Scapular winging beyond shoulder pathology: a two-case series highlighting neurological red flags for surgeons

Scapular winging is an uncommon but clinically important sign that is often initially attributed to local shoulder pathology or isolated peripheral nerve injury. We report two patients with exertional scapular winging caused by different neurological disorders that are relevant to orthopaedic and surgical practice. The first patient presented with shoulder pain, weakness, sensory disturbance, and a reduced biceps reflex. Electrophysiology demonstrated a C6 radicular syndrome, and cervical magnetic resonance imaging revealed syringomyelia at the C6 level. The second patient developed acute nocturnal shoulder pain followed by persistent weakness and scapular winging. Electrophysiology and nerve ultrasound showed a long thoracic nerve lesion consistent with neuralgic amyotrophy. Both patients were treated conservatively. Pain improved, but scapular winging persisted. These cases show that scapular winging is a clinical sign with a broad differential diagnosis and that structured neurological assessment is essential to avoid misdiagnosis and inappropriate local treatment.