Subscapularis Tear

Subscapularis tear includes the tear of the subscapularis muscle or subscapularis tendon. Subscapularis muscle lies under the lower 2/3rd of scapula. Scapula is a flat bone that lies at the back of chest wall over the ribs on right and left side. Upper outer end of scapula is known as glenoid, which forms a shoulder joint with head of the humerus. Scapula moves horizontally along the posterior (back) surface of chest wall. Medial (inner) tendon of the subscapularis muscle is attached to inner lower border of scapula and outer (lateral) tendon forms anterior boundary of rotator cuff and attaches to humerus bone. Subscapular tendon tear is located near the attachment of the tendon with humerus or at anterior rotator cuff. Subscapularis muscle tear is located over the muscle mass of lower middle scapula.

Subscapularis Tear

Rotator Cuff-

Rotator cuff consists of thick tough bundle of fibrous tissue contributed by 4 muscles, which covers shoulder joint. The anterior section of rotator cuff is formed by the spread of tendon of subscapularis muscle. Thus rotator cuff is formed by the tendon of following 4 muscles.

  • Supra-spinatous muscle
  • Infra-spinatous muscle
  • Teres Minor muscle
  • Subscapularis muscle

Function of Rotator Cuff-

  • Assist shoulder joint movement,
  • Stabilized scapula and shoulder joint
  • Facilitate abduction and adduction movement at the shoulder joint
  • Assists in internal and external rotation of shoulder joint

About Subscapularis Muscle-

Subscapularis muscle is a large triangular muscle that lies underneath and is attached to the inner surface of scapula. Subscapularis muscle is also attached to lesser tubercle of humerus on lateral (outer) side. Subscapularis tendon forms the major portion of the anterior section of rotator cuff. Subscapularis muscle is the largest muscle of 4 muscles contributing to form rotator cuff. Subscapularis muscles provide over 50% of muscle and tendon mass to support shoulder joint.

Function of Subscapularis Muscle-

  • Internal rotation of humerus at the shoulder joint
  • Stabilized humerus when arm is abducted,
  • Prevent anterior dislocation of shoulder joint.

About Subscapularis Tear-

Subscapularis tear includes tear of subscapularis muscle and tendon. Subscapularis muscle tear is mostly localized over subscapular muscle mass, which lies in front of the lower 2/3rd of scapula. Subscapular tendon tear on the contrary is localized over anterior shoulder joint. The subscapularis tendon forms the anterior section of the rotator cuff. Subscapularis tendon or muscle tear is either partial or full thickness and injuries are confirmed with MRI studies.D Symptoms of the muscle and tendon tear are different. The causes of subscapularis tear are as follows-

Causes of Subscapularis Tear-

  • Subscapular Tear Caused By Sports Injury-
    • Shoulder Joint Forceful Movements Causes Subscapular Muscle or Tendon Tear-this is common in the following listed games:
      • Baseball pitchers
      • Football injury G
      • Volleyball injury
      • Tennis player
    • Contact Sport-Direct impact on shoulder joint and scapula may result in subscapular muscle or ligament tear.
      • Wrestler
      • Football player injury
      • Soccer Injury
      • Boxing injury
      • Rugby injury
    • Repeated Shoulder Joint Movements-
      • Orchestra conductor
      • Drummer
      • Weight lifting E
  • Automobile Accident
    • Direct impact caused by solid object following accident can cause Subscapular tear.
  • Work Accident
    • Direct shoulder joint or chest wall impact can cause partial or full thickness tear.
    • Handling heavy equipment may cause overstretching of the upper arm, shoulder joint and scapula resulting in subscapular muscle or tendon tear.
  • Surgery
    • Shoulder joint surgery or arthroscopy may cause subscapularis tendon or muscle tear.

Symptoms and Signs Of Subscapularis Tear

  • Pain-
    • Intensity- Intensity of the pain is moderate to severe. Pain is severe with movement of the shoulder joint. Patient is unable to perform routine activities.
    • Tenderness- Touch and palpation over the injured area is very painful. Pain is severe when lying flat on the injured scapula or shoulder joint.
    • Pain Over Shoulder Joint- Presence of severe pain over anterior shoulder joint suggests pain is caused by tear of rotator cuff tendon of subscapularis muscle.
    • Pain Over Lower Scapula- Pain localized over lower scapula suggests pain may be caused by tear of subscapular muscle.
    • Severe Pain During Abduction- Painful abduction of upper arm suggests either subscapularis tendon or muscle tear.
    • Severe Pain During Adduction Of Upper Arm At Shoulder Joint- Suggests possible injury of subscapularis muscle.
  • Restricted Shoulder Joint Movement-
    • Restricted Internal Rotation- Internal rotation of upper arm at shoulder joint is restricted because of the tear of the tendon of subscapularis muscle.
    • Restriction of Abduction- Abduction is restricted when subscapularis tendon or muscle is torn.
  • Skin Discoloration-
    • Skin Discoloration Over Anterior Shoulder Joint- Suggests possible injury of subscapularis tendon
    • Skin Discoloration Over Lower 2/3rd of Scapula- Suggests subscapularis muscle tear.
  • Shoulder Joint Weakness- Patient is often unable to lift object with injured arm.

Diagnosis and Investigation of Subscapularis Tear

  • Bear Hug TestA
    • Test is performed in standing or sitting position. The hand of the injured arm is rested on opposite shoulder. Examiner lifts the patient’s hand away from the shoulder during test. Next the examiner requests patient to bring the hand back to rest on shoulder. Patient will have to overcome resistance applied by examiner’s hand. Patient suffering with subscapular muscle tear always complaint of initiation of severe pain.
  • Belly Press TestB
    • Test is performed in standing position. The injured arm is flex at elbow joint and rested over front of the belly. Examiner will place his hand between patient’s hand and abdomen. Examiner will push the patient’s hand away from belly. Examiner expects patient to resist the push. Severe pain will be felt at shoulder joint or over the scapula while preventing arm from being pushed away from belly suggesting tear of the subscapularis muscle.
  • Ultrasound Study
    • Ultrasound examination of the scapula and shoulder joint is performed. The examination may show hematoma and tear over the muscle, tendon or anterior rotator cuff.
  • MRI Examinationc
    • Selective MRI study of the muscles may show tear of tendon or muscles.

Treatment For Subcapularis Tear

  • Medications For Subscapularis Tear
    • Pain-
      • Mild to Moderate Pain- Treated with Non-Steroidal Anti-Inflammatory Medications. Most common medications prescribed are Motrin, Naproxen and Celebrex.
      • Severe to Very Severe Pain- Treated with opioids. Most common opioid prescribed are short acting hydrocodone (Vicodin, Lortab or Norco) and oxycodone (Percocet or Oxy IR).
    • Muscle Spasm
      • Muscle Relaxants- Muscle spasm is treated with muscle relaxants. Most common muscle relaxants used are Baclofen, Flexeril and Skelaxin.
  • Manual Therapy For Subscapularis Tear
    • Massage therapy
      • Massage therapy is often used following surgery.
    • Physiotherapy
      • Physiotherapy is tried prior to surgery. Physiotherapy is continued for 6 to 8 weeks. Physiotherapy with anti-inflammatory medication may help to relieve the pain and rebuild the strength of the subscapularis muscle. Partial thickness tear may completely heal following physiotherapy.
  • Interventional Therapy For Subscapularis Tear
    • Cortisone Injection
      • Cortisone with local anesthetics injected in and around the injured tendon and muscle.
      • Patient is scheduled for 3 to 4 injection. Each injection is performed with 2-week interval.
  • Surgery For Subscapularis Tear:
    • Arthroscopic RepairF
      • Partial or full thickness tear of subscapularis muscle is repaired by arthroscopic surgery. The rupture site is visualized by arthroscopic camera and sutured using arthroscopic equipment.
    • Open Surgery-
      • Skin incision is made over the injured tendon and tear.
      • The injured tendon or muscle is exposed and sutured.
  • Shoulder Joint Replacement
    • Severe pain may continue after several surgeries to repair tendon or muscle tear.
    • If multiple surgical treatments fail to relieve the symptom then few cases may be considered for shoulder joint replacement.

References:

A. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear.

Barth JR1, Burkhart SS, De Beer JF.

Arthroscopy. 2006 Oct;22(10):1076-84.

B. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions.

Scheibel M1, Magosch P, Pritsch M, Lichtenberg S, Habermeyer P.

Arthroscopy. 2005 Oct;21(10):1229-35.

C. Subscapularis tendon rupture in an 8-year-old boy: a case report.

Bhalla A1, Higashigawa K, McAllister D.

Am J Orthop (Belle Mead NJ). 2011 Sep;40(9):471-4.

D. Subscapularis tendon tears.

Lyons RP1, Green A.

J Am Acad Orthop Surg. 2005 Sep;13(5):353-63.

E. Isolated subscapularis tear from minimal trauma in a recreational athlete: a case report.

Davis BA1, Edwards JJ.

Arch Phys Med Rehabil. 2001 Dec;82(12):1740-3.

F. Arthroscopic subscapularis repair.

Kuntz AF, Raphael I, Dougherty MP, Abboud JA.

J Am Acad Orthop Surg. 2014 Feb;22(2):80-9.

G. Traumatic subscapularis tendon tear in an adolescent american football player.

Gibson ME1, Gurley D2, Trenhaile S3.

Sports Health. 2013 May;5(3):267-9. doi: 10.1177/1941738112470912.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: July 10, 2014

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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