subscapularis tendon is one of the four rotator cuff tendons which in addition include supraspinatus , infraspinatus , and teres minor .
subscapularis inserts onto the lesser tuberosity of the humerus , whereas the other rotator cuff tendons insert into the greater tuberosity.1 in 1834 , smith was credited as describing the first case series of subscapularis repair.1 tears , involving the subscapularis tendon , have not been considered as common .
autopsy and cadaveric studies have shown the incidence of subscapularis tears to be between 3% and 13%.2 more recently , there has been a renewed interest in understanding the subscapularis muscle tears . in just the past decade
, there have been several articles dedicated to diagnosing and treating subscapularis tendon tears.34 as our understanding of the shoulder has increased , so as the rate at which subscapularis tendon tears have been identified . clinical examination supported by radiological investigations
has helped in identifying subscapularis tendon tears.5 subscapularis tears can be isolated,2345 part of the anterosuperior rotator cuff tear,678 or a continuum of large and massive rotator cuff involvement.9 however , the authors could not find from literature the incidence of isolated subscapularis or combined subscapularis and other rotator cuff tendon tears
( 2007 ) grading system from grade 1 to 5.10 there are several articles published showing the short term results measuring the outcome of open repair and arthroscopic subscapularis repair.1112 however , the midterm and long term outcome studies for arthroscopic subscapularis repair are few .
we studied the midterm functional results of subscapularis tendon repair in association with repair of other cuff muscles .
35 patients who underwent arthroscopic rotator cuff repair between may 2008 and june 2012 were included in this retrospective study .
there were 22 males and 13 female patients with mean age of 58.2 years ( range 41 - 72 years ) .
rotator cuff tears were diagnosed on clinical examination and magnetic resonance imaging ( mri ) findings [ figures 1 and 2 ] .
clinical tests included the gerber 's lift - off test , bear - hug test , and belly - press test along with an assessment of other rotator cuff tendons .
radiological evaluation was done with 1.5 t mri by an experienced musculoskeletal radiologist reporting on the scans .
inclusion criteria were ( 1 ) all patients who underwent arthroscopic isolated subscapularis or combined subscapularis and other rotator cuff tear repairs ( 2 ) minimum 2 years followup postoperatively .
the exclusion criteria were ( 1 ) rotator cuff tears treated by open methods ( 2 ) massive irreparable rotator cuff tears ( 3 ) cases of glenohumeral arthritis ( 4 ) cases with severe cuff tear arthropathy ( hamada et al .
classification grade 3 or more and above).13 magnetic resonance imaging axial cut showing the subscapularis tear magnetic resonance imaging saggital view showing subscapularis tear all operations were performed by the senior authors together ( dr and ks ) .
only patients with confirmed partial to full thickness subscapularis tears were included in this study .
all patients gave informed consent to participate in this study . in the followup , all patients
were subjected to thorough physical examination , including lift - off test , belly - press test , and bear - hug sign .
visual analogue scale ( vas ) and modified university of california at los angeles ( ucla ) score were calculated .
all patients were asked to list all of their current activities and state of their satisfaction with their shoulders .
the physical examination also evaluated their active range of motion and graded their strength throughout their range of motion on a scale from 0 to 5 according to mrc .
all the data were analyzed statistically using paired t - test and  p  value was calculated using spss 18 software [ ibm , chicago , usa ] .
we start with repair of the subscapularis tendon before addressing any other pathology in shoulder as recommended in literature.69 all surgeries were performed with the patients in beach chair position .
subscapularis tendon edges were freshened using shaver , and the lesser tuberosity surface was made raw using a rasp .
a good debridement of tendon edges and medial and inferior release is necessary for completely retracted subscapularis tendon tears for optimum repair .
all subscapularis repairs were performed using 5 mm metal suture anchors ( double loaded , arthrex ) [ figure 3 ] .
subscapularis tendon insertion is 2.5 cm in width and generally one double loaded suture anchor suffices if < 50% of the tendon is torn . if > 50% of tendon insertion is torn two suture anchors are used .
upon completion of the repair , the arm is internally and externally rotated to confirm the completeness of the repair [ figure 4 ] .
arthroscopic view showing the insertion of the suture anchor into the lesser tuberosity during subscapularis repair .
the viewing is through a 70 arthroscope arthroscopic view showing complete subscapularis repair and the complete coverage of the lesser tuberosity by the subscapularis tendon .
the area is being viewed through a 70 arthroscope subscapularis tendon tears were classified according to lafosse 's et al .
classification.13 associated supraspinatus and infraspinatus tendon tears were also documented and classified according to the thickness of the involved tendons and were repaired .
all patients were given a sling with a wedge , applied in the operating room .
the sling is worn full time for 6 weeks ; however , the wedge was removed after 4 weeks . during the first 6 weeks , patients are instructed to perform active elbow flexion and extension with arm at the side .
after 6 weeks , patients begin a passive stretching program that includes overhead stretches with a rope and pulley .
a 70 arthroscope was also used while performing subscapularis repair for better visualization . subscapularis tendon edges
were freshened using shaver , and the lesser tuberosity surface was made raw using a rasp .
a good debridement of tendon edges and medial and inferior release is necessary for completely retracted subscapularis tendon tears for optimum repair .
all subscapularis repairs were performed using 5 mm metal suture anchors ( double loaded , arthrex ) [ figure 3 ] .
subscapularis tendon insertion is 2.5 cm in width and generally one double loaded suture anchor suffices if < 50% of the tendon is torn . if > 50% of tendon insertion is torn two suture anchors are used .
upon completion of the repair , the arm is internally and externally rotated to confirm the completeness of the repair [ figure 4 ] .
arthroscopic view showing the insertion of the suture anchor into the lesser tuberosity during subscapularis repair .
the viewing is through a 70 arthroscope arthroscopic view showing complete subscapularis repair and the complete coverage of the lesser tuberosity by the subscapularis tendon .
the area is being viewed through a 70 arthroscope subscapularis tendon tears were classified according to lafosse 's et al .
classification.13 associated supraspinatus and infraspinatus tendon tears were also documented and classified according to the thickness of the involved tendons and were repaired .
all patients were given a sling with a wedge , applied in the operating room .
the sling is worn full time for 6 weeks ; however , the wedge was removed after 4 weeks . during the first 6 weeks , patients are instructed to perform active elbow flexion and extension with arm at the side . after 6 weeks , patients begin a passive stretching program that includes overhead stretches with a rope and pulley .
25 ( 71.4% ) patients presented with lafosse grade 2 tears and 7 ( 20% ) patients with grade 1 tear [ table 1 ] .
combined rotator cuff tears were more common ( 71.4% ) than isolated subscapularis tear ( 28.6% ) [ table 2 ] .
the grading of subscapularis tears found in this study the pattern of rotator cuff tears mechanism of injury was most commonly traumatic fall ( 70% ) in the cases of isolated subscapularis tears ( 7 out of 10 ) .
however , combined rotator cuff cases did not give a history of significant trauma in most cases and were degenerative in origin ( 76% cases , 19 out of 25 cases ) .
isolated subscapularis tear also tends to happen at a younger age ( mean 52.3 years ) as compared to the occurrence of subscapularis tears along with other rotator cuff tendon tears ( mean age 63.4 years ) .
the mean vas score decreased significantly from 8.03 in preoperative period to 1.44 in the postoperative period .
, there were 22 excellent , 11 good , and 2 fair results among 35 patients . around
elevation increased from 73.68 to 170.88. external rotation increased from 23.09 to 71.18 , and internal rotation increased from l5 , s1 to t7 in the followup [ figures 5 and 6 ] .
clinical photograph showing full abduction on right side after two years followup clinical photograph showing internal rotation after two years followup power of cuff muscles increased from a mean of 2.5 to 4.74 in elevation , 2.24 to 4.79 in external rotation , and 2.29 to 4.82 in internal rotation .
persistent belly - press and lift - off positive postsurgery were found in 14.28% cases ( 5 out of 35 ) .
thus , the postoperative results of both isolated and combined rotator cuff tears were comparable after arthroscopic repair as 2 years postoperative vas and ucla scores were not significantly different in both groups p = 0.23 and 0.12 , respectively .
the present study represents the largest series to date in patients with rotator cuff injury that have been treated with an all arthroscopic subscapularis tendon repair .
several authors have reported on clinical outcomes after open repair of isolated subscapularis tendon tears.511 we identified only a few studies reporting the results of arthroscopic repair of subscapularis tendon tears.1415 the present study shows the good results after arthroscopic repair of subscapularis tears ( mean post of ucla 33.15 and mean vas 1.44 ) .
the results of both isolated subscapularis and combined subscapularis and other tendon tears were comparable [ table 3 ] .
the preoperative and 2 years postoperative vas and ucla scores and range of movements mechanism of injury was most commonly traumatic fall ( 70% ) in the cases of isolated subscapularis tears , whereas combined rotator cuff cases were degenerative in origin ( 76% cases ) .
isolated subscapularis tear also tends to happen at a younger age ( mean 52.3 years ) .
all these data indicate that the etiopathogenesis of isolated subscapularis tear may be different to that of the occurrence of subscapularis tear along with other rotator cuff tendon tears .
bennett9 ( 2003 ) published a series of 8 patients with 2 years followup after arthroscopic repair of isolated subscapularis tendon tears .
the postoperative constant score was 74 points , but no information was given about postoperative clinical subscapularis tests or structural integrity of the repair .
adam et al . ( 2000)14 reported excellent results after arthroscopic repair of isolated subscapularis tears in 7 patients after a minimum followup of 3 years .
lafosse et al.15 ( 2007 ) studied 17 patients , the first series with detailed information on postoperative results of arthroscopic subscapularis repair for isolated tears .
they found good clinical results with a postoperative constant score of 84 points in 17 patients after a followup of 29 months , a rerupture rate of 12% evaluated by computed tomography arthrograms , and a rate of persistent positive or weakened belly - press tests in 24% of patients . in a multicenter study ,
edwards et al.16 reported the results of open repair in 84 isolated subscapularis tendon tears . the constant score averaged 79.5 points after 45 months . marked fatty infiltration of subscapularis muscle negatively influenced the postoperative belly - test , but postoperative constant score was not influenced by fatty degeneration .
additional tenodesis or tenotomy of long head of the biceps had a significant positive influence on the outcome .
gerber and krushell6 ( 1991 ) reported on 16 patients with an average followup of 43 months and a score of 82% in the age and gender matched constant score after open repair of an isolated subscapularis tear .
gerber et al.7 and edwards et al.16 each reported persistent positive lift - off and belly - press tests in the postoperative course representing a partial subscapularis muscle insufficiency at a rate of 31% and 20% , respectively .
it was shown that positive postoperative subscapularis tests were not indicative of a poor clinical outcome , as their patients did not achieve lower constant scores , but edwards et al.16 stated that the community used shoulder scores do not adequately reflect subscapularis muscle strength .
persistent belly - press and lift - off positive postsurgery were found in 14.28% cases ( 5 out of 35 ) in this series .
et al.7 and edwards et al.16 that positive postoperative subscapularis tests were not indicative of a poor clinical outcome , as their patients did not achieve lower shoulder scores . in a study by burkhart and tehrany,17 ( 2002 ) the authors were first to describe the technique and preliminary results of arthroscopic repair of the subscapularis tendon .
this study evaluated 25 patients with a mean age of 61 years who had either anterosuperior or isolated subscapularis tendon tears repaired with an arthroscopic surgical technique .
the mean followup in this study was 10.7 months with 23 good to excellent results , 1 fair result , and 1 poor result .
warner et al.3 ( 2001 ) evaluated 19 patients with a mean age of 58 years in whom they did anterosuperior and subscapularis tendon repairs .
the mean followup in their study was approximately 3.3 years with 5 had an excellent result , and 3 had good results .
flury et al.18 ( 2006 ) evaluated 63 patients with a mean age of 56 years who had either anterosuperior or isolated subscapularis tendon tears repaired with an open surgical technique .
the mean followup in their study was 2.9 years with 98% patient being satisfied with the operation .
this series is one of the largest series of arthroscopic subscapularis repair and goes on to show the good results of undertaking such a repair .
the surgeon attempting to repair subscapularis would greatly benefit if he also has a 70 arthroscope in his setup .
the limitations of study are that this study is a case series ( level 4 evidence ) . the ideal study design to see
however , we can not undertake such a study because we tend to repair all our diagnosed subscapularis tears .
we conclude that the midterm results of arthroscopic subscapularis tendon repair are good , and it remains a good option for the management of subscapularis tendon tear along with other rotator cuff muscle repair .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
 background : rotator cuff tears are a common cause of shoulder pain and dysfunction . 
 more recently , there has been a renewed interest in understanding the subscapularis tears . 
 there are multiple articles in the literature showing the short term results of isolated subscapularis tendon repair . however , the midterm and long term outcome studies for arthroscopic subscapularis repair are few . 
 this study evaluates the functional outcome after arthroscopic subscapularis repair.materials and methods : the records of 35 patients who underwent an arthroscopic subscapularis repair between may 2008 and june 2012 were included in this retrospective study . 
 the records of all patients were reviewed . 
 there were 22 males and 13 female patients with mean age of 58.2 years ( range 41 - 72 years ) . 
 all patients had a complete history , physical examination , and radiographs of their shoulders . 
 visual analogue scale ( vas ) , range of movements , power of cuff muscles , and modified university of california at los angeles ( ucla ) score were assessed.results:the mean followup was 2.8 years ( range 2 - 4 year ) . 
 functional outcome after arthroscopic subscapularis repair has an excellent outcome as analysed by clinical outcome , vas score and ucla score . 
 results were analyzed and had statistically significant values . 
 the vas for pain improved significantly ( p < 0.001 ) , and the mean modified ucla score improved significantly ( p < 0.001 ) from 14.24  4.72 preoperatively to 33.15  2.29 at 2 years postoperative . according to the ucla system 
 , there were 22 excellent , 11 good , and 2 fair results . around 
 95% of patients returned to their usual work after surgery.conclusion:at a median followup of 2 years , 95% of patients had a good to excellent result after an arthroscopic subscapularis tendon repair . 
 we conclude that the midterm results show that arthroscopic subscapularis repair remains a good option for the treatment of patients with subscapularis tendon repair . 
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