Subscapularis tendon tear

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Subscapularis tendon tears are a less common rotator cuff tear, and have been considered more difficult to diagnose pre-operatively (both clinically and radiological) and have been known as a "hidden lesion". Accurate pre-operative diagnosis is important as it affects the surgical approach and delayed/missed treatment can result in poor functional outcomes compared to earlier diagnosis ⁴.

Epidemiology

~~The clinical prevalence of~~ ~~~~subscapularis tendon~~ ~~tears has been estimated at ~15% (range 5-27%) although is higher in cadaveric studies ~33% (range 29-37%)~~ ¹.~~ Subscapularis tears account for ~4% (range 2-6%) of rotator cuff tears ³. The clinical prevalence of subscapularis tendon tears has been estimated at ~15% (range 5-30%) although is higher in patients undergoing rotator cuff surgery at ~55% (range 49-59%) and in cadaveric studies ~33% (range 29-37%) ^1,4.

Clinical presentation

Many patients are asymptomatic. Symptomatic subscapularis tendon tears present with anterior shoulder pain and instability ^1,3.

Pathology

Three patterns of subscapularis tendon tears have been described ^1-3:

supraspinatus tendon involvement or as part of a massive rotator cuff tear
- 80% of subscapularis tears also have a supraspinatus tendon tear
rotator interval ~~involvement~~ extension potentially involving the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL) and can lead to biceps instability
isolated
- : rare
- ; most commonly traumatic
in the setting of anterior glenohumeral instability

Subscapularis tears typically start as articular-sided partial-thickness tears superomedially and progress inferolaterally. The entire tendon can be torn but the overlying superficial fascia and transverse humeral ligament can be intact. Less commonly, bursal-sided partial-thickness tears and/or interstitial delamination ¹.

Associations

Besides the above structures implicated in patterns of subscapularis tendon tears, there is an association with:

subcoracoid impingement³
SLAP tears in the context of biceps pulley injury ³

Classification

Lafosse grading scheme

Fox and Romeo classification

Radiographics features

MRI

Findings are the same for tendon pathology elsewhere. ~~In particular,~~Findings specific for ~~subscapularis tendinopathy,~~subscapular abnormalities:

lesser tuberosity bone marrow oedema and cysts ~~at the lesser tuberosity was significantly~~especially when combined with muscle belly fatty atrophy is indicative of chronic tears ^2,3
comma sign: full-thickness superior subscapularis tears along with SGHL and CHL tears retracted superiorly
long head of biceps tendon medial subluxation/dislocation³
superior subscapularis abnormalities are associated ~~although not 100% specific~~with biceps pulley lesions ²³.

-<p><strong>Subscapularis tendon</strong> <strong>tears </strong>are a less common <a title="Rotator cuff tear" href="/articles/rotator-cuff-tear">rotator cuff tear</a>, and have been considered more difficult to diagnose pre-operatively (both clinically and radiological) and have been known as a "hidden lesion". Accurate pre-operative diagnosis is important as it affects the surgical approach. </p><h4>Epidemiology</h4><p>The clinical prevalence of <a title="Subscapularis tendon" href="/articles/subscapularis-muscle-2">subscapularis tendon</a> tears has been estimated at ~15% (range 5-27%) although is higher in cadaveric studies ~33% (range 29-37%) <sup>1</sup>. Subscapularis tears account for ~4% (range 2-6%) of rotator cuff tears <sup>3</sup>. </p><h4>Clinical presentation</h4><p>Many patients are asymptomatic. Symptomatic subscapularis tendon tears present with anterior shoulder pain and instability <sup>1,3</sup>.</p><h4>Pathology</h4><p>Three patterns of subscapularis tendon tears have been described <sup>1-3</sup>:</p><ul>
+<p><strong>Subscapularis tendon</strong> <strong>tears </strong>are a less common <a href="/articles/rotator-cuff-tear">rotator cuff tear</a>, and have been considered more difficult to diagnose pre-operatively (both clinically and radiological) and have been known as a "hidden lesion". Accurate pre-operative diagnosis is important as it affects the surgical approach and delayed/missed treatment can result in poor functional outcomes compared to earlier diagnosis <sup>4</sup>.</p><h4>Epidemiology</h4><p>Subscapularis tears account for ~4% (range 2-6%) of rotator cuff tears <sup>3</sup>. The clinical prevalence of <a href="/articles/subscapularis-muscle-2">subscapularis tendon</a> tears has been estimated at ~15% (range 5-30%) although is higher in patients undergoing rotator cuff surgery at ~55% (range 49-59%) and in cadaveric studies ~33% (range 29-37%) <sup>1,4</sup>. </p><h4>Clinical presentation</h4><p>Many patients are asymptomatic. Symptomatic subscapularis tendon tears present with anterior shoulder pain and instability <sup>1,3</sup>.</p><h4>Pathology</h4><p>Three patterns of subscapularis tendon tears have been described <sup>1-3</sup>:</p><ul>
~~-<li>rotator interval involvement</li>~~
~~-<li>isolated<ul>~~
~~-<li>rare</li>~~
~~-<li>most commonly traumatic </li>~~
~~-</ul>~~
+<li>
+<a title="Rotator interval" href="/articles/rotator-cuff-interval">rotator interval</a> extension potentially involving the <a title="Superior glenohumeral ligament" href="/articles/glenohumeral-ligaments">superior glenohumeral ligament (SGHL)</a> and <a title="Coracohumeral ligament" href="/articles/coracohumeral-ligament">coracohumeral ligament (CHL)</a> and can lead to <a title="Long head of biceps tendon dislocation" href="/articles/long-head-of-biceps-tendon-dislocation">biceps instability</a>
-</ul><p>Subscapularis tears typically start as articular-sided partial-thickness tears superomedially and progress inferolaterally. The entire tendon can be torn but the overlying superficial fascia and transverse humeral ligament can be intact. Less commonly, bursal-sided partial-thickness tears and/or interstitial delamination <sup>1</sup>.</p><h4>Classification</h4><ul><li>Lafosse grading scheme</li></ul><h4>Radiographics features</h4><h5>MRI</h5><p>Findings are the same for tendon pathology elsewhere. In particular, for subscapularis tendinopathy, bone marrow oedema and cysts at the lesser tuberosity was significantly associated although not 100% specific <sup>2</sup>. </p>
+<li>isolated: rare; most commonly traumatic in the setting of anterior <a title="Glenohumeral instability" href="/articles/glenohumeral-instability">glenohumeral instability</a>
+</li>
+</ul><p>Subscapularis tears typically start as articular-sided partial-thickness tears superomedially and progress inferolaterally. The entire tendon can be torn but the overlying superficial fascia and transverse humeral ligament can be intact. Less commonly, bursal-sided partial-thickness tears and/or interstitial delamination <sup>1</sup>.</p><h5>Associations</h5><p>Besides the above structures implicated in patterns of subscapularis tendon tears, there is an association with:</p><ul>
+<li>
+<a title="Subcoracoid impingement" href="/articles/subcoracoid-impingement">subcoracoid impingement</a> <sup>3</sup>
+</li>
+<li>
+<a title="SLAP tears" href="/articles/superior-labral-anterior-posterior-tear">SLAP tears</a> in the context of biceps pulley injury <sup>3</sup>
+</li>
+</ul><h4>Classification</h4><ul>
+<li>Lafosse grading scheme</li>
+<li>Fox and Romeo classification</li>
+</ul><h4>Radiographics features</h4><h5>MRI</h5><p>Findings are the same for tendon pathology elsewhere. Findings specific for subscapular abnormalities:</p><ul>
+<li>lesser tuberosity bone marrow oedema and cysts especially when combined with muscle belly fatty atrophy is indicative of chronic tears <sup>2,3</sup>
+</li>
+<li>
+<a title="Comma sign of subscapularis tear" href="/articles/comma-sign-of-subscapularis-tear">comma sign</a>: full-thickness superior subscapularis tears along with SGHL and CHL tears retracted superiorly</li>
+<li>
+<a title="Long head of biceps tendon dislocation" href="/articles/long-head-of-biceps-tendon-dislocation">long head of biceps tendon medial subluxation/dislocation</a> <sup>3</sup>
+</li>
+<li>superior subscapularis abnormalities are associated with <a title="Biceps pulley injury" href="/articles/biceps-pulley-injury">biceps pulley lesions</a> <sup>3</sup>
+</li>
+</ul>

References changed:

4. Lenz R, Kircher J, Schwalba K, Weber M, Tischer T. Subscapularis Tendon Tears - Usefulness of Written MRI Reports For Guiding Patient Referral to Shoulder Specialists. Rofo. 2021;193(7):797-803. <a href="https://doi.org/10.1055/a-1328-3142">doi:10.1055/a-1328-3142</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/33477184">Pubmed</a>

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shoulder
shoulder mri
ssc
ssc tear

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