Is your patient at risk for scapular winging during recovery from breast cancer?

Scapular winging, also known as scapula alata (SA), describes the lack of proper muscular support that keeps the medial scapula positioned snugly against the thoracic wall. Potential causes of this condition include weakness of the serratus anterior, trapezius, and rhomboids, often related to nerve injuries of the long thoracic, spinal accessory, or the dorsal scapular nerve. Breast cancer and axillary surgery is a known risk factor for scapular winging, and the aim of a recent article was to identify patients who were at increased risk of developing the condition following radiotherapy.

Adriaenssens and colleagues report an incidence rate of scapular alata in the literature of 0-74.7%, a variability that does not help to deduce patients who are truly at risk. Women age 18 or older with a diagnosis of primary breast cancer removed by mastectomy or by breast-conserving surgery were included in their study. The pathological stage, treatment doses for radiotherapy and when applicable, the treatment doses for chemotherapy are described for the control and for the intervention group. The original study from which the data was collected is known as the TomoBreast clinical trial and focused on pulmonary and cardiac toxicity measurement. Within the data collection, scapular position was measured in physiotherapy prior to and 1-3 months following radiotherapy. (Check this link to learn more about radiotherapy.)

The physical examination included assessment of clinical symptoms like dysesthesia, heaviness, swelling, fatigue, warmth, burning, and pain. Measures of bilateral arm volume, shoulder range of motion, and the scapular slide test to assess the distance between the inferior angle of the scapula and the spine were completed. In standing, the scapula was observed for relaxed position and for scapular plane elevation to shoulder height; scapular alata was designated as present if inferior angle tilting or winging was noted.

Resulting analysis of the 119 eligible female patients include the following: prior to radiotherapy but after surgery, 10.9% (13 subjects) were positive for scapular winging. 1 to 3 months after completion of radiotherapy, winging resolved in 8 of the 13, and persisted in the remaining 5 subjects. New onset of scapular alata occurred in 1 subject. Significant factors for SA included young age, lower body mass index, and axillary dissection. Regarding the inverse relationship of increased weight to decreased scapular winging, the authors posit that patients with decreased body weight have less fat to cushion the nerves and therefore are at higher risk of nerve injury, OR that patients with higher body mass may not have winging as easily observed due to overlying adipose tissue. Having axillary lymph node dissection was confirmed in this study as a risk factor for scapular winging.

The authors conclude that scapular winging should be "actively evaluated" and describe assessments at various points in the treatment of breast cancer such as prior to surgery, following surgery, and prior to or following radiotherapy. As scapular winging correlated to loss of shoulder motion, quality of life may be impaired. If you are wanting to learn more about rehabilitation management of patients following breast cancer diagnosis and treatment, sign up now for faculty member Susannah Haarmann's Breast Oncology course in San Diego in 2 weeks! This is the last chance to take the course this year!