CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 349, pp 139-148

0 1998 Lippincott-Raven Publishers

SECTION

11

ORIGINAL ARTICLES
Serratus Anterior Dysfunction
Recognition and Treatment
Jon J.P. Warner,MD; and Ronald A. Navarro, MD

Recognition of scapular winging may be dificult, and potential errors in treatment can result. Such treatment errors may cause morbidity for the patient. In addition, electrical
evidence of long thoracic nerve injury usually is
required to confirm the etiology of scapular
winging as being caused by serratus anterior
dysfunction. Although various conditions may
result in scapular winging, primary serratus
anterior dysfunction can be treated effectively
by transfer of the pectoralis major tendon;
however, this surgical approach sometimes may
give an unacceptable cosmesis, and there may
be local morbidity to the donor site of the iliotibial band graft that is used to augment the
tendon transfer. The authors report eight patients with primary chronic scapulothoracic
winging refractory to conservative treatment.
From The Harvard Shoulder Service, Department of
Orthopaedic Surgery, Massachusetts General Hospital,
Boston, MA.
Reprint requests to Jon J.P. Warner, MD, The Harvard
Shoulder Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital, Gray Building, Sixth
Floor, 55 Fruit Street, Boston, MA.
Received: September 15, 1997.
Revised: November 3, 1997.
Accepted: November 7, 1997.

139

Five of these patients had an incorrect diagnosis, and this resulted in 17 surgical procedures
without resolution of their pain or improvement
of function. Of the eight patients who required
additional surgery to stabilize the scapula, only
five patients had an electromyographic study
that showed long thoracic nerve palsy, although
all patients had profound scapulothoracic winging. All patients underwent a modified pectoralis major transfer with autogenous semitendinosus and gracilis tendon augmentation
using two small incisions. Although one patient
had a postoperative infection develop, the remaining seven patients had resolution of their
winging, improved function, and satisfactory
cosmesis.

Although prior clinical series have documented the presentation, natural history, and
treatment of scapular winging, the incidence
and consequences of diagnostic error and incorrect treatment have not been emphasi~ed.2-4,6-12,15-18,22,25,26,28 In addition, most
clinical series3.22 have required documented
electrical evidence of long thoracic nerve
palsy to confirm the diagnosis of serratus anterior dysfunction before surgical treatment.

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Clinical Orthopaedics
and Related Research

Warner and Navarro

Patients with serratus anterior dysfunction

and scapular winging may have various vague
reported symptoms that suggest other diagnoses, including glenohumeral instability.15.22
The serratus anterior functions to maintain
scapular stability during arm elevation. It
does this by causing upward rotation and protraction of the scapula. Dysfunction of this
muscle will cause winging of the scapula as
the patient attempts to elevate the ann1S,21,22
Although most patients with symptomatic
scapular winging will improve with nonoperative care, including periscapular splinting
and muscle strengthening, some may require
surgical treatment to stabilize the scapuTenlothoracic articulation.3,*,10,16,18,22,2S,28
don transfers that have been used to restore
normal scapulothoracic movement include
the pectoralis minor,2' teres major,28 rhomboids,8 and pectoralis major.3,10,22 The latter
technique is the most common surgical treatment method, and it generally is performed
through a large incision over the shoulder
and thorax and a large incision over the lateral thigh for harvesting of the autogenous iliotibial band graft, which is used to augment
the transferred pectoralis major tendon. Although this approach usually is satisfactory,
surgical morbidity from graft harvest and unsatisfactory cosmesis from the long surgical
incision have been reported.22
This article has two purposes: first, to report a group of patients with chronic symptomatic serratus anterior dysfunction and
scapulothoracic winging, many of whom had
incorrect diagnoses and surgical treatments;
and second, to describe a modified surgical
technique that uses small incisions and autogenous semitendinosus and gracilis grafts to
augment the tendon transfer.

PATIENTSAND METHODS
Patient Presentation
During a 3-year period, 14 patients were seen with
symptomatic scapular winging. Nine patients had
electrical evidence of long thoracic nerve palsy on
electromyographic analysis, whereas five either

failed to show abnormal function of the long thoracic nerve or had an inadequate or incomplete
study. All patients initially were treated with a
conservative program consisting of scapular
bracing and periscapular muscle strengthening.
Four patients had improvement of their pain and
function during a 1-year period. Two failed to
have improvement but did not want additional
treatment. The remaining eight patients all had
diagnoses other than scapular winging, and all
had experienced failure of various therapy programs elsewhere. Five of these patients had at
least one surgical procedure (Table 1). Five of
these eight patients had electromyographic confirmation of a long thoracic nerve injury. Several
patients had multiple surgical procedures for various diagnoses. These included acromioclavicular
joint resection, posterior capsular shift, acromioplasty, and anterior capsular shift. There were
four men and four women with four right and four
left shoulders involved. Their average age was 33
years (range, 2 4 4 3 years). Four patients related
the onset of their symptoms to heavy lifting in
work activities, but no specific injury could be
recollected. Three thought their pain began after a
motor vehicle accident, and one had pain develop
after an altercation (Table 1). None of these patients were involved in litigation at the time of
their treatment. The duration of shoulder pain before their presentation for treatment averaged 40
months (range, 12-86 months). There was no correlation with the duration of symptoms and the
success of a conservative treatment program.

Physical Findings
All patients were found to have painful scapular
winging characterized by prominence of the inferior tip of the scapula and loss of protraction
of the scapula during shoulder elevation and discomfort felt posteriorly over the shoulder and in
the periscapular region. There were no functional differences between patients with electromyographic evidence of long thoracic nerve
palsy and those without such evidence. None
could actively flex their shoulders above 120".
The average forward flexion was 97" (range,
80"-120'). No patient had findings of trapezius
dysfunction, which would include drooping of
the shoulder girdle and lateral displacement of
the scapula.' All had a strong and symmetric
shoulder shrug. In addition, all patients had full
and supple passive range of motion.

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Serratus Anterior Dysfunction

141

TABLE 1. Patient Demographics

~

~~~~~

Patient

Injury

Electromyograph

Initial
Diagnosis

25-year-old man

Heavy lifting

Negative

Acromioclavicular
joint injury
Posterior instability

33-year-old man
44-year-old woman

Heavy lifting
Automobile
accident

Positive
Positive

Posterior instability
Impingement
Instability

35-year-old woman

Automobile
accident

Negative

Rotator cuff tear

Instability

36-year-old man

Heavy lifting

Positive

Impingement
Frozen shoulder
Reflex sympathetic
dystrophy

26-year-old woman

Automobile
accident

Negative

38-year-old man
3 1-year-old woman

Altercation
Heavy lifting

Positive
Positive

impingement
Scapulothoracic
bursitis
Impingement
Impingement
Scapulothoracic
bursitis

An additional finding in all patients was relief

of shoulder discomfort and the ability to flex their
shoulder above 150" when the scapula was stabilized by manually compressing it against the chest
wall. This was termed the scapular stabilization
test, and it appeared to be reproducible in all cases.
One patient had an anterior deltoid deficiency
as the result of a prior open acromioplasty procedure. He also had a diagnosis of reflex sympathetic dystrophy. This individual first underwent
treatment for his reflex sympathetic dystrophy
and then had an anterior deltoid reconstruction
before having surgical reconstruction of his
chronic scapulothoracic winging. Another patient
had mild osteoarthritis as the result of an intraarticular screw that had been placed during a Bristow procedure to treat a diagnosis of instability.
One patient had painful posterior subluxation despite two prior posterior capsular shift proce-

Prior Surgery
1. Acromioclavicular

joint resection
2. Arthroscopy
3. Posterior shift
4. Revision
Posterior shift
Posterior shift
1. Arthroscopy
2. Acromioplasty
3.Biceps tenodesis
4. Anterior shift
5. Acromioclavicular
joint resection
1. Rotator cuff repair
2. Bristow procedure
3.Removal of screw
1. Arthroscopy
2. Acromioclavicular
joint resection
3.Acromioplasty
4. Closed manipulation

dures. The scapular stabilization test in this patient eliminated his symptoms and findings of
posterior shoulder subluxation and improved his
ability to flex his shoulder from 110"to 150".
Nine of 14 patients had an electromyographic
study that showed a long thoracic nerve palsy,
whereas the others had studies that failed to show
electrical evidence of a nerve injury. All of these
studies were performed at other institutions using
different electromyographic services. These patients declined a repeat electromyographic study.

Nonoperative Treatment
Six patients who had winging and did not have
prior surgical treatment initially were treated
with a modified scapulothoracic brace with a
scapular pad to stabilize the scapula. They also
were instructed to refrain from reaching above
the level of the shoulder. In all cases the brace

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Warner and Navarro

was tolerated poorly, although during the course

of 1 year, four of these patients had resolution of
their winging. The two remaining patients removed their braces after 3 weeks, and although
their winging did not recover during the following year, they elected not to have additional
treatment.
The other eight patients underwent surgical reconstruction to restore scapular stability. These
included the five who had prior surgeries for
other diagnoses and three who had winging and
no prior surgical treatment but who declined to
have scapular bracing. All of these patients had
symptoms more than 1 year.

Surgical Technique
The procedure is performed with the patient under
general anesthesia and positioned on a full length
pneumatic (bean) bag in a semilateral position with
the torso tilted backward 30". The ipsilateral lower
extremity, thorax, shoulder, and arm are prepared
in a sterile manner. Preoperative broad spectrum
antibiotics are administered parenterally.

Tendon Harvest
The leg and thigh are exsanguinated, and the
tourniquet is inflated to 350 mm Hg. The technique for harvesting the semitendinosus and gra-

Fig 1. Incision for harvesting of semitendinosus and gracilis tendons. (Inset = method of
tendon harvest using tendon stripping device.)

Clinical Orthopaedics
and Related Research
cilis has been described previously (Fig 1).20 A 3cm incision is made slightly medial and inferior to
the palpable tibial tubercle over the palpable semitendinosus and gracilis tendons. After subcutaneous undermining the sartorius fascia is divided
in line with and just above the semitendinosus and
gracilis tendons. These tendons are elevated with
a right angle clamp and all fascia1 connections to
the crural fascia are sharply divided. A tendon harvesting devices (Tendon Stripper Concept-Linvatec, Largo, FL) is used to dissect each tendon
proximally into its muscle-tendon junction where
it is divided. Each tendon is dissected to its insertion and divided. Closure of the sartorius fascia is
done with absorbable suture of 0 gauge, and the
skin closure is done with 3-0 subcuticular absorbable suture.
The tendon grafts usually have a length of 22 to
24 cm, and are sewn together along their length,
with each end tapered to allow easy passage
through the end of the pectoralis major tendon.

Pectoralis Major Dissection

A 4-cm incision is made beginning just lateral
and inferior to the coracoid process and slightly
medial to the anterior axillary crease (Fig 2A).
Undermining of the subcutaneous plane allows
exposure of the deltopectoral interval and the inferior border of the pectoralis major muscle and
its insertion. The interval between the clavicular
(superior) and sternal (inferior) portion of the
muscle is defined. Using blunt dissection from
deep to the sternal portion, the interval is developed (Fig 2B). A Penrose drain is placed around
the sternal portion of the muscle, and dissection
proceeds laterally toward its insertion (Fig 2C).
The long head of the biceps is protected in the
bicipital groove as the sternal portion of the tendon of the pectoralis major is divided sharply
from its insertion. The muscle is dissected proximally and medially to separate it sufficiently
from its clavicular portion so that it can be pulled
inferiorly in the direction of the transfer.
The semitendinosus and gracilis tendon graft
then is woven through the end of the sternal portion of the pectoralis major tendon so that two
limbs of the graft can be sewn to one another and
to the pectoralis major tendon (Fig 2D). Care is
taken to sew the end of the pectoralis tendon
around the tendon graft so that it is tubularized
and thus easily can pass through the tissue tunnel
along the chest wall once it is transferred.

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April, 1998

Serratus Anterior Dysfunction

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143

Fig 2A-G. (A) Incisionfor pectoralis major transfer. (6)The sternal and
clavicular heads of the pectoralis major insertion are identified. Note
that the sternal head twists as it courses to its insertion so that it inserts
underneath the clavicular head on the humerus. (C) A Penrose drain
has been placed around the sternal head of the pectoralis major, which
has been dissected free from the clavicular head to its insertion on the
humerus. (D) The tendons of the semitendinosus and gracilis are woven through the end of the pectoralis major tendon after the sternal
head of the pectoralis major has been mobilized for transfer. (E)The
sternal head of the pectoralis major and the semitendinosus and gracilis graft are oriented for transfer to the inferior pole of the scapula.
This transfer will be through a deep soft tissue tunnel along the chest
wall. The small inferior incision over the inferior pole of the scapula has
been made. (F) The tendon is transferred from anterior around the
chest wall and through a drill hole in the inferior pole of the scapula. (G)
Transferred pectoralis major along the chest wall and through drill hole
in inferior scapula.

Tendon Transfer
The shoulder is flexed forward to bring the inferior pole of the scapula anteriorly, and a 3- to 4cm incision is made over its palpable edge. The
overlying muscle of the latissimus is split, and the
muscle attachments along the inferior pole of the
scapula, on its inner and outer surfaces, are elevated subperiosteally with an electrocautery device and with a bone elevator. Blunt retractors are
inserted to expose the bone of the inferior
scapula. A motorized burr or drill is used to make
a hole through the inferior angle of the scapula.
This hole is placed in the thin portion of the bone

approximately 2 cm medial to the thickened cortical edge of the inferior pole of the scapula (Fig
2E). The hole is approximately 8 to 10 mm in diameter to allow for passage of the tendon graft.
A long curved clamp is placed through the incision over the inferior scapula, and a soft tissue tunnel is developed along the thoracic rib cage to the
proximal incision over the front of the shoulder.
Care is taken to dilate this tunnel so that the tendon
graft and pectoralis major can move freely. Using
this clamp, the sutures in the end of the tendon graft
are passed through the soft tissue tunnel and
through the hole in the inferior scapula. The tendon

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Clinical Orthopaedics
and Related Research

Warner and Navarro

graft is pulled through the hole in the inferior

scapula and proximally back up the soft tissue tunnel and to the pectoralis major tendon (Fig 2E-F).
This allows it to be secured by suturing it to itself
along its length and back to the pectoralis tendon
(Fig 2G). The graft configuration forms a u-shape,
and by folding it over itself it gives twice the thickness of the composite tendon graft. Before the graft
is sutured in place, the scapula is pushed forward
manually on the chest wall and tension is maintained in the tendon transfer. The subcutaneouslayers and skin are closed using absorbable sutures.

Postoperative Treatment
The patient is discharged from the hospital on the
first postoperative day, and a shoulder immobilizer is worn with the arm at the side for the first 4
weeks. During this period passive shoulder motion is performed to ensure that the tendon transfer does not scar to the soft tissue tunnel along the
chest wall. The patient is permitted to remove the
shoulder immobilizer to shower. Active range of
motion begins after 4 weeks; strengthening exercises are prohibited until 3 months after the procedure. Lifting more than 20 pounds with the
surgically treated arm or contact and collision
sports are prohibited for 1 year after surgery.
After 2 months a biofeedback program is instituted to help the patient train the tendon transfer to
actively stabilize the scapula during shoulder flexion. It is the authors' impression that the speed of
recovery of scapular stabilization is better with this
technique than with other methods of muscle training. The biofeedback program is done using surface
electrodes (Myotrac Model 4000, Thought Technologies Ltd, Montreal, Canada) placed over the
transferred pectoralis muscle. The biofeedback unit
gives visual and audible feedback from electromyographic activity occumng with muscle contraction. The threshold level initially is set low and
is increased as the patient is able to maintain muscle activity more consistently during shoulder flexion. Biofeedback training is performed initially
with the patient in a side lying position to eliminate
the effects of gravity. The patient is asked to adduct
the flexed arm against resistance provided by the
therapist to promote contraction of the pectoralis
major. This resistance is maintained for 5 seconds
for five to 10 repetitions to allow the patient to become familiar with the biofeedback signal. The patient then attempts to flex the shoulder anterior to
the plane of the scapula while maintaining the pec-

toralis muscle contraction by maximizing the

biofeedback audible and visible signals. If the patient has difficulty maintaining pectoralis contraction during flexion, the therapist provides some
concomitant resistance to adduction during flexion.
Once the patient is able to maximize pectoralis contraction consistently without gravity, he or she is
asked to sit up and attempt flexion. Usually two to
four sessions are required to produce this effect.

RESULTS
One patient had a wound infection develop in
the second week after surgery and was treated
with debridement and removal of the graft at
another institution; the patient was lost to followup. The remaining seven patients were observed for an average of 32 months (range,
24-40 months) after surgery. There were no
complications in these patients. No patient
had donor site symptoms from harvesting of
the semitendinosus and gracilis tendons. Five
patients underwent biofeedback training of
the transferred muscle, although the first two
patients underwent surgery before biofeedback was used routinely. All seven patients
had resolution of their painful scapular winging with restoration of normal scapular protraction and improved arm elevation. Forward
flexion improved to an average of 150"
(range, 120"-165O), compared with the preoperative average of 97" (range, 80"-120") (Fig
3A-B). All patients were satisfied with the
cosmesis of their incisions (Fig 3C-D). The
one patient with 120" flexion postoperatively
had a deltoid reconstruction to repair an anterior deltoid defect resulting from a prior open
acromioplasty. The patient who had two prior
posterior capsular shift procedures had complete resolution of his instability symptoms,
correction of his scapular winging, and
marked improvement of his forward flexion.
He now is working doing medium level manual labor.

DISCUSSION
This study reports an experience with diagnosis and treatment of patients with symp-

Number 349

April, 1998

Serratus Anterior Dysfunction

145

Fig 3A-D. (A) Thirty-five year old woman with chronic left scapular winging and pain. (B) Two years
after pectoralis major transfer there is full range of motion and good scapular control. (C) Cosmesis
of the donor site incision for hamstring tendon harvest is satisfactory. (D) Cosmesis of the shoulder
incision is satisfactory.

tomatic scapulothoracic winging. Prior series3.22 have reported patients with similar
symptoms; however, the group of patients
in this study was complex because of multiple prior surgical procedures for diagnoses

other than scapular winging. In addition,

only nine of 14 patients had electrical documentation of injury to the long thoracic
nerve, although all had profound winging
characterized by loss of scapular protrac-

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Warner and Navarro

tion. This failure to document an injury to

the long thoracic nerve makes confirmation
of the diagnosis difficult, and this misdiagnosis could have been because of an inadequate electromyographic study. An alternative explanation is that there was direct
injury to the serratus anterior and that this
resulted in loss of scapular stabilization. In
either case, eight of the patients for whom a
conservative approach failed were treated
successfully by a dynamic muscle-tendon
transfer technique.
Scapular winging may occur not only
from serratus anterior dysfunction, but also
as the result of trapezius palsy' and muscular
dystrophy.13 Trapezius palsy typically gives
the appearance of a shoulder girdle that
droops with lateral displacement of the
scapula. The patient often is unable to shrug
the shoulder. None of the patients had this
appearance. Serratus anterior dysfunction
presents with loss of scapular protraction
during attempted shoulder elevation with the
inferior tip of the scapula being prominent.
This was the appearance of all of the patients. Quantification of the degree of winging usually is based on observation; however, all of the patients had very apparent
winging of the inferior tip of the scapula.
Scapular winging also can be secondary,
caused by glenohumeral joint stiffness and
shoulder instability.24 In the former case
there is passive limitation of glenohumeral
motion, and in the latter case there is a positive apprehension finding. All of the patients
had supple glenohumeral joint motion, and
one of the patients who had surgery had posterior instability that resolved after treatment
of his winging. Thus. it was thought that it
was the scapular winging that was the primary problem in these patients.
The scapular stabilization test was found
to be particularly helpful in confirming that
the pain and limitation of shoulder elevation
were caused by loss of scapular stabilization.
In all of the patients this maneuver reproducibly eliminated their pain and improved
their ability to elevate the shoulder. Although

Clinical Orthopaedics
and Related Research

the accuracy of this maneuver as a diagnostic

test was not studied, it was thought it correlated with the success of scapular stabilization surgery.
Patients with scapular winging may have
various symptoms that might suggest other
clinical conditions. These can include rotator
cuff disease and glenohumeral instability. The
profile of five of the patients suggested that
their initial treating physicians made diagnoses of instability, impingement, acromioclavicular joint disease, and biceps tendonitis.
Because of these misdiagnoses, 17 prior surgical procedures were performed on these five
patients without relief of their symptoms.
It is possible to understand why these patients may have symptoms that suggest impingement and instability if one considers the
biomechanics of the glenohumeral and scapulothoracic motion relationships. First, scapulothoracic dysfunction can contribute to
glenohumeral instability, as loss of normal
scapular rotation can destabilize the glenohumeral joint by failing to provide a stable
glenoid platform underneath the rotating
humeral head during abduction or flexio11.21.2~This association of scapular winging
and instability has been described previously.21,22,24Three of the patients had procedures for glenohumeral instability, and although the two who had an anterior repair did
not have symptoms of instability when they
presented for treatment, the patient who had
two prior posterior capsular shifts continued
to have instability symptoms. In this individual the tendon transfer resulted in more normal scapulothoracic motion, and his posterior
instability symptoms resolved without the
need for any additional capsular tightening
procedure.
Secondary impingement also can occur as
a result of serratus anterior dysfunction. In
this case the scapular winging results in the
forward and downward movement of the
coracoacromial arch; this reduces available
clearance for the rotator cuff and greater
tuberosity as the shoulder is flexed forward.21,24
This might explain why some of the

Number 349
April, 1998

patients had symptoms that led their surgeons

to perform surgery for impingement.
Although various surgical techniques have
been described to treat chronic scapulothoracic winging, the most commonly used
method uses the sternal head of the pectoralis
major, which is lengthened by autogenous
fascia lata graft.3,*2This procedure is reliable
for restoration of scapular stability but has the
potential disadvantages of requiring a large
incision over the shoulder and hemithorax and
a large incision over the lateral thigh. One
study has described deformity of the lateral
thigh from muscle herniation after harvest of
the iliotibial band and postoperative fluid collection at the donor site.22
In the treatment of these patients a modified technique was used that uses the two medial hamstring tendons that were harvested
through a small incision below the knee.20
Two additional small incisions were made
over the pectoralis tendon and over the inferior pole of the scapula. The rationales for
these modifications were to improve cosmesis
and limit graft site morbidity (Fig 3C-D).14 In
addition, graft strength of the combined semitendinosus and gracilis tendons is greater than
that of a 10-mmstrip of the iliotibial band.19,23,27
This tendon repair configuration doubled the
composite graft thickness, which would additionally increase its strength.
In addition, a method of biofeedback
training of the transferred pectoralis major
was used in all of the patients except for the
first two undergoing surgery. Although there
was no specific analysis of the advantages of
this method, it was found to be easy to apply.
It was the impression of the surgeons and
that of the patients that it markedly improved
their ability to control the scapula during arm
elevation. During the course of training, it
appeared that the transferred pectoralis major muscle was active through the entire motion of shoulder flexion.
All patients who present with shoulder
pain should have a careful evaluation of
scapulothoracic motion and function as a
part of their overall shoulder examination.

Serratus Anterior Dysfunction

147

Chronic, refractory, painful scapulothoracic

winging that is alleviated with the scapular
stabilization test can be treated by transfer of
the pectoralis major tendon, and a modified
technique that uses small incisions and semitendinosus and gracilis autograft is safe and
cosmetically acceptable to patients.

References
1. Barron OA, Levine WN, Bigliani LU: Surgical
Management of Chronic Trapezius Dysfunction. In
Warner JJP, Iannotti JP, Gerber C (eds): Complex
and Revision Problems in Shoulder Surgery.
Philadelphia, Lippincott-Raven 377-384, 1997.
2. Chaves JP: Pectoralis minor transplant for paralysis
of the serratus anterior. J Bone Joint Surg
33B:228-230,1951.
3. Connor PM, Yarnaguchi K, Manifold SG, et al: Split
pectoralis major transfer for serratus anterior palsy.
Clin Orthop 341:134142,1997.
4. Foo CL, Swanson M: Isolated paralysis of the serratus anterior: A report of 20 cases. J Bone Joint Surg
65B:552-556,1983.
5. Fowler PJ: Semitendinosus tendon and the Kennedy
ligament augmentation device in anterior cruciate
ligament reconstruction. Operative Tech Orthop
2:117-124, 1992.
6. Gozna ER, Hanis WR: Traumatic winging of the
scapula. J Bone Joint Surg 61A:1230-1233, 1979.
7. Gregg JR, Labosky D, Harty M, et al: Serratus anterior paralysis in the young athlete. J Bone Joint Surg
61A:825-832,1979.
8. Herzmark MH: Traumatic paralysis of the serratus
anterior relieved by transplantation of the rhomboidei. J Bone Joint Surg 33A235-238.1951.
9. Horowitz MT, TocantinsYLJ: Isolated paralysis of the
serratus anterior (rnagnus) muscle. J Bone Joint
Surg 20920-725, 1938.
10. Iceton J, Harris WR: Results of pectoralis major
transfer for winging of the scapula. J Bone Joint
SNg 69B:108-110,1987.
11. Johnson JTH, Kendall MO: Isolated paralysis of the
serratus anterior muscle. J Bone Joint Surg 37A:
567-574,1955.
12. Kauppila LI: The long thoracic nerve: Possible
mechanisms of injury based on autopsy study. J
Shoulder Elbow Surg 2:244-248, 1993.
13. Ketenjian AY Scapulocostal stdbilization for scapular winging in fascioscapulohumeral muscular dystrophy. J Bone Joint Surg 60A:476480, 1978.
14. Kramer J, Nusca D, Fowler PJ: Concentric and eccentric knee flexor and extensor capability following ACL reconstruction using the semitendinosus
tendon. Am J Sports Med 21:285-291,1993.
15. Leffert RD: Neurological Problems. In Rockwood Jr
CA, Matsen 111 FA (eds). The Shoulder. Philadelphia, WB Saunders CO750-790,1990.
16. Lindstrom N, Danielsson L: Muscle transposition in
serratus anterior paralysis. Acta Orthop Scand 32:
369-373,1962.

148

Warner and Navarro

17. Mah JY, Otusko NY Scapular winging in the young

athlete. J Pediatr Orthop 12:245-247, 1992.
18. Marmor L, Bechtol CO: Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle. A case report. J
Bone Joint Surg 45A: 156-160,1963,
19. Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in kneeligament repairs and reconstructions. J Bone Joint
Surg 66A: 344-352, 1984.
20. Pagnani MJ, Warner JJP, OBrien SJ, Warren RF:
Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of
harvest. Am J Sports Med 12:565-57 1, 1993.
21. Perry J: Biomechanics of the Shoulder. In Rowe CR
(ed). The Shoulder. New York, Churchill Livingstone 1-35, 1988.
22. Post M: Pectoralis major transfer for winging of the
scapula. J Shoulder Elbow Surg 4:l-9, 1995.

Clinical Orthopaedics
and Related Research

23. Swenson TM, Harner CD, Fu FH: Endoscopic ACL

reconstruction using a quadrupled semitendinosus
graft. Pittsburgh Orthop J 6:25-33, 1995.
24. Warner JJP, Micheli LJ, Arslanian LE, Kennedy J,
Kennedy R: Scapulothoracicmotion in normal shoulders and shoulders with glenohumeral instability and
impingement syndrome. A study using Moire topographic analysis. Clin Orthop 285: 191-199, 1992.
25. Vastamiiki M: Pectoralis minor transfer in serratus anterior paralysis.Acta M o p Scand 55:293-295,1984.
26. Vastamaki M, Kauppila LI: Etiologic factors in isolated paralysis of the serratus anterior muscle. A report of 197 cases. J Shoulder Elbow Surg
2~240-243, 1993.
27, Zarins B, Rowe CR: Combined anterior cruciate-ligament reconstruction using semitendinosustendon and
iliotibial tract. J Bone Joint Surg 68A:160-177, 1986.
28. Zeier FG: The treatment of winged scapula. Clin Orthop 91~128-133, 1973.