SCAPULOPEXY (Scapula-to-Rib Tethering)

The Goal

Dr. Kevin Wall provides specialized, fellowship-trained surgical treatment with Scapulopexy to restore scapular stability for patients in Richmond, VA, and the surrounding Central Virginia communities. Scapulopexy is a soft tissue stabilization procedure designed to treat functional STAM 2 (scapular winging from discoordinated muscle activity) without resorting to a permanent bone fusion or muscle transfer. The goal is to create a durable, biological checkrein that holds the shoulder blade against the chest wall. Unlike a fusion (which stops all motion between the scapula and chest wall), a scapulopexy allows the scapula to still move somewhat but physically prevents it from pulling away from the ribs (winging). It serves as an "internal seatbelt" for patients whose natural stabilizers have failed.

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:

Indications

This procedure is best suited for patients with Functional STAM Type 2A and B, which may result from connective tissue disorders (like Ehlers-Danlos) where the muscles are too weak or the joints too loose to maintain stability voluntarily. It is absolutely critical that patients undergo expert evaluation to determine if the serratus is truly paralyzed or just hypoactive.

  • Why not a tendon transfer? In these patients, the serratus anterior muscle isn't paralyzed, it’s just hypoactive and the brain has learned to allow the scapula to wing when it should not. The goal of any surgery would be to put the scapula back where it belongs on the chest wall and keep it there during shoulder motion. A tendon transfer (historically a pectoralis major transfer) would accomplish this goal but it is far more invasive and a permanent alteration of the chest anatomy. A scapulopexy accomplishes the same goal with less morbidity and gives the brain a chance to relearn the correct, coordinated use of the scapula.

  • Why not a fusion? Fusion is also permanent and eliminates far more scapular motion. Scapulopexy preserves more natural motion and is less invasive, making it an ideal middle ground for most patients.

The Procedure

  • The Concept: Dr. Wall uses a robust allograft tendon to tether the bottom corner of the scapula directly to the underlying rib.

  • The Technique:

    1. Pectoralis Minor Release: First, the tight pectoralis minor in the front is released arthroscopically to remove the anterior pulling force.

    2. Graft Placement: Through a small incision on the back, the tendon graft is looped around the rib and securely anchored to the corner of the scapula using high-strength sutures.

    3. Tensioning: The graft is tensioned specifically to allow functional shoulder motion but restrict the scapula from winging outward.

Post-Op Protocol

The success of this surgery depends on the graft healing to the bone and not stretching out during the recovery phase. Eventually, some stretching of the graft is expected and permitted, but ideally after the brain has relearned the correct control of the scapula.

  • Immobilization (Phase 1: 0–4 weeks):

    • Strict Protection: You must wear a sling to keep the shoulder blade unloaded.

    • The "No-Reach" Rule: You are strictly forbidden from reaching forward (protraction), pushing open doors, or reaching across your body, as these motions pull directly against the tether.

  • Mobilization (Phase 2: 4–10 weeks):

    • The sling is discontinued.

    • Vertical Motion Only: You will begin active-assisted range of motion focusing on lifting the arm straight up (flexion/abduction) while keeping the shoulder blades squeezed back. No strengthening at this time.

  • Strengthening (Phase 3: 10+ weeks):

    • Progressive strengthening of all scapular muscles.

    • Full return to activities is typically expected by 4–6 months.

When to Seek Care

You should schedule a consultation if:

  • You have severe scapular winging that you cannot correct voluntarily.

  • You have limited ability to raise your arm in front of you but there are no significant findings on a shoulder MRI (some mild rotator cuff or biceps disease are common findings in a young patient’s MRI who has functional STAM 2 and cannot lift their arm)

  • You have a connective tissue disorder (like EDS) and your shoulder feels like it is constantly "sliding out" of place on your back.

  • You want a surgical solution for your winging that preserves more motion than a fusion.

  • You have failed physical therapy for "scapular dyskinesis."