Subscapularis tendon tears

The Destiny of the Subscapularis Tendon after Arthroscopic Supraspinatus Repair

Background

The purpose of this study was to identify the changes in untreated subscapularis in patients who underwent supraspinatus repair and to evaluate the factors related to the changes in the subscapularis.

Methods

A cohort of patients who underwent isolated supraspinatus repair with preservation of the subscapularis was reviewed. Changes in the subscapularis, including any newly formed lesion and aggravation of an existing lesion, were evaluated 12 months postoperatively on magnetic resonance imaging along with an examination to identify causative factors after supraspinatus repair. Clinical scores were compared between patients with and without subscapularis changes.

Results

A total of 528 patients were reviewed. Changes in the subscapularis, including newly formed lesions and aggravation of an existing lesion, were shown in 90 patients (17.0%). Upon regression analysis, changes in the subscapularis were associated with the initial existence of a subscapularis lesion (grade I: p = 0.042, grade II: p = 0.025), an accompanying biceps lesion (p = 0.038), and a retear of the repaired supraspinatus (p = 0.024). No significant differences were shown in clinical scores between patients with and without subscapularis changes after supraspinatus repair.

Conclusions

Untreated asymptomatic subscapularis may undergo morphological changes even after repair of the torn supraspinatus. Preoperative subscapularis lesions, biceps long head pathology, and retears of the repaired supraspinatus were associated with subscapularis pathology in patients who underwent supraspinatus repair.

The High Resistance Loop (H-Loop) Technique for Arthroscopic Repair of Subscapularis

The subscapularis tendon is more challenging and riskier to repair than the posterior upper rotator cuff. The knotless anchor suture in subscapularis repair simplified the repair process and had an excellent postoperative effect. We describe a new knotless anchor stitching method, the H-Loop technique. The simplicity and efficiency of the technique make it particularly suitable for small subscapular tendon tears.

Abduction causes increased strain gradient compared to forward flexion: Evidence from a cadaver model of simultaneous strain study of the rotator cuff tendons

BACKGROUND

Various strain studies of the supraspinatus have been done in isolation. Given that rotator cuff muscles function as a group, it may be physiologically representative to measure strain behaviour with the glenohumeral joint intact. Here, we explored a novel method in measuring simultaneous strain behaviour of the rotator cuff tendons and investigated the effect of full-thickness anterior tear of the supraspinatus on the infraspinatus and subscapularis tendons.

METHODS

Nine cadaveric shoulders were evaluated on a customized rig. Using linear differential variable transducers to measure strain, each shoulder was subjected to up to 60° of elevation in the coronal, scapular, and sagittal planes. We also assessed 30° of external rotation and up to 60° of internal rotation of the humerus. Full-thickness anterior tear of the supraspinatus was then made before re-assessing strain patterns in the scapular plane.

FINDINGS

Strain measurements of the intact tendons revealed a significant strain gradient between the articular and bursal sides of the supraspinatus during increasing degrees of elevation in the coronal and scapular planes. Full thickness anterior tear of the supraspinatus is localised to the tendon and does not affect the surrounding cuff musculature, with a potential shielding effect of the infraspinatus during early glenohumeral abduction.

INTERPRETATION

Significant strain gradient exists between the articular and bursal sides of the supraspinatus during abduction but not during forward flexion in an intact glenohumeral joint. Rehabilitation exercises for anterior supraspinatus tears can be appropriately targeted on the remaining intact rotator cuff musculature.

Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making

Background

Several classifications have been proposed for subscapularis tendon tearing (SCTs); however, there remains a poor agreement between orthopedic surgeons regarding the diagnosis and management of these lesions. Distinguishing the various tear patterns and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment.

Purpose

The purpose of this study was to outline the current literature regarding SCT classification and treatment and conduct a survey among shoulder and elbow surgeons to identify the approaches regarding surgical decision-making for these injuries.

Methods

In this systematic review, we analyzed 12 articles regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. In addition, 4 international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1161 ASES members. One hundred sixty five surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in 4 parts including indications/contraindications, treatment plan, and the factors affecting outcomes in the survey.

Results

Classification criteria were extremely variable with differing recommendations and descriptions of tear morphology; most were based on tear size, associated shoulder pathology, or lesser tuberosity footprint exposure. Considering the multiple classification systems and the overall poor agreement regarding SCT management, our study found that the most widely agreed upon (more than 80%) statements included early surgery is advised for traumatic SCT, chronic degenerative SCT (without fatty infiltration) associated with acute supraspinatus tear is a candidate for repair, and rotator cuff arthropathy is a contraindication for SCT repair.

Conclusion

Our study was able to identify both patient and tear characteristics that are well agreed upon among surgeons in the treatment of these injuries. Lafosse classification is generally widely accepted; however, it needs to be improved by some additions. Continued collaboration among surgeons is needed to establish an acceptable and broadly applicable classification system for the management of these injuries.

The subscapularis muscle: A meta-analysis of its variations, prevalence, and anatomy

BACKGROUND

The subscapularis (SSC) is the largest rotator cuff muscle and is involved in the medial rotation, abduction, adduction, and anterior stabilization of the shoulder. It is anatomically variable, as is the morphology and prevalence of the accessory SSC (aSSC), a rare muscle slip attached to the SSC. There is no current review investigating the prevalence and morphometrics of the SSC and aSSC.

PURPOSE

To investigate the prevalence of the morphological variants of the SSC and aSSC via meta-analysis and review the relevant literature involving cadaveric, magnetic resonance imaging, and ultrasonographic studies.

STUDY DESIGN

Meta-analysis.

MATERIALS AND METHODS

Literature data reporting the prevalence rates and morphometrics of the SSC and aSSC and their variants were pooled. Literature searches and data analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Anatomical Quality Assurance guidelines.

RESULTS

Forty-six studies, totaling 2166 shoulders, were assessed. The SSC showed an overall length, thickness, cross-sectional area, and volume of 152.2 mm (95% confidence interval, CI, 103.8-200.5 mm), 5.6 mm (95% CI, 4.6-6.6 mm), 18.1 cm² (95% CI, 14.2-22.0 cm² ), and 126.9 cm³ (95% CI, 87.2-166.5 cm³ ), respectively. The SSC displayed substantial variations in its origin and insertion points and in the composition of its tendon. The aSSC had an overall pooled prevalence of 24.6% (95% CI, 0.0%-76.9%).

CONCLUSIONS

The SSC and aSSC have been implicated in multiple shoulder pathologies, including muscle and tendon ruptures and neurovascular compromise. A better understanding of SSC and aSSC variants when diagnosing and treating their related pathologies will reduce patient morbidity and improve treatment regimens.

Arthroscopic approach does not yield better results than open surgery after subscapularis repair: a systematic review

PURPOSE

This study aimed to compare the long-term outcomes of arthroscopic versus mini-open repair in patients with isolated subscapularis tendon tears.

METHODS

Google Scholar, PubMed, and Embase databases were searched for studies evaluating isolated subscapularis tears subsequently treated by arthroscopic or mini-open repair. The inclusion criteria were clinical studies reporting isolated subscapularis lesions treated by arthroscopic or mini-open repair, a minimum follow-up of 12 months, and clinical and functional outcomes reported in the study results. Articles not reporting functional outcomes or studies that reported results for anterosuperior rotator cuff tears without a separate analysis of subscapularis tendon tears were excluded. Studies older than 20 years and studies with a minimum follow-up of less than 12 months were also excluded.

RESULTS

A total of 12 studies met the inclusion criteria; 8 papers were included in the arthroscopic repair group, and 6 were included in the mini-open repair group (2 studies reported results for both techniques). The mean age reported was 49.3 years, and 85.1% of patients were male. The dominant limb was involved in 77.6% of the patients, and a traumatic onset of symptoms was verified in 76.3%. The mean time to surgery was 9.6 months. The Constant-Murley score showed positive results for the arthroscopic and mini-open groups, with mean postoperative values of 84.6 and 82.1, respectively. Promising results were also observed for pain, with a mean of 13.2 (out of 15) points for the arthroscopic group and 11.7 for the mini-open group. The long head of the biceps was involved in 78% of the patients, and LHB tenodesis or tenotomy were the most common concomitant procedures performed.

CONCLUSIONS

There was no significant difference in clinical and functional outcomes between open and arthroscopic repair. Moreover, the same complication rates were reported in both treatments, but arthroscopic repair led to less postoperative pain.

LEVEL OF EVIDENCE

IV.

Subscapularis tendon tear classification and diagnosis: A systemic review and meta-analysis

Background

In the current study, we performed a systematic review and meta-analysis regarding the comparison of accuracy, sensitivity, and specificity of the techniques in diagnosing SSC tendon tears. Also, we performed a systematic review of the classification of SSC tendon tears.

Methods

English language, peer-reviewed journal publications from the first date available to March 2022 were extracted by searching PubMed and Web of Science databases. A forest plot was used to graphically show the results of pooled sensitivity, specificity, and accuracy of different diagnostic modalities.

Results

There were six studies on using MRI to diagnose subscapularis tendon tears, five studies on MRI, four studies on clinical examination, one on ultrasonography, and one on CT arthrography. Pooled sensitivity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.71 (CI: 0.54; 0.87), 0.83 (0.77; 0.88), 0.49 (0.31; 0.67), 0.39 (0.29; 0.51), and 0.90 (0.72–0.97), respectively. The pooled specificity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.93 (CI: 0.89; 0.96), 0.86 (0.75; 0.93), 0.89 (0.73; 0.96), 0.93 (0.88; 0.96), and 0.90 (0.69; 0.98), respectively. The pooled diagnostic accuracy values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.84 (CI: 0.80; 0.88), 0.85 (0.77; 0.90), 0.76 (0.66; 0.84), 0.76 (0.70; 0.81), and 0.90 (0.78; 0.96), respectively.

Conclusion

According to our systematic review and meta-analysis, MR arthrography was the most accurate in diagnosing subscapularis tears. MR arthrography was the most sensitive, and MRI and ultrasonography were the most specific in detecting subscapularis tears.

Quantitative MRI indicators and features for partial subscapularis tendon tears on conventional shoulder MRI

Background

Diagnosing partial subscapularis (SSC) tendon tears still faces challenges. A failure rate of massive posterosuperior rotator cuff tear repair will be highly increased when extending more than one-third of SSC tendon. This study aims to investigate the quantitative indicators and features of partial SSC tears on conventional shoulder MRI and improve the preoperative diagnostic accuracy.

Materials and methods

Four hundred and thirty-seven patients underwent MRI and arthroscopy were retrospectively reviewed; 89 patients with partial SSC tears in case group and 50 patients with normal SSC in control group were included. Six MRI features with the explicit definition of some quantitative indicators were evaluated.

Results

Fissure sign showed the highest diagnostic efficiency for the partial SSC tears, with a specificity of 92%, sensitivity of 75.3%, and accuracy of 81.3%. Thinning of SSC, fluid collection under the coraco-glenoid arch (CGA), and combined SSP complete tear also showed high specificity of 86%, 80%, and 80%, respectively, while the sensitivity and accuracy were moderate, with a sensitivity of 38.2%, 50.6%, and 48.3%, respectively, an accuracy of 55.4%, 61.2%, and 59.7%, respectively. The specificity, sensitivity, and accuracy of lesser tuberosity cysts were all moderate with values of 68%, 56.2%, and 60%, respectively. However, fat accumulation under the CGA showed no significant difference between the partial SSC tears group and the control group.

Conclusion

Several specific MRI features with quantitative indicators defined in this study can be used to improve the accuracy of preoperative MRI diagnosis of partial SSC tears.

Arthroscopic single portal - single row knotless repair of subscapularis tendon tear: Technical note

The subscapularis (SSc) is the most powerful muscle of the rotator cuff. His role in shoulder stability and shoulder motion is well studied and due to functional and frequent association with concomitant other lesions, the repair of the SSc tendon is always desirable to restore force and stability to the shoulder.

The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study

BACKGROUND

Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC.

METHODS

A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test.

RESULTS

In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively.

CONCLUSIONS

The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.

Evaluation of complete and incomplete subscapularis tendon tear on preoperative magnetic resonance imaging

BACKGROUND

This study aims to evaluate the significance of preoperative magnetic resonance imaging findings to predict subscapularis tear confirmed at arthroscopic surgery.

METHODS

Sixty-four consecutive shoulders that underwent preoperative magnetic resonance imaging examination and arthroscopic shoulder operations were retrospectively reviewed. Under arthroscopic examination, complete subscapularis tear was defined as a full-thickness tear and incomplete subscapularis tear as tendon detachment larger than 5 mm from the insertion on the joint side.

RESULTS

In arthroscopic findings, they were included 11 shoulders with complete subscapularis tear, 13 with incomplete subscapularis tear, and the remaining 28 shoulders without subscapularis tear. Subscapularis discontinuity by axial magnetic resonance imaging had the highest sensitivity and specificity in detecting complete subscapularis tear compared with other magnetic resonance imaging findings. Long head biceps subluxation or dislocation showed significantly higher prevalence in the complete and incomplete subscapularis tear groups than in the group with no tear. Incomplete subscapularis tear groups had a higher incidence of superior subscapularis recess fluid, and this fluid was present in all the shoulders with incomplete subscapularis tear.

CONCLUSIONS

The presence of subscapularis discontinuity is useful for diagnosis of complete subscapularis tear. In addition, in cases of incomplete subscapularis tear, the presence of superior subscapularis recess fluid had 100% sensitivity. Thus, this finding may be a characteristic diagnosis of subscapularis tear including incomplete tear.

Association Between Medial Displacement of the Middle Glenohumeral Ligament and Subscapularis Tear Severity

Background:

The intraoperative invisible middle glenohumeral ligament (MGHL) test has been shown to be associated with a subscapularis tendon retraction. However, the preoperative location of the MGHL and its association with subscapularis tear severity has not been evaluated.

Purpose:

To determine (1) the interrater reliability for identification and position of the MGHL, (2) any association between the MGHL position and subscapularis tears, and (3) the cutoff point at which MGHL position can predict subscapularis tear severity.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

The magnetic resonance imaging (MRI) scans and surgical records of 176 patients were retrospectively reviewed by 3 independent orthopaedists. MGHL's identification, level (its position on axial MRI), and medial retraction ratio (distance from the lesser tuberosity to the MGHL divided by the width of the glenoid) were documented, and the interobserver agreement of the 3 indices was assessed. We calculated the association between subscapularis tears and the MGHL level and medial retraction ratio. Receiver operating characteristic (ROC) curve analyses were conducted to establish the optimal threshold of the MGHL medial retraction ratio to predict subscapularis tear.

Results:

The MGHL was identified by at least 2 reviewers in 124 individuals (70.5%). The interobserver reliability was very good for MGHL identification (κ = 0.766), moderate for MGHL level (κ = 0.582), and excellent for MGHL medial retraction ratio (intraclass correlation coefficient = 0.848). A low, positive correlation between MGHL level and subscapularis tear severity was found (Somers d = 0.392, P < .001), as well as a significant association between the medial retraction ratio and Lafosse classification of subscapularis tear size ( P < .001). A medial retraction ratio of ≥1.25 had a sensitivity of 0.70, a specificity of 0.83, and a positive likelihood ratio of 4.20, with excellent accuracy (area under the ROC curve = 0.820) to predict severe subscapularis tear.

Conclusion:

The MGHL was identified in 70.5% of shoulder MRIs. The location of the MGHL on preoperative MRI, as described by its level and the medial retraction ratio, was significantly associated with subscapularis tear severity, and a medial retraction ratio of ≥1.25 was predictive of a severe subscapularis tear.

Diagnostic performance of conventional magnetic resonance imaging for detection and grading of subscapularis tendon tear according to Yoo and Rhee classification system in patients underwent arthroscopic rotator cuff surgery

OBJECTIVES

To assess the diagnostic accuracy of conventional MRI for detecting and grading subscapularis (SSC) tears by applying the Yoo and Rhee classification.

MATERIALS AND METHODS

A total of 179 patients who underwent MRI followed by arthroscopic rotator cuff surgery were enrolled. Two musculoskeletal radiologists evaluated the SSC using axial, oblique sagittal, and oblique coronal MRI according to the Yoo and Rhee classification. Using arthroscopic findings as the reference standard, the sensitivity, specificity, accuracy, and interobserver agreement of SSC tears were analyzed.

RESULTS

Arthroscopy confirmed that the numbers of type I, IIA, IIB, III, IV, and V tears were 35, 70, 35, 9, 9, and 0, respectively. The sensitivity, specificity, and accuracy of readers 1 and 2 for the detection of tears (type IIA or higher) were 85%, 75%, and 82%, and 89%, 70%, and 83%, respectively, while those for the detection of surgical candidates (type IIB or higher) were 77%, 75%, and 75%, and 77%, 83%, and 82%, respectively. The interobserver agreement for detecting SSC tear presence was substantial (κ = 0.70) for reader 1 vs. reader 2, and those for detecting the surgical candidate group was substantial (κ = 0.68) for reader 1 vs. reader 2. The interobserver agreement for grading SSC tears was excellent (κ = 0.86) for reader 1 vs. reader 2.

CONCLUSION

Conventional MRI showed 82.5% and 78.5% average accuracy in detecting IIA and IIB or higher tears by applying the Yoo and Rhee classification for the diagnosis of SSC tears with an excellent interobserver agreement in tear grading.

Arthroscopic Subscapularis Repair Using 18-Gauge Spinal Needle as a Suture Passer to Eliminate Iatrogenic Tendon Damage from Modern Suturing Devices

Suture passing devices are frequently used for subscapularis tendon repair. However, some of these devices can further damage the tendon by creating a larger tear. Use of an 18-gauge spinal needle as a suture passer helps eliminate damage to the tendon. By using its smaller diameter, the needle prevents tendon cut-through and enhances the precision of the repair.

The Subscapularis Muscle: A Proposed Classification System

Background

On the basis of the available literature, we proposed the hypothesis that the number of muscle bellies is morphologically constant. The main purpose of this study was to examine the morphological variability of the SM and to create a new classification of it based on number of muscle bellies.

Methods

Sixty-six adult cadavers of Central European population (45 females, 21 males) were obtained and fixed in 10% formalin before examination.

Results

The SM was found in all 66 specimens (45 females, 21 males, 31 left and 35 right sides). After meticulous dissection, we distinguished nine types on the basis of number of bellies. Type I was characterized by single belly and occurred in 1.5%. Type II had a double belly and was present in 3%. Type III, the most common type, occurring in almost 32% of the studied population, had three bellies. The frequency of type IV, characterized by four bellies, was also high, just over 30%. The following types were less frequent: type V with five bellies (18.2%), type VI with six bellies (7.6%), type VII with seven bellies (3%), type VIII with eight bellies (1.5%), and type IX with nine bellies (3%). All of the types had origin on the anterior surface of the scapula.

Conclusions

The SM is morphologically variable in the number of its bellies. Evolutionary changes are probably the reason. The most common type was the SM with three bellies, in line with Larson's model of the division of the SM into three parts. Subsequent studies should be carried out based on MRI or ultrasonography examination to confirm if it is possible to show all types (presented in this study) among group of patients during MRI.

Predicting the clinically significant subscapularis tendon tear: malposition and tear of the long head of the biceps tendon on shoulder magnetic resonance imaging

BACKGROUND

The diagnostic accuracy of magnetic resonance imaging (MRI) is low for detecting a subscapularis tendon tear.

PURPOSE

To identify MRI findings that may predict the presence of a clinically significant subscapularis tendon tear requiring surgical repair.

MATERIAL AND METHODS

We reviewed shoulder MR images of patients who had undergone arthroscopic rotator cuff repair at our institution between June 2018 and May 2019. Patients were divided into two groups: the study group (n = 51), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI and intermediate or higher grade of the tendon tear proven on arthroscopy; and the control group (n = 18), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI but no tear or low-grade partial thickness tear of the tendon shown on arthroscopy. Preoperative MR images were retrospectively evaluated by two readers for the size of the subscapularis tendon tear, bone reactions at the lesser tuberosity, and long head of the biceps tendon (LHBT) pathology.

RESULTS

The subscapularis tendon tear measured by reader 2 was larger in the study group than in the control group. The prevalence of a tear (P = 0.006 for reader 1; P = 0.011 for reader 2) and malposition (P < 0.001 for both readers) of the LHBT were significantly greater in the study group.

CONCLUSION

A tear and malposition of the LHBT on MR images may predict the presence of a clinically significant subscapularis tendon tear.

Clinical outcome and return to sports activity after surgical treatment for recurrent shoulder instability with a modified Latarjet procedure

INTRODUCTION

The Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity.

HYPOTHESIS

The hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy.

MATERIAL AND METHODS

Thirty-two patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients' demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables.

RESULTS

All patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A.

DISCUSSION/CONCLUSION

The longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach.

LEVEL OF EVIDENCE

III; Retrospective cohort study.

Analysis of the results and adverse factors of arthroscopic repair of degenerative subscapular lesions

OBJECTIVE

To carry out a review of degenerative subscapularis ruptures (SSC) after their arthroscopic repair and to evaluate whether the results are comparable in terms of pain and function to those of younger patients with traumatic ruptures.

METHODS

The data of 80 SSC tears of the 660 rotator cuff tears operated on by the same team of surgeons from June 2008 to June 2018 were retrospectively reviewed. The clinical data of the surgical indications were collected: age, gender, laterality, intervention delay, associated pathologies, location of pain, value of the Visual Analogue Scale (VAS) and the Constant-Murley test (CMT); surgical data were also collected: type and size of lesion, associated biceps injury and associated surgical procedure, coracoid stenosis and associated surgical procedure, number and type of anchors used. A statistical study was performed with multiple linear regression test, parametric tests (Student's t or ANOVA) and non-parametric tests.

RESULTS

Of 80 patients, 36 were women (45%) and 44, men (55%); mean age 61years (range 47 to 81); mean delay of surgery 3.5months (range 1 to 6); right shoulder affected in 46 cases (57.5%), left in 34 (42.5%); 22 (27.5%) were isolated lesions, 58 (72.5%) were associated with supraspinatus rupture (SE). The mean improvement was 5.0 points in terms of the VAS and 39.9 points on average in the CMT. New breakage rate, 1.25%. Adverse factors: size of the tear, delay in intervention, women. Patients with type I-B rupture have a better overall result in the CMT than types I-A and III. The longer the delay, the worse results are observed, both for the VAS and the CMT. Women present worse and statistically significant results both in the VAS (P=.00) and in the CMT (P=.01).

CONCLUSIONS

Excellent and good results have been obtained in this group of patients, but there are adverse factors such as the size of the tear, the duration of the symptoms and the association of other pathologies, especially in women.

Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

CONTEXT

There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making.

OBJECTIVE

To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology.

DATA SOURCES

PubMed, MEDLINE, Ovid, and Cochrane Reviews databases.

STUDY SELECTION

Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities.

RESULTS

A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21).

CONCLUSION

The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

A very rare case of an accessory subscapularis muscle and its potential clinical significance

The subscapularis muscle is the largest muscle of the rotator cuff and its main function is internal rotation. It is morphologically variable in both point of origin and insertion. The presence of an accessory subscapularis muscle can lead to brachial plexus neuropathy. This report presents a very rare accessory subscapularis muscle originating from two distinct bands on the subscapularis and teres major muscles. The insertion was divided among four tendons. The fourth tendon is bifurcated. One of these was connected to the tendon of the subscapularis muscle and the other three inserted into the base of the coracoid process of the scapula. This anomalous muscle has the potential to entrap the nerves of the posterior cord such as the axillary, lower subscapular, and thoracodorsal nerves.

Anatomy of the Subscapularis: A Review

The subscapularis is the largest and most powerful muscle of the rotator cuff. Occupying the vast majority of the subscapular fossa, it is the only internal rotator of the rotator cuff. The subscapularis innervation is classically taught as a dual innervation of 1 upper subscapular and 1 lower subscapular nerve arising from the posterior cord of the brachial plexus. However, there is a large amount of research that suggests there is significant variance in the innervation of the muscle from multiple upper subscapular nerves to multiple lower subscapular nerves arising from various portions of the plexus. Although one of the main functions of the subscapularis is to internally rotate the humerus, there is substantial evidence that displays its importance in glenohumeral stability as well. The insertion of the subscapularis is both tendinous as well as muscular. The more superior tendinous portion inserts on the lesser tuberosity while the more muscular portion inserts inferior to the less tuberosity. The medial to lateral spread of the insertion is quite variable ranging from only on the lesser tuberosity to merging with fibers from the supraspinatus. Understanding the anatomy of the subscapularis improves subscapularis management during shoulder arthroplasty including techniques for takedown, release, and repair.

Diagnostic and therapeutic musculoskeletal ultrasound applications of the shoulder

High frequency ultrasound is a valuable tool for assessing soft tissue injuries about the shoulder. It has advantages over other imaging modalities including relatively low cost, portability, and dynamic real-time visualization. It has a high sensitivity for identifying tendon degeneration, bursitis, and rotator cuff tears. Ultrasound is also an excellent modality for diagnostic and therapeutic needle-guided procedures. A detailed knowledge of shoulder anatomy and transducer positioning is required for obtaining adequate diagnostic value from ultrasound. This Monograph is designed to help develop scanning protocols for optimizing image acquisition for musculoskeletal assessment of the shoulder. Muscle Nerve, 2019.

Editorial Commentary: Precise Repair of Partial Subscapularis Tendon Tears Is Essential

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.

Simultaneous, Bilateral Acute Subscapularis Ruptures and Their Arthroscopic Management

We present the first known case of bilateral, acute ruptures of the subscapularis tendons following a bicycle accident in a 43-year-old male. He underwent right shoulder arthroscopic, anatomic subscapularis tendon repair two weeks postinjury, with the left side staged for surgical treatment six weeks after the index procedure. Postoperatively, the patient remained in a sling for 6 weeks before advancing with therapy protocols. The interval between arthroscopic treatments allowed for independence with activities of daily living and focused, early therapy for each shoulder. This approach yielded a right-sided constant score of 89 and subjective shoulder value of 90%; the left side was 87 and 90%, respectively, at 33 months postoperatively. The patient’s only postoperative complaint was slightly diminished external rotation, a near-universal limitation after unilateral repair. This represents a successful outcome that balances functional independence, concentrated rehabilitation, and adherence to safe indications for primary repair. While bilateral traumatic shoulder injuries in a young person is a rare clinical entity, early and staged treatment can lead to good patient outcomes.

Irreparable rotator cuff tears: challenges and solutions

Irreparable rotator cuff tears are common conditions seen by shoulder surgeons, characterized by a torn and retracted tendon associated with muscle atrophy and impaired mobility. Direct fixation of the torn tendon is not possible due to the retracted tendon and lack of healing potential which result in poor outcome. Several treatment options are viable but correct indication is mandatory for a good result, pain improvement, and restoration of shoulder function. Patient can be treated either with a conservative program or surgically when necessary, by different available modalities like arthroscopic debridement, partial reconstruction, subacromial spacer, tendon transfer, and shoulder replacement with reverse prosthesis. The aim of this study was to review literature to give an overview of the available possible solutions, with indications and expected outcomes.

Bipolar pedicled teres major transfer for irreparable subscapularis tendon tears: an anatomic feasibility study

BACKGROUND

Subscapularis (SSC) tendon tears are a challenging problem because they can significantly alter shoulder mechanics and function. Tendon retraction and advanced fatty degeneration associated with a chronic tear may make it irreparable. Tendon transfers options for such tears are viable, but results in the setting of associated glenohumeral instability are inconsistent. With the potential to recreate the SSC line of pull, the teres major (TM) may be a viable option for transfer. This cadaveric study investigated the feasibility and outlined the steps of a bipolar, pedicled TM transfer for irreparable SSC tendon tears.

METHODS

Eight fresh frozen cadaver torsos from 4 women and 4 men (average age, 84 years; range, 68-96 years) were dissected. Anatomic details comparing TM to SSC were examined, including muscle width, length, thickness, and line of pull in the scapular plane. In addition, a surgical technique was described for implementing the pedicled TM transfer.

RESULTS

Measurements between the TM and SSC were comparable, with the exception of muscle belly width, which was significantly greater in the SSC. With transfer of the TM, there was no impingement or tension on the brachial plexus or the neurovascular pedicle of the TM. The line of pull of the TM relative to the SSC had a difference of 9°.

CONCLUSIONS

This study demonstrates that a bipolar TM tendon transfer is an anatomically feasible option for reconstruction of an irreparable SSC tendon tear. Further clinical studies are necessary to understand its outcome in in vivo conditions.

The Role of Tendon Transfers for Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

This review aims to describe the tendon transfer options for treating irreparable rotator cuff tears (RCTs). Options for transfer include latissimus dorsi and lower trapezius transfers for posterior-superior RCTs and pectoralis major and latissimus dorsi transfer for anterior-superior RCTs.

RECENT FINDINGS

While the latissimus dorsi tendon transfer has historically been performed for posterosuperior RCTs, the lower trapezius transfer is a more anatomic option and has demonstrated promising results in recent studies. Similarly, the pectoralis major transfer has historically been the tendon transfer of choice for anterosuperior RCTs. However, the latissimus dorsi tendon transfer has recently been shown to be a safe and anatomic tendon transfer for subscapularis insufficiency. The treatment of irreparable RCTs involves complex decision making. Tendon transfer procedures can restore the glenohumeral joint force couples, allowing restoration of near-normal shoulder kinematics. Benefits include reliable pain relief, increased function, and increased strength. Proper selection of donor tendon is crucial, and the principles of tendon transfer procedures must be adhered to for maximal benefit.

Subscapularis tendon tears: Management and arthroscopic repair

Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.Due to the tendency of the tendon to retract medially, acute and traumatic full-thickness tears should be repaired. Chronic tears without significant degeneration should be considered for repair if no contraindication exists.Arthroscopic repair can be performed using a 30-degree arthroscope and a laterally-based single row repair; one anchor for full thickness tears ⩽ 50% of tendon length and two anchors for those ⩾ 50% of tendon length.Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.Timing of post-operative rehabilitation is dictated by the size of the repair and the security of the repair construct. The stages of rehabilitation typically involve a period of immobilisation followed by range of movement exercises, with a delay in active internal rotation (IR) and strengthening in IR. Cite this article: EFORT Open Rev 2017;2:484-495. DOI: 10.1302/2058-5241.2.170015.

Comparison of Clinical and Structural Outcomes by Subscapularis Tendon Status in Massive Rotator Cuff Tear

BACKGROUND

The subscapularis tendon is essential in maintaining normal glenohumeral biomechanics. However, few studies have addressed the outcomes of tears extending to the subscapularis tendon in massive rotator cuff tears.

PURPOSE

To assess the clinical and structural outcomes of arthroscopic repair of massive rotator cuff tears involving the subscapularis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2010 and January 2014, 122 consecutive patients with massive rotator cuff tear underwent arthroscopic rotator cuff repair. Overall, 122 patients were enrolled (mean age, 66 years; mean follow-up period, 39.5 months). Patients were categorized into 3 groups based on subscapularis tendon status: intact subscapularis tendon (I group; n = 45), tear involving less than the superior one-third (P group; n = 35), and tear involving more than one-third of the subscapularis tendon (C group; n = 42). All rotator cuff tears were repaired; however, subscapularis tendon tears involving less than the superior one-third in P group were only debrided. Pain visual analog scale, Constant, and American Shoulder and Elbow Surgeons scores and passive range of motion were measured preoperatively and at the final follow-up. Rotator cuff integrity, global fatty degeneration index, and occupation ratio were determined via magnetic resonance imaging preoperatively and 6 months postoperatively.

RESULTS

We identified 37 retears (31.1%) based on postoperative magnetic resonance imaging evaluation. Retear rate in patients in the C group (47.6%) was higher than that in the I group (22.9%) or P group (20.0%) ( P = .011). Retear subclassification based on the involved tendons showed that subsequent subscapularis tendon retears were noted in only the C group. The improvement in clinical scores after repair was statistically significant in all groups but not different among the groups. Between-group comparison showed significant differences in preoperative external rotation ( P = .021). However, no statistically significant difference was found in any shoulder range of motion measurements after surgery.

CONCLUSION

Arthroscopic repair of massive tears results in substantial improvements in shoulder function, despite the presence of combined subscapularis tears. However, this study showed a high failure rate of massive posterosuperior rotator cuff tear repair extending more than one-third of the subscapularis tendon. When combined subscapularis tendon tear was less than the superior one-third of the subscapularis tendon, arthroscopic debridement was a reasonable treatment method where comparable clinical and anatomic outcomes could be expected.

Diagnostic Performance of MR Arthrography with Anterior Trans-Subscapularis versus Posterior Injection Approach for Subscapularis Tendon Tears at 3.0T

OBJECTIVES

To compare the diagnostic performance of shoulder magnetic resonance arthrography (MRA) with the anterior trans-subscapularis versus posterior injection approach to diagnose subscapularis tendon (SCT) tears.

METHODS

One hundred and sixty-seven arthroscopically confirmed patients (84 anterior and 83 posterior approaches) were included. Two readers retrospectively scored SCT tears. Proportions of correctly graded tears between MR arthrography and arthroscopy were calculated. Retrospective error analysis was performed.

RESULTS

The sensitivity and specificity were 80 % (24/30) and 72 % (39/54) by reader 1, 73 % (22/30) and 76 % (41/54) by reader 2 in the anterior approach, and 86 % (30/35) and 79 % (38/48) by reader 1, 80 % (28/35) and 88 % (42/48) by reader 2 in the posterior approach, respectively. There were no significant differences in sensitivity and specificity between the two groups. Proportions of correctly graded tears of both readers were 48 % and 36 % in the anterior approach, and 70 % and 68 % in the posterior approach, respectively. The intratendinous collection of contrast material was not statistically significantly different between anterior (n = 8) and posterior (n = 3) approach group.

CONCLUSIONS

For the MRA diagnosis of SCT tears, there was no significant difference between the anterior trans-subscapularis and the posterior approach.

KEY POINTS

• Anterior trans-subscapularis and posterior approaches showed no significant difference for SCT tears • Intratendinous collection of gadolinium is more frequent in anterior trans-subscapularis approach • Extent of SCT tears tends to be overestimated in anterior trans-subscapularis approach • Posterior approach should be considered for diagnosing SCT tear.

Poor Agreement on Classification and Treatment of Subscapularis Tendon Tears

PURPOSE

To assess the inter- and intraobserver agreement for classification and management of subscapularis tendon pathology based on arthroscopy and magnetic resonance imaging (MRI).

METHODS

Twenty-two orthopaedic surgeons from the Multicenter Orthopaedic Outcomes Network (MOON) shoulder group reviewed still arthroscopic and MRI images of the subscapularis tendon from patients with a random assortment of subscapularis morphology. The surgeons were asked to classify the pathology based on 2 systems (Lafosse and Lyons) and choose whether they would repair the tendon and, if so, the method of repair (open or arthroscopic). The survey was administered 3 times to each surgeon. Inter- and intraobserver reliability between testing rounds was determined by kappa analysis.

RESULTS

Interobserver reliability on classification of tears was poor based on MRI (k = 0.18 to 0.19) and fair based on arthroscopy (k = 0.26 to 0.29). Interobserver agreement on whether surgical treatment was indicated was fair for both MRI (k = 0.28) and arthroscopy (k = 0.38), while the agreement for type of surgery was poor based on MRI (k = 0.18) and fair based on arthroscopy (k = 0.28). Interobserver agreement did not improve when both MRI and arthroscopy were provided simultaneously (k = 0.24 to 0.30). Intraobserver reliability for classification and treatment was fair to moderate for both MRI (k = 0.32 to 0.50) and arthroscopic imaging (k = 0.39 to 0.56). When considering just those patients with normal tendons, surgeon agreement improved. For all questions, the arthroscopic images had a higher level of agreement among surgeons than the MRI (P < .001).

CONCLUSIONS

Although surgeons tended to have higher reliability when presented with arthroscopic images compared with MRI, there was very little agreement on the classification and management of subscapularis tendon tears.

Tendon transfers for irreparable rotator cuff tears: An update

Shoulder dysfunction in the setting of irreparable rotator cuff tears (RCTs) can be treated successfully with different types of tendon transfer: Latissimus dorsi transfer for irreparable posterosuperior RCTs works best for young, active patients with an intact subscapularis, no pseudoparalysis or previous surgery, and a functioning teres minor.A more anatomical transfer for irreparable posterosuperior RCTs is a lower trapezius transfer, and early results are promising.Isolated irreparable tears of the subscapularis can be successfully managed with pectoralis major tendon transfer with a concentric humeral head. However, restricted external rotation (ER) may occur, depending on technique.Pectoralis minor transfer can successfully address combination irreparable tears of the upper border subscapularis and the supraspinatus without significant loss of ER.Rotator cuff arthropathy with ER lag benefits most from a reverse total shoulder arthroplasty and a combination latissimus dorsi and teres major transfer (LDTMT) regardless of patient age. Cite this article: Axe JM. Tendon transfers for irreparable rotator cuff tears: An update. EFORT Open Rev 2016;1:18-24. doi: 10.1302/2058-5241.1.000003.

CLINICAL DIAGNOSIS OF SUBSCAPULARIS TENDON TEAR USING THE BEAR HUG SEMIOLOGICAL MANEUVER

Objective: To evaluate the Bear Hug maneuver for clinically diagnosing subscapularis tendon tears, and compare this with other maneuvers described previously (Lift-off, Napoleon and Belly Press). Methods: Forty-nine patients with rotator cuff injuries who had undergone arthroscopy to repair the injury and had previously been assessed using the semiological maneuvers mentioned above were evaluated. Results: The diagnostic values obtained for the Bear Hug test were as follows: sensitivity 75%, specificity 56%, positive predictive value 62%, negative predictive value 70% and accuracy 65%. Conclusion: The highest sensitivity and negative predictive value values were obtained with the Bear Hug test. The highest specificity value was seen with the Lift-off test. The Belly press test gave the greatest specificity, positive predictive and accuracy values.

Repair of Acute-on-Chronic Subscapularis Insufficiency in an Adolescent Athlete

A 13-year-old right-hand-dominant skeletally immature boy presented to the authors' clinic after being blocked during an overhead dodgeball throw and hearing an abrupt "pop" in the shoulder. He had pain in the subdeltoid region that was most prominent during sports-related activity, particularly throwing. The patient had nonoperative management of a lesser tuberosity avulsion fracture 1 year earlier after a similar injury that occurred during a basketball game. He had returned to normal sporting activity 2 months before the most recent injury. Repeat advanced imaging showed an avulsion fracture of the subscapularis tendon, with a significantly retracted 2-cm component as well as a less retracted component, suggesting acute-on-chronic injury. Given this retraction and the symptoms during throwing, the patient was counseled that surgical management would best facilitate an asymptomatic return to sports-related activity. This case showed acute-on-chronic subscapularis tendon insufficiency with avulsion of the lesser tuberosity and significant retraction of the subscapularis tendon without tearing, a rare injury pattern in adolescents. For fixation of the avulsed lesser tuberosity fracture, an open approach technique was used in which SpeedBridge (Arthrex, Naples, Florida) sutures were passed behind the bone fragment. Four anchors were placed medial and lateral to the subscapularis insertion points to create a knotless double-row footprint. Compared with the published literature, this method of subscapularis fixation offered secure anatomic repair in a time-efficient, user-friendly manner.

Accuracy of long head of the biceps subluxation as a predictor for subscapularis tears

PURPOSE

The aim of this study is to understand the relation between long head of the biceps tendon (LHBT) subluxation and full-thickness tears of the subscapularis.

METHODS

Magnetic resonance imaging (MRI) scans of 94 patients undergoing shoulder arthroscopy were evaluated preoperatively for the presence or absence of LHBT subluxation. Intraoperative pathology of the biceps and subscapularis tendons was recorded. The diagnostic accuracy of LHBT subluxation on preoperative MRI in determining full-thickness subscapularis tendon tears was calculated.

RESULTS

Of the 94 patients in this study, 26 were diagnosed with LHBT subluxation preoperatively. Of these 26 patients, 9 were confirmed to have full-thickness tears of the subscapularis tendon (Lafosse grade 2 or higher). Of the remaining 68 patients who did not appear to have LHBT subluxation preoperatively, 2 were confirmed to have full-thickness tears of the subscapularis tendon. Thus LHBT subluxation on MRI as a predictor for full-thickness subscapularis tears had a sensitivity of 82%, specificity of 80%, positive predictive value of 35%, and negative predictive value of 97%. LHBT subluxation was directly correlated with the severity of the subscapularis tendon tear (P < .001).

CONCLUSIONS

The diagnostic value of subluxation of the LHBT, as seen on an axial MRI scan, lies primarily in its negative predictive value. If the LHBT is not subluxated, it is unlikely that a full-thickness tear of the subscapularis tendon is present. Surgeons should be cautious about relying on biceps subluxation as a primary diagnostic tool in predicting subscapularis tears.

LEVEL OF EVIDENCE

Level IV, study of diagnostic test.

Pectoralis major tendon transfer for irreparable subscapularis tears

BACKGROUND

Subscapularis insufficiency is a debilitating condition with few treatment options. Historically, pectoralis major tendon transfer has been suggested when the subscapularis tendon or muscle is deemed irreparable; however, the results of this salvage procedure have been mixed.

METHODS

A comprehensive review of the peer-reviewed literature addressing pectoralis major tendon transfers was performed. The clinical presentation, relevant anatomy, biomechanical rationale, surgical indications, technical considerations, reported outcomes, and significant complications are reviewed in this report. Where possible, attempts at direct comparison of outcomes among surgical techniques and surgical indications have been made.

RESULTS AND CONCLUSIONS

Despite the heterogeneous reporting of clinical results, it is clear that surgical indications affect outcomes. Specifically, isolated subscapularis insufficiency shows the best prognosis with pectoralis major tendon transfer. Patients with anterosuperior instability after large rotator cuff tears or shoulder arthroplasty have the least predictable pain relief and worse functional outcomes.

LEVEL OF EVIDENCE

Review article.

The influence of partial subscapularis tendon tears combined with supraspinatus tendon tears

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.

LEVEL OF EVIDENCE

Basic science study, biomechanics.

Arthroscopic treatment of anterosuperior rotator cuff tears

This study evaluated pre- and postoperative clinical and structural outcome data on anterosuperior rotator cuff tears involving the supraspinatus and subscapularis treated by arthroscopic methods. Between June 2006 and October 2007, a total of 155 consecutive patients underwent an arthroscopic repair for a supraspinatus or supraspinatus and infraspinatus (superior) rotator cuff tear. Of these, 44 (28%) were identified on preoperative imaging to have involvement of the subscapularis. Confirmation of subscapularis tears occurred during arthroscopic repair of the superior rotator cuff. If the subscapularis was found to be torn, it was documented, and an arthroscopic repair was performed. Postoperative clinical and radiographic outcomes were assessed with the belly press and lift-off tests, range of motion, strength, pain score, Constant score, and either a magnetic resonance imaging arthrogram or a computed tomography arthrogram at an average of 15 months postoperatively. Failure was determined based on rotator cuff integrity on radiologic studies. Sixteen of the 44 anterosuperior rotator cuff tears identified on preoperative imaging were found to have a full-thickness subscapularis tear requiring repair on arthroscopic examination. On preoperative imaging, subscapularis tears were all either grade 1 or grade 2 (no complete grade 3 tears). Mean follow-up was 16.9 months (range, 13-24 months). Compared with preoperative values, significant postoperative improvements occurred in Constant scores, forward flexion, strength, and pain scores (P<.01). Patients also showed significant improvements in both the lift-off and belly press tests (P<.001). Mean postoperative patient satisfaction was 7.9 (range, 5-10) with 10 (59%) of 17 patients being extremely satisfied. Two of the 17 patients with an anterosuperior rotator cuff tear had confirmed retears of the supraspinatus (1 partial and 1 full-thickness) with no radiographic evidence of retear of any of the subscapularis repairs at most recent follow-up.

Non-insertional tendinopathy of the subscapularis

Purpose:

(1) Describe a previously unreported finding involving the intra-articular portion of the subscapularis, the Conrad lesion. (2) Describe a novel classification system for the spectrum of non-insertional tendinopathy of the subscapularis. (3) Report the outcomes of surgical treatment of this spectrum of pathology.

Materials and Methods:

Outcomes of 34 patients (23 males and 11 females, mean age 60.5 ± 7.5) with non-insertional tendinopathy of the subscapularis treated arthroscopically were retrospectively reviewed. All patients had anterior shoulder pain with no weakness during belly-press testing and no subscapularis footprint involvement on magnetic resonance imaging. All patients were managed with subscapularis tendon debridement and side-to-side repair along with treatment of concomitant pathology.

Results:

Seven patients had a Type I lesion (so-called Conrad lesion) – a nodule on the leading edge of the subscapularis. Eighteen patients had a Type II lesion – a visible split tear with degeneration in the upper ½ of the intra-articular tendon. Nine patients had a Type III lesion – more extensive splitting in the tendon with advanced tendon degeneration. At a mean follow-up of 24 months, 97% of patients were completely satisfied. Significant improvements were seen in forward elevation (152 ± 12° to 172 ± 5°, P < 0.001) and visual analog scale pain scores (5.9 ± 1.7-0.6 ± 1.0, P < 0.001). Internal rotation strength and external rotation motion at the side were maintained. ASES scores averaged 95.4 ± 7.4, disabilities of arm, shoulder and hand scores averaged 6.19 ± 9.8, Western Ontario Rotator Cuff scores averaged 91.7 ± 9.3 and the average University of California at Los Angeles score was 33.1 ± 2.4.

Conclusions:

We present a previously unreported finding of the subscapularis, the Conrad lesion, along with a novel classification system for non-insertional tendinopathy of the subscapularis. Arthroscopic treatment of this spectrum of tendinopathy along with concomitant shoulder pathology eliminated pain and improved patient outcomes without detrimental effects.

Level of Evidence:

IV, Retrospective Case Series.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BACKGROUND

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

OBJECTIVES

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

SEARCH METHODS

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

SELECTION CRITERIA

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

MAIN RESULTS

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

AUTHORS' CONCLUSIONS

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

Open repair of isolated traumatic subscapularis tendon tears with a synthetic soft tissue reinforcement

BACKGROUND

Missed or chronic subscapularis tendon ruptures may have muscle atrophy and tendon retraction resulting in a large defect with high risk of re-tear after a surgical repair. To improve the clinical results of this challenging surgery, the repaired tendon could be augmented with endogenous or exogenous materials. The purpose of this study was to evaluate the structural tendon integrity and clinical outcomes after an open subscapularis tendon repair with a synthetic soft tissue reinforcement.

MATERIALS AND METHODS

Ten patients were managed with an open repair of the subscapularis tendon with augmentation by means of SportMesh, a readily available synthetic degradable poly(urethaneurea) scaffold. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the visual analog scale for pain and the DASH scoring system. All patients had an ultrasonographic study at the latest follow-up.

RESULTS

The visual analog scale for pain (mean ± standard deviation) improved significantly (P < 0.01) from 7.9 ± 1.1 preoperatively to 1.95 ± 1.85 at the latest clinical follow-up evaluation. The mean DASH score at the latest clinical follow-up was 12.63 %. Ultrasound imaging revealed a structural intact repair at follow-up in 9 shoulders (90 %) with average 5.4 mm in thickness (4.3 mm in the contralateral healthy side).

CONCLUSIONS

At a median follow-up of 23 months, 80 % (8 of 10) of patients had a good or excellent result after an open subscapularis tendon repair with a soft tissue reinforcement. As a synthetic material, SportMesh Soft Tissue Reinforcement eliminates the risk of collagen reactions, which may result from collagen or dermis patches. Although the follow-up is relatively short, our series shows a promising durable repair with a 10 % re-tear rate at an average of 23 postoperative months. Level of evidence Case Series, Treatment Study, Level IV.

MRI study of associated shoulder pathology in patients with full-thickness subscapularis tendon tears

Subscapularis tendon tears are a well-established cause of shoulder pain. The objective of the current study was to evaluate the associated shoulder pathology in patients with full-thickness subscapularis tendon tears using magnetic resonance imaging. Forty-seven magnetic resonance imaging studies taken between 2008 and 2009 with a diagnosis of full-thickness subscapularis tendon tears were reviewed. The size of the subscapularis tendon tear, amount of muscle volume loss, Goutallier grade, biceps tendon pathology, coracohumeral distance, and associated rotator cuff tears were recorded. Statistical analysis was performed. Patients 55 years and older vs those 54 years and younger had an average subscapularis tear size of 35 vs 19 mm, an average Goutallier grade of 2.7 vs 0.8, and a total muscle volume loss of 25% vs 5%, respectively. Patients with a dislocated vs normal biceps tendons had an average subscapularis tear size of 37 vs 23 mm, an average Goutallier grade of 3 vs 0.9, and a total muscle volume loss of 28% vs 7%, respectively. Patients with vs without concomitant rotator cuff tears had an average subscapularis tear size of 32 vs 17 mm, an average Goutallier grade of 2.3 vs 0.6, and a total muscle volume loss of 21% vs 3%, respectively. Overall average coracohumeral distance measured in the axial plane was 10.8±4.6 mm. Average coracaohumeral distance was 14.8 vs 8.1 mm in patients with a Goutallier grade of 0 vs 3 or 4, resepectively, and 13.6 vs 8.5 mm in patients with no rotator cuff tear vs those with a supra- and infraspinatus tear, respectively. Increased age, dislocated biceps tendons, and concomitant rotator cuff tears in patients with full-thickness subscapularis tendon tears are associated with larger subscapularis tendon tear size, higher Goutallier grades, and increased subscapularis muscle volume loss. Decreased coracohumeral distance is associated with a higher Goutallier grade and rotator cuff tears.

A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans

PURPOSE

To determine and propose a systematic approach to evaluating magnetic resonance imaging (MRI) scans for subscapularis tears and compares preoperative MRI interpretations with findings of the same shoulders at arthroscopy.

METHODS

The study was composed of 202 patients who underwent shoulder arthroscopy by 1 of 5 orthopaedic surgeons during a 3-month period. All patients had MRI scans performed within 6 months before arthroscopy.

RESULTS

Of the 202 patients, 82 had subscapularis tendon tears confirmed at the time of arthroscopy. The orthopaedic surgeons correctly diagnosed 60 of 82 patients (73%) with subscapularis tendon tears on preoperative MRI that were subsequently identified by arthroscopy. The orthopaedic surgeons correctly diagnosed 113 of 120 patients (94%) as not having subscapularis tendon tears. This resulted in an overall sensitivity of 73%, specificity of 94%, positive predictive value of 90%, negative predictive value of 84%, and accuracy of 86%. The frequency of subscapularis tears was highest when the long head of the biceps was displaced from the groove (88%), a combined supraspinatus/infraspinatus tear existed (71%), or the long head of the biceps tendon was torn (69%).

CONCLUSIONS

Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. A consistent finding is that larger subscapularis tendon tears are more easily detected using MRI scans whereas smaller tears are more frequently missed.

LEVEL OF EVIDENCE

Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

Imaging evaluation of the rotator cuff

The rotator cuff is a complex network of interwoven tendons that plays a key role in glenohumeral movement and stability. Cuff abnormality is a common source of shoulder pain, but the clinical presentation is often nonspecific and, as a result, diagnostic imaging, especially magnetic resonance imaging, plays a key role in evaluating these patients. This article reviews imaging modalities available for evaluating the cuff, normal cuff anatomy, and common pathologic conditions that affect it.

Does open repair of anterosuperior rotator cuff tear prevent muscular atrophy and fatty infiltration?

BACKGROUND

Repair of cuff tears involving rotator interval reportedly improves function. However, it is unclear whether successful repair prevents shoulder degenerative changes.

QUESTIONS/PURPOSES

Therefore, we (1) documented the minimal 4-year function of patients who underwent open surgical repair for rotator interval tears; (2) evaluated repaired tendon healing with postoperative MRI; and (3) sought to determine the influence of tendon healing on muscular and glenohumeral joint changes.

METHODS

We retrospectively analyzed 22 patients (23 shoulders) treated by open transosseous reinsertion of supraspinatus and subscapularis tendons. The mean age of the patients was 53 years (range, 37-64 years). The tear was traumatic in four cases. Repair healing and muscular changes were assessed using MRI. The minimum followup was 46 months (mean, 75 months; range, 46-103 months).

RESULTS

We observed an improvement in the absolute Constant-Murley score from 63 points preoperatively to 76 points postoperatively. With the last followup MRI, the supraspinatus tendon repair had failed in two of the 23 shoulders, whereas the subscapularis tendon repair had healed in all cases. Once healing of the repaired tendon occurred, supraspinatus muscle atrophy never worsened. However, on MRI fatty infiltration of the rotator cuff muscles increased despite successful tendon repair. Glenohumeral arthritis remained stable. Postoperative abduction and internal rotation strengths were better when the standardized supraspinatus muscle area was greater than 0.5 at the final evaluation.

CONCLUSION

Durable functional improvement and limited degenerative articular and muscular changes can be expected in most patients 4 to 10 years after open repair of anterosuperior cuff tears provided that healing of the cuff is obtained.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.