SCAPULA-TO-SCAPULA TETHERING

The Goal

Dr. Kevin Wall provides specialized, fellowship-trained surgical treatment with scapula-to-scapula tethering to restore stability and eliminate winging for patients in Richmond, VA, and the surrounding Central Virginia communities. This innovative, motion-sparing procedure is designed for patients with complex scapular winging—specifically those where the shoulder blades wing outward due to a coordination disorder (Functional STAM Types 2, 3, or 4). Rarely, this procedure is also an option in patients with trapezius paralysis or FSHD. The goal is to create an "internal seatbelt" that physically prevents the shoulder blades from drifting apart or winging out, while still allowing the patient to lift their arms and maintain flexibility. Unlike a fusion, this procedure preserves the natural gliding mechanism of the scapula.

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:

• Pre-Operative Instructions

• Post-Operative Instructions

• Physical Therapy Protocols

Indications

This procedure is usually reserved for Functional STAM patients who have failed extensive neuromuscular retraining (physical therapy) and Botox injections. It is the procedure of choice for:

• Bilateral Winging: In select patients where both shoulder blades are unstable.

• Bilateral Type 2B (Irreducible) functional STAM: Where the scapula cannot be held in place voluntarily.

• Type 3 (Dystonic) & Type 4 (Myoclonus): Rare cases involving involuntary muscle contractions where a rigid fusion is too aggressive, but a soft-tissue restraint is needed to dampen the chaotic motion.

• Trapezius Paralysis: In the very rare case of bilateral trapezius paralysis, or injury to one of the muscles (levator, rhomboid) that is part of the typical surgery for this condition, or a patient is elderly or cannot tolerate a scapulothoracic fusion.

• Combined Paralysis: In cases such as FSHD when the patient is either a child, has lung disease or prefers to not undergo a scapulothoracic fusion.

The Procedure

• The Concept: Dr. Wall creates a dynamic tether between the two scapulae. This tether acts like a checkrein: when you try to lift your arms, the tether becomes taut, preventing the bottom of the shoulder blades from flaring outward (winging). It effectively holds your scapulae back, as if you were standing with your chest out, “at attention.”

• The Graft: A robust Allograft (donor tendon, typically Achilles) is used. It is incredibly strong.

• The Technique:

  • Minimally Invasive: Performed through small incisions on the back.

  • Placement: The graft is passed subcutaneously (under the skin from the medial border of the left scapula to the medial border of the right scapula.

  • Fixation: The graft is securely anchored to the bone of the scapulae using high-strength suture buttons.

  • Tensioning: Dr. Wall precisely tensions the graft with the arms in a functional position to ensure it is tight enough to prevent winging but loose enough to allow breathing and reaching.

Post-Op Protocol

The recovery focuses on protecting the graft from stretching out while it heals.

• Immobilization (Phase 1: 0–6 weeks):

  • Sling: You must wear a sling to keep the tension off the graft but the sling can go on either arm and be moved at any time.

  • Strict Restriction: No reaching forward (protraction) or reaching across your body, as this stretches the tether. You must keep your shoulders "retracted" (squeezed back).

• Mobilization (Phase 2: 6–12 weeks):

  • The sling is discontinued.

  • Controlled Motion: You begin active-assisted range of motion. The focus is on vertical motion (lifting arm up) while maintaining scapular retraction.

  • No Stretching: You are strictly forbidden from doing "scapular protraction" stretches.

• Strengthening (Phase 3: 12+ weeks):

  • Progressive strengthening of the rhomboids and trapezius to support the tether.

  • Full return to activities is typically expected by 4–5 months.

When to Seek Care

You should schedule a consultation if:

• You suffer from uncontrolled winging of both shoulder blades.

• You have a diagnosis of "Scapular Dyskinesis" or "Dystonia" that hasn't improved with therapy.

• You have tried a "brace" or "posture shirt" that helps, and you are looking for a permanent, internal solution.

• You want to stabilize your shoulder blades without undergoing a permanent bone fusion.