Triangle Tilt

The Triangle Tilt is recommended for patients diagnosed by 3D CT scan with a scapular hypoplasia, elevation and rotation, or SHEAR, deformity and for those with persistent internal rotation contractures. The average candidate for the Triangle Tilt has internal rotation of the arm at the shoulder and poor supination. A characteristic elbow flaring is seen along with sloping of the shoulder. As a result, the arm can appear shorter in length. Scapular elevation is visible in images from a CT scan of the upper body. 

The Triangle Tilt is a two-hour procedure. The patient stays for one night in the hospital to ensure proper splinting and positioning of the arm. Post-operatively, a ‘SARO brace’ is worn for a period of six weeks following surgery to allow for the newly tilted triangle to heal and strengthen. The type of brace used depends on the individual patient’s problem. The brace must be worn at all times and is not to be removed (even for bathing) for 3-6 weeks typically. The brace may be worn only at night for an additional 12-18 weeks if recommended by Dr. Nath. During the six-week post-operative phase, only passive range of motion for the wrist and fingers is done. During weeks 8-10, passive range of motion (PROM) and assisted active range of motion (AAROM) is done. Therapy is resumed at week 11+. Light weight-bearing exercise resumes slowly and gradually increases over time, as tolerated. Heavy weight-bearing exercises and rough sports should be avoided for one-year post-operatively.  

As shown in the before and after pictures, the Triangle Tilt often improves the length, movement and positioning of the arm by improving exaggerated internal rotation. Thus, secondary effects of internal rotation such as elbow flaring and sloping of the shoulder are improved. Concomitant winging of the scapula is also improved by the Triangle Tilt. 

Most importantly, the Triangle Tilt usually allows the arm to fit better into the shoulder joint, leading to improved anatomy of the joint. After the procedure, the patient’s shoulder joint will remodel close to normal anatomy after Triangle Tilt. 

Following the procedure Dr. Nath places the patient in the SARO brace that maintains the arm in partial abduction with the elbow in extension and the forearm in supination. This brace is custom-made the day before by an orthotics facility designated by Dr. Nath, as the brace was developed for this specific surgery. 

The patient wears this brace 24/7 for up to 6 weeks following surgery. Dr. Nath will inform the patient’s parents how long the patient needs to wear the brace when he discharges them from the hospital. The length of time in this brace may be different for each patient. 


  • 1. Evaluation in Houston office (no charge for initial consultation)
  • 2. Telemedicine, submit all medical records to the office with video 
  • 3. Outreach Event evaluation for in person evaluation free of charge( must bring documentation if required for condition)


Infants can be evaluated by video, simply remove clothing to the waist and show spontaneous movements of both arms while lying on the back. You can of course also have your child evaluated by Dr. Nath in person. Please visit and sign up for our email list to see when Dr. Nath will be in your area next.  

We also able to schedule a visit with Dr. Nath in Houston, please contact our office at 713-592.9900. 

In the interim, please contact our staff therapist Cindy Servello. via email at  She will contact you and would be happy to answer any questions you might have.  

We also need to see any medical records pertaining to your child’s injury, specifically previous surgical reports, CT or MRI reports and images, and EMG (nerve conduction study) results. The records may be faxed to 713-592-9921, emailed to, or mailed to Texas Nerve & Paralysis Institute, 6400 Fannin St. Ste 2420, Houston, Texas 77030.

Please also fill out, sign and submit the Consent Form .  This must be included with all documentation prior to Dr. Nath's review of the records.


Please send us a video or photos showing your/your child’s current range of motion using the movement chart shown.  All movements should be included with a maximum of 30 seconds time. 

Please have someone film you/your child wearing a tank top or sports bra, so that the shoulder blade is visible.

Videos taken on camera phones may be emailed to Videos taken on regular video cameras may be uploaded to our website due to large file size. 

Click below for video upload: