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Subscapularis Tendon Tears Abstract Pathology of the subscapularis tendon is both infrequently identified and not commonly considered as a major source of shoulder pain and dysfunction. Subscapularis tendon pathology can present as isolated tears; partial-thickness tears; anterosuperior tears, also involving the supraspinatus tendon; complete rotator cuff avulsion; and rotator interval lesions, in which instability of the long head of the biceps tendon may dominate the clinical presentation. Although an accurate physical examination is paramount, modalities such as arthroscopy, magnetic resonance imaging, and ultrasound have advanced knowledge of the spectrum of abnormalities involving the subscapularis tendon. Nonsurgical management may be effective for most partial tears. Surgically, open repair is more frequent than use of arthroscopic techniques. Tears of the subscapularis tendon portend a different prognosis than do supraspinatus tendon tears, especially when the injury is acute and diagnosis is delayed. R otator cuff tears are a common cause of shoulder pain and dysfunction, and they become more prevalent with advancing age. Tears typically occur in the supraspinatus tendon and extend posteriorly into the infraspinatus tendon. 1 Rotator cuff tears that involve the subscapularis tendon are far less common. 2 Although isolated subscapularis tears have recently received the most attention, Gerber and colleagues 3,4 have shown that subscapularis tendon tears in association with a supraspinatus tendon tear are far more common. Some have sug- gested that the subscapularis is the “forgotten” tendon, largely ignored in the literature despite its impor- tance as a major component of the rotator cuff. 5 Given the rarity of diagnosis of subscapularis tendon tears, it is rea- sonable to assume that many of these tears are missed. In fact, subscapularis tears can present in a variety of clinical situations, including isolated subscapularis tears, partial- thickness tears, anterosuperior tears involving the supraspinatus tendon, complete rotator cuff tear or avulsion, and rotator cuff interval lesions with instability of the long head of the biceps tendon. Smith, in 1835, was likely the first to report the occurrence of subscapularis tearing; he described the findings of seven postmortem cases of rotator cuff tearing and found ev- idence of subscapularis tearing in all of them. 6 In an autopsy series, Cod- man 7 reported a 3.5% incidence of subscapulis tendon tears, whereas DePalma 8 found a 20.8% incidence of partial subscapularis tears in 96 cadaver shoulders. However, in a study of 18 patients with fresh anterior dislocations at surgery, DePalma et al 9 reported that 3 of the patients had subscapularis tendon avulsions Robert P. Lyons, MD, and Andrew Green, MD Dr. Lyons is Shoulder and Elbow Spe- cialist, OrthoCarolina Orthopaedics and Sports Medicine, Presbyterian Ortho- paedic Hospital, Charlotte, NC. Dr. Green is Associate Professor of Or- thopaedic Surgery, Rhode Island Hospi- tal, Brown University School of Medi- cine, Providence, RI. Dr. Lyons or the department with which he is affiliated has received nonincome support (such as equipment or ser- vices), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Stryker. Nei- ther Dr. Green nor the department with which he is affiliated has received any- thing of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Reprint requests: Dr. Lyons, OrthoCaro- lina, 1915 Randolph Road, Charlotte NC 28207-1101. J Am Acad Orthop Surg 2005;13:353- 363 Copyright 2005 by the American Academy of Orthopaedic Surgeons. Volume 13, Number 5, September 2005 353 and that, in 12, the subscapularis was stretched over the humeral head. The authors asserted that the latter finding was a major factor in the development of recurrent anteri- or glenohumeral instability. More recent studies have evalu- ated the presence of subscapularis tendon tears in association with tears of the superior and posterior rotator cuff. Frankle and Cofield 10 found that subscapularis tears occurred in 8% of patients with rotator cuff tear. A magnetic resonance imaging (MRI) study of 2,167 patients with rotator cuff tears found that in 2%, the subscapularis tendon was involved. 11 Twenty-seven percent of the subscapularis tears were partial-thickness and 73% were full-thickness tears. Isolated subscapularis tears, as described by Gerber and colleagues, 3,4 appear to be much less common. Anatomy The subscapularis muscle is the larg- est and most powerful rotator cuff muscle. It arises from the anterior surface of the scapula. The upper two thirds of the subscapularis inserts along the lesser tuberosity; the lower one third inserts along the humeral metaphysis (Fig. 1).The subscapularis has between four and six tendon slips that arise from deep within the muscle. 12 The slips con- verge superiorly and laterally to form a stout main tendon that lies within the upper third of the muscle and inserts along the superior aspect of the lesser tuberosity. These bands serve to increase the surface area to which the muscle fibers attach and to concentrate the vector of the muscle pull. 13 The upper fibers of the subscapularis tendon interdigitate with the anterior fibers of the supraspinatus tendon to contribute to the structure of the rotator cuff interval as well as to the transverse humeral ligament. The coracohumeral ligament and the superior glenohumeral ligament contribute to the rotator cuff interval, 12 which can be divided into the lateral and medial aspects. 14 The lateral aspect is that part lateral to the articular cartilage-bone transition of the humeral head. The lateral aspect is composed of the following four layers (superficial to deep): (1) the superficial fibers of the coracohumeral ligament, (2) the fibers of the subscapularis and supraspinatus tendons, (3) the deep fibers of the coracohumeral ligament, and (4) the superior glenohumeral ligament and joint capsule. The medial aspect in- cludes two layers: (1) the coracohumeral ligament and (2) the superi- or glenohumeral ligament and joint capsule. The common insertion of the coracohumeral and superior glenohumeral ligaments onto the lesser tuberosity forms the “reflection pulley,” which is a ligamentous sling that stabilizes the long head of the biceps before it enters into the inter- tubercular groove. 15 Tears of the upper aspect of the subscapularis tendon may be associated with subluxation or dislocation of the long head of the biceps. In addition, a tear of the supraspinatus contribution to the rotator cuff interval may lead to loss of the normal tension of the reflection pulley and result in subluxation or dislocation of the long head of the biceps. The subscapularis muscle is in- nervated by the upper and lower subscapular nerves. 16 Occasionally there is also a middle subscapular Figure 1 The subscapularis insertion on the lesser tuberosity of the humerus consists of a tendinous upper two thirds (straight arrow) and a muscular lower one third (curved arrow). (Adapted with permission from Walch G, Nove-Josserand L, Levigne C, Renaud E: Tears of the supraspinatus tendon associated with ″hidden″ lesions of the rotator interval. J Shoulder Elbow Surg 1994; 3:353.) Subscapularis Tendon Tears 354 Journal of the American Academy of Orthopaedic Surgeons nerve that is most closely related to the upper nerve. The upper subscapular nerve consistently originates from the posterior spinal cord (C5-C6) and usually innervates the bulk of the muscle. More variation exists in the origin of the lower subscapular nerve (C5-C7). An ana- tomic study of 40 cadavers found that in 60%, the lower subscapular nerve derived as an independent branch of the posterior cord. 17 In 23%, the lower subscapular nerve arose near the origin of the axillary nerve; in 12%, from the thoracodorsal nerve; and in 5% of cases, as a trunk from the posterior cord, along with the axillary and thoracodorsal nerves. The lower subscapular nerve always supplies both the axillary portion of the subscapularis muscle and tendon and the teres major, indi- cating a common embryologic origin of the two muscles. In many instances, the axillary nerve gives off one or two small branches, which supply the axillary portion of the subscapularis muscle and articular capsule of the glenohumeral joint before passing posteriorly through the quadrangular space. 16 In a few patients, the branches have origins in both the axillary nerve and lower subscapular nerve. The axillary nerve supplies an articular filament that enters the shoulder joint below the subscapularis muscle. Intramuscularly, that branch also distributes to the axillary portion of the subscapularis muscle. The superior subscapularis recess, or bursa, is an evagination of the glenohumeral joint that extends superiorly and anteriorly over the subscapularis muscle, as might a saddlebag. 18 This bursa does not communicate with the subacromial bursa. The subcoracoid bursa is present below the coracoid process, between the subscapularis tendon and coracobrachialis and the short head of the biceps tendon. Although the subcoracoid bursa does not communicate with the glenohumeral joint, it can communicate with the subacromial bursa. The subcoracoid bursa extends further caudally than the superior subscapularis recess. Septations can occur in the subcoracoid bursa, and a septation typically separates the subcoracoid bursa from the superior subscapularis recess. Function The principle function of the subscapularis tendon is internal rotation of the humerus. Muscles that act syn- ergistically with the subscapularis tendon in performing this function include the teres major, pectoralis major and latissimus dorsi. Depend- ing on the position of the arm, the subscapularis tendon also has a role in flexion, extension, adduction and abduction of the shoulder . 16 In a force couple with the supraspinatus and infraspinatus tendons, the subscapularis opposes the action of the deltoid by pulling the humeral head inferiorly during humeral abduction and elevation. 19 The subscapularis muscle and tendon also contribute to glenohumeral stability 19 as muscle contraction causes tensioning of the tendon and anterior capsular structures. There is also a stabilizing/buttressing effect as a result of the bulk of the muscle. With increasing abduction, the subscapularis contribution to stability decreases. Complete rupture or avulsion of the subscapularis tendon is more commonly associated with shoulder pain and weakness than with anterior glenohumeral instability because the anterior inferior capsular ligaments usually remain intact. Mechanism of Injury Tears of the subscapularis tendon are predominantly the result of a degenerative process, but less commonly, traumatic injury can result in acute subscapularis tearing. Acute traumatic injuries occur in a younger age group than degenerative rotator cuff tears. 1 Despite the relative rarity of traumatic acute tears of the subscapularis compared with those of the supraspinatus and infraspinatus tendons, it is important to remember traumatic acute tears in the context of shoulder injury because of the implications for management. The most common mechanisms of injury are hyperextension and external rotation of the shoulder. 1 Ger- ber and Krushell 3 reported on a group of 16 patients who sustained isolated complete subscapularis tears as the result of forced external rotation with the arm at the side. However, the greatest force can be applied to the subscapularis tendon when an external rotation and abduction force is applied with the arm maximally rotated and abducted 60°. 20 Neviaser and Neviaser 21 reported the association of subscapularis tearing and anterior glenohumeral dislocation. Others have documented the occurrence of partial and complete subscapularis tendon tears in association with anteri- or dislocation. 9,22 Anterior superior impingement has been described as a mechanism by which the undersurface of the subscapularis tendon and rotator cuff interval contact the anterior superior glenoid rim. 23 This impingement can occur in positions of flexion, internal rotation, and adduction. In the Neer impingement position, the supraspinatus and subscapularis tendons contact; in the Hawkins impingement position, the contact primarily involves the subscapularis tendon. 24 Coracoid impingement also has been implicated as a cause of subscapularis tendon tears. Forward elevation, internal rotation and cross- body adduction presumably cause impingement of the subscapularis tendon between the lesser tuberosity and the coracoid process. 25,26 Several studies have described shoulder lesions associated with subscapularis tendon tears. 11 In one study of 2,167 rotator cuff tears, bi- Robert P. Lyons, MD, and Andrew Green, MD Volume 13, Number 5, September 2005 355 ceps tendon disorders were identified in 25 of 45 patients with subscapularis tears. Twenty-two of these patients had medial dislocation of the biceps tendon. Tung et al 18 reported a high correlation between subscapularis tears and medial subluxation of the biceps, biceps tendinopathy, tear of the superior glenoid labrum, and fluid within either or both the superior subscapularis recess or subcoracoid bursa. Classification In general, rotator cuff tears are classified according to the size of the tear and the number of tendons involved. Other classification schemes specif- ically consider subscapularis pathology, such as the following classification devised by Pfirrmann et al. 27 Grade 1 tears involve less than one quarter of the cephalocaudal dimension of the subscapularis tendon. Grade 2 tears involve more than one quarter of the tendon. Grade 3 tears are complete detachment of the subscapularis tendon from the lesser tuberosity. Nerot et al 28 and Walch et al 29 pro- posed classifications for subscapularis tendon tears that also account for lesions of the rotator cuff interval. First, subscapularis tendon tears are either isolated or associated with other pathology. Second, the tears are classified according to the extent of tearing. 28,29 Subscapularis tendon tears are described as partial thickness/partial length, full thickness/partial length, full thickness/complete length with no retraction, and full thickness/ complete length with retraction. In nonretracted tears, the lateral head of the coracohumeral ligament re- mains attached to the lateral side of the bicipital groove. Involvement of the superior glenohumeral and coracohumeral ligaments is recorded, as well. 30 Clinical Evaluation The clinical presentation varies de- pending on the mechanism of injury and especially whether the injury is acute traumatic or chronic. The primary symptom usually is shoulder pain, which often is located more anteriorly than that experienced with most rotator cuff tears. The pain also may be related to associated pathology involving the biceps tendon. Gerber and Krushell 3 noted that patients with subscapularis tendon tears report pain with the arm both below and above shoulder level, anterior shoulder pain, pain at night, and weakness. Physical Examination Findings for patients with subscapularis injuries or pathology are often distinctly different from findings for patients with involvement of the superior and posterior rotator cuff. Anterior shoulder tenderness is more common than with supraspinatus tendon tears. Patients with complete subscapularis tendon tears often have increased passive external rotation compared with the unaffected shoulder 3 (Fig. 2). There is usually considerable weakness of internal rotation. Despite this weakness, several muscles, including the pectoralis major, latissimus dorsi, and teres major , contribute to shoulder internal rotation and can compensate for loss of the subscapularis. Subscapularis weakness can be demonstrated with a variety of examination maneuvers. The lift-off test best isolates the subscapularis muscle as the only internal rotator of the shoulder in maximum exten- Figure 2 A, Uninjured left shoulder shows normal external rotation. B, Right shoulder with complete subscapularis tendon tear reveals increased external rotation. Figure 3 Subscapularis Tendon Tears 356 Journal of the American Academy of Orthopaedic Surgeons sion and internal rotation. 3 The patient places a hand behind his or her back at the lower lumbar level and lifts it away from the back (Fig. 3). The test is positive when the patient cannot lift or hold his or her hand away from the back. The lift-off test is accurate only when the patient has a full range of passive internal rotation and when active internal rotation is not limited by pain. The belly press, or Napoleon sign, refers to the position in which Napo- leon Bonaparte posed for portraits 31 (Fig. 4). In this test, the patient presses a palm against his or her belly with the wrist in a neutral position and the elbow anterior to the thorax. In a positive test, the patient will volar flex the wrist, and the elbow will fall posteriorly as the patient harnesses the posterior deltoid to compensate for lack of the subscapularis. Burkhart and Tehrany 31 found that eight of nine patients with a positive Napoleon test had complete tears of the subscapularis tendon. All seven patients with a negative Napo- leon test had subscapularis tears of only the upper half of the tendon. Associated biceps pathology sometimes can be demonstrated. Bennett 30 described a test for subluxation of the long head of the biceps. The patient’s arm is brought to 90° abduction with the arm in full external rotation. From this position, the arm is passively brought to full cross- body adduction and internal rotation in an effort t o bring the biceps tendon from one extreme to the other within the bicipital groove. No validation study on the accuracy of this test has been published to date. Other tests commonly used to diagnose superior labral lesions include the active com- pression, anterior slide, and compres- sion rotation tests. 32 However, the overall accuracy of these tests ranges between 54% and 77%. Radiographic Evaluation Anteroposterior, axillary lateral, and outlet view radiographs should be obtained but are generally normal in patients with subscapularis tendon rupture. However, in patients with chronic pathology and muscle tearing, there may be static anterior subluxation of the humeral head visible on the axillary lateral radiograph. 33 Elevation of the humeral head relative to the glenoid on a true anteroposterior radiograph and narrowing of the acromial humeral space are also signs of chronic massive rotator cuff tearing that may include the subscapularis tendon. In addition, osteo- phytes or hyper trophic changes of the bicipital groove have been associated with biceps tendon pathology. 34 Ultrasound, computed tomography arthrography, MRI, and magnetic resonance arthrography all can be used to confirm the presence of subscapularis tendon tearing. Walch et al 35 found that contrast extravasa- tion from the glenohumeral joint onto the lesser tuberosity on computed tomography arthrography was highly associated with isolated subscapularis tendon tearing. Severe fatty degeneration on preoperative MRI correlates with poor intraoperative tendon quality and is a poor prognos- tic sign for the ability to repair subscapularis tears. 6 Tears of the subscapularis tendon are characterized on MRI as areas of disorganized tendon morphology and of abnormally high signal intensity on T2-weighted images. 27 The chronicity of the involvement can be de- termined by assessing the subscapularis muscle quality on sagittal oblique images that include the scapula medial to the glenoid. Although Figure 3 A, Right shoulder. Negative lift-off test. B, Left shoulder. Positive lift-off test. Figure 4 A, Right arm. Negative belly press test. B, Left arm. Positive belly press test. Robert P. Lyons, MD, and Andrew Green, MD Volume 13, Number 5, September 2005 357 Pfirrmann et al 27 reported that magnetic resonance arthrography was 91% sensitive and 86% specific for subscapularis muscle-tendon tears; subscapularis tendon tears are often missed on interpretation of MRI. Tung et al 18 found that prospective interpretation of preoperative MRI by radiologists noted subscapularis tears in only 31% of patients (5/16) in whom subscapularis tearing was identified at surgery. Such oversight can be the result of both inadequate imaging that fails to include T2- weighted axial images and inexperi- ence of the reader. The pulley sign is the extra- articular collection of contrast material just anterior to the superior border of the subscapularis tendon on axial images. 35 The presence of the pulley sign suggests injury to the reflection pulley, the common insertion of the coracohumeral and superior glenohumeral ligaments at the lesser tuberosity that stabilizes the long head of the biceps (Fig. 5). Le- sions of the superior border of the subscapularis tendon without biceps tendon subluxation and without pulley lesions are more difficult to iden- tify on imaging studies. Ultrasound is noninvasive, pro- vides bilateral information, and is less expensive than MRI, open surgery, and/or arthroscopy. Farin and Jaroma 36 compared data using ultrasound with data using open surgery and arthroscopy; they found ultrasound to be 89% sensitive and 93% specific for the detection of rotator cuff pathology. The sensitivity of ultrasound was correlated to the size of the cuff tear; 78% of partial- thickness tears, 82% of small tears, 95% of large tears, and 100% of massive tears were detected. Also, ultrasound may depict interstitial lesions within the substance of the cuff that might be incorrectly interpreted as normal at arthroscopy. 36 Teefey et al 37 compared the accuracy of ultrasound with that of arthroscopy in detecting rotator cuff lesions. Ultrasound correctly identified six of seven tears of the subscapularis tendon and was found to be 100% sensitive and 85% specific in detecting all rotator cuff lesions. These results compare favorably with those of MRI. However, ultrasound may not be able to differenti- ate extensive partial-thickness tears from full-thickness tears. Management Optimal management of subscapularis tendon tears depends first on de- riving an accurate diagnosis. Atrau- matic disorders often can be treated nonsurgically with activity modifica- tion, anti-inflammatory medications, and physical therapy. It i s likely that some degenerative subscapularis tendon tears are successfully treated without ever being diagnosed. Most chronic degenerative subscapularis tendon tears occur in association with supraspinatus tendon tearing and can be treated surgically when nonsurgical management fails. Early surgical treatment is considered es- sential for acute traumatic tears because prompt repair is associated with better outcome than delayed in- tervention. 38 Primary repair of old or remote traumatic tears is often im- possible and can require tendon and muscle transfer for reconstruction. Figure 5 A, Axial T1-weighted spin-echo magnetic resonance arthrographic image demonstrates contrast material interposed between the undersurface of the distal subscapularis tendon and the lesser tuberosity, ie, the pulley sign (straight black arrow). Note also the dislocated long head of the biceps tendon interposed between the subscapularis tendon and the lesser tuberosity (curved arrow). The straight white arrow indicates the subscapularis tendon. B, Sagittal oblique spin-echo T1-weighted magnetic resonance arthrographic image demonstrates contrast material extending between the undersurface of the upper margin of the subscapularis and the lesser tuberosity of the humerus. Note also the irregular appearance of the partially torn fibers of the subscapularis (arrow). (Courtesy of Antoni Parellada, MD, Philadelphia, PA.) Subscapularis Tendon Tears 358 Journal of the American Academy of Orthopaedic Surgeons Arthroscopic Diagnosis and Management Arthroscopy is an effective means of diagnosing unsuspected subscapularis tendon tears, particularly because most partial or incomplete tears involve the articular side of the tendon. The subscapularis tendon insertion is visualized with the arthro- scope in the posterior portal and the shoulder elevated >45° and internally rotated. 39 This position relaxes the subscapularis muscle tendon unit and facilitates visualization of the ex- posed lesser tuberosity. The stability of the biceps tendon and integrity of the coracohumeral and superior glenohumeral ligaments also can be as- sessed. A p robe placed through an anterior por tal is used to pull down on the biceps tendon in an attempt to subluxate or dislocate it. A large portion of the subscapularis tendon visible by arthroscopy is veiled by the middle and inferior glenohumeral ligaments. Pearsall et al 40 and Wright et al 41 found that the intra-articular portion of the subscapularis constituted approximately 25% of the entire cephalocaudal dimension of the subscapularis tendon. The fact that the arthroscopi- cally visible region of the subscapularis is confined to a trapezoidal area at the superior and superolateral border of the subscapularis tendon may compromise the sensitivity of arthroscopy to diagnose tears of the subscapularis. Burkhart and Tehrany 31 were the first to report on arthroscopic repair of the subscapularis tendon and were able to demonstrate reversal of prox- imal humeral migration in 8 of 10 patients. Larger tears require capsular release and tendon mobilization to the insertion area on the lesser tuberosity. Partial-thickness tears that involve the deeper portion of the upper subscapularis can be repaired from within the glenohumeral joint because of the extension of the superior subscapularis recess over the superior aspect of the subscapularis tendon (Fig. 6). Open Surgical Management Anterior deltopectoral and superi- or deltoid-splitting approaches have been reported for open surgical repair of subscapularis tendon tears. 38 The specific surgical approach is dic- tated by the size and extent of the tear, its chronicity, and the complex- ity and difficulty of the procedure. Figure 6 A, Left shoulder partial subscapularis tendon tear seen from a standard arthroscopic posterior glenohumeral portal. B, Left shoulder subscapularis tendon repair with suture anchor viewed from a posterior glenohumeral portal. A cannula is seen in the anterior portal. Robert P. Lyons, MD, and Andrew Green, MD Volume 13, Number 5, September 2005 359 Acute isolated subscapularis tendon tears are best repaired through a deltopectoral approach, which leaves the deltoid muscle intact. This approach permits direct access to the retracted subscapularis tendon and facilitates mobilization. Dissection inferior to the tendon and muscle must be performed carefully to avoid the axillary nerve. Similarly, dissection medially under the conjoined tendon can be performed while pro- tecting the musculocutaneous nerve and brachial plexus. This is particularly important in chronic tears. Yung et al 42 described a “safe zone” for a 360° circumferential release of the subscapularis tendon. They recommended identification of the axillary nerve as well as careful observation for the lower subscapular nerve on the anteroinferior border of the subscapularis muscle. Com- plete release of the subscapularis muscle-tendon unit requires freeing (1) its superior margin from the coracoid, (2) the posterior surface from the anterior capsule and scapular neck, (3) the inferior border from the axillary nerve and circumflex vessels, and (4) the anterior surface from the conjoined tendon. The upper two thirds, or tendinous portion, of the subscapularis can be mobilized sep- arately by performing a transverse release from the lower one third, or muscular portion. Dissection on the anterior surface of the subscapularis should be limited to that area under the conjoined tendon or within a margin of approximately 1.5 cm medial to the glenoid rim. The subscapular nerves are brought into the surgical field with external humeral rotation or when traction is applied to a detached subscapularis tendon. When the superior and posterior components of the cuff tear are extensive, a combined superior deltoid- splitting and anterior deltopectoral surgical approach may be required 38 (Fig. 7). A superior deltoid-splitting approach can be used if the subscapularis tear is not too extensive. Smaller supraspinatus tendon tears in association with subscapularis tendon tears usually can be repaired through the deltopectoral approach. However, when acromioplasty is required, it may be better to attempt the repair through a superior deltoid- splitting approach. Alternatively, an arthroscopic acromioplasty may be performed, followed by an open deltopectoral approach to repair the anterosuperior tear. When the supraspinatus component of the tear is larger or extends to the infraspinatus, a combined deltopectoral and superior deltoid-splitting approach may be required. Warner et al 38 used a deltopectoral approach initially because they felt that the subscapularis tear was the more crucial part of the combined anterosuperior lesions. How- ever, in 15 of 19 patients, a superior approach was required to repair the supraspinatus and infraspinatus tendon tears. The associated lesions of the tendon of the long head of the biceps (subluxation, dislocation, and partial- thickness tears) can be addressed during the open procedure by relocation with reconstruction of the transverse humeral ligament, tenodesis, or biceps tenotomy. Although transverse ligament reconstruction was initially advocated, tenodesis is preferable. 43 Partial-thickness tears also should be treated with tenodesis. Figure 7 Combined anterior deltopectoral and superior deltoid-splitting approaches in a left shoulder. (Adapted with permission from Warner JJ, Higgins L, Parsons IM IV, Dowdy P: Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg 2001;10:41.) Subscapularis Tendon Tears 360 Journal of the American Academy of Orthopaedic Surgeons Results In contrast with the many published results of posterosuperior cuff repair, few studies report the results of surgical management of subscapularis tendon tears. The reported outcomes are variable, with those of acute repair superior to those of late repair. At an average 2-year follow-up, Deutsch et al 1 reported good results for the repair of 14 isolated subscapularis tears in 13 patients. With a 43-month follow-up, Gerber and Krushell 3 reported good or excellent results in 13 of 16 patients with acute traumatic subscapularis tears; the Constant scores averaged 82% of those of age-matched controls. 44 Warner et al 38 reported on 19 patients with subscapularis tendon tears in combination with supraspinatus and infraspinatus tendon tears. This group represented only 4% of those who underwent rotator cuff surgery over a 6-year peri- od. Nine of the patients had had pri- or unsuccessful surgery. The mean Constant score improved from 38% preoperatively to 69% of normal postoperatively. Patients treated <6 months after onset of symptoms had a mean score of 99% of normal, whereas those treated 6 to 12 months after onset had a mean score of 68%. Patients treated >1 year after the onset of symptoms had a mean score of 49%. Warner et al 38 also found that severe fatty degeneration on preoperative MRI correlated with poor tendon quality during surgery. Further, these patients failed to achieve 90° of forward elevation postoperatively. Physical findings consistent with subscapularis tendon insufficiency persisted in 14 of the 19 patients. The authors con- cluded that delay in the diagnosis of anterosuperior cuff lesions carried a poor prognosis because of the result- ant atrophy and degeneration of the muscle belly and tendon. Frankle and Cofield 10 reported on 24 anterosuperior rotator cuff tears in 301 cuff repairs. The average post- operative forward elevation was 134°, and 25% of patients continued to have significant weakness and pain. Results of surgical management appeared to depend on the chronicity of the subscapularis tear and on the extent of associated rotator cuff tearing. A multicenter study of 56 patients also demonstrated that the prognosis for anterosuperior cuff tears is inferior to the prognosis for both isolated subscapularis tears and posterosuperior cuff tears. Postoper- ative subscapularis tendon deficiency was present in 53% of the patients, whereas deficiency of the supraspinatus and infraspinatus was present in 58%. 45 There are fewer reports on results of arthroscopic repair of subscapularis tendon tears. Burkhart and Tehrany 31 reported the preliminary results of 25 arthroscopic subscapularis repairs at an average follow-up of 10.7 months. The average UCLA shoulder rating score improved from 10.7 preoperatively to 30.5 postoperatively. Good and excellent results were achieved in 92% of the patients. A recent study of the arthroscopic repair of isolated subscapularis tendon tears confirms that the technique is feasible and that the outcomes remain stable over time (2- to 4-year follow-up). 46 The preoperative findings of a positive belly press, lift-off test, and test for biceps inflammation were reliably eliminated. Another study with a 2- to 4-year follow-up demonstrated that anterosuperior (supraspinatus/subscapularis) cuff tears also can be reliably treated ar- throscopically. 47 Late Reconstruction Some chronic subscapularis tendon tears may not be repairable. Trau- matic complete subscapularis tears can retract far medially and be difficult to mobilize for repair. In addition, the muscle tissue is usually ex- ceedingly atrophic and, even when repaired, would not function proper- ly. When patients present late, reconstruction with muscle or tendon transfers may be the only option to treat pain, weakness, and dysfunction related to chronic subscapularis deficiency. 48 Pectoralis major and minor transfers have been described, using a variety of techniques, including transfers both superficial and deep to the coracoid process. Summary Subscapularis tendon tears are much less common than other rotator cuff tears, so the extent of the reported literature on this subject is limited. This may contribute to the fact that subscapularis tears are often misdi- agnosed and treatment delayed. Some chronic and degenerative tears can be treated nonsurgically. Early surgical management is indicated for acute traumatic injuries. Late primary repair is possible for some chronic tears but may require reconstruction. Associated lesions of the posterosuperior rotator cuff, rotator interval, and biceps can be a cause of pain and dysfunction and require concomitant treatment. 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