Subscapularis Tendon Tears: Identifying Mid to Distal Footprint Disruptions (original) (raw)
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Editorial Commentary: Precise Repair of Partial Subscapularis Tendon Tears Is Essential
Arthroscopy, 2019
The subscapularis is a very important anatomic structure that is essential for maintaining proper glenohumeral joint mechanics and shoulder function. It establishes a force couple with the infraspinatus and teres minor to stabilize the glenohumeral joint in the transverse plane. The subscapularis muscle also opposes the deltoid with humerus abduction and elevation. Recent advances in imaging and arthroscopy techniques have led to greater detection of subscapularis tendon tears. Furthermore, there have been detailed descriptions of the subscapularis insertional anatomy showing that the subscapularis tendon has 4 different facets of insertion to the lesser tuberosity. The tear patterns of the subscapularis are also different from that of the supraspinatus tendon where the complete isolated subscapularis tendon tear is not common. However, the subscapularis partial tear combined with supraspinatus or 3 tendon tears is more common, with most being first-facet tears. Clinically, upper-portion subscapularis partial tendon tears may be considered relatively benign, but biomechanically these tears result in increased external rotation and altered glenohumeral kinematics. Therefore, in my opinion, it is very important to precisely repair these partial subscapularis tendon tears for anatomic, structural, and functional restoration of the shoulder.
Subscapularis Tendon Tears: Classification, Diagnosis and Repair
Recent Advances in Arthroscopic Surgery
Rotator cuff tears include a panel of tendon lesions, and superior cuff tears are often combined with subscapularis lesions that are more difficult to repair. We propose in this chapter to describe the Lafosse subscapularis tears classification and to describe the arthroscopic repair that can be performed easily with a needle as shuttle. The advantages of these surgical techniques are simplicity, safety and quickness. The procedure is performed under general anaesthesia with the patient in beach chair position. A classic arthroscopic posterior portal is used to perform glenohumeral exploration, and cuff tendons are analysed. Once subscapularis tear is confirmed, the tendon must be released after repair with anterolateral portal. Then, a triple-loaded anchor is positioned at the edge of the bicipital groove to perform both biceps tenodesis and subscapularis repair.
Interstitial Tear of the Subscapularis Tendon, Arthroscopic Findings and Technique of Repair
The archives of bone and joint surgery, 2016
Tears of the subscapularis tendon have been significantly recognized as a source of shoulder pain and dysfunction in the past decade, thanks to arthroscopic evaluation of the shoulder and biomechanical and anatomical studies of the tendon. Current classification of subscapularis tendon tear is based on insertion site of the tendon. Recently, a classification for non-insertional types of subscapularis tendon tear has been published. Interstitial tear of subscapularis tendon has not been described in classifications available in the literature. This report describes significant interstitial tear of the subscapularis tendon. This tear looks normal in superior, bursal and articular sides. Then its specific arthroscopic findings as "Air bag sign" and repair technique of the pathology is explained.
Clinical and surgical diagnostic evidence in subscapularis tendon injuries
Lo Scalpello - Otodi Educational
Objective. The purpose of the present study was to estimate the diagnostic accuracy of a spectrum of physical examination tests, explaining how to perform them and compare them with arthroscopic findings to identify which have the best ability to accurately detect a subscapularis tear in a population of primary care patients with shoulder pain. Methods. Three established clinical tests were evaluated in 56 consecutive patients prior to shoulder arthroscopy. The tests included the Lift Off test, Napoleon test, and Bear Hug test. The integrity or not of the subscapularis tendon at surgery was considered as the gold standard. Lesions to the subscapularis were graded according to Lafosse. Results. Among the 56 patients there were 17 with arthroscopic diagnosis of subscapularis lesions accounting for an incidence of 30%. The sensitivity for subscapularis tears for the Lift-off test, Napoleon test, and Bear Hug test was 80.15, 58.82, and 82.35%, respectively. Specificity was 54.55, 56.82, and 55.56%, respectively. A significant correlation was found between arthroscopic findings and physical examination only for the Bear Hug. Conclusions. In the present study, the Bear Hug test was found to have the highest sensitivity of all tests studied. Nevertheless, it appears advisable to perform more than one clinical test to further improve the clinical ability to detect subscapularis tears.
The Challenges of Arthroscopic Diagnosis of Subscapularis Tears
Revista de Chimie
Visualisation of subscapularis lesions is difficult during open surgery. Introduction of arthroscopic procedures for rotator cuff surgery improved the diagnosis of subscapularis tears, but it still can be more challenging than for other rotator cuff tendon tears. The SFA classification of subscapularis tears is reproducible and correlates well with the arthroscopic findings. The arthroscopic diagnosis of subscapularis tear is made easier by: shoulder internal rotation, biceps tenodesis, dissection of the rotator interval, recognition of the sentinel and comma signs.
Arthroscopic subscapularis tendon repair
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2002
Purpose: Our objective was to evaluate the preliminary results of 25 consecutive arthroscopic subscapularis tendon repairs. Type of Study: Case series. Methods: All 25 shoulders had longer than 3 months follow-up, with an average of 10.7 months (range, 3 to 48 months). The average age was 60.7 years (range, 41 to 78 years). The average time from onset of symptoms to surgery was 18.9 months (range, 1 to 72 months). The shoulders were evaluated using a modified UCLA score, Napoleon test, lift-off test, radiographs, and magnetic resonance imaging (MRI). Indications for surgery included clinical and/or MRI evidence of a rotator cuff tear. An arthroscopic suture anchor technique devised by the senior author (S.S.B.) was used for repair. Results: UCLA scores increased from a preoperative average of 10.7 to a postoperative average of 30.5 (P Ͻ .0001). By UCLA criteria, excellent and good results were obtained in 92% of patients, with 1 fair and 1 poor result. Forward flexion increased from an average 96.3°preoperatively to an average 146.1°postoperatively (P ϭ .0016). Eight of 9 patients with a positive Napoleon test had complete tears of the subscapularis. All 7 patients with a negative Napoleon test had a tear of the upper half only. The lift-off test could not be performed reliably due to pain or restricted motion in 19 of the 25 patients. Eight patients had isolated tears of the subscapularis. The remaining 17 patients had associated rotator cuff tears with an average total tear size of 5 ϫ 8 cm. Ten patients had proximal migration of the humerus preoperatively. Eight of these 10 patients had durable reversal of proximal humeral migration following surgery. These 8 patients improved their overhead function from a preoperative "shoulder shrug" with attempted elevation of the arm to functional overhead use of the arm postoperatively. Conclusions: (1) The senior author has been able to consistently perform arthroscopic repair of torn subscapularis tendons, with good and excellent results, in 92% of patients. (2) The Napoleon test is useful in predicting not only the presence of a subscapularis tear, but also its general size. (3) Combined tears of the subscapularis, supraspinatus, and infraspinatus tendons are frequently associated with proximal humeral migration and loss of overhead function. Arthroscopic repair of these massive tears can produce durable reversal of proximal humeral migration and restoration of overhead function.
Orthopaedics & Traumatology: Surgery & Research, 2012
Hypothesis: Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus. Material and methods: In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well as
Journal of Shoulder and Elbow Surgery, 2006
Ruptures of the subscapularis tendon, isolated or combined, are rare, and the treatment modalities are controversial. Of 1345 patients who underwent rotator cuff repair in a 7-year period, 73 had either an isolated rupture of the subscapularis or a subscapularis rupture combined with rupture of the supraspinatus. All reconstructions were performed through a deltopectoral approach. Reinsertion of the subscapularis was combined with reconstruction of the supraspinatus in 32 patients. Of the patients, 63 (86%) were reexamined at a mean follow-up of 35 months. The modified Constant score improved from 62% preoperatively to 91% at follow-up. Isolated or combined reconstructions did not result in significant differences with respect to the Constant score. Of the patients, 62 (98%) were satisfied with the operation. Rerupture was found by ultrasound in 8 subscapularis tendons (13%) and 4 supraspinatus tendons (13%). The rerupture rate showed a significant correlation with the Goutallier stage of fatty degeneration and the interval between injury and operation. (J Shoulder Elbow Surg 2006; 15:659-664.) Rupture of the subscapularis tendon is rare in patients with ruptures of the rotator cuff; the incidence had been reported as 4% to 8%. 7,9 Rupture typically occurs traumatically through forced abduction or external rotation. 14,18 The injury may occur in isolation or combined with rupture of the supraspinatus. The rupture of the supraspinatus may pre-exist or may occur at the time of the injury or as a degenerative secondary development. 27 Without treatment, rupture of the subscapularis leads to pain, loss of func-tion, and weakness. In the long term, dynamic anterior instability can lead to the development of glenohumeral arthrosis. 3,33 This is why surgical reinsertion is recommended in the case of acute subtotal and total ruptures of the subscapularis tendon. It is less clear how to proceed in the case of a concomitant rupture of the supraspinatus tendon; only a few reports exist on this subject. We have been performing direct reinsertion of the subscapularis and, if necessary, of the supraspinatus tendon using a deltopectoral approach since 1995. Several questions have arisen through newly published insights into alternative methods. What results are achieved with this technique, and are they influenced by simultaneous treatment of a rupture of the supraspinatus? Are there limiting factors, and if so, from which point onward should transfer surgery be discussed? How does this technique compare with arthroscopic procedures? 1,6 Answering these questions should make it possible to provide a more detailed indication for surgery and the surgical procedure and to be better able to advise the patient with regard to the expected result and risk of rerupture.
The influence of partial subscapularis tendon tears combined with supraspinatus tendon tears
Journal of Shoulder and Elbow Surgery, 2014
Background: With the advent of arthroscopy, more partial subscapularis tears are being recognized. The biomechanical effects of partial subscapularis tears are unknown, and there is no consensus as to their treatment. Therefore, the objective of this study was to evaluate and to quantify the changes in range of motion and glenohumeral kinematics for isolated subscapularis partial tears, combined subscapularis and supraspinatus tears, supraspinatus repair, and combined supraspinatus and subscapularis repair. Methods: Six cadaveric shoulders were tested in the scapular plane with 0 , 30 , and 60 shoulder abduction under 6 conditions: intact; ¼ subscapularis tear; ½ subscapularis tear; ½ subscapularis and complete supraspinatus tear; supraspinatus repair; and supraspinatus and subscapularis repair. Maximum internal and external rotation and glenohumeral kinematics were measured under physiologic muscle loading condition. A repeated measures analysis of variance with a Tukey post hoc test was used for statistical analysis. Results: Maximum external rotation was significantly increased after ¼ subscapularis tear at 30 abduction and in all abduction angles with ½ subscapularis tear (P < .05). The 2 repair conditions did not restore external rotation to the intact level. At maximum internal and external rotation, there was a significant superior shift in the humeral head apex position with ¼ subscapularis tear at 30 abduction and with ½ subscapularis tear at 60 abduction (P < .05). Repair of the supraspinatus tendon partially corrected abnormal kinematics; however, neither repair restored abnormal kinematics to intact. Conclusion: Additional repair of the partial subscapularis tear with supraspinatus tear did not affect external rotation or glenohumeral kinematics. Further studies are needed to evaluate different subscapularis repair techniques.
Arthroscopic repair of the subscapularis tendon: indications, limits and technical features
Muscles, ligaments and tendons journal, 2013
The rationale to anatomically repair this tendon is to restore the functional biomechanics of the shoulder. Clinical and imaging assessment are required before undertaking arthroscopy. In this way, associated pathologies of the biceps and labrum may be successfully addressed. The arthroscopic repair of the tendon implies to use suture anchors and reinsert the tendon itself over the footprint. Results after arthroscopy are comparable to those observed after open procedures.