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Review: Muscle Tendon Transfers Around the Shoulder

Key findings

  • Muscle tendon transfers (MTTs) can reduce pain and improve function in a broad range of shoulder pathologies, from irreparable subscapularis and posterosuperior rotator cuff tears to scapulothoracic abnormal motion associated with muscle palsy
  • When an MTT is considered, the patient must have exhausted all nonoperative management and understand the likely postoperative outcomes and potential complications
  • Potential complications of MTTs are low and similar to those of other orthopedic surgeries including infection, hematoma and failure of tendon transfer healing, so shoulder surgeons with appropriate training should perform them

Muscle tendon transfers (MTTs) are effective for reducing pain and improving range of motion in a variety of shoulder pathologies:

  • Irreparable subscapularis and posterosuperior rotator cuff tears (RCTs)
  • Irreparable posterior RCTs in the setting of reverse shoulder arthroplasty
  • Scapulothoracic abnormal motion associated with serratus anterior and trapezius palsy
  • Complete deltoid deficiency and posterior cuff deficiency in the setting of reverse shoulder arthroplasty

Jon J.P. Warner, MD, and Bassem T. Elhassan, MD, co-chiefs of the Shoulder Service and co-directors of the Harvard Shoulder & Elbow Fellowship in the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues recently reviewed the anatomy, biomechanics, diagnosis and surgical indications for MTT around the shoulder. They also comprehensively describe currently used techniques and their potential complications. Their paper appears in the American volume of the Journal of Bone and Joint Surgery.


Any patient with deficient muscles secondary to irreparable tear or muscle paralysis could be considered for MTT if conservative management and other measures have failed to improve their function.
When physical therapy is implemented, our recommendations are:

  • Six to nine months of physical therapy for traumatic serratus anterior palsies
  • Up to 24 months of physical therapy for nontraumatic palsies

It is optimal to have preserved range of motion before doing MTT, but some patients may require release of their shoulder at the time of the MTT to improve their outcome.


The principles of MTT include ensuring that:

  • The transferred muscle is expendable (transferrable without compromising the function of the donor site)
  • The transferred muscle has normal or near normal strength
  • The transferred and recipient muscle tendon units have similar excursion and tension
  • The line of pull of the transferred tendon will replace or augment the function of the deficient muscle via a directionally similar biomechanical force

MTT Techniques

The authors review the following techniques in detail:

  • For serratus anterior palsy—Pectoralis major tendon transfer, direct (with osseous insertion)
  • For trapezius palsy—Triple tendon transfer (T3)
  • For irreparable subscapularis tear—Latissimus dorsi tendon transfer
  • For irreparable posterosuperior RCT—Scope-assisted lower trapezius transfer (SALTT; most common) and latissimus dorsi tendon transfer

Tables in the article list indications for each procedure and their advantages and disadvantages.

Potential complications of MTTs include infection, hematoma, and failure of tendon transfer healing. Therefore, these complex procedures should be performed by shoulder surgeons with appropriate training.

Refer a patient to the Shoulder Service

Learn more about the Harvard Shoulder & Elbow Fellowship

Related topics


Bassem Elhassan, MD, orthopaedics professor at Harvard Medical School, co-chief of the Shoulder Service and program director of the Shoulder Surgery Fellowship at Massachusetts General Hospital, has developed techniques for achieving excellent outcomes in rotator cuff tears that were previously considered irreparable.


Evan A. O'Donnell, MD, Jon J.P. Warner, MD, and colleagues in the Department of Orthopaedics, conclude from a systematic review that outpatient shoulder arthroplasty is a safe, cost-minimizing intervention associated with improved outcomes and high patient satisfaction when patients properly selected.