TRIPLE TENDON TRANSFER

The Goal

Dr. Kevin Wall provides specialized, fellowship-trained surgical treatment with triple tendon transfers to restore shoulder height and overhead function for patients in Richmond, VA, and the surrounding Central Virginia communities. This procedure is offered to patients with paralysis of their trapezius muscle. The trapezius is the largest muscle in the upper back and the primary elevator of the shoulder. When it is paralyzed—most commonly due to a spinal accessory nerve injury from a previous neck surgery or biopsy—the shoulder droops, the scapula wings out to the side, and patients are unable to lift their arm above shoulder height. The goal of this procedure is to reconstruct the paralyzed trapezius by transferring three healthy muscles from nearby to take its place, restoring the ability to shrug and lift the arm.

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

Dr. Wall utilizes the Triple Tendon Transfer, which is a modern, biomechanically superior modification of the historical Eden-Lange procedure.

The "Old" Eden-Lange vs. The Triple Transfer

It is important to distinguish this modern technique from older methods you may read about:

  • The "Old" Eden-Lange: Historically, surgeons transferred the rhomboid muscles into the infraspinatus fossa (the flat part of the shoulder blade). While this helped stability, it often failed to restore full overhead motion and created a bulky, uncosmetic mass on the back of the shoulder.

  • The Triple Tendon Transfer (Modern Technique): Dr. Wall transfers the Levator Scapulae, Rhomboid Minor, and Rhomboid Major directly to the Scapular Spine (the top ridge of the bone).

    • Why this is better: By anchoring these muscles to the top of the scapula rather than the back, we recreate the exact shape and line of pull of the native trapezius. This provides superior leverage for lifting the arm and avoids the "bulky" appearance of the older technique.

The Technique

  • Harvest: Through an incision on the back, the three healthy muscles on the medial border of the scapula are identified and detached with their bony insertion. By taking a piece of bone with each one, the strong native insertion biology is preserved. This technique also allows for eventual bone-to-bone healing.

  • Transfer:

    • Levator Scapulae: Transferred laterally to replace the Upper Trapezius (restoring the "shrug").

    • Rhomboid Minor & Major: Transferred to the middle and medial scapular spine to replace the Middle and Lower Trapezius (restoring stability and rotation).

  • Fixation: The transferred tendon-bone units are secured back to their new locations on the scapula using heavy-duty suture and bone tunnels to ensure a permanent hold.

Post-Op Protocol

Recovery from this surgery is unique because of the specialized brace required to take tension off the repair while it heals.

  • Immobilization (Phase 1: 0–8 weeks):

    • The Gunslinger Brace: Unlike standard shoulder surgeries, a simple sling is not sufficient. You will wear a specialized "Gunslinger" brace that holds your arm suspended in mid-air

    • Purpose: This position brings the scapula closer to the spine, putting the repaired muscles in a relaxed, shortened position so they can heal without stretching out.

    • Strict Restriction: You must remain in the brace 24/7 for 8 weeks. No shoulder motion is allowed.

  • Formal PT Start: Physical therapy typically begins at Post-Op Week 8, once the brace is removed.

  • Mobilization (Phase 2: 8–16 weeks):

    • Therapy focuses on "waking up" the transferred muscles. Because these muscles used to pull the shoulder back (retraction) and now must lift the shoulder up (elevation), specialized biofeedback therapy is used to retrain your brain to use them in their new role. A sling is temporarily provided in the first two weeks of this phase since the arm has not been allowed to move in a long time and is weak.

  • Strengthening (Phase 3: 16+ weeks):

    • Progressive strengthening begins. Full return to activity is expected around 6 months.

When to Seek Care

You should schedule a consultation if:

  • You have a history of a neck lymph node biopsy or mass removal and have had shoulder weakness ever since.

  • Your shoulder visibly "droops" lower than the other side, and you are unable to shrug your shoulder.

  • You have been told you have lateral winging (the shoulder blade slides away from the spine) rather than medial winging (sticking out near the spine).

  • You have been told you have a "spinal accessory nerve injury" that has not healed after 12 months of observation.