Subscapularis Tear

Subscapularis Tendon Overview

The subscapularis tendon is one of the four tendons that come together to form the rotator cuff.  The rotator cuff tendon attaches to the top of the arm bone (humerus) just beyond the cartilage surface of the humeral head.  The tendon wraps around, forming a cuff of tissue around the humeral head covering the front (anterior), top (superior), and back (posterior).

The four tendons come from four muscles that begin on the scapula: 

  • Subscapularis
  • Supraspinatus
  • Infraspinatus
  • Teres Minor

By beginning on the scapula, then attaching around the humeral head, the rotator cuff is in an ideal position to squeeze or compress the humeral head into the socket, providing stability throughout a vast range-of-motion. It does participate in complicated rotational movements of the arm, such as throwing a baseball.  However, even day-to-day activities rely on a functioning rotator cuff to ensure that the position and strength of the arm is capable of all the activities the hand would like to do. 

The subscapularis tendon is the tendon in the front (anterior) part of the shoulder.  It is the largest and most powerful muscle involved in the rotator cuff, and its tendon is the largest part of the rotator cuff.  An injury to the subscapularis tendon is generally painful, weakens the shoulder, and is often associated with problems of the biceps tendon which is right next to it. Typically, isolated subscapularis tears happen between the ages of 30 and 50 due to a work- or sport-related traumatic injury, and they are more common in men than women.  When we get older, the subscapularis tendon can tear with strenuous daily activities or a sudden fall or slip to the ground.  Often, the tears in older patients include the supraspinatus tendon too (which is right next to the subscapularis), as well as the biceps tendon.  Want to see more? In this video, Dr. Romeo explains subscapularis tears using a shoulder model.

Subscapularis Tear FAQ

Why are subscapularis tears often misdiagnosed?

Injuries to the subscapularis may be overlooked when patients initially present with a shoulder problem. In the past, the medical literature sometimes referred to as “the forgotten tendon.” Your subscapularis tear might very well be forgotten too — or misdiagnosed, if a complete examination of all four tendons of the rotator cuff is not performed.

A significant subscapularis injury is present in less than 20% of all rotator cuff tears. Even when there is a tear, many of them involve a small area of the tendon that is compensated by the healthy muscles and tendons around the shoulder. Anterior shoulder pain that persists after an injury should trigger a full evaluation of the subscapularis. 

In addition to understanding the mechanism of injury, a careful and unique set of examination tests that are different from the tests for the other parts of the rotator cuff are necessary to fully assess the subscapularis.

Ten years ago, Dr. Romeo and others reported that more than half of subscapularis tendon injuries seen at the time of arthroscopy were not reported on standard preoperative MRI’s.  However, as the technology improved, and the potential of a subscapularis injury was better understood, high-quality MRI’s provide the information needed to help confirm this diagnosis before going to the operating room. 

Of course, at the time of arthroscopic rotator cuff repair surgery, Dr. Romeo inspects all four tendons of the rotator cuff, including the subscapularis, to ensure that the tendon is in its normal position and functioning properly.   As a recognized leader in the management of rotator cuff conditions,  Dr. Romeo is adept at identifying if a subscapularis tear is the prime cause of pain, restricted motion, and limited function.

How is a subscapularis tear treated?

If the tear is not severe, treatments may include rest, activity modification, anti-inflammatory medication, physical therapy, a corticosteroid injection, or a combination of the above. After that, outpatient arthroscopic shoulder surgery is considered.

Exercise & Physical Therapy: The first step in treatment is to try home exercise, along with a series of physical therapy sessions. A primary goal of physical therapy is to preserve or even extend your arm’s range of motion and alleviate any pain. Once the pain is reduced, and motion is improving, it is equally important to expand the physical therapy program to include exercises that will strengthen muscles, taking some of the stress off the subscapularis tendon.

Cortisone Injection: In conjunction with physical therapy, many patients find short-term relief with cortisone injections that fight inflammation. Cortisone is a corticosteroid that has been shown to have a dramatic effect on the pain and swelling associated with a variety of rotator cuff injuries  through its powerful ability to reduce inflammation. However, corticosteroid injections are avoided if surgery is being considered due to an increased risk of infection.

Surgery: If the tear is significant, and not responding to a conservative approach, an outpatient procedure using arthroscopic technique is the preferred method to treat these tears.

Arthroscopic Subscapularis Repair Details

Like all rotator cuff surgeries, this procedure is done arthroscopically so that the best visualization of the tendon injury is possible, as well as the ability to manage all types of tears and injuries to surrounding structures such as the biceps tendon. 

Arthroscopic subscapularis repair requires techniques and instruments that vary from the more common repair of the supraspinatus tendon tear. During the procedure, Dr. Romeo can see the entire subscapularis tendon by moving the arm during the arthroscopy, as well as inspecting the tendon from both the inside (within the joint) and the outside (in the space between the subscapularis tendon and the overlying scapula bone.  

Once the area has been completely assessed, the final plan for preparation of the tendon and bone and affixing of the tendon to the bone is established.  Special sutures and surgical tapes are passed through the tendon, then securely fixed to the bone with anchors that hole on to the sutures. Other injuries to other parts of the rotator cuff can be managed using a similar process. Dr. Romeo will also look check the labrum for injuries and for any issues related to the biceps tendon that can be detected and fixed.

Subscapularis Repair Surgery Recovery

After a surgical procedure, recovering patients are sent home with a sling and pillow brace to wear for six weeks. Swelling is a normal part of the recovery process, and Dr. Romeo recommends applying ice packs to the shoulder several times a day to help ease swelling and discomfort. Special cold therapy machines can also be ordered in advance of the procedure to help with the benefits of cooling off the surgical site (cryotherapy). Dr. Romeo will give you specific instructions for post-op pain management before you go home on the day of surgery.

During the first six weeks, the exercise program is conservative and only simple range-of-motion activities are permitted. It takes about six weeks for the bone and the tendon to grow back together. Although the sutures and anchors are strong, too much movement or performing activities and exercises that causes the subscapularis muscle to work on a regular basis during the first six weeks can lead to the tendon pulling out of the sutures and tapes. 

After this, a strengthening program is put in place for the next three months. Physical therapy is important not only for building flexibility and strength, but also to keep scar tissue from forming at the site of the repair. 

From four and a half months on, sport-specific and work-related activities can be performed. A full recovery is expected by six months, although heavy physical demands or competitive sports activities may take up to a year before they equal the preinjury performance of the shoulder.

For more information about causes and treatment of subscapularis tears, please request an appointment with experienced Chicago orthopaedic surgeon Dr. Anthony Romeo. Call our office today to schedule your visit.

Want to see more? Watch Dr. Romeo present his recommendations regarding Subscapularis Tears to other orthopaedic surgeons.

Shoulder Surgery Videos

Want to watch Dr. Romeo perform a subscapularis repair? Click the Youtube video below to watch this operation performed on a real patient.

Repair of Subscapularis Tendon

Anatomy of the Shoulder

Additional Subscapularis Tear Links

Here a few of Dr. Romeo’s recent medical journal articles about subscapularis tears:

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