Although rotator cuff tears represent 20% of shoulder injuries in the general population,1 isolated subscapularis tendon ruptures account for only 10% of rotator cuff tears.1 In the pediatric population, subscapularis tendon tears are most commonly associated with an avulsion fracture of the lesser tuberosity. Isolated subscapularis tendon ruptures are infrequently reported.2–4
Subscapularis tendon injuries occur due to forced hyperextension or external rotation of an abducted arm.5 Rotator cuff tears present with pain, weakness, stiffness, and reduced range of motion, having overlapping symptomatology with acute tendonitis or impingement syndrome.6 Coupled with the rarity of the injury, the diagnosis of subscapularis tendon tears is often overlooked. According to previous reports, the diagnosis of subscapularis tendon injuries in pediatric patients is often delayed and management is typically conservative.4,6 When operative management is indicated, an open deltopectoral approach has been used2,4,6 and may include concomitant open reduction and internal fixation3 when there is an avulsion fracture of the lesser tuberosity.
The authors describe an adolescent athlete who sustained a traumatic isolated subscapularis tendon rupture while being tackled in a football game. This was repaired arthroscopically with concomitant subpectoral biceps tenodesis due to medial instability of the long head of the biceps tendon (LHBT) within 10 days of injury. He returned to sport within 8 months of operative management.
A 15-year-old high school quarterback injured his right shoulder while his arm was in full extension during a football game 5 days prior to presentation. He immediately felt pain, numbness, and tingling in his right arm.
On initial examination, the patient noted severe pain (7 of 10) and was unable to use his arm secondary to pain. There was no obvious deformity of the shoulder. He was tender to palpation on the anterior shoulder. He was able to achieve 25° of scaption, 10° of external rotation, internal rotation to the level of L5 of active range of motion, and positive results on lift-off test and belly-press test. On passive range of motion, the patient exhibited an increase in external rotation with the elbow in adduction. Standard radiographs showed no osseous deformity. On the basis of the clinical history and findings on physical examination, the senior author (B.F.) suspected a subscapularis injury. Magnetic resonance imaging was performed and revealed a full-thickness subscapularis tendon tear with no evidence of an avulsion fracture of the lesser tuberosity (Figure 1). The findings of the physical examination and the results of magnetic resonance imaging were consistent with a subscapularis tendon rupture. It was recommended that the patient undergo arthroscopic subscapularis tendon repair.
Magnetic resonance image at initial presentation showing a full-thickness subscapularis tendon tear (arrow).
In the operating room, the patient was placed in a beach chair position with the arm placed at 0° of adduction and 20° of external rotation. Standard posterior and anterior portals, as well as an accessory anterosuperolateral viewing portal at the anterosuperior angle of the acromion, were established. Diagnostic arthroscopy was notable for fibrillation and partial tearing of the superior labrum, indicating a type 1 superior labral anterior and posterior (SLAP) lesion (Figure 2A), which was debrided with an arthroscopic shaver and a radiofrequency wand (Arthrex, Naples, Florida). Further evaluation indicated full-thickness detachment of the subscapularis tendon from the lesser tuberosity, without an avulsion fracture of the lesser tuberosity (Figure 2B), and medial instability of the LHBT (Figure 2C). With arthroscopic scissors, the LHBT was released from the superior labrum to facilitate subsequent mini-open subpectoral biceps tenodesis.
Intraoperative arthroscopic images from the posterior portal showing a concomitant superior labral anterior and posterior (SLAP) tear (A), a full-thickness subscapularis tendon rupture without avulsion fracture (B), and medial instability of the long head of the biceps tendon [LHBT] (C).
Labral tape sutures were passed through the subscapularis tendon at the junctions of the inferior one-third and superior two-thirds, along with the superior one-third and inferior two-thirds, with a Scorpion suture-passing device (Arthrex). The subscapularis footprint was freshened to a bleeding cortical surface with an arthroscopic shaver. The inferior suture limb was then implanted with a 4.75-mm polyetheretherketone (PEEK) suture anchor within the inferior one-third of the lesser tuberosity footprint (Arthrex; Figure 3A and Figure 3B, respectively). This process was then repeated with the superior suture limb, implanting it within the superior one-third of the lesser tuberosity footprint with a second 4.75-mm PEEK suture anchor as described by Agarwalla et al.7 Stable fixation of the subscapularis tendon construct was achieved, visualized, and confirmed with internal and external rotation of the arm (Figure 4).
Intraoperative arthroscopic images from the posterior portal showing labral tape being passed through the inferior aspect of the subscapularis tendon (A) with fixation occurring with a Swivelock (Arthrex, Naples, Florida) at the junction of the inferior one-third and superior two-thirds of the subscapularis footprint (B). The process was repeated for the superior aspect of the subscapularis tendon.
Intraoperative arthroscopic images from the posterior portal (A) and anterior portal (B) showing the final stable fixation construct of the subscapularis repair.
The mini-open subpectoral biceps tenodesis was then performed, beginning with a 3-cm incision made 2 cm lateral to the superior axillary fold. Blunt dissection beneath the pectorals major muscle belly and tendon was performed to locate the biceps tendon, which was then retrieved and pulled through the axillary incision. The LHBT was whipstitched 2 cm from the musculotendinous junction with a No. 2 FiberLoop (Arthrex). A 6.5-mm–diameter humeral socket was drilled within the bicipital groove, along the course of the biceps tendon, at the lower border of the pectoralis major tendon. The long head of the biceps tendon was then implanted into the socket with a 6.25-mm PEEK tenodesis screw. Then the No. 2 FiberLoop was tied unto itself to reinforce the repair, thus completing the mini-open subpectoral biceps tenodesis (Figure 5).
Intraoperative arthroscopic images through the axillary incisions. The tendon placed into the tunnel prior to polyetheretherketone (PEEK) screw insertion (A). Final PEEK screw fixation (B). Abbreviation: LHBT, long head of the biceps tendon.
A five-phase rehabilitation protocol was initiated 2 weeks postoperatively. The initial phase involved passive range of motion and scapular proprioceptive neuromuscular facilitation techniques to prevent soft tissue adhesions and atrophy of scapular stability musculature. The second phase of treatment was initiated 4 weeks postoperatively and included isometric exercises in all planes (except internal rotation) at 0° of abduction. Six weeks postoperatively, the patient began active range of motion training and scapular stabilization exercise. Due to his accelerated progress, the patient was quickly advanced to low resistance strengthening in all planes except internal rotation.
Three months postoperatively, the patient reported 80% of normal function and minimal pain (2 of 10). On physical examination, he achieved 161° of flexion, 162° of abduction, 95° of external rotation, and 50° of internal rotation measured at 90° of abduction. At this time, the third phase of the rehabilitation program began, which included implementation of dynamic neuromuscular control training and higher intensity shoulder strengthening. One month later, the patient entered the fourth phase of rehabilitation, which focused on overhead isolated rotator cuff strengthening as well as dynamic trunk and lower extremity conditioning with throwing movements. At 20 weeks postoperatively, he began supervised low intensity throwing simulation with an emphasis on release point mechanics and rotator cuff overhead deceleration exercise.
At 28 weeks postoperatively, the patient demonstrated equal or greater force production and active range of motion in all planes of the affected shoulder. Trends in the patient's passive and active range of motion are displayed in Figure 6. A throwing program was initiated, with return to full throwing and baseball participation at 8 months after surgery. At final follow-up 8 months postoperatively, the patient achieved 185° of scaption, 80° of external rotation, and internal rotation to the level of T9. He also demonstrated 5/5 strength with negative results on bear-hug, belly-press, and lift-off tests.
Trends in passive range of motion (PROM) and active range of motion (AROM) during physical therapy for an adolescent boy following isolated subscapularis tendon rupture. Abbreviation: ER, external rotation.
Previous reports of an isolated subscapularis tendon rupture in an adolescent patient described initial conservative management prior to operative management via an open deltopectoral approach.2,4,6 In previous cases, patients reported positive outcomes at a minimum of 6 months postoperatively. The current authors described an adolescent patient who had an isolated subscapularis tendon rupture following a traumatic impact on his extended arm that was repaired arthroscopically within 10 days of the initial injury.
Rupture of the subscapularis tendon is often overlooked and may ultimately present as a chronic case with an average time of 8.5 months from injury to diagnosis.2,3 Despite its rarity, clinicians should have a high index of suspicion in patients who present with anterior shoulder pain or weakness and a history of an acute traumatic injury with the arm forced into extension and external rotation.1 Provocative physical examination maneuvers such as the belly-press, lift-off, or bear-hug test, with an accuracy of 80.9%, 77.8%, and 82.4%, respectively, can indicate potential injury to the subscapularis tendon,8 which can be confirmed by diagnostic imaging.
Magnetic resonance imaging and magnetic resonance arthrography are the imaging modalities of choice because they are both sensitive and specific in assessing the integrity of rotator cuff tendons.9,10 Although the results of ultrasound examination may be dependent on the skill and experience of the operator, ultrasound has been shown to be as efficacious as magnetic resonance imaging in identifying and measuring rotator cuff deficiencies.11 Thus, the choice of imaging modality can be based on other factors, such as cost or necessity to evaluate for concomitant injury.
Conservative management of subscapularis tendon ruptures includes pain medications, cortisone injections, and physical therapy. Adult patients undergoing early surgical intervention exhibited greater improvement than those who received conservative treatment; however, the difference may not be clinically detectable.12 Despite this finding, patients who received nonoperative management exhibited limited internal rotation, chronic shoulder pain, instability, and weakness.13–15 Operative repair of a subscapularis tendon tear can be performed arthroscopically; however, visualization and instrument manipulation may prove difficult in arthroscopy. Thus, some prefer an open deltopectoral approach to maximize visualization and simplify the technical nature of the procedure.16 However, either technique results in good functional outcomes, return to sport, and a low incidence of re-rupture.17–19
Despite comparable outcomes in arthroscopic and open techniques,17–19 arthroscopic rotator cuff repairs confer the advantages of reduced pain, hospitalization time, and infection rate and earlier return to previous level of activity.20 Due to the rarity of subscapularis tendon rupture in adolescent patients, heightened clinical suspicion based on the mechanism of injury is necessary to allow for an early diagnosis. Early diagnosis of a subscapularis tendon rupture may enable arthroscopic primary repair because retraction of the tendon is minimal. As the time from injury progresses, the degree of retraction increases, making an arthroscopic procedure more technically difficult and increasing morbidity.6 The outcomes of the current patient, who underwent arthroscopic repair, were comparable to those when an open deltopectoral approach is used. Thus, this technique may be a safe procedure with adequate functional outcomes that allow pediatric patients the opportunity to return to their previous level of activity. However, further investigation with a larger sample is needed to demonstrate the safety and efficacy of this technique.
Arthroscopic subscapularis repair in adolescent athletes yields adequate functional outcomes. Due to the rarity of this injury, it is imperative to optimize patient outcomes through clinical suspicion and early diagnosis.
- Ono Y, Sakai T, Carroll MJ, Lo IK. Tears of the subscapularis tendon: a critical analysis review. JBJS Rev. 2017;5(3):01874474-201703000-00003. doi:10.2106/JBJS.RVW.16.00054 [CrossRef] PMID:28359072
- Gouron R, Deroussen F, Juvet-Segarra M, Mancheron C, Bonnaire B, Collet LM. Isolated rupture of the subscapularis tendon in children: a case report and literature review. J Pediatr Orthop B. 2013;22(2):138–140. doi:10.1097/BPB.0b013e32835c2a4a [CrossRef] PMID:23197182
- Garrigues GE, Warnick DE, Busch MT. Subscapularis avulsion of the lesser tuberosity in adolescents. J Pediatr Orthop. 2013;33(1):8–13. doi:10.1097/BPO.0b013e318270d0d6 [CrossRef] PMID:23232372
- Provance AJ, Polousky JD. Isolated avulsion fracture of the subscapularis tendon with medial dislocation and tear of biceps tendon in a skeletally immature athlete: a case report. Curr Opin Pediatr. 2010;22(3):366–368. doi:10.1097/MOP.0b013e328337fea5 [CrossRef] PMID:20186061
- Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br. 1991;73(3):389–394. doi:10.1302/0301-620X.73B3.1670434 [CrossRef] PMID:1670434
- Polousky JD, Harms S. Subscapularis tendon injuries in adolescents: a report of 2 cases. J Pediatr Orthop. 2011;31(5):e57–e59. doi:10.1097/BPO.0b013e31821f92ca [CrossRef] PMID:21654450
- Agarwalla A, Puzzitiello RN, Leong N, Forsythe B. Arthroscopic repair of an isolated subscapularis tendon rupture in an adolescent patient. Arthrosc Tech. 2018;7(5):e523–e527. doi:10.1016/j.eats.2018.01.004 [CrossRef] PMID:29868429
- Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22(10):1076–1084. doi:10.1016/j.arthro.2006.05.005 [CrossRef] PMID:17027405
- Adams CR, Brady PC, Koo SS, et al. A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans. Arthroscopy. 2012;28(11):1592–1600. doi:10.1016/j.arthro.2012.04.142 [CrossRef] PMID:22922004
- Furukawa R, Morihara T, Arai Y, et al. Diagnostic accuracy of magnetic resonance imaging for subscapularis tendon tears using radial-slice magnetic resonance images. J Shoulder Elbow Surg. 2014;23(11):e283–e290. doi:10.1016/j.jse.2014.03.011 [CrossRef] PMID:24927884
- Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am. 2004;86(4):708–716. doi:10.2106/00004623-200404000-00007 [CrossRef] PMID:15069134
- Moosmayer S, Lund G, Seljom US, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. J Bone Joint Surg Am. 2014;96(18):1504–1514. doi:10.2106/JBJS.M.01393 [CrossRef] PMID:25232074
- Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med. 2011;39(4):710–714. doi:10.1177/0363546510393944 [CrossRef] PMID:21310940
- Vezeridis PS, Bae DS, Kocher MS, Kramer DE, Yen YM, Waters PM. Surgical treatment for avulsion injuries of the humeral lesser tuberosity apophysis in adolescents. J Bone Joint Surg Am. 2011;93(20):1882–1888. doi:10.2106/JBJS.K.00450 [CrossRef] PMID:22012525
- Goeminne S, Debeer P. The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients. J Shoulder Elbow Surg. 2012;21(8):e6–e11. doi:10.1016/j.jse.2012.01.017 [CrossRef] PMID:22572400
- Burkhart SS, Brady PC. Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy. 2006;22(9):1014–1027. doi:10.1016/j.arthro.2006.07.020 [CrossRef] PMID:16952733
- Bartl C, Scheibel M, Magosch P, Lichtenberg S, Habermeyer P. Open repair of isolated traumatic subscapularis tendon tears. Am J Sports Med. 2011;39(3):490–496. doi:10.1177/0363546510388166 [CrossRef] PMID:21189357
- Mall NA, Chahal J, Heard WM, et al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012;28(9):1306–1314. doi:10.1016/j.arthro.2012.02.018 [CrossRef] PMID:22607828
- Seppel G, Plath JE, Völk C, et al. Long-term results after arthroscopic repair of isolated subscapularis tears. Am J Sports Med. 2017;45(4):759–766. doi:10.1177/0363546516676261 [CrossRef] PMID:28106463
- Hughes JD, Hughes JL, Bartley JH, Hamilton WP, Brennan KL. Infection rates in arthroscopic versus open rotator cuff repair. Orthop J Sports Med. 2017;5(7):2325967117715416. doi:10.1177/2325967117715416 [CrossRef] PMID:28795072