Subscapularis Tear in the Shoulder | Shoulder Arthroscopy, Bangalore

Before getting directly into subscapularis tear, let’s first understand the function of subscapularis muscle in the shoulder.

Do you know why we can internally rotate the shoulder effortlessly? If not, here it is, it is because of subscapularis muscle in our shoulder. To explain it further, when your arm is internally rotated, your palm is facing back, behind your body. You may be aware of rotator cuff, a group of muscles that attaches your upper arm to the shoulder, the subscapularis is the largest muscle in the rotator cuff. You can lift and rotate your arm because of the assistance of subscapularis muscle. Subscapularis connects shoulder blade to the humerus. In fact, subscapularis is the largest & strongest cuff muscle, providing 53% of total cuff strength. Subscapularis muscle plays a pivotal role in overhead sports, such as swimming, racquet sports and throwing.

Subscapularis tear:

However, rotator cuff muscles are prone to tear owing to overuse, trauma or age-related conditions and subscapularis muscle is not an exception. Though tears of the subscapularis tendon are less common compared to supraspinatus and infraspinatus tendon tears, they can be much more painful, since the restraints to the long head of biceps tendon are often also torn and the biceps tendon dislocates from its groove. The biceps tendon then also becomes painful and weak. The severity of the tear can range from mild to tearing up the whole muscle. Treatment is given based on the size of the tear. Subscapularis tears are generally seen near the end of the tendon that connects to the humerus. It can also lead to issues with biceps muscle.

Symptoms of subscapularis tear:

The first noticeable symptom of subscapularis tear is shoulder pain, especially in the front of the shoulder. When your arm is rotated, you can feel or hear “clicking”. In general, symptoms of a subscapularis tear are quite similar to other rotator cuff tears. These include:

pain that gets worse at night
shoulder or arm weakness
pain that gets worse when you lift your arm

However, there are a set of symptoms that are unique to this injury. They are the following:

bicep weakness
having a hard time reaching for something in your back pocket or reaching for your back
pain in the space under your collarbone
your affected arm rotating outwards (palm facing forwards) without you moving it

Causes of subscapularis tear:

An injury to the shoulder generally triggers off subscapularis tear in the young people. This usually happens when your arm is overextended, whereas in elderly people, age-related degeneration leads to subscapularis tear. An impingement in the shoulder can also lead to subscapularis tear as the impingement puts pressure on the subscapularis, leading to tear.

Diagnosis of subscapularis tear:

In the unlikely event, if you are suffering from subscapularis tear, you will experience pain at the front of the shoulder. Moreover, while doing activities of daily living, you will feel weakness, especially while forward lifting and twisting the arm inwards. If you are a sports person, you may feel severe pain in the shoulder while playing. Diagnosis of the tear is generally made, first, by taking a full history. You will be asked if you have hurt your arm of shoulder of late, the specific symptoms you experience and the activities that you find trouble carrying out.

Your doctor may proceed to a couple of tests to narrow down what might be causing the pain. Some of the tests include:

Lift-off test: You will be asked to put your hand on your lower back and then try to lift it. If you can’t lift your hand, it signals a subscapularis tear.

Bear hug test: You will be asked to put the hand of the affected arm on the opposite shoulder. Your doctor will try to pull your hand off your shoulder by rotating your forearm outwards. If you can’t hold your palm on your shoulder or struggle holding it, it also signals a subscapularis tear.

Belly press test: You will put your hand on your stomach and press down, using only your hand (not your wrist or elbow). If this hurts, you might have a subscapularis tear.

The above tests can throw light on what is causing your shoulder to hurt. If your doctor is suspicious, you may be asked to undergo an MRI to make the diagnosis certain as well as to find out the intensity of the tear.

Treatment for subscapularis tear:

Treatment for the tear is tailored based on the tear size and how much the tear negatively impacts your life. Generally the conservative line of treatment is adopted if the tear is small and you can perform your everyday activities. It includes prescribing pain medications, heat, icing etc. For elderly people, physiotherapy is also recommended.

However, if the tear runs deep and across the full thickness of the muscle, you have significant disability from the injury, tear is not improving after about six months of conservative treatment, your doctor might consider surgery.

After the operative procedure, your arm will put in a brace in order to prevent you from rotating the arm outward for about six weeks. After this time period, physiotherapy may be initiated and you can gradually increase your range of motion. After about ten weeks, you can start doing exercises to strengthen your arm.

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Q&As on Subscapularis tear in the shoulder

1) What is a subscapularis tear in the shoulder?

The subscapularis is one of the four muscles that make up the rotator cuff. It’s the substantial one in front of the shoulder.

Compared to supraspinatus and infraspinatus tendon tears, collectively referred to as “rotator cuff tears,” subscapularis tendon tears are less frequent. But since the biceps tendon’s long head is often ripped from its splint, the injuries may be considerably more painful. Additionally, the biceps tendon starts to hurt and deteriorate.

2) What are the symptoms of subscapularis tear in the shoulder?

A subscapularis tear might present specific symptoms strikingly similar to those of other rotator cuff injuries. These comprise:

The ache that worsens at night
Arms or shoulders giving out
The suffering that worsens as you raise your arm

A subscapularis tear has additional symptoms that are specific to this condition, including:

Bicep ache.
It is difficult to get inside your back pocket or reach your back.
Discomfort in the area beneath your collarbone.
Palm is pointing in front while your injured arm rotates outward without your motion.

3) What are the causes of subscapularis tears in the shoulder?

Trauma is often the cause of subscapularis tears. The most frequent reasons include falls onto an extended hand or when an arm is unexpectedly wrenched away from the body as a consequence of a fall.

An isolated full-thickness degenerative tear of the subscapularis is quite uncommon. However, when one ages and has minor partial tears of the subscapularis tendon, this often results in discomfort in the biceps tendon, which runs adjacent to the subscapularis tendon and rubs against it. This is comparable to the metaphor of a rope rubbing against itself and beginning to tear.

4) How is subscapularis tear in the shoulder diagnosed?

A person with a tear in the subscapularis muscle in their shoulder may have discomfort in the front of the shoulder and weakness while engaging in activities such as forward lifting, twisting the arm inwards, and sports. On examination, the physician can discover the following: increased passive exterior rotation, weak internal rotation, and positive test results for subscapularis tears which are confirmed with the Bear-hug test, the belly-press test, and Gerber’s lift-off test.

Both an ultrasound and an MRI can confirm a tear in the subscapularis muscle and biceps involvement.

5) How is subscapularis tear in the shoulder treated?

Physiotherapy rehabilitation is an effective treatment option for individuals with low demand and older patients.

When dealing with an active individual, surgical repair is the best option. Depending on the competence of the surgeon, the tear pattern, and the patient, the procedure may either be done using arthroscopy or open surgery. A tenodesis of the biceps is necessary in most cases if the muscle in question is damaged.

It’s possible that some tears are too old (chronic) and massive to be repaired directly. A Pectoralis Major transfer procedure may be carried out successfully in such situations.