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. 2022 Apr 12;28:101867. doi: 10.1016/j.jcot.2022.101867

Current concepts review in the management of subscapularis tears

Girinivasan Chellamuthu 1,∗, Shyam Sundar 1, David V Rajan 1
PMCID: PMC9043658  PMID: 35494488

Abstract

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as “forgotten or hidden lesions” are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.

1. Introduction

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other Rotator Cuff Tear (RCT) might result from a traumatic event or more commonly from intrinsic degeneration. Smith, one of the first to record RCT, in his classic description of 7 shoulders, noted 2 isolated SSc tears and 3 combined SSc and Supraspinatus (SSp) tears.1 However, literature published in the following years noted only 3.5 to 8% involvement of SSc in RCTs.2,3 Since tears of the SSc were mostly partial and articular-sided, the earlier open procedures did not identify the tears resulting in lesser documentation of such tears.4

With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as “forgotten or hidden lesions” are now being increasingly recognized.5,6 Isolated SSc tears are relatively rare.7 They occur in combinations. The common association is the SSp tear – described collectively as the anterosuperior cuff tears by Warner et al.8

The repair of SSc was first described by Hauser in 1954.9 Arthroscopic repair was first published by Burkhart.10 Because of the vital structures nearby, retraction of torn tendon, and the limited working space, the SSc repair is quite challenging. The concepts in SSc biomechanics and repair are evolving with an increased understanding of its need in the mobility and stability of the glenohumeral joint. This article gives a review of anatomy, physical examination, imaging, classification, and operative management of the SSc tears with updates on the latest developments in each of these sections.

2. Clinical anatomy

The SSc is the largest of the scapular muscles. The origin is from the subscapular fossa of scapula. The tendon gets inserted into the Lesser Tuberosity (LT) of the humerus. Upper and lower subscapular nerves from the posterior cord of the brachial plexus supply the muscle. Accessory upper subscapular nerves have also been described to innervate SSc.11 The subscapular artery from the third part of the axillary artery provides the main blood supply to SSc. An accessory SSc muscle though rare has been recognized.

SSc has been traditionally described to have 3 parts. Zielinska et al. investigated the number of bellies of the SSc tendon. They vary from 1 to 9. They classified the SSc into 9 types depending on the number of bellies present – from type 1 having a single belly to type 9 with 9 bellies. Type 3 was the most common type followed by type 4 and type 5. The clinical usefulness of this classification and its correlation with shoulder stability is yet to be analyzed.

2.1. Foot-print anatomy

Various authors have studied the foot-print anatomy of the SSc tendon.12, 13, 14, 15, 16 It is frequently described to have comma-shaped insertion on LT occupying the superior and the anteromedial part of LT.12,13,17 A 3D analysis by Yoo et al.16 described the insertion of SSc by 4 facets with the first two facets contributing to 60% of insertion. The first facet was the largest one with anteroposterior and mediolateral dimensions as 13.5 and 13.8 mm respectively. The mediolateral dimension decreased from superior to inferior. The angle of insertion of the tendon in four facets also varied with an angle like that of SSp in the first facet and an angle almost parallel to the humerus shaft axis in other facets.

2.2. Relationship to the biceps tendon and pulley structures

The SSc (SSc) at its insertion forms an important part of the biceps pulley. The SSc contributes to the fasciculus obliquus forming the roof of the pulley.18,19 It contributes to the floor as it interdigitates with the anterior part of Superior Glenohumeral Ligament (SGHL) insertion. Thus, any instability of the Long Head of the Biceps (LHBT) would indicate a tear in SSc. Also histologically transverse humeral ligament has been found to be an extension of SSc.20, 21, 22

2.3. Comma sign

When there is a tear of the anterosuperior portion of SSc this gets retracted medially exposing the attachment of SGHL and CHL. These are visible as “comma” shaped structures with typical bent configurations arthroscopically. This is called the comma sign.23,24 This can be used to identify the superolateral corner of SSc. There have been research works on the exact anatomy and composition of comma tissue.21,24,25 Arai et al. studied the comma tissue in cadavers to analyze the histological and anatomical composition of the tissue contributing to the comma sign. The rotator interval tissue thickens and laterally connects the articular part of SSp and the bursal part of SSc. This tissue is mainly composed of the capsule. Antero-inferiorly this tissue covers the bicipital groove and fuses with SGHL and coracohumeral ligament at the anterosuperior part of SSc insertion. This relatively less elastic and thickened tissue forms the fiber bundle of SSc. They proposed that after SSc tear the resulting varied degradation of this fiber bundle makes it more elastic. This contributes to its intactness even in cuff tears.25 It is proposed this thickened rotator interval structure forming the comma sign is the anterior end of the rotator cable. An MRI-based analysis26 confirms the findings of Arai et al. Tissue of the comma sign noted by Arai et al. corresponds to fasciculus obliquus previously described. This has been suggested to be the anterior continuity of the rotator cable(Fig. 1a).25,26

Fig. 1.

Fig. 1

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a) Line diagram of Subscapularis tear with comma sign showing fiber bundle of comma tissue as a continuation of rotator cable and subluxated long head of the biceps. b-d) three proton density-weighted axial images with fat saturation. The comma tissue (dot) runs from the rotator cable (RC) (arrows in b) to the deeper portion of SSc. The long head of the biceps tendon (LHB) (∗) is dislocated, anterior to the comma tissue. (SST, supraspinatus; IST, infraspinatus: CHL, coracohumeral ligament; CGL, coracoglenoid ligament; SGHL, superior glenohumeral ligament). Reprinted from J Shoulder Elbow Surg. 2021 May; 305:1107–16. – “Zappia M, Ascione F, Romano AM, Di Pietto F, Nastrucci G, Collina A et al. Comma sign of subscapularis tear: diagnostic performance and magnetic resonance imaging appearance” with permission from Elsevier.

2.4. Biomechanics

SSc represents 53% of the total rotator cuff muscle mass and thus has the largest force-generating capacity as well. It acts in synergy with Pectoralis Major (PM), Teres Major, and Latissimus Dorsi (LD) in medially rotating shoulder. Depending upon the position of the arm it can also adduct and extend the arm. It provides anterior stability to shoulder.27 The release of the anterior capsule and SSc resulted in anterior translation of shoulder, particularly in the mid-range of abduction.28 This is particularly significant in throwing athletes where though the muscle is not active, the tendon is found to provide anterior stability in throwing motions29

2.5. Pathophysiology of tears

Traumatic tears of SSc are rare. They are seen in young patients with forced extension or forced lateral rotation of the abducted arm.30 Non-traumatic tears are common. Lo and Burkhart suggested subcoracoid stenosis and impingement as important causes for SSc tears. They attributed coracoid to cause roller-wringer effect on SSc leading to tensile undersurface fiber failure and SSc tear.31 In patients with SSc tears, the coracohumeral interval (CHI) is significantly decreased.32,33 An increased version has been associated with anterior cuff tears.34 The literature however is inconclusive on the causative role of these factors.32,34, 35, 36 In patients with SSc tears, anterior translation of humeral head occurs, and this negatively correlates with the CHI. Thus the reduced CHI can be because of an SSc tear rather than being a cause of the tear.37

3. Presentation

SSc tears often present only with anterior shoulder pain. Rarely classical history of shoulder trauma can be found. Internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine clinical examination. The MRI findings are typically seen only in about 31% of cases.38

3.1. Clinical tests

3.1.1. Lift-off test (LOT)

LOT was reported by Gerber et al., in 1991.30,39 The patient is instructed to keep his wrist on the mid lumbar region. Then the patient is instructed to medially rotate the shoulder by bringing up the wrist as the clinician gives resistance. If the patient is unable to do so or extends the elbow, the test is positive. The other way of doing this test is, the clinician passively maximally internal rotates the shoulder of the patient so that the forearm and wrist are lifted off the back. If the patient can hold this position when the examiner takes his hand off, there is adequate SSc power, and the test is considered negative. If the hand goes back slightly then the test is considered weak. If the hand goes back fully to rest on the back, then the test is considered positive. This is called the internal rotation lag sign. It has been shown that the lag sign increased the sensitivity of the test.40 LOT cannot be performed in around 18% of patients. When LOT is positive it indicates a severe tear.41

3.1.2. Belly press test (BPT)

BPT was reported by Gerber in 1996.30 When the passive internal rotation is restricted, LOT cannot be performed. BPT is useful in such a scenario. The patient is instructed the press the belly, internally rotating the glenohumeral joint. When SSc power is adequate and the patient internally rotates the shoulder, the elbow stays in front of the body. When the SSc power is inadequate, the patient cannot press the belly by internally rotating the glenohumeral joint. He presses by extending the humerus. This takes the elbow behind the thorax.

In the same position of the BPT, the clinician pushes the hand of the patient over his belly into maximal internal rotation and instructs the patient to hold in this position. If the clinician notices a sudden external rotation as he removes his hand this is termed as the Belly-off sign. This sign has nearly the highest sensitivity and specificity for SSc tears42

3.1.3. Napoleon test

It is a modification of the BPT.10,43 It was named so as Napoleon Bonaparte holds his hands against his stomach for patriots. The test is based on the angulation of the wrist when the patient presses the belly with his palms. When the wrist is straight the test is negative. When the wrist is between 30 and 60° the test is intermediate indicating a partial SSc tear. When the wrist is flexed up to 90° the test is considered positive.

3.1.4. Bear hug test (BHT)

Barth described BHT in 2006.44 The patient is instructed to keep the hand of the affected side over the unaffected shoulder. Palm faces down. The clinician then attempts to lift the palm by applying a force perpendicular to the arm. If the patient is not able to maintain forced medial rotation and the weakness is greater than 20% compared to the opposite side, there is an SSc tear. BHT when positive in 45° of shoulder flexion, indicates involvement of upper SSc fibers. When it is positive in 90° of shoulder flexion it indicates involvement of lower SSc fibers41

An Electromyography study comparing the BPT and LOT by Tokish et al. showed that BPT, where the elbow is anterior to midline and shoulder is in almost 45° of abduction, activated the upper subscapular fibers significantly more than the lower subscapular fibers. The LOT, where the elbow is posterior to the midline and the shoulder is in almost 0° of abduction, activated the lower subscapular fibers more than the upper subscapular fibers.44,45

Ercan et al. combined all three tests (BHT, LOT, and BPT) in the evaluation of SSc tears. When two of the three tests are positive, then the patient is diagnosed to have SSc tear clinically. They compared the sensitivity and specificity of this combined clinical tests method to the sensitivity and specificity of MRI and concluded that the combined clinical tests method had equal sensitivity and specificity when compared to MRI. Also, the BHT was found to be the most sensitive and accurate clinical test for the diagnosis of SSc tear.46 Dakkak et al.47 in their systematic review analyzing the usefulness of various combinations of clinical tests to detect SSc tear have concluded that the combination of BHT and BPT has been found optimal for diagnosis of the SSc tear.

4. Imaging

4.1. Radiography

Orthogonal views of the affected shoulder are generally taken. They help us identify avulsion fractures, osteoarthrosis, and subluxation of the joint due to alteration in the force couples resulting from RCTs. Upward migration is significant. Acromio-humeral distance of 6 mm or less is indicative of long-standing infraspinatus cuff tear generally irreparable.48 Irregularity in the greater or lesser tuberosities indicates cuff tears. The other findings on radiography include os acromiale, calcifications, and subacromial osteophytes that can cause impingement. Machine learning is stretching the capability of radiological tests in recent years. Kang et al. recently proposed a machine-learning algorithm to diagnose SSc tears with moderate accuracy by using changes in the LT in axillary view of radiographs49

4.2. Ultrasonography (US)

The US offers accuracy in diagnosing RCTs with advantages of affordability, bedside possibility, absence of contraindications, and examination of the shoulder in different positions. However, the main demerit is operator dependence and low inter-operator reliability in image acquisition and interpretation.50 US is particularly useful in the case of partial tears.51 US was recommended to be used as the first line of investigation in younger individuals (age >40) with non-traumatic cuff pathology.52 Systematic assessment of the shoulder is necessary. Pertaining to cuff tears, each tendon should be examined from musculotendinous junction to their bony insertion in a position where it is maximally stretched. For SSc, when the shoulder position is changed from lateral to medial rotation, a dynamic US assessment can be done. Signs of incomplete SSc tear include thinning of SSc tendon and hypoechoic cleft in SSc tendon. Complete absence of tendon fibers, naked appearing lesser tuberosity indicate a full-thickness tear. LHBT instability indicates SSc tear.53 It has been shown that US is more accurate and reliable for diagnosing SSc tears and outperformed MRI in diagnosing incomplete tears54

4.3. Computed tomography (CT)

CT arthrography can be used in a patient with a contraindication to MRI or with a history of surgery causing artifacts in the MRI.52 CT is also useful when the plan is to do a reverse shoulder replacement.

4.4. Magnetic resonance imaging (MRI)

The MRI is currently the most advanced imaging available. The specificity is up to 100%. However, the sensitivity is between 36 and 40%.51 This is considerably low when compared to the sensitivity of MRI for posterosuperior cuff tears. SSc tears are quite difficult to be identified on standard shoulder MRIs.55 Hyperintense signal along the entire thickness of SSc, poorly defined contour or a discrete gap indicates a full-thickness tear. Adams et al. reported an approach to read MRI for SSc tears using 4 criteria – 2 on axial and 2 on sagittal oblique cuts. In the axial cuts, the diagnostic indicators were tear of the SSc from LT and subluxation of LHBT in a plane where both the tuberosities are visualized. In sagittal cuts, indicators of SSc tear were the atrophy of SSc muscle medial to glenoid and the tear of SSc at the lesser tuberosity.56 They claimed increased specificity and sensitivity with this method of assessment.

4.5. Associated signs of SSc tear in MRI

Various signs have been described to identify the tears of SSc in MRI.38,57, 58, 59, 60 The associated signs of a tear include defects in the axial views, and oblique sagittal views, collection in the superior subscapular recess (Fig. 2), subluxation, or dislocation of the LHBT (Fig. 3), marrow edema, or LT cyst, fatty degeneration of SSc (Fig. 4) and reduced CHI. Lee et al. compared the effectiveness of all these signs in detecting SSc tear and concluded that all the signs were relatively specific but fluid in the superior subscapular recess was the most sensitive sign.61 Fluid in the Superior subscapular recess was shown to have 100% sensitivity in partial SSc tears.62 Reichel et came up with a cut-off value of CHI less than 9.5 mm on MRI to be highly specific for SSc tears.63

Fig. 2.

Fig. 2

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T2 weighted fat saturated sagittal image with collection in the Superior Subscapularis recess.

Fig. 3.

Fig. 3

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Proton Density Weighted Fat saturated axial MRI cut showing dislocated biceps and tear of Subscapularis.

Fig. 4.

Fig. 4

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T1 weighted sagittal MRI cut showing fatty infiltration of Subscapularis and Supraspinatus muscle in a patient with anterosuperior cuff tear.

4.6. Comma sign on MRI

While comma sign has been used to identify SSc tears arthroscopically, recent studies correlating MRI and arthroscopic findings, showed that MRI can be used to identify comma sign (Fig. 1). Comma sign was significantly associated with Lafosse type 3,4, and 5 SSc tears.26,64 Jung et al.65 in 2013, described a sign anatomically similar to a comma sign in MRI involving SGHL, CHL, ends of SSP, and SSC which they termed “bridging sign”. They proposed this sign to be specific for full-thickness SSc tear along with tear of the anterior end of SSP.

Ramadan et al. evaluated the sensitivity and specificity of 1.5T non-contrast MRI in identifying the SSc tears. They compared the results of radiologists and shoulder surgeons. MRI was 70.2% sensitive and 61.9% specific in detecting SSc tears. Shoulder surgeons had good specificity in identifying SSc tears while Musculoskeletal radiologists had good sensitivity.66

The three objective findings to be considered in the assessment of SSc tears are the CHI, retraction of the torn tendon, and stage of fatty degeneration. In axial sections, the CHI is the shortest distance between the posterolateral tip of the coracoid and the humeral head (Fig. 5). This measurement is important to decide if coracoplasty is needed. The normal CHI for males is 13.8 ± 3.1 mm and for females is 12.4 ± 2.4 mm.67 There is no consensus on the cut-off value after which coracoplasty must be considered. CHI less than 6 mm is considered as an indication for coracoplasty68 Some studies claim that coracoplasty did not alter the outcomes after SSc repair.69 Generally, retraction medial to glenoid and SSc fatty infiltration of stage 3 or more are considered as indicators of irreparability of SSc. The fatty infiltration stages were classically described on CT by Goutallier et al.70 However, this has been found to correlate moderately on MRI as well71

Fig. 5.

Fig. 5

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Proton Density Weighted Fast suppressed axial MRI cut showing measurement of coracohumeral distance.

5. Classification of tears

Over years quite a few classification systems have been described for SSc tears.16,57,72, 73, 74 These systems help in standardized reporting of tears, decide on management options and conclude on the prognosis of different tear patterns. The earliest classification system was by Fox et al.74 The commonly used classification is by Lafosse et al.73,75 The recent system by Yoo et al. is based on the insertion of SSc.16

5.1. Fox and romeo classification74

Type I: partial (incomplete) thickness SSc tear.

Type II: complete thickness tear of the superior 25% of SSc tendon.

Type III: complete thickness tear of superior 50%; and.

Type IV: complete rupture of the entire length of SSc.

5.2. Lafosse et al. classification73

Type I – Superior one-third of the SSc tendon – Partial tear (involving deep fibers).

Type II – Superior one-third of SSc tendon – complete tear.

Type III – Superior two-thirds of SSc tendon – complete tear.

Type IV – Complete SSc tendon tear, the humeral head is anatomical in the glenohumeral joint and fatty infiltration is stage 3 or less.

Type V – Complete SSc tendon tear, the humeral head is eccentric, and fatty infiltration is stage 3 or more.

5.3. Yoo et al. Classification16

This classification is based on the division of SSc footprint into 4 facets.

Type I - Fraying of the SSc tendon or a longitudinal split in tendon.

Type II – Partial detachment in the first facet.

IIA <50% of SSc tendon detachment involving the 1st facet.

II B >50% of SSc tendon detachment in the 1st facet. There is no complete disruption of lateral band.

Type III – Complete first facet detachment with disruption of the lateral band (full-thickness superior one-third of SSc tear).

Type IV -Tear involving the 1st and 2nd facet.

Type V - Complete SSc tendon tear involving the entire length.

Types IIA and IIB can present as concealed lesions which can be appreciated only by the bursal arthroscopy and after removing LHBT from its groove. The pictorial representation of facets of insertion of SSc is shown in Fig. 6.

Fig. 6.

Fig. 6

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Footprint of Supraspinatus and Subscapularis. The Subscapularis footprint is divided into 4 facets as described by Yoo et al.16 Reprinted from Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2015 Jan 1; 311:19–28 – “Yoo JC, Rhee YG, Shin SJ, Park YB, McGarry MH, Jun BJ et al. Subscapularis Tendon Tear Classification Based on 3-Dimensional Anatomic Footprint: A Cadaveric and Prospective Clinical Observational Study” with permission from Elsevier.

5.4. Arthroscopic diagnosis of tears

Arthroscopy is described as the gold standard of SSc tears diagnosis. However, tears can be missed in a routine diagnostic arthroscopy from the posterior viewing portal if not carefully looked for. This is because of the difficulty in visualizing the lesser tuberosity. There are some signs on arthroscopy that warrant a thorough evaluation of SSc for tears. They include.

  • 1.

    Subluxation or dislocation of the LHBT medially,

  • 2.

    Scuffing or tear in the anterior aspect of the LHBT is described as the “sentinel sign” by Sahu et al.76 and

  • 3.

    The comma sign.23

The Partial Articular Tendon Avulsions (PASTA) and occult tears are difficult to identify. The techniques described to improve the visualization of SSc arthroscopically include the use of a 70-degree arthroscope from the posterior portal, making the anterior portal as viewing portal, posterior level push and medial rotation of the humerus, and dislocating the LHBT laterally to identify the tear in the medial groove of the LHBT. If found, this may indicate an occult SSc tear.77,78

5.5. Deceiving tear patterns

5.5.1. Concealed tears

Yoo et al.16 described partial SSc tears looked normal or with minimal fraying on intra-articular arthroscopy. The tear pattern could be identified revealing the 1st facet only after retraction of LHBT on bursal arthroscopy. They termed these lesions as concealed intra-tendinous SSc tears.

5.5.2. Floating SSc tear

Yamakado79 in his series of 448 SSc tears noticed that 27 tears were not complete. The outermost part of the SSc which continued as the transverse humeral ligament and fasciculus obliquus was intact in these cases. The initial arthroscopic picture was misleadingly normal. Rotational movements revealed dyssynchronous movements between the SSc and humeral head and helped identify the partial tear. He called this a floating SSc tear. With the detailed description of fiber bundles of comma sign by Arai et al.,80 the distinctiveness of floating SSc tears is doubtful as they seem to represent the SSc tear with a comma sign.

5.5.3. Management

The mode of non-surgical management of SSc tears is like that of the other cuff tears with pain medications and physical therapy. The mode of surgical management of SSc tears has been mainly arthroscopic from the time of the first published report of the technique by Burkhart et al., in 2002.10 Open procedures are considered when there is a need for tendon augmentation. Retraction of the SSc tendon and fatty degeneration are the factors to be considered in deciding the type of surgery.

5.5.4. Arthroscopic repair

A commonly used position for arthroscopic repair is the beach chair position.75 However, lateral decubitus position can be used depending on the surgeons' convenience. The commonly used implant for fixation is a suture anchor. The configuration can be in the form of single or double-row repair. Commonly suture configuration used is the mattress configuration.75,81

5.5.5. LHBT management

There is also no consensus on the management of LHBT during repair.81 Some studies support addressing the LHBT in the form of tenodesis or tenotomy.82 A recent study on the long-term outcome of SSc repair found that LHBT interventions did not correlate with the functional outcomes.83 It has been noted that though most of the published studies addressed the LHBT, there was no conclusive evidence on the need for LBHT interventions – either tenodesis or tenotomy81

5.5.6. Single vs double-row repair

There is very little evidence on the outcomes following single vs double row techniques in isolated SSc repair. Bartl et al.84 and Heikenfeld et al.85 treated all their patients in their cohort with the single row technique. The failure rates were 5% and 10% respectively. Grueninger et al.86 treated all patients with the double-row technique with a failure rate of 0%. Two studies directly compared the single and double row techniques and found no difference in outcomes are retear rates between the two.87,88 Evidence is not robust enough to arrive at a conclusion and future studies are needed in this regard. Kurnaz et al. used single-row repair for Lafosse type I and II tears and double-row repair for type III and IV tears.89

5.5.7. Isolated vs combined repairs

Studies have evaluated the outcomes of isolated SSc repair with anterosuperior cuff tear repair involving both the SSc and SSp. The outcomes do not significantly vary across groups.90,91In combined anterosuperior repairs, Hackl et al.92 have recently described a technique of “comma sign directed repair” and evaluated its biomechanical superiority when compared with traditional single-row repairs. In this technique, after single-row repair of SSc, the suture from the proximal-most anchor of SSc repair is not cut but rather incorporated into the anterior anchor of a lateral row of transosseous equivalent repair of the SSp. This simple step helped the tendon withstand more loading cycles as compared to single row repair resulting in a decrease in micromotion though the ultimate load to failure remained the same. However clinical research on this pattern of repair is needed.

5.5.8. Retears

Liu et al.93 reported 10 years of clinical and MRI follow-up of 35 shoulders following repair of isolated SSc tears. The repair was done by a single row of suture anchors, by open technique in 26 shoulders, and by arthroscopy in the remaining 9 shoulders. The improvement in function was maintained at the final follow-up. Retear was seen in 4 shoulders. Severe fatty infiltration was seen in 26% of cases but this did not correlate with the functional outcome. In a systematic review by Xiao et al.75 the retear rate for isolated SSc repair was between 0 and 17%. For combined tears, SSc retears rate following repair was from 0 to 32%. Risk factors for retears include retraction of more than 19 mm and fatty degeneration of grade III or more.90 The management of retears should be in the form of salvage procedures.

5.5.9. Salvage procedures

Fatty degeneration of Goutallier stage III or IV and retraction of Patty stage III are generally considered irreparable.70,73,94 The salvage procedures for such tears include anterior capsule reconstruction, reverse shoulder arthroplasty, and tendon transfer.95, 96, 97, 98 Reserve Shoulder arthroplasty is reserved for older patients or those with arthritic changes. In younger patients, tendon transfer has been the treatment of choice.

5.5.10. Tendon transfer

Two commonly used options for tendon transfer in irreparable SSc tears are PM transfer and LD transfer. PM transfer has been classically performed for SSc transfer since Wirth et al. described it in 1997.99 The procedure as such has undergone many modifications to improve the functional outcomes and minimize the complications. Resch et al.100 modified the original technique and passed the upper part of PM between the musculocutaneous nerve and conjoint tendon. Gavriilidis et al.101 described a technique using the clavicular head of PM. This was transferred behind the conjoint tendon. Elhassan and Warner102 described a technique PM transfer by passing the sternal head beneath the clavicular head to provide a fulcrum for the sternal head and be more in line with the pull of the SSc.

Though long-term outcomes are good for PM transfer techniques, there are arguments that PM transfer is not synergistic, and a tendon from the muscle of the anterior chest wall cannot replicate the muscle arising from the anterior part of the scapula which is posterior to rib cage. The line of pull of PM and SSc are different. The LD transfer seemed more anatomical considering the line of pull. The muscle is innervated by the thoracodorsal nerve which arises from the posterior cord same as the upper and lower subscapular nerves. Thus, LD transfer would be more synergistic. LD transfer was first attempted in an anatomical feasibility study by Elhassan.103 A biomechanical study comparing the effectiveness of PM and LD in cadavers concluded that LD will be a more suitable option.104 The technique of LD transfer has evolved from open to arthroscopy assisted and fully arthroscopic. Kany et al. recently described an updated arthroscopy-assisted technique of LD transfer.105 The literature on long-term outcomes of LD transfer is however lacking. A recent review by Burnier and Lafosse highlights the need for comparative analysis between LD and PM transfers for SSc. The ability of this transfer to maintain strength in long run is questionable and is as such suited for low-demand individuals.106 Luo et al.98 in their systematic review compared 184 PM transfer cases from 9 studies with 83 LD transfer cases from 3 studies. They concluded that overall outcomes are good in both the transfers and LD transfer might have a slightly better outcome.

5.5.11. Anterior capsular reconstruction

Anterior capsular reconstruction (ACR) is recently proposed as a salvage procedure instead of tendon transfers. Open ACR technique using dermal allograft was first described in 2017 by Rogers et al.97 In the same year, the same group published the technique of arthroscopic ACR also107 Biomechanical studies comparing ACR and tendon transfers have been promising.96,108 Omid et al. in their biomechanical study concluded that ACR provided better glenohumeral stability than LD transfer but led to decreased range of motion.108 However, outcome studies and comparative studies are needed to validate the procedure.

In combined irreparable tears with SSc tear, Superior capsular reconstruction (SCR) is also an option. Ulrich et al.109 had 12 patients with SSc tear in their cohort of SCR patients. The outcomes of these patients were not considerably different when compared to those without SSc tears.

6. Conclusion

The SSc tear is a unique type of rotator cuff tear. The diagnosis is not always straightforward. Careful physical assessment and a strong suspicion during imaging and arthroscopy are needed. There has been an increased understanding of the patho-anatomy of the SSc tears in recent years. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, LHBT management, and the role of coracoplasty. Future research must focus on these areas.

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No external funding was received for study.

CRediT authorship contribution statement

Girinivasan Chellamuthu: Conceptualization, Data curation, Formal analysis, Methodology, administration, Resources, Supervision, Validation, Visualizsation, Writing – original draft, reviewing drafts. Shyam Sundar: Conceptualization, Data curation, Formal analysis, Methodology, administration, Resources, Supervision, Validation, Visualizsation, Writing – original draft, reviewing drafts. David V. Rajan: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, administration, Resources, Supervision, Validation, Visualizsation, reviewing drafts.

Declaration of competing interest

Nil.

Acknowledgements

Nil.

Contributor Information

Girinivasan Chellamuthu, Email: giri.c.nivasan@gmail.com.

Shyam Sundar, Email: drshyam.msortho@gmail.com.

David V. Rajan, Email: davidvrajan@gmail.com.

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