Clinical Pearls is the newest SMR feature. Since much of current clinical practice is still based on anecdotal evidence, it is imperative for clinicians to incorporate both research and clinical experience when working with patients. Clinicians with decades of experience commonly have priceless advice to offer young professionals in clinical practice as well as research. Therefore, clinical pearls will allow the leading experts in Sports Medicine (orthopaedic surgeons, physicians, and other clinicians) to combine research and decades of clinical experience into a comprehensive discussion on a topic of expertise. This open forum will allow priceless insight into clinical sports medicine to be passed along and discussed. It is designed to bring the experts to you! I hope you enjoy Clinical Pearls and like always please provide feedback to help us better serve you.
Clinical Pearls: Tears of the Subscapularis Tendon
John D. Kelly IV, MD
University of Pennsylvania
Prior to the advent of rotator cuff arthroscopy partial tears of the subscapularis tendon were at undetectable amounts. Since rotator cuff arthroscopy, partial tears of the subscapularis tendon are becoming increasingly recognized with some studies reporting up to approximately a 40% prevalence upon shoulder arthroscopy. The old adage, ‘you may have not seen it, but it has seen you’ certainly applies here. There is an old proverb: ‘the eye sees what the mind knows’. Indeed, if subscapularis tear patterns are not appreciated, subtle tears will be missed.
The subscapularis is the largest rotator cuff tendon and it plays a large role in humeral head depression and shoulder stability. Since the subscapularis tendon rests anterior to the shoulder articulation, it confers appreciable protection against posterior instability – posterior humeral head translation applies considerable eccentric stress to the subscapularis tendon complex. Many clinicians are becoming increasingly aware of the potential implications of partial subscapularis injury due to the rise in clinical reports identifying combined partial supraspinatus and upper subscapularis tears.
Subscapularis tears usually originate proximally in the upper band and tend to propagate distally to the lower band. Tears may occur from traumatic external rotation or shoulder extension stresses. In addition attritional tears may occur secondary to subcoracoid impingement. Burkhart has posited the ‘roller wringer’ effect as a means of tendon attrition whereupon the tendinous portion of the upper subscapularis is pinched between the lesser tuberosity and the coracoid tip. A coraco-humeral interval of less than 6mm is considered stenotic.
Patients with tears of the subscapularis may complain of achey, anterior shoulder pain as well as weakness with abduction and internal rotation. Tucking one’s shirt in the back may be particularly troublesome as this requires coupled internal rotation and extension. Since the proximal biceps tendon derives medial stability from the subscapularis tendon insertion, biceps tendon symptoms may be present with a subscapularis tendon tear.
Examination findings include increased passive external rotation, especially in adduction, as well as loss of internal rotation strength. The ‘Belly Press’ test, whereupon the patient attempts to apply pressure to the abdomen while maintaining a straight wrist, has been shown to be reasonably sensitive for subscapularis tears (https://www.ncbi.nlm.nih.gov/pubmed/14564261).
The ‘Bear Hug’ test, first described by Burkhart et al. (https://www.ncbi.nlm.nih.gov/pubmed/17027405), has been shown by Chao and Thomas et al (https://www.ncbi.nlm.nih.gov/pubmed/18971057) to be perhaps the best test for detecting upper subscapularis tendon tears. To perform this maneuver, the examiner asks the patient to place the involved side hand on the contra lateral shoulder with the elbow in 45 degrees of forward flexion.
The subject then resists the tester’s attempts to pull the hand away from the shoulder. Normally, in the presence of a competent tendon, the subject will maintain the hand position on the shoulder despite the examiner’s efforts.
Partial and full thickness tears of the subscapularis should be repaired in active individuals. Arthroscopy affords superior visualization and mobilization. Even massive retracted tears can be safely liberated from adjacent scar and repaired back to the lesser tuberosity. A coracoidplasty should accompany repair in an effort to prevent tear recurrence. Finally, a medially subluxed biceps tendon should undergo tenodesis or tenotomy in order to protect the repair from undue stress.
Please feel free to leave any questions and I will be happy to answer them.
Great first post for "clinical pearls". Thank you for the insight Dr. Kelly!
Does an interstitial tendon tear at lesser tuberosity attachment with a medial subluxation of the long head biceps tendon with the joint require surgery? If no surgery is done, what might happen as on ages. I am an active 50 year old?
That injury typically requires surgical intervention. The subscap tear can alter joint mechanics which over time may lead to arthritis. The subluxing biceps tendon will cause significant pain and also will most likely lead to a degeneration of the tendon. Being active will likely be difficult with this injury. I hope this helps.
For an active athlete having a small interstitial tear in the subscapularis tendon, what are the movements to be avoided and what is the average expected recovery period? also please suggest if there are any recommended food supplements to help recovery.
You want to avoid forced external rotation and extension. Also crossed arm adduction may increase coracoid impingement. Extra vitamin c and low caloric plant based diet may help reduce inflammation. I hope this helps.
Hello Dr. Kelly – I am 34, male, and have been diagnosed with a partial subscap tear. I don't know the extent of the tear (in percentage torn) but my doctor has said that her institution will not operate on this type of injury, as a matter of policy. She believes it will heal on its own in time (several months).
My question: Is this possible? Many sources online recommend surgery for this injury. FYI, the pain is minor and I still have most range of motion. Arm behind the back causes discomfort, though no problem tucking in shirt.
And second question: Is riding a bike to be avoided during recovery?
Thanks a bunch!
Anonymous please email me at firstname.lastname@example.org and I will put you in contact with Dr. Kelly. Thank you.
14 y/o athlete with 50-75% tear of subscap at insertion. Was told this will heel on its own and would return to sport in 4-6 wks, Is this likely?
Had full thickness subscap tear repaired with bioscrew and tenodesis to reattach medially subluxed biceps tendon in Jan. 2011, following motor vehicle accident. (Surgeon suspected the torque from seat belt restraint plus violent twist of steering wheel contributed to injury). I'm a reasonably active mid-50's male, with history of seizure disorder and prior diagnosis of partial subscapularis tear secondary to a seizure event. Original injury was conservatively managed.
Three years after the repair, symptoms have returned. Significant weakness, anterior shoulder pain radiating down biceps when lifting anything or tucking in shirt or with lateral motion.
How common are recurrences of this type of injury? Am having contrast MRI this week.
If you were performing a biceps tenodesis that turned into a tenotomy by mistake (tendon retracted) and found a small subscap tear while you were there would you fix the tear or leave it? Could the tear get bigger?
Message back from Dr. Kelly, MD:
Presence of a subluxed biceps tendon raises suspicion for an upper subscp tear. Careful inspection of the subscap footprint with a 70 degree scope is essential to assess integrity. If there is any footrpint exposure, I do not hesitate to repair. The subscap is the largest cuff tendon. We routinely fix partial supraspinatus tears. Partial sub scap tears are thought to progress in time.