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Large image of Figure 1.

Figure 1

Medial subluxation of biceps tendon

Large image of Figure 2a.

Figure 2a

Comma sign, Figure 2b. Comma Tissue

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Figure 3

Exposed Footprint During ‘Lever Push’

Large image of Figure 4.

Figure 4

Upper Third Subscapularis Tear

Large image of Figure 5.

Figure 5

Upper Subscapularis Atrophy

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Figure 6

Torn and Retracted Subscapularis

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Abstract

Background

Several classifications have been proposed for subscapularis (SC) tears; 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 subscapularis tear classification and treatment, as well as 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 papers regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. Additionally, four international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1,161 ASES members. 165 surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in four 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 subscapularis tear management, our study found that the most widely agreed upon (more than 80%) statements included: early surgery is advised for traumatic subscapularis tear, chronic degenerative SC tear (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 tendon (SCT) is the largest muscle-tendon unit of the rotator cuff muscles.33x33Smucny, M., Shin, E.C., Zhang, A.L., Feeley, B.T., Gajiu, T., Hall, S.L. et al. Poor Agreement on Classification and Treatment of Subscapularis Tendon Tears Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2016; 32: 246–251https://doi.org/10.1016/j.arthro.2015.08.006 (e1)

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It is one of the most important anterior dynamic and static stabilizers of the shoulder joint30x30Richards, D.P., Burkhart, S.S., and Campbell, S.E. Relation between narrowed coracohumeral distance and subscapularis tears. Arthroscopy. 2005 Oct; 21: 1223–1228https://doi.org/10.1016/j.arthro.2005.06.015

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and is one of the chief internal rotator muscles of the glenohumeral joint.4x4Bartl, C., Scheibel, M., Magosch, P., Lichtenberg, S., and Habermeyer, P. Open repair of isolated traumatic subscapularis tendon tears. Am. J. Sports Med. 2011 Mar; 39: 490–496https://doi.org/10.1177/0363546510388166

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SCT tears cause both shoulder pain and loss of function.22x22Lyons, R.P. and Green, A. Subscapularis tendon tears. J. Am. Acad. Orthop. Surg. 2005 Sep; 13: 353–363https://doi.org/10.5435/00124635-200509000-00009

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,23x23Mall, N.A., Chahal, J., Heard, W.M., Bach, B.R. Jr., Bush-Joseph, C.A., Romeo, A.A. et al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012 Sep; 28: 1306–1314https://doi.org/10.1016/j.arthro.2012.02.018

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Recognition and diagnosis of subscapularis tendon tears have increased due to the advances in arthroscopic surgery. A tear of the subscapularis can occur in conjunction with other rotator cuff muscle tears or can be isolated. The reported incidence of rotator cuff tears involving the subscapularis is 19 to 40%.2x2Arai, R., Sugaya, H., Mochizuki, T., Nimura, A., Moriishi, J., and Akita, K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008 Sep; 24: 997–1004https://doi.org/10.1016/j.arthro.2008.04.076

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Additionally, the reported incidence of isolated subscapularis tears among all rotator cuff tears is approximately 4%, and it is often seen in young patients after traumatic injury.8x8Deutsch, A., Altchek, D.W., Veltri, D.M., Potter, H.G., Laurencin, C.T., and Warren, R.W. Isolated injuries of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Journal of Shoulder and Elbow Surgery. 1996; 5: S11

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,9x9Edwards, T.B., Bradley Edwards, T., Walch, G., Nové-Josserand, L., Boulahia, A., Neyton, L. et al. Arthroscopic Debridement in the Treatment of Patients With Isolated Tears of the Subscapularis Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2006; 22: 941–946https://doi.org/10.1016/j.arthro.2006.05.009

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The most common mechanism of injury is either forced external rotation with abduction or forced extension.14x14Gerber, C., Hersche, O., and Farron, A. Isolated Rupture of the Subscapularis Tendon. Results of Operative Repair. The Journal of Bone & Joint Surgery. 1996; 78: 1015–1023

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Degenerative injuries are also seen in patients without a history of trauma. In one study, arthroscopic examination of patients 50 years old and older revealed that 50% of patients had a subscapularis tear. 34x34Ticker, J.B. and Burkhart, S.S. Why repair the subscapularis? A logical rationale. Arthroscopy. 2011 Aug; 27: 1123–1128https://doi.org/10.1016/j.arthro.2011.03.001

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,38x38Yoo, J.C., Rhee, Y.G., Shin, S.J., Park, Y.B., McGarry, M.H., Jun, B.J. et al. Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: a cadaveric and prospective clinical observational study. Arthroscopy. 2015 Jan; 31: 19–28https://doi.org/10.1016/j.arthro.2014.08.015

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The authors acknowledged that some of these tears were asymptomatic and did not cause any obvious force couple imbalance; however, non-repaired, clinically important subscapularis tendon tears have been known to compromise the clinical results of repair of other rotator cuff tendons. Determining which subscapularis tears are clinically significant and need to be repaired is essential and will impact the outcome of much of rotator cuff repair surgery. Distinguishing the different tear patterns of tears and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment.38x38Yoo, J.C., Rhee, Y.G., Shin, S.J., Park, Y.B., McGarry, M.H., Jun, B.J. et al. Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: a cadaveric and prospective clinical observational study. Arthroscopy. 2015 Jan; 31: 19–28https://doi.org/10.1016/j.arthro.2014.08.015

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The absence of a universally accepted classification compromises the communication of treatment options and outcomes amongst surgeons. Although several investigators have attempted to classify subscapularis tears with few suggesting treatment based on these classifications, there continues to remain a void in a universally accepted classification and corresponding treatment plan. Smunscy et al reviewed the use of contemporary classification systems and found that orthopedic surgeons used varying classifications and that there was poor agreement between surgeons regarding tear severity and prognosis.33x33Smucny, M., Shin, E.C., Zhang, A.L., Feeley, B.T., Gajiu, T., Hall, S.L. et al. Poor Agreement on Classification and Treatment of Subscapularis Tendon Tears Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2016; 32: 246–251https://doi.org/10.1016/j.arthro.2015.08.006 (e1)

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We conducted a survey among shoulder and elbow surgeons in the US to find out which aspects of the current classification are more accepted and tried to identify the approaches regarding the correct decision-making. 162 fellowship-trained shoulder and elbow surgeons participated in our survey.

In this systematic review paper, we discuss the current classification systems and existing relevant information regarding the treatment plans, indications for surgery, and outcomes for subscapularis tears in addition to reporting a consensus statement.

MATERIALS & METHODS

In this systematic review, both PubMed and Scopus were searched from January 1990 to November 2019 regarding subscapularis tendon tear and repair. The eligible articles included case-control studies, case series, randomized clinical trials, cohort studies, and technique articles and review articles. Subscapularis, classification, outcome, surgical technique were used as keywords in search strategy planning. Papers not published in English as a full text were excluded from the review. The title and abstract of the papers were reviewed. The papers that evaluated at least one of the classification systems or used it for finding the factors that affect the outcome or modification of the surgical technique were selected, and the papers which did not utilize classification systems were excluded. The full texts of the remaining articles were carefully reviewed. We did the manual search in the references of the selected articles to broaden the review. 12 papers met the inclusion criteria and were included in this systematic review as depicted in Table 1.

Table 1Summary of systematic review of subscapularis tendon tear classifications
Classification systemsBennet et al3x3Arun, G.R., Kumar, P., Patnaik, S., Selvaraj, K., Rajan, D., Singh, A. et al. Outcome of arthroscopic subscapularis tendon repair: Are the results improving with improved techniques and equipment?. A retrospective case series Indian Journal of Orthopaedics. 2016; 50: 297https://doi.org/10.4103/0019-5413.181788

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,

Toussaint et al19x19Kreuz, P.C., Remiger, A., Lahm, A., Herget, G., and Gächter, A. Comparison of total and partial traumatic tears of the subscapularis tendon. J. Bone Joint Surg. Br. 2005 Mar; 87: 348–351https://doi.org/10.1302/0301-620x.87b3.15515

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,

Yoo et al31x31Seppel, G., Plath, J.E., Völk, C., Seiberl, W., Buchmann, S., Waldt, S. et al. Long-term Results After Arthroscopic Repair of Isolated Subscapularis Tears. Am. J. Sports Med. 2017 Mar; 45: 759–766https://doi.org/10.1177/0363546516676261

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,

Lafosse et al18x18Kim, T.K., Rauh, P.B., and McFarland, E.G. Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases. Am. J. Sports Med. 2003 Sep; 31: 744–750https://doi.org/10.1177/03635465030310051801

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,

Fox et al15x15Godenèche, A., Nové-Josserand, L., Audebert, S., Toussaint, B., French Society for Arthroscopy (SFA), Denard, P.J. et al. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg. Sports Traumatol. Arthrosc. 2017 Jul; 25: 2114–2120https://doi.org/10.1007/s00167-016-4374-9

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,

Bartl et al4x4Bartl, C., Scheibel, M., Magosch, P., Lichtenberg, S., and Habermeyer, P. Open repair of isolated traumatic subscapularis tendon tears. Am. J. Sports Med. 2011 Mar; 39: 490–496https://doi.org/10.1177/0363546510388166

Crossref | PubMed | Scopus (57)
| Google ScholarSee all References
,

Edward et al 8x8Deutsch, A., Altchek, D.W., Veltri, D.M., Potter, H.G., Laurencin, C.T., and Warren, R.W. Isolated injuries of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Journal of Shoulder and Elbow Surgery. 1996; 5: S11

Abstract | Full Text PDF
| Google ScholarSee all References
,

Pfirrman et al23x23Mall, N.A., Chahal, J., Heard, W.M., Bach, B.R. Jr., Bush-Joseph, C.A., Romeo, A.A. et al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012 Sep; 28: 1306–1314https://doi.org/10.1016/j.arthro.2012.02.018

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Treatment based on classification systemLafosse et al18x18Kim, T.K., Rauh, P.B., and McFarland, E.G. Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases. Am. J. Sports Med. 2003 Sep; 31: 744–750https://doi.org/10.1177/03635465030310051801

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,

Fox et al15x15Godenèche, A., Nové-Josserand, L., Audebert, S., Toussaint, B., French Society for Arthroscopy (SFA), Denard, P.J. et al. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg. Sports Traumatol. Arthrosc. 2017 Jul; 25: 2114–2120https://doi.org/10.1007/s00167-016-4374-9

Crossref | Scopus (38)
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,

Garavaglia et al11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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(Laffose classification),

Piasecki et al33x33Smucny, M., Shin, E.C., Zhang, A.L., Feeley, B.T., Gajiu, T., Hall, S.L. et al. Poor Agreement on Classification and Treatment of Subscapularis Tendon Tears Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2016; 32: 246–251https://doi.org/10.1016/j.arthro.2015.08.006 (e1)

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, (Bennet classification)

Kim et al36x36Toussaint, B., Barth, J., Charousset, C., Godeneche, A., Joudet, T., Lefebvre, Y. et al. New endoscopic classification for subscapularis lesions. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S186–S192https://doi.org/10.1016/j.otsr.2012.10.003

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(Fox classification)
Classification system and outcome of surgeryRhee et al24x24Meyer, D.C., Zimmermann, S.M., Wieser, K., Bensler, S., Gerber, C., and Germann, M. Lengthening of the subscapularis tendon as a sign of partial tearing in continuity. J. Shoulder Elbow Surg. 2016 Jan; 25: 31–37https://doi.org/10.1016/j.jse.2015.06.014

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, (compared Yoo and Lafosse classification systems)
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For this consensus study, four international experts in subscapularis repair surgery participated in the structured designing of the consensus questionnaire form process.21x21Linstone HA, Turoff M. The Delphi Method: Techniques and Applications Westview Press; 1975. Available from: https://books.google.com/books/about/The_Delphi_Method.html?hl=&id=52xHAAAAMAAJ

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The primary questionnaire form was drafted after comprehensive literature review and writing the systematic review. The questionnaire form was divided into four subtopics as it related to classification systems: indications, contraindications, treatment plan, and the factors affecting outcomes in the survey.

The questionnaire form was aimed at addressing areas of current controversy within subscapularis tear classification and repair. The available supported or refuted evidence for each question in the literature was added to the questionnaire form.

The primary draft of the questionnaire form was distributed to four experts for review in open-ended format and was subsequently revised and developed based on these initial answers. The final questionnaire form consisted of 32 statements, which was distributed to over 1000 ASES members. 165 surgeons participated and chose whether they agree, disagree, or abstain for each statement. (Appendix I) The results of the survey are described in this paper in combination with the systematic review as they relate to each topic.

SYSTEMATIC REVIEW

Tear Classification by Associated Pathology

Some classifications were based not only on the evaluation of the degree of subscapularis involvement but on the presence of associated pathologic injury in the shoulder.5x5Bennett, W.F. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001 Feb; 17: 173–180

Abstract | Full Text | Full Text PDF | PubMed | Scopus (206)
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,37x37Walch, G., Nove-Josserand, L., Levigne, C., and Renaud, E. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J. Shoulder Elbow Surg. 1994 Nov; 3: 353–360https://doi.org/10.1016/S1058-2746(09)80020-7

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Supraspinatus tears were found to accompany 90% of subscapularis tears in one review.18x18Kim, T.K., Rauh, P.B., and McFarland, E.G. Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases. Am. J. Sports Med. 2003 Sep; 31: 744–750https://doi.org/10.1177/03635465030310051801

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This is likely due to the intimate association of both tendons by virtue of the anterior cable and coracohumeral ligament (CHL). The upper part of the subscapularis fibers are connected to the anterior fibers of the supraspinatus muscle by the CHL and form the rotator cuff interval.22x22Lyons, R.P. and Green, A. Subscapularis tendon tears. J. Am. Acad. Orthop. Surg. 2005 Sep; 13: 353–363https://doi.org/10.5435/00124635-200509000-00009

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The leading upper edge of the subscapularis-tendon unit is one of the important parts of the biceps pulley. The uppermost part of the subscapularis, in conjunction with the SGHL (superior glenohumeral ligament) and the CHL (coracohumeral ligament), comprises the anterior wall of the proximal bicipital sling.15x15Godenèche, A., Nové-Josserand, L., Audebert, S., Toussaint, B., French Society for Arthroscopy (SFA), Denard, P.J. et al. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg. Sports Traumatol. Arthrosc. 2017 Jul; 25: 2114–2120https://doi.org/10.1007/s00167-016-4374-9

Crossref | Scopus (38)
| Google ScholarSee all References
,36x36Toussaint, B., Barth, J., Charousset, C., Godeneche, A., Joudet, T., Lefebvre, Y. et al. New endoscopic classification for subscapularis lesions. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S186–S192https://doi.org/10.1016/j.otsr.2012.10.003

Abstract | Full Text | Full Text PDF | PubMed | Scopus (28)
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Subscapularis tears may be associated with or without the SGHL/ MCHL complex tear and may cause biceps tendon subluxation.5x5Bennett, W.F. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001 Feb; 17: 173–180

Abstract | Full Text | Full Text PDF | PubMed | Scopus (206)
| Google ScholarSee all References
,36x36Toussaint, B., Barth, J., Charousset, C., Godeneche, A., Joudet, T., Lefebvre, Y. et al. New endoscopic classification for subscapularis lesions. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S186–S192https://doi.org/10.1016/j.otsr.2012.10.003

Abstract | Full Text | Full Text PDF | PubMed | Scopus (28)
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(Figure 1) Because the outcomes of repair of the subscapularis are affected by other associated pathology in the shoulder, classification that assess these concomitant pathologies are helpful in determining goals for therapeutic interventions and outcomes.23x23Mall, N.A., Chahal, J., Heard, W.M., Bach, B.R. Jr., Bush-Joseph, C.A., Romeo, A.A. et al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012 Sep; 28: 1306–1314https://doi.org/10.1016/j.arthro.2012.02.018

Abstract | Full Text | Full Text PDF | PubMed | Scopus (61)
| Google ScholarSee all References
,36x36Toussaint, B., Barth, J., Charousset, C., Godeneche, A., Joudet, T., Lefebvre, Y. et al. New endoscopic classification for subscapularis lesions. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S186–S192https://doi.org/10.1016/j.otsr.2012.10.003

Abstract | Full Text | Full Text PDF | PubMed | Scopus (28)
| Google ScholarSee all References
,37x37Walch, G., Nove-Josserand, L., Levigne, C., and Renaud, E. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J. Shoulder Elbow Surg. 1994 Nov; 3: 353–360https://doi.org/10.1016/S1058-2746(09)80020-7

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 Opens large image

Figure 1

Medial subluxation of biceps tendon

We would like to catalog the current classification schemes as follows:

Bennett classified and described the subscapularis tendon tear by two different categories: type (isolated, double or triple) followed by mentioning the probable lesion of CHL, SGHL or LCHL.5x5Bennett, W.F. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001 Feb; 17: 173–180

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(Table 2). Clearly Bennett placed great value in the degree of violation of biceps pulley integrity with more damage correlating to higher degrees of medial biceps subluxation.

Table 2Bennett et al. Subscapularis Tear Classification
I: Number of tendons involvedII: Length and depth of the subscapularis tear
1: Isolated subscapularis (without any injury in the other tendons or CHL, SGHL, LCHL, or Bankart lesion.A: Partial length and partial thickness
2: Double tendon tears (associated with supraspinatus tear)B: Partial length and full-thickness
3: Triple tendon tears (associated with supraspinatus and infraspinatus tears)C: Complete length and full-thickness with no retraction (In non-retracted tears, the attachment of the CHL, specifically the lateral head of the CHL to the bicipital groove, remains intact.)
D: Complete length and full-thickness tear with retraction
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Similarly, Toussaint et al proposed a classification system for subscapularis tears based on the associated involvement of the bicipital sling.36x36Toussaint, B., Barth, J., Charousset, C., Godeneche, A., Joudet, T., Lefebvre, Y. et al. New endoscopic classification for subscapularis lesions. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S186–S192https://doi.org/10.1016/j.otsr.2012.10.003

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(Table 3) Toussaint et al’s classification scheme relies both on the lesion at the lesser tuberosity and on those affecting the bicipital sling. It is important to note that in their system, the potential for lesion progression remains unclear, indicating why they used the term “type” instead of “stage” or “grade”.

Table 3Toussaint et al. Subscapularis Tear Classification
Type 1: Partial subscapularis tendon separation from the lesser tuberosity and normal anterior bicipital sling wall
Type 2: Partial subscapularis tendon separation from the lesser tuberosity and partial tear in the anterior bicipital sling wall
Type 3: Complete subscapularis tendon separation from the lesser tuberosity and complete tear in the anterior bicipital sling wall with a preserved attachment of the most superficial fibers of the sling
Type 4: Complete subscapularis tendon separation from the lesser tuberosity with a free lateral edge (full-thickness tear with different amounts of retraction)
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Classification Based on Lesser Tuberosity Footprint Exposure and Tendon Detachment

Burkhart described the insertion of the subscapularis tendon on the lesser tuberosity and humerus as a comma-shaped attachment. (Figure 2a) The proximal part of the insertion on the lesser tuberosity is broad, and the distal part on the humerus is narrow. The mean height of the insertion is reported as 25.8 mm, and the width is 18.1 mm.2x2Arai, R., Sugaya, H., Mochizuki, T., Nimura, A., Moriishi, J., and Akita, K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008 Sep; 24: 997–1004https://doi.org/10.1016/j.arthro.2008.04.076

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 Opens large image

Figure 2a

Comma sign, Figure 2b. Comma Tissue

Burkhart et al suggested placing the arm in abduction and internal rotation – the so-called ‘lever push’ to best visualize the subscapularis footprint. (Figure 3) Using the 70-degree scope was recommended for better visualization. In cases with chronic retracted subscapularis tears, they proposed finding the ‘comma sign’ to distinguish the edge of the retracted tendon. The torn medial sling of the biceps extends to the superolateral border of the subscapularis tendon and forms a comma like appearing tissue at the superolateral aspect of the tendon. (Figure 2b)

 Opens large image

Figure 3

Exposed Footprint During ‘Lever Push’

The proximal two-thirds of the subscapularis insertion is attached to the lesser tuberosity, and the distal third is attached to the humerus proper. The upper third is thick and tendinous while the lower two-thirds of the footprint is chiefly musculo-ligamentous.5x5Bennett, W.F. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001 Feb; 17: 173–180

Abstract | Full Text | Full Text PDF | PubMed | Scopus (206)
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,20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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,38x38Yoo, J.C., Rhee, Y.G., Shin, S.J., Park, Y.B., McGarry, M.H., Jun, B.J. et al. Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: a cadaveric and prospective clinical observational study. Arthroscopy. 2015 Jan; 31: 19–28https://doi.org/10.1016/j.arthro.2014.08.015

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Yoo et al proposed a facet exposure and lateral band detachment classification system based on the evaluation of the subscapularis footprint exposure.38x38Yoo, J.C., Rhee, Y.G., Shin, S.J., Park, Y.B., McGarry, M.H., Jun, B.J. et al. Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: a cadaveric and prospective clinical observational study. Arthroscopy. 2015 Jan; 31: 19–28https://doi.org/10.1016/j.arthro.2014.08.015

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They proposed and described two facets for the subscapularis insertion. The first rectangular proximal facet dimension is 13.8mm by 13.5 mm, and it is one-third of the subscapularis tendon’s entire attachment. The first two facets are about 60% of the subscapularis tendon’s entire footprint. The first facet fiber attachment is closest to the supraspinatus attachment and elevates the scapular plane rather than rotating the shoulder.26x26Omi, R., Sano, H., Ohnuma, M., Kishimoto, K.N., Watanuki, S., Tashiro, M. et al. Function of the shoulder muscles during arm elevation: an assessment using positron emission tomography. J. Anat. 2010 May; 216: 643–649https://doi.org/10.1111/j.1469-7580.2010.01212.x

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In addition to the first and second facet, on the lateral edge of these facets, there is a lateral hood insertion. This long and straight insertion is usually intact in the partial thickness tears of the subscapularis tendon. The intact lateral hood edge confirms that the subscapularis tear is not full-thickness. Thus, in this classification, the footprint of the SCT should be evaluated, and subscapularis tear detachments are classified in Table 4. The authors found that the majority of cases were Type 2B and concluded that the lateral hood and its involvement are essential in differentiating and classifying the upper one-third complete and partial tears.

Table 4Yoo et al. Subscapularis Tear Classification
Type 1: Longitudinal split or fraying of the leading edge of the subscapularis tendon
Type 2A: Detachment of subscapularis tendon from less than 50% of the first facet
Type 2B: Detachment of subscapularis tendon from more than 50% of the first facet without complete disruption of the lateral hood
Type 3: Complete detachment of subscapularis tendon from the entire surface of the first facet and complete tear of the lateral band (equal to full-thickness tear of the upper third of the subscapularis tendon)
Type 4: First and second facet exposed with medial retraction of the subscapularis (equal to upper two-thirds of the subscapularis detachment)
Type 5: Complete detachment of the subscapularis (involving the lower muscular part)
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Subscapularis Tear Classification Based on Size of the Tear

Other classification systems classified the subscapularis tendon tear based principally on the size of the tear and detachment of the tendon from its insertion.

Lafosse reported a tiered classification for a subscapularis tear as depicted in Table 5.20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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Table 5Lafosse et al. Subscapularis Tear Classification
Type 1: Partial tear and erosion on the superior third of the subscapularis
Type 2: Complete detachment of the superior third of the subscapularis
Type 3: Complete detachment of the superior two-thirds of the subscapularis without involvement the inferior one-third muscular part (limited tendon retraction)
Type 4: Complete subscapularis tear from the humeral insertion (well centered humeral head and fatty infiltration involving less than or equal to grade three tear)
Type 5: Complete subscapularis tear from the humeral insertion with humeral head antero-superior subluxation and contact with the coracoid (associated with fatty infiltration)
Type A: Isolated deep layer SCT tear (for visualization it is required to elevate the subscapularis tendon by the probe)
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Similarly, Fox et al proposed a classification system based on the size of the tear.12x12Fox JA, Noerdlinger MA, Sasso LM, Romeo AA. Arthroscopic Subscapularis Repair Textbook of Arthoscopy. 2004;241–257. doi:10.1016/b978-0-7216-0013-0.50027-2

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(Table 6)

Table 6Fox et al. Subscapular Tear Classification
Type 1: Partial-thickness tear of the subscapularis
Type 2: Complete tear of the superior 25% of the subscapularis
Type 3: Complete tear of 50 % of the subscapularis
Type 4: Complete rupture of the subscapularis
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Bartl et al used the above classification in addition to grading the amount of SCT retraction.4x4Bartl, C., Scheibel, M., Magosch, P., Lichtenberg, S., and Habermeyer, P. Open repair of isolated traumatic subscapularis tendon tears. Am. J. Sports Med. 2011 Mar; 39: 490–496https://doi.org/10.1177/0363546510388166

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(Table 7).

Table 7Bartl et al. Subscapularis Tear Classification
Grade 1: Tendon edge is near the lesser tuberosity
Grade 2: Tendon edge is at the medial side of the humerus
Grade 3: Tendon edge is near the glenoid or more medial
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Edwards defined a classification based on the size of the SCT tear and used it in addition to biceps tendon pathology (normal, ruptured, subluxated, and dislocated) and incorporated the Goutallier fatty infiltration classification.9x9Edwards, T.B., Bradley Edwards, T., Walch, G., Nové-Josserand, L., Boulahia, A., Neyton, L. et al. Arthroscopic Debridement in the Treatment of Patients With Isolated Tears of the Subscapularis Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2006; 22: 941–946https://doi.org/10.1016/j.arthro.2006.05.009

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,10x10Edwards, T.B., Walch, G., Sirveaux, F., Molé, D., Nové-Josserand, L., Boulahia, A. et al. Repair of tears of the subscapularis. Surgical technique. J. Bone Joint Surg. Am. 2006 Mar; 88https://doi.org/10.2106/JBJS.E.00842 (1–10)

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,16x16Goutallier, D., Postel, J.-M., Bernageau, J., Lavau, L., and Voisin, M.-C. Fatty Muscle Degeneration in Cuff Ruptures. Pre- and postoperative evaluation by CT scan. Clinical Orthopaedics and Related Research. 1994 Jul; : 78–83

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(Table 8)

Table 8Edwards et al. Subscapularis Tear Classification
Type 1: Superior one-third subscapularis tear
Type 2: Superior two-thirds subscapularis tear
Type 3: Complete subscapularis tear
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Additionally, Pfirrmann introduced a broader classification based the size of the SCT tear.27x27Pfirrmann, C.W., Zanetti, M., Weishaupt, D., Gerber, C., and Hodler, J. Subscapularis tendon tears: detection and grading at MR arthrography. Radiology. 1999 Dec; 213: 709–714

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(Table 9)

Table 9Pfirrmann et al. Subscapularis Tear Classification
Grade 1: Tear involves less than 25% of the upper part of the subscapularis tendon dimension
Grade 2: Tear involves more than 25% of the upper part of the subscapularis dimension
Grade 3: Complete tear and detachment of the subscapularis from the lesser tuberosity
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RESULTS

One hundred and sixty-fix surveys were completed and returned of the 1161 ASES identified members, with a response rate of approximately 14%. The following will discuss the results of the survey and its treatment implications separating into two subcategories including treatment based on classification and generalizations for surgical indications and contraindications.

Treatment Based on Classification

When asked which type of classification utilized when considering subscapularis tears, the majority of participants (59.9%) chose the Lafosse Classification. However, 36% demonstrated that they don't use any formal system in their clinical practice.

Surgeons had different approaches to the treatment plan based on the classification system. The majority of participants (80.9%) agreed that the Lesser Tuberosity Footprint Exposure and Tendon Detachment is important in the treatment plan.38x38Yoo, J.C., Rhee, Y.G., Shin, S.J., Park, Y.B., McGarry, M.H., Jun, B.J. et al. Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: a cadaveric and prospective clinical observational study. Arthroscopy. 2015 Jan; 31: 19–28https://doi.org/10.1016/j.arthro.2014.08.015

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Additionally, 69.8% agreed that the fatty infiltration stage affects the treatment approach in subscapularis tear repair.11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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In the case of Type 1 Lafosse, classified as only minor fraying at the insertion, 80.9% of participants agreed that débridement surgery without repair is an appropriate plan.

Furthermore, 88.9% of participants agreed that biceps tenodesis should be done during subscapularis tendon repair in Lafosse type 1 and 2 if there is uncertainty regarding the stability of the biceps tendon, despite the biceps tendon’s normal status. Of note, the survey included biceps tenodesis rather than tenotomy in the proposed question (Question 22, Appendix I) under the assumption that this was the more common practice and the addition of tenotomy to this question would only have further increased the majority response that was obtained. There was, however, no consensus regarding whether there is a role for subscapularis release before subscapularis repair in Lafosse type 3 for prevention of axillary nerve injury, as only 46.9% of participants agreed with that approach.

Most participants (88.3%) did agree that regarding the amount of release needed for subscapularis repair, division of the adhesion between the coracoid tip and conjoint tendon and identification of the leading edge of the tendon was adequate. Additionally, 79.6% agreed that the comma tissue or connecting tissue from subscapularis to supraspinatus tendon is important for repair.

The majority of participants (65.4%) disagreed with the statement that plexus nerve release is required in subscapularis Lafosse type 4 repair to achieve shoulder external rotation. 53.7% of participants also disagreed with the statement that teres minor tendon transfer is appropriate for Lafosse type 5 subscapularis tears.

Most participants (62.3%) disagreed with the statement that for a full thickness tear, a double row of suture anchors is needed for tendon fixation. However, for a partial thickness tear, 86.4% agreed that a single row of suture anchors is adequate for subscapularis repair fixation.

When asked which type of subscapularis tear is clinically important and should be repaired during rotator cuff repair, the majority of participants selected complete upper 1/3 length tear (86.4%), complete <1/2 length tear (75.3%), and partial <1/2 length tear (51.9%). Only 38.3% of participants asserted that a partial upper 1/3 length tear should be repaired. There were some noticeable differences among surgeons depending on their repair technique, specifically open vs. arthroscopic repair. Of the participants that preferred arthroscopic repair, 55.2% thought that a partial <1/2 length tear was clinically important and should be repaired during RCR, as compared to only 42.9% of surgeons who preferred open repair. Furthermore, 94.3% of participants who preferred open repair thought that a complete upper 1/3 length tear should be repaired, as compared to 85.6% of surgeons who preferred arthroscopic repair. (Table 10)

Table 10Indications for repair based on tear size/location in surgeons that perform open vs. arthroscopic repair
Partial upper 1/3 length tearPartial <1/2 length tearComplete upper 1/3 length tearComplete <1/2 length tear
Arthroscopic (76.7%)40.8%55.2%85.6%76.0%
Open (21.5%)34.3%42.9%94.3%77.1%
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When asked about preference for surgical repair of a complete tear of the subscapularis tendon, most participants (76.5%) selected arthroscopic repair surgery as compared to 21.6% of participants selecting open repair surgery.

Lafosse et al and Fox et al proposed some treatment recommendations based on tear morphology.12x12Fox JA, Noerdlinger MA, Sasso LM, Romeo AA. Arthroscopic Subscapularis Repair Textbook of Arthoscopy. 2004;241–257. doi:10.1016/b978-0-7216-0013-0.50027-2

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,20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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In type 1 and 2, (Figure 4) Lafosse et al classification without bicipital involvement, the authors advised only repairing the subscapularis tear if this repair does not compromise the biceps stability. If there is uncertainty regarding the stability of the biceps, they advised biceps tenodesis, despite the biceps tendon’s normal status. However, Fox et al proposed only performing biceps tenodesis in association with an unstable biceps tendon injury during the subscapularis repair surgery. Lyons et al advise biceps tenodesis for all associated biceps injuries (partial thickness tear, subluxation, or dislocation).22x22Lyons, R.P. and Green, A. Subscapularis tendon tears. J. Am. Acad. Orthop. Surg. 2005 Sep; 13: 353–363https://doi.org/10.5435/00124635-200509000-00009

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Figure 4

Upper Third Subscapularis Tear

Lafosse et al further recommended that for types 3 and 4, a complete release of the subscapularis should be performed before performing the repair to compensate for retraction. In type 3, the subscapularis tendon should be released from its anterior side by exposing the posterior aspect of the coracoid process. Lafosse et al advised that at least two suture anchors be used for fixation.

In type 4 tears, Lafosse et al advised the use of wire or suture traction (the traction stitch should be inserted in the axis of the subscapularis tendon) and suggested that reduction of the tendon can be performed after sufficient release is accomplished. The release in type 4 is more difficult due to the inferior extensive adhesions and extensive involvement of adjacent tissues. The authors used three suture anchors for fixation. Release of adhesions to the brachial plexus was required to achieve painless external rotation mobility of the shoulder joint according to these investigators.20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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Fox et al proposed that for the release of the subscapularis, the medialization of the SCT edge near the juxta-articular edge of the humerus is sufficient and acceptable. He advised that the number of the suture anchors should be based on the size of the tear and that a distance of 5-8 mm between the suture anchors is acceptable.12x12Fox JA, Noerdlinger MA, Sasso LM, Romeo AA. Arthroscopic Subscapularis Repair Textbook of Arthoscopy. 2004;241–257. doi:10.1016/b978-0-7216-0013-0.50027-2

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In Lafosse type 5, as a complete repair is not possible Lafosse et al advised partial repair of the inferior part of the subscapularis coupled with teres minor tendon transfer.20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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In the presence of fatty infiltration, the chance of re-tear increases. In these cases, Lafosse et all offered some treatment recommendations: In subscapularis tears classified as Goutallier stage 0 and 1, direct reinsertion is advised. In stage 2, and young and active patients, reinsertion is also recommended. However, the re-rupture rate at this stage is 28%. In stage 2, and with a time interval between injury and repair of more than one year, reinsertion is not advised. In stages 3 and 4, tendon reinsertion is not recommended.11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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Garavaglia et al used a modification of the Lafosse classification. They introduced subtypes for the Type 1 Lafosse et al classification. For Subtype 1A, there was only minor fraying at the subscapularis insertion. In Subtype 1B, there was a partial tear at the deep posterior part of subscapularis tendon fibers at the insertion site. These authors advised only débridement for concomitant supraspinatus tear. Lafosse et al advised subscapularis repair and biceps tenodesis before supraspinatus repair in these Type I injuries. 13x13Garavaglia, G., Ufenast, H., and Taverna, E. The frequency of subscapularis tears in arthroscopic rotator cuff repairs: A retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int. J. Shoulder Surg. 2011 Oct; 5: 90–94https://doi.org/10.4103/0973-6042.91000

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,20x20Lafosse, L., Lanz, U., Saintmard, B., and Campens, C. Arthroscopic repair of subscapularis tear: Surgical technique and results Orthopaedics & Traumatology. Surgery & Research. 2010; 96: S99–S108https://doi.org/10.1016/j.otsr.2010.09.009

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Kim et al applied the Fox classification in their indications and treatment for subscapularis repair. They used one suture anchor in the treatment of Fox type 2 and, two suture anchors in type 3.17x17Kim, I.-B. and Kim, M.-W. Risk Factors for Retear After Arthroscopic Repair of Full-Thickness Rotator Cuff Tears Using the Suture Bridge Technique: Classification System. Arthroscopy. 2016 Nov; 32: 2191–2200https://doi.org/10.1016/j.arthro.2016.03.012

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Piasecki et al stated the Bennett classification was the most commonly used system. They recommended repairing the isolated partial subscapularis tear if more than 50% of tendon insertion is compromised in athletes. They did recommend débridement in tears less than 50 % in width. They did coracoplasty in athletes with prior subcoracoid impingement symptoms.28x28Piasecki DP, Nicholson GP. Tears of the Subscapularis Tendon in Athletes—Diagnosis and Repair Techniques Clinics in Sports Medicine. 2008;27(4):731–745. doi:10.1016/j.csm.2008.06.005

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Generalizations for Surgical Indications and Contraindications

The participants answered several questions regarding surgical indications and contraindications for subscapularis tear:

The vast majority of participants (96.9%) agreed that early surgery is advised for a traumatic subscapularis tear. One participant noted that surgical timing depends on many factors, including patients’ data (age, functional demand etc.), as well as tear type. Furthermore, 83.3% of participants agreed with the statement that three months of non-operative treatment failure is an indication for SCT repair when considering degenerative tears. 8% disagreed with this assertion and the remainder of the participants commented that it depends on tear size/type and/or if there is clinical insufficiency.

Although the majority of participants (56.8%) agreed that a patient with a painless SCT tear (in the presence of weakness without fatty degeneration change) is a candidate for surgery, with only 24.7% disagreeing, a good deal of participants noted that this recommendation is not definitive and it depends on patient specific factors such as age, activity level, and comorbidities.

When asked which abnormal test examination is more reliable for determining the need for SCT repair, the leading answers were belly press test (36.6%), bear hug (34.2%), lift off (19.3%), and modified lift off test (5%).

Regarding contraindications for subscapularis tear, most participants answered that fatty degeneration more than Goutallier Grade 3 on MRI of the whole length (74.1%) or of the upper and middle third (50.6%) would negatively influence the decision to operate. Additionally, the majority of participants (79.6%) disagreed with the assertion that pseudoparalysis is a contraindication for SCT repair. However, 80.9% of participants agreed that rotator cuff arthropathy is a contraindication for SCT repair.

Regarding access to long term rehabilitation and its effect on the surgical decision-making process, the majority of participants (59.9%) agreed that a patient who does not have access to quality shoulder rehabilitation is a candidate for SCT repair.

The overwhelming majority (95.7%) of participants also agreed that a patient with a chronic degenerative subscapularis tear (without fatty infiltration) associated with acute supraspinatus tear is a candidate for SCT repair.

A controversial topic that arose was the effect of age on guiding the treatment plan. When asked if age (70 years old or greater) guides the treatment plan for subscapularis tears, 45.7% of participants agreed and 47.5% disagreed. The literature review revealed that there were no clear definitive recommendations for surgery for lesions of the subscapularis. This is in part due to the variance and general lack of acceptance in classification schemes.

Edwards et al generally proposed that the indication for surgery in degenerative and traumatic cases is at least three months of non-operative treatment failure. A patient who is not interested in following the necessary rehabilitation program after surgical repair is considered for arthroscopic débridement instead of the subscapularis repair.9x9Edwards, T.B., Bradley Edwards, T., Walch, G., Nové-Josserand, L., Boulahia, A., Neyton, L. et al. Arthroscopic Debridement in the Treatment of Patients With Isolated Tears of the Subscapularis Arthroscopy. The Journal of Arthroscopic & Related Surgery. 2006; 22: 941–946https://doi.org/10.1016/j.arthro.2006.05.009

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Lyons et al advised initial nonsurgical treatment for atraumatic injury because some degenerative SCT injuries are successfully treated without surgery. However, a good many of chronic degenerative subscapularis tears are associated with a concomitant supraspinatus tear, and if the non-surgical treatment fails, then surgery is advised. In traumatic subscapularis tears, early surgery is recommended by Lyons.22x22Lyons, R.P. and Green, A. Subscapularis tendon tears. J. Am. Acad. Orthop. Surg. 2005 Sep; 13: 353–363https://doi.org/10.5435/00124635-200509000-00009

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The time interval between injury and surgery has been shown to affect the outcome of the operation.22x22Lyons, R.P. and Green, A. Subscapularis tendon tears. J. Am. Acad. Orthop. Surg. 2005 Sep; 13: 353–363https://doi.org/10.5435/00124635-200509000-00009

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Fox et al introduced broad indications and contraindications for surgery: pain, little atrophy or fatty degeneration, (Figure 5) less than Goutallier stage 3 on MRI, and positive belly press, lift-off, or modified lift-off tests. Contraindications for surgery were listed as pseudoparalysis, absence of pain, severe atrophy or fatty degeneration equal or more than Goutallier stage 3 on MRI, and rotator cuff arthropathy.12x12Fox JA, Noerdlinger MA, Sasso LM, Romeo AA. Arthroscopic Subscapularis Repair Textbook of Arthoscopy. 2004;241–257. doi:10.1016/b978-0-7216-0013-0.50027-2

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Piasecki et al recommended nonoperative treatment or pectoralis transfer or salvage procedure in the patients with retracted tear older than one year or stage 3 or more significant fatty degeneration.28x28Piasecki DP, Nicholson GP. Tears of the Subscapularis Tendon in Athletes—Diagnosis and Repair Techniques Clinics in Sports Medicine. 2008;27(4):731–745. doi:10.1016/j.csm.2008.06.005

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Figure 5

Upper Subscapularis Atrophy

DISCUSSION

Classification and Prognosis

One of the major objectives of the survey was determining the main outcome predictors of subscapularis tears. Regarding chronic SCT tear repair, the amount of retraction (79.6%) was determined to be the most important outcome predictive factor with the second most being length of tear (6.8%). Furthermore, 77.2% of participants agreed that there is a role for measuring the SC muscle retraction in outcome prediction.

The majority of participants (90.1%) agreed that the degree of fatty infiltration predicted the outcome of repair. When considering a tear 1 year post-injury, 84% of participants agreed that a complete upper 1/3 subscapularis tear without fatty infiltration and massive retraction is repairable. The majority of participants (75.9%) also agreed that a complete 1/2 subscapularis tear without fatty infiltration and massive retraction is repairable at this time interval. 76.5% of participants also agreed that the simultaneous repair of SCT and other rotator cuff tendon tears affects the outcome.

In terms of postoperative recovery, most participants (63.6%) agreed that the type of tear (partial vs. complete) affects the recovery program. Some studies reported the result of the subscapularis repair and attempted to correlate with tear classification.1x1Adams, C.R., Schoolfield, J.D., and Burkhart, S.S. The results of arthroscopic subscapularis tendon repairs. Arthroscopy. 2008 Dec; 24: 1381–1389https://doi.org/10.1016/j.arthro.2008.08.004

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,3x3Arun, G.R., Kumar, P., Patnaik, S., Selvaraj, K., Rajan, D., Singh, A. et al. Outcome of arthroscopic subscapularis tendon repair: Are the results improving with improved techniques and equipment?. A retrospective case series Indian Journal of Orthopaedics. 2016; 50: 297https://doi.org/10.4103/0019-5413.181788

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,6x6Bennett, W.F. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003 Feb; 19: 131–143https://doi.org/10.1053/jars.2003.50053

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,35x35Toussaint, B., Audebert, S., Barth, J., Charousset, C., Godeneche, A., Joudet, T. et al. Arthroscopic repair of subscapularis tears: preliminary data from a prospective multicentre study. Orthop. Traumatol. Surg. Res. 2012 Dec; 98: S193–200https://doi.org/10.1016/j.otsr.2012.10.004

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Rhee et al used two different classification systems; Lafosse et al and Yoo et al. He found neither classification helpful in predicting the outcome of treatment. In their survey, the authors found that the surgical outcome for subscapularis repair was equal for tears less than one-fourth of the entire tendon length and tears greater than one-fourth of the tendon length.29x29Rhee, Y.G., Lee, Y.S., Park, Y.B., Kim, J.Y., Han, K.J., and Yoo, J.C. The outcomes and affecting factors after arthroscopic isolated subscapularis tendon repair. Journal of Shoulder and Elbow Surgery. 2017; 26: 2143–2151https://doi.org/10.1016/j.jse.2017.05.017

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These investigators found fatty infiltration of the subscapularis muscle to occur quickly after tear,23x23Mall, N.A., Chahal, J., Heard, W.M., Bach, B.R. Jr., Bush-Joseph, C.A., Romeo, A.A. et al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012 Sep; 28: 1306–1314https://doi.org/10.1016/j.arthro.2012.02.018

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so they concluded that the duration of the interval between the injury and repair is important to the outcome.11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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However, in partial subscapularis tears, the intact portion of the subscapularis was found to prevent fatty infiltration and atrophy.32x32Shindle, M.K., Chen, C.C.T., Robertson, C., DiTullio, A.E., Paulus, M.C., Clinton, C.M. et al. Full-thickness supraspinatus tears are associated with more synovial inflammation and tissue degeneration than partial-thickness tears. Journal of Shoulder and Elbow Surgery. 2011; 20: 917–927https://doi.org/10.1016/j.jse.2011.02.015

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Kreuz et al reported the delay between the time of the injury and surgery also affects the outcome; however, they stated that improvement after surgery is less in partial tears compared to complete tears.19x19Kreuz, P.C., Remiger, A., Lahm, A., Herget, G., and Gächter, A. Comparison of total and partial traumatic tears of the subscapularis tendon. J. Bone Joint Surg. Br. 2005 Mar; 87: 348–351https://doi.org/10.1302/0301-620x.87b3.15515

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Flury et al showed that simultaneous repair of both subscapularis and supraspinatus tendons does not affect the outcome and retear rate when compared to isolated subscapularis repair.11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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Several studies also report a worse outcome of subscapularis repair surgery after a long time interval between injury and surgery.12x12Fox JA, Noerdlinger MA, Sasso LM, Romeo AA. Arthroscopic Subscapularis Repair Textbook of Arthoscopy. 2004;241–257. doi:10.1016/b978-0-7216-0013-0.50027-2

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,14x14Gerber, C., Hersche, O., and Farron, A. Isolated Rupture of the Subscapularis Tendon. Results of Operative Repair. The Journal of Bone & Joint Surgery. 1996; 78: 1015–1023

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,19x19Kreuz, P.C., Remiger, A., Lahm, A., Herget, G., and Gächter, A. Comparison of total and partial traumatic tears of the subscapularis tendon. J. Bone Joint Surg. Br. 2005 Mar; 87: 348–351https://doi.org/10.1302/0301-620x.87b3.15515

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These studies indicated that repair of a complete subscapularis tear less than six months after injury is optimal. If the interval exceeded one year, the studies displayed an increase in the re-rupture rate.11x11Flury, M.P., John, M., Goldhahn, J., Schwyzer, H.-K., and Simmen, B.R. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?. Journal of Shoulder and Elbow Surgery. 2006; 15: 659–664https://doi.org/10.1016/j.jse.2005.07.013

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Seppel et al demonstrated early surgical treatment was associated with good functional outcome.31x31Seppel, G., Plath, J.E., Völk, C., Seiberl, W., Buchmann, S., Waldt, S. et al. Long-term Results After Arthroscopic Repair of Isolated Subscapularis Tears. Am. J. Sports Med. 2017 Mar; 45: 759–766https://doi.org/10.1177/0363546516676261

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Burkhart et al believed in delayed repair of SCT tear, and they did not accept the fatty infiltration and atrophy as a contraindication for subscapularis repair. Their case series had an average interval of 1.5 years between the injury and surgery. They concluded that the muscle did not return to its full function after surgery. However, because some of the lost function of the subscapularis muscle is due to the tenodesis effect, they concluded that their patients had some overall functional improvement.7x7Burkhart, S.S. and Tehrany, A.M. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy. 2002 May; 18: 454–463https://doi.org/10.1053/jars.2002.30648

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Retraction of the muscle is one predictor of the outcome in subscapularis repair.39x39Zumstein, M.A., Jost, B., Hempel, J., Hodler, J., and Gerber, C. The clinical and structural long-term results of open repair of massive tears of the rotator cuff. J. Bone Joint Surg. Am. 2008 Nov; 90: 2423–2431https://doi.org/10.2106/JBJS.G.00677

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(Figure 6) Meyer et al showed that partial subscapularis tear causes a 32% elongation of the length of the tendinous part of the subscapularis and 10% muscle shortening before a substantial defect occurs. The authors found that a length of the subscapularis muscle less than 60 mm on preoperative MRI is a sign of a subscapularis tear. Thus, an evaluation of the length of the subscapularis is helpful in understanding the integrity of the tendon and the amount of musculotendinous retraction.24x24Meyer, D.C., Zimmermann, S.M., Wieser, K., Bensler, S., Gerber, C., and Germann, M. Lengthening of the subscapularis tendon as a sign of partial tearing in continuity. J. Shoulder Elbow Surg. 2016 Jan; 25: 31–37https://doi.org/10.1016/j.jse.2015.06.014

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Finally, Nové-Josserand reported the preoperative tear retraction was a better predictor of the outcome compared to the size of the tear.25x25Nové-Josserand, L., Saffarini, M., Hannink, G., and Carrillon, Y. Influence of pre-operative tear size and tendon retraction on repair outcomes for isolated subscapularis tears. International Orthopaedics. 2016; 40: 2559–2566https://doi.org/10.1007/s00264-016-3299-8

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 Opens large image

Figure 6

Torn and Retracted Subscapularis

CONCLUSION

Despite several efforts to generate a universally accepted classification system for subscapularis tears, no single method is widely accepted. The literature is replete with several classification schemes based on size, biceps pulley involvement, footprint exposure, retraction, and atrophy. Others attempt to place prognostic values to classification. 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. A collaborative effort would be indeed helpful in establishing an acceptable and broadly applicable classification system that would enable orthopedic surgeons to reach consensus on proper methods of recognition, prognostication, and appropriate intervention.

Supplementary data

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Institutional review board approval was not required for this systematic review.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Level of Evidence: Level IV; Review

 

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