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
www.FoundationsinMFR.com and www.RochesterPainRelief.com
Thanks Fritz – This article gave me a deeper perspective on winged scapulas. Typically do you find that you have to see a client quite a number of times before you start seeing a difference using myofascial release?
Hi Judy,
I make one promise to any new client, that within three session, at the most, they will notice positive, lasting changes. After a few decades of treating with myofascial release, I am quite confident with this promise. Most clients find the promise to hold true.
Thanks for an informative article. I practice therapeutic Thai Massage and I have found that imbalances in the spine respond quite well to regular manipulations and stretches. I have seen definite improvements with regular sessions.
Thank You Fritz,
I practice several different modalities of therapy depending on the individual as well as the need.
I find myself using myofascial release with more if my athletes I work on. This is a powerful healing modality.
Gina
Hi Walt,
I agree with half of what you say but I believe you are missing the boat also. Yes scapular winging is almost always caused by something else – things like scoliosis like you state, or very often a hip disparity causing upper body compensation. But there are several things you say that I believe are not true and very misleading to readers.
First you state that “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.” If you believe this to be untrue, what do you believe is the cause of the pain and dysfunction? Myofascial restrictions? Where do they come from?
Secondly you state that “98.4% of us have a lateral spinal curve, or a scoliosis”. The study you quote is using “any degree of deformity” as criteria for coming up with the 98.4% number. This statistic does not tell us deformity or scoliosis is normal, but rather almost everyone has at least a very small “degree of deformity”. “Deformity” implies something wrong from birth or in structure and I would argue that 90% of these “deformities” are muscular imbalances in nature and are correctable. Birth deformities are indeed very rare. Most experts state 80% of scoliosis is idiopathic and most are adolescent (onset between 10 and 15 years old) which shows that they are not genetic or birth defects but environmental in cause (muscular imbalances, unilateral dominance, injuries, psychological/emotional).
You also state that strengthening does not work. I think you know that statement is incorrect because it is illogical. Muscles move bones. Fact. Thus balancing muscular function does work because it will reposition bones and hold them there. The only way to have bone position or posture change and maintain that position is through muscular reeducation. The reason why most strengthening you see does not work is probably because people are trying to strengthen muscles while their posture is out of alignment. We use the phrase: straighten before you strengthen. Getting the joints and bones into proper alignment and then strengthening the muscles will have very positive affects on scoliosis and all over postural imbalances.
I have seen absolutely dramatic positive improvements in scoliosis in clients by using postural alignment therapy in my 13 years as an therapist and postural alignment therapist.
Thanks for the discussion, Matt.
Hi Matt, Thanks for your opinions here. Reading through your website, I can see that a postural correction approach is in your genetic code, which is fine. I used to share a similar view. The article I cite was what led me to view things differently, in a more liberal fashion. I pulled a paragraph from your website, but I am adding a sentence (in bold):
Isn’t running/tennis/golf the cause of my pain?
If running caused knee pain, every runner would have knee pain and that’s just not true. If tennis is the cause of your elbow pain, every tennis player would have elbow pain and they don’t. If golf was causing your back pain, every other golfer would also be suffering from back pain and they are not. If poor posture, or postural asymmetry was causing your pain, every person with poor posture or postural asymmetry would have pain, and they are not. If the activity was causing your pain that means you’d have to live with pain or give up your favorite activity, but luckily that’s not the case. I believe your compromised posture is the cause of your pain and you can correct it by doing postural alignment therapy.
You asked me “If you believe this to be untrue (skeletal asymmetry), what do you believe is the cause of the pain and dysfunction? Myofascial restrictions? Where do they come from?”. If the skeletal asymmetry caused the pain, every person with this sort of scapular winging would be in pain, and this is just not the case. I am simply putting a model out there that pain is multidimensional and resists being organized in a logical manner, much like I was taught. Postural asymmetry alone is not a cause of pain.
You said: “Deformity” implies something wrong from birth or in structure and I would argue that 90% of these “deformities” are muscular imbalances in nature and are correctable.” Deformity does not necessarily imply something wrong from birth, as you state, as deformities can be acquired from trauma, etc. You argue that “90% of these “deformities” are muscular imbalances in nature and are correctable.”. Can you give me some evidence to back this up? By definition, “idiopathic” is defined as: relating to or denoting any disease or condition that arises spontaneously or for which the cause is unknown. You creating a rationale for causation that is incomplete but inserting your opinions. 98.4& of us do have a lateral curvature of the spine, to some degree (from the paper I cited). 80% of scoliosis is idiopathic (your un-cited statement, but I will accept this number). Muscular weakness and skeletal asymmetry COULD be causing the curvature, but by definition, the curve is idiopathic , of unknown origin.
Mat, in my prior work, I “corrected or lessened” postural asymmetries in hundred pf patients with successful reduction in their pain. Then, as I transitioned into newer models of pain explanation, I paid very little attention to any asymmetries and my patients still got better. The postural approach can work, much as other approaches can work as well. Which lead one to ask “if all of these seemingly disparate approaches can successfully reduce/eliminate pain, can the explanatory models all be correct?”. I would never say that you are wrong or treating incorrectly, as your successes show otherwise. With the myofascial release approach I was taught, changes were explained in a certain rather outdated and metaphysical manner. Yes, postural asymmetry was one of the basic tenants of evaluation and treatment planning, along with many other methods. But the more I learn, the less I believe what I was taught was happening under my hands. Now, my mind understand change in a different way, but my hands are doing quite similar things as in the past.
I will stand by my position that when one takes the average person who is suffering from pain and work on strengthening, only a percentage of people see their pain lessen or eliminated. Of course muscles move bones, I would never argue disagree with that statement you made, but what does this have to do with my statements? It sounds like you underwent an extensive training program to learn what you know, much similar to my own. You have seen positive changes from this work, which reinforces the accuracy of the model you were taught. But if all of what you were taught is the only way, how can you explain the successes of others who treat pain with no agenda to correct postural deficits?
The bottom line of the paper I cited and my reason for making the original blog post as to say that postural asymmetry IS the norm, by the 98.4% statistic quoted. But You or anyone would be hard-pressed to say that 98.4% of people have pain, or have pain as a result of their postural asymmetry.
[…] about how the “normal” asymmetries that result from these changes can impact issues such as a winged scapula in another blog post. This is only one of dozens of postural asymmetries that we see on a daily basis that do not […]
Myofascial release is the real deal. The problem with working out and strengthening, until you are healed, is that it causes more inflamation and more adhesions (scar tissue) to form compressing nerves and restricting blood flow, leading to atrophy and an unaligned posture. It just exacerbates the situation generally. The myofascial release will naturally allow the body to correct your posture, realigning oneself itself, if the adhesions are broken down through trigger points and myofascial unwinding. I have been to some of the country’s top orthopedic surgeons, as well as neurologists. One identified the winged scapula, but offered no solution. None of these MDs mentioned internal scar tissue, adhesions, or adhesive capsulitis. My mother (retired OT) and her Chinese Acupuncturist were the ones that made me aware of myofascial release. It saved my posture and has relieved me of the worse chronic pain I have ever experienced. Acupunture and massage are also very effective. Warm weather, saunas, and hot tubs have assisted in the healing prosess.
Glad you found myofascial release helpful!