PECTORALIS MAJOR TRANSFER TO SCAPULA

The Goal

Dr. Kevin Wall provides specialized, fellowship-trained surgical treatment for Serratus Anterior Paralysis (historically known as medial winging) to restore shoulder stability and function for patients in Richmond, VA, and the surrounding Central Virginia communities. The goal of a pectoralis major transfer to the scapula is to replace the function of a paralyzed serratus anterior muscle, often caused by a permanent long thoracic nerve injury. When the serratus anterior is not working, the shoulder blade "wings" medially (the bottom and inner border sticks out) and the patient loses the ability to lift their arm in front of them. By transferring the sternal head of the pectoralis major tendon to the bottom of the scapula, we create a new, functional checkrein that holds the scapula against the chest wall and restores the power to elevate the arm.

It is essential that patients are thoroughly evaluated for true serratus paralysis. Electromyography (EMG) studies for serratus paralysis can occasionally be false positives (the diagnosis of serratus paralysis is made when it, in fact, does not exist) due to technical error. Additionally, and perhaps even more common historically, a serratus paralysis was diagnosed when in reality, the patient had functional STAM 2. In this condition, the serratus is hypoactive because the brain is not correctly coordinating its activation. But much less invasive sugeries such as a scapulopexy with an arthroscopic pectoralis minor release should be attempted in those patients first. The goal of such procedures being to tether the scapula where it belongs and give the brain a chance to relearn correct muscle activation. Dr. Wall provides fellowship-level knowledge on these conditions and how to manage them.

This page is designed to educate you specifically about this procedure. Additional information that generally applies to most of Dr. Wall’s surgeries can be found on these pages:

The Procedure

  • The Indication: This surgery is reserved for patients with Structural STAM 2 (Serratus Anterior Paralysis) who have failed 1–2 years of conservative management (observation for nerve recovery) and still have significant winging and limitation of motion.

  • The Transfer: Dr. Wall performs a Split Pectoralis Major Transfer, utilizing only the sternal head of the muscle while leaving the clavicular head intact to preserve chest aesthetics and function.

  • Graft Extension: Because the native pectoralis tendon isn’t always long enough to reach the back of the scapula, Dr. Wall might extend the tendon using a robust allograft (donor tendon).

  • Fixation: The graft is tunneled around the chest wall, under the skin, and securely anchored to the bottom corner of the scapula where the most important part of the paralyzes serratus attaches. This re-establishes the line of pull necessary for scapular protraction.

Post-Op Protocol

Recovery from this tendon transfer is prolonged and requires strict adherence to restrictions to allow the graft to heal to the bone.

  • Immobilization (Phase 1: 0–8 weeks): You must remain in a sling at all times, except for hygiene. No shoulder motion is permitted during this entire 8-week period to protect the transfer but you may move your elbow, wrist, and hand.

  • Formal PT Start: Professional physical therapy begins at Post-Op Week 8.

  • Phase 2 (8–12 weeks): You will transition out of the sling. Therapy follows a graduated return to motion protocol: passive to active-assist to active range of motion.

    • Focus: Scapular positioning and proprioception ("retraining" the brain to use the pec muscle to move the scapula).

    • Imaging: A CT scan is obtained at Week 10 to confirm the tendon has healed to the bone.

  • Phase 3 (12–16 weeks): Progressive stretching and strengthening begin as tolerated.

  • Phase 4 (16 weeks+): Return to full activities as tolerated.

When to Seek Care

You should schedule a consultation if:

  • You have been diagnosed with a long thoracic nerve injury or serratus anterior palsy.

  • Your shoulder blade "wings" prominently (medial border sticks out) when you push against a wall or lift your arm.

  • You have waited more than a year for your nerve to heal, but you still cannot lift your arm above shoulder height.

  • You experience relief of your symptoms when an examiner manually holds your shoulder blade in place (a positive Scapular Stabilization Test).