- Anaesthetic
- General + nerve block
- Duration
- 2–3 hours
- Stay
- 1–2 nights
- Orthosis
- 6 weeks (abduction–ER brace)
- Active ROM
- From 6 weeks
- Strengthening
- From 12 weeks
What it is.
Lower trapezius tendon transfer (LTT) is a reconstructive procedure for irreparable posterosuperior rotator cuff tears. When the supraspinatus and infraspinatus tendons are too retracted and fatty-infiltrated to repair directly, the lower trapezius muscle can be rerouted to take over their function - restoring external rotation and assisting with overhead elevation.
Because the lower trapezius tendon alone is not long enough to reach the greater tuberosity, an Achilles tendon allograft is used to bridge the gap between the scapular spine and the humeral footprint.
Why it is done.
Massive rotator cuff tears that cannot be repaired directly leave patients with significant loss of external rotation and overhead function. Without reconstruction, the shoulder progressively weakens and may develop cuff tear arthropathy. Lower trapezius tendon transfer is indicated when:
- The posterosuperior rotator cuff (supraspinatus and infraspinatus) is irreparable on MRI - advanced retraction and fatty infiltration.
- The deltoid is functioning normally.
- The subscapularis (front of the cuff) is intact or reconstructable.
- The patient has meaningful functional goals that justify a major reconstruction.
The lower trapezius is an ideal donor because its line of pull closely mimics the infraspinatus, and its loss from the scapula is well compensated by the middle and upper trapezius.
How it is performed.
The procedure is performed under general anaesthetic with a regional nerve block. The patient is positioned in the lateral decubitus (side-lying) position. Through a posterior approach, the lower trapezius tendon is detached from the scapular spine. An Achilles tendon allograft is sutured to the lower trapezius to extend its reach. The combined construct is passed beneath the deltoid and secured to the greater tuberosity footprint using suture anchors.
Rehabilitation protocol.
A written copy of this protocol is provided to your physiotherapist. This is a complex reconstruction with strict early restrictions to protect the tendon transfer. An abduction–external rotation orthosis is worn at all times (except for supervised exercise and washing) for the first 6 weeks.
Phase I - weeks 0–6 (maximal protection)
- Abduction–external rotation orthosis worn at all times except exercise and washing.
- No passive internal rotation, adduction, or extension of the shoulder.
- No forced forward flexion.
- No upper-extremity weight bearing.
- Active range of motion: elbow, wrist, hand, and cervical spine.
- From post-operative week 3: gentle passive range of motion for forward flexion, scapular plane elevation, and external rotation (neutral to end range).
- Strengthening: scapular retraction, shrugs, submaximal deltoid isometrics only.
Phase II - weeks 6–12 (active range of motion)
- Facilitate the latissimus dorsi as an external rotator and depressor.
- Wean from orthosis.
- No forced internal rotation, adduction, or extension.
- No shoulder strengthening or lifting/carrying.
- Progress from assisted active to full active range of motion: supine, then side-lying, then antigravity positions for forward flexion, elevation, external rotation, and internal rotation.
- Prone rowing exercises.
- Submaximal rotator cuff isometrics, wall push-up plus, proprioceptive exercises.
Phase III - week 12 onwards (initial strengthening)
- Gentle terminal stretching and joint mobilisations as needed.
- Deltoid and periscapular strengthening.
- External rotation isometrics progressing to isotonics.
- Internal rotation, biceps, triceps, and general upper-extremity strengthening.
- Light closed-chain exercises.
- Proprioception and rhythmic stabilisation drills.
Phase IV - advanced strengthening and return to activity
- Progressive resistance training.
- Push-up plus progression.
- Gentle weight training - hands in sight, no wide grip.
- Avoid cross-body movements (combined internal rotation and adduction).
- Minimise overhead loading.
- Light sport and recreation as tolerated.
- Advanced proprioception and closed-chain progression.
View the recovery roadmap for the full rehabilitation journey, or visit For Physiotherapists for protocol requests.
Frequently asked questions.
What is a lower trapezius tendon transfer?
It is a surgical procedure that reroutes the lower trapezius muscle, extended with an Achilles tendon allograft, to replace the function of an irreparable posterosuperior rotator cuff tear. The transferred tendon restores external rotation and helps with overhead function.
Who is a candidate for lower trapezius tendon transfer?
Patients with irreparable posterosuperior rotator cuff tears who have lost external rotation strength and overhead function but still have a functioning deltoid and an intact or reconstructable subscapularis. It is typically considered when direct repair is not possible due to tendon retraction and fatty infiltration.
How long is the recovery after lower trapezius tendon transfer?
An abduction–external rotation orthosis is worn for the first 6 weeks. Active range of motion begins at 6 weeks. Initial strengthening starts at 12 weeks. Return to light sport and recreation follows, though combined internal rotation and adduction movements are avoided long-term.
Why is an Achilles tendon allograft used?
The lower trapezius tendon alone is not long enough to reach the greater tuberosity. An Achilles tendon allograft extends the tendon, bridging the gap and providing a strong fixation point on the humerus.
What movements should be avoided after lower trapezius tendon transfer?
Combined internal rotation and adduction (such as reaching behind the back), forced forward flexion, and upper-extremity weight bearing should be avoided in the early phases. Long-term, cross-body movements and wide-grip overhead lifting are minimised to protect the transfer.
References.
- Elhassan BT, et al. Lower trapezius tendon transfer for massive irreparable posterior-superior rotator cuff tears: early outcomes. J Shoulder Elbow Surg. 2020;29(12):2558–2564.
- Valenti P, et al. Lower trapezius transfer with Achilles tendon allograft for irreparable posterosuperior rotator cuff tears. Orthop Traumatol Surg Res. 2021;107(4):102890.