!

Pterygoid scapulae in a child: treatment features

In children, the deformity is most often caused by scoliosis. The disease is asymptomatic, so drug treatment is ineffective and dangerous. Children respond well to manual therapy, especially when signs are identified early in the development of the disease. You can notice protruding shoulder blades in children yourself and contact a specialist.

The child's shoulder blades are sticking out. Photos of physical therapy classes.

If a child’s shoulder blades are sticking out, then gymnastics, swimming, and sports that strengthen the muscle corset are necessary. It is necessary to exclude pathogenic factors and enroll the child in sports sections. But if one shoulder blade protrudes in a child, then this may be a sign of serious diseases that require consultation with a specialist, making the correct diagnosis in order to prescribe and begin treatment.

Osteochondroma (osteocartilaginous exostosis) is an exostosis covered with a synovial bursa, consisting of a bone base and its cartilaginous covering. Most often it is located near the epiphyses and grows slowly until a certain time. But after the cold period it begins to grow rapidly, often without an obvious reason. The highest intensity of osteochondroma growth coincides with the intensity of skeletal growth. At the end of the period of skeletal growth, as a rule, the growth of osteochondroma also stops. The continued growth of exostosis is characterized by its transformation into a tumor of cartilage tissue.

The clinical picture is characterized by the presence of single or multiple formations of various sizes, localized in the metaphyseal sections of long tubular bones (humerus, tibia and femur) and much less often in flat bones (ilium, scapula, spine).

Radiographs show an eccentrically located structureless focus of lytic destruction of a round or oval shape with areas of speckled calcification. The focus of destruction is delimited from the unchanged parts of the bone by a zone of sclerosis. Thinning and swelling of the cortical layer is characteristic during bone growth. There are no pathological fractures.

Malignancy of solitary osteochondroma is observed in 1-2%, multiple osteochondromas - in 5-10% of cases. More often it occurs when localized in the pelvic bones and scapula, and is manifested by a noticeable acceleration of tumor growth. Characteristic changes on radiographs are blurred contours and increased calcifications in the soft tissue component of the tumor. There is a significant discrepancy between the clinical and radiological sizes of the tumor.

The only treatment for osteochondromas is surgery. The operation consists of wide exposure of the base of the tumor, deep resection of it along with part of the healthy bone, and removal of the tumor with the synovial membrane covering it. Prolonged delay of surgery often leads to malignancy of the tumor. Plastic surgery of the marginal bone defect is not required. After removal of the osteochondroma, a lasting recovery occurs.

Patient P., 20 years old, was admitted to the surgical department of one of the clinics of the Department of General Surgery of the Kuban State Medical University as planned.

Brief anamnesis: three months ago, for the first time, I noticed the appearance of a tumor-like swelling in the area of ​​the right shoulder blade, which increased in size. In the clinic at the place of residence, a puncture of the indicated formation was performed and 100 ml of serous fluid was removed.

The posterior protrusion of the right scapula is noted, and a soft-elastic formation extending under the scapula is also determined. No local changes in the skin are observed. Regional lymph nodes are not enlarged, their consistency is not changed.

When performing an ultrasound examination of the soft tissues of the scapular region, vague signs of infiltration of the right suprascapular region are noted. Pulmonary disease was excluded after chest x-ray. A round formation measuring 50×40×20 mm with fairly clear contours and an uneven dense structure was found near the right shoulder blade. General blood and urine analysis without pathological changes.

After an examination to clarify the diagnosis, surgery was performed under local anesthesia.

Using an arcuate incision bypassing the scapula from the medial side and below its angle, a revision of the space-occupying lesion was performed. It is located between the anterior surface of the scapula and the chest and has a size of 25x30 cm. The presence of a thick-walled fibrous-modified capsule is noted. When the capsule was opened, 250 ml of serous fluid was released. A mushroom-shaped osteochondral formation with a diameter of 8 cm was detected on the anterior surface of the scapula. Due to the impossibility of radical removal of the formation under local anesthesia, it was decided to perform a biopsy and plan the second stage of treatment.

The course of the postoperative period was unremarkable. The wound healed by primary intention. A computed tomography scan was performed. A picture of marsupial exostosis of the anterior surface of the right scapula was revealed. No tumor lesions of the lungs, mediastinal organs, or chest were detected. Pathohistological examination of the biopsy specimen: mature cystic teratoma.

After preoperative preparation, surgical treatment was performed.

Under endotracheal anesthesia, soft tissues were dissected using a stick-shaped incision bypassing the scapula from the medial side and below. After dislocation of the scapula into the wound, the thick-walled capsule with a wall thickness of up to 5 mm, extending from the paravertebral line to the anterior axillary line, was completely removed. A massive mushroom-shaped exostosis was removed, and the angle of the scapula was resected to exclude recurrence. The removed tissues are sent for histological examination. The extensive residual cavity was drained through a separate counter-aperture according to Reden. The drainage was removed on the 3rd day. In order to prevent the formation of a residual cavity, elastic bandaging of the chest was performed. Postoperative wounds healed by primary intention. Control computed tomography: condition after surgical treatment, limited fluid accumulation on the right side wall of the chest without signs of an acute inflammatory process. Postoperative diagnosis: osteochondroma of the right scapula.

Editorial Board Comment

Osteochondroma (osteocartilaginous exostosis) is a benign tumor consisting of pathological growth of bone and cartilage tissue. It accounts for 35% of benign bone tumors and 9% of all bone tumors. Osteochondromas occur in childhood and gradually increase throughout life.

The clinical picture of osteochondral exostoses is poor. Upon reaching a certain size or with superficial localization, a non-displaceable formation of bone density is determined by palpation, usually painless. Pain occurs when the tumor compresses the nerve trunks. The tumor grows slowly and evenly. If the tumor is large, movement restrictions in a nearby joint may occur. Pain and accelerated growth are observed during the transformation of osteochondroma into secondary chondrosarcoma.

Interpretation of the X-ray picture of osteochondromas does not present any particular difficulties and is perfectly described by S.A. Reinberg in the manual “X-ray diagnosis of diseases of bones and joints” (1965): “... Osteochondroma, in addition to bone, contains cartilaginous tissue covering the surface of the tumor in the form of a cap. Osteochondroma “sits” on a more or less wide stalk and rises on the bone in the form of a cauliflower... The contours are sharply outlined. The cortical substance of the bone passes to the surface of the tumor or enters the middle of the growth, sometimes crumbling into separate layers of bone, running in the form of rays to the surface of the tumor. The pattern of osteochondroma is not homogeneous, but consists of regular bone islands, fan-shaped fascicles and septa lying among the light background of cartilage... Of great practical clinical and radiological importance is the frequent complication of osteochondroma with secondary bursitis..., which directs diagnostic thought along the wrong path, and only x-ray examination brings clarity , combining and reconciling the totality of all clinical and radiological data.”

Long-term osteochondromas can become malignant in 1-2% of cases, multiple ones - in 5-10%. Secondary chondrosarcomas arise due to dysplasia and changes in the differentiation of cartilage tissue, which occur in the so-called “cartilage cap”. It is known that the more osteochondral exostoses are formed in one individual (the so-called exostosis disease), the higher the likelihood of secondary chondrosarcoma. More often, this transformation occurs when the tumor is localized in the ribs, sternum, scapula, and pelvic bones. Another cause of malignancy of osteochondral exostoses may be non-radical surgery.

If a bone tumor is suspected, the patient is subject to a full clinical and instrumental examination. It is necessary to perform x-rays of the affected bone in two projections. In a number of cases, radioisotope scanning of the entire skeleton makes it possible to exclude exostotic disease and also indicates the activity of the process in the pathological focus. CT (if necessary MRI) of the affected bone is mandatory today. These methods provide a detailed picture that allows one to judge the true size of the tumor, the degree of involvement of bone tissue and adjacent structures, and the malignancy of osteochondral exostosis, thereby providing invaluable assistance to the surgeon in preoperative planning.

If the clinical and radiological picture is consistent with true osteochondral exostosis, an open biopsy is not required. If there is a suspicion that the tumor has transformed into a secondary chondrosarcoma, a puncture or trepanobiopsy of the formation is performed. It must be remembered that during the operation, the tissue along the biopsy is excised en bloc with the underlying tumor in order to avoid the occurrence of implantation metastasis.

Treatment of osteochondral exostoses is only surgical and, for small tumor sizes, limited to marginal resection of the bone within healthy tissue. The incisions must be adequate so that the surgeon can see at least 2-3 cm of healthy bone tissue in the wound on all sides of the base of the tumor. Long-existing osteochondromas can reach large sizes and occupy more than half a cylinder of tubular bone or spread deeply through spongy bones, rarely complicated by pathological fractures and trophic changes in adjacent tissues and skin. In these situations, radical removal of osteochondral exostosis may require reconstruction of the resulting bone defect. To achieve radicalism in the surgical treatment of secondary chondrosarcomas, it is necessary to remove tissue adjacent to the tumor with a pseudocapsule and wider marginal or even segmental bone resection.

Despite the paucity of the clinical picture, uncomplicated x-ray diagnosis, and long-term course, this tumor should be treated by clinics with sufficient experience.

Possible complications after surgery and prognosis

An operation when the shoulder blades protrude is a necessary measure and is resorted to as a last resort. Surgery is traumatic and requires a long recovery period. In 90% of cases, the results of surgical treatment are satisfactory. However, most operations lead to disability due to limited movement in the joint. According to some data, the number of postoperative complications is 60%. Of these, 5-20% are wound infections. Ankylosis of the joint is observed in 9-10% of cases. The rest consists of:

• hematomas;
• seromas;
• tissue necrosis;
• loss of sensitivity, etc.

Conservative therapy for pterygoid scapula has a good prognosis. With adequate treatment and early diagnosis, it can be cured completely.

Surgery

In cases where conservative treatment does not bring results, the patient is referred for surgery. There are two methods for doing this:

1. The first method is based on replacing the paralyzed serratus muscle with a healthy one, by transplanting it from an unaffected area. This method is called functional.
2. The second method involves attaching the shoulder blade to the ribs. This method is called stabilizing. After such an operation, the scapula no longer takes part in the movement of the shoulder girdle.