gymnastics, the patient was able to return to full 
function and activities of daily living, as well as 
lifting activities at the gym. Her scapular winging 
improved. 
Discussion
The recognition and treatment of MDI and scapular 
winging pose significant challenges for healthcare 
professionals, particularly within the athletic popula-
tion. Given the rarity of these cases–a thorough 
understanding of their diagnosis and management is 
essential for optimizing patient outcomes. This case 
study of a 20-year-old collegiate gymnast with severe 
scapular winging caused by shoulder instability and a 
circumferential glenoid labral tear highlights the 
complexities associated with identifying and manag-
ing such injuries, as well as the critical role of inter-
professional collaboration in achieving a successful 
recovery. 
Recognition and diagnosis of circumferential labral 
tears can be challenging. According to Tokish et al., 
key recognition criteria include a history of multiple 
dislocations (typically five or more), substantial 
general shoulder pain and instability regardless of the 
timing of the last episode, positive provocative tests 
for labral tear in all directions, and being a highly 
active person. The difficulty in diagnosis arises from 
a combination of extensive muscle guarding during 
provocative testing, poor diagnostic accuracy from 
MRI arthrography, and an initial presentation that 
mimics unidirectional anterior instability1,2,3. 
In this particular case, the athlete had substantial 
scapular winging which further compounded the 
complexity. Kuhn Et al. describes primary and 
secondary scapular winging. Primary scapular wing-
ing is caused by nerve injury–usually to the long 
thoracic nerve–and was ruled out in this case by 
electromyography (EMG). Secondary scapular 
winging occurs because of glenohumeral or subacro-
mial compensations. In cases like this, it is important 
to recognize secondary scapular winging, and to 
distinguish whether the scapular winging is a com-
pensatory pattern for underlying shoulder instability, 
or if the abnormal scapular position caused the 
instability and subsequent labral tearing. Initiating 
scapulothoracic strengthening upon recognition of 
Axial MRI slices of the left shoulder demonstrating anterior labral tear (large arrow), subtle reverse Hill Sachs (small arrow), posterior labral 
fraying
20

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