Pain at the front of the shoulder, weakness when internally rotating the arm, and difficulty with tasks like tucking in a shirt or reaching behind the back may indicate a subscapularis tear. It is the most commonly missed rotator cuff tear, frequently overlooked on standard examinations, and one that Dr. Kushalappa Subbiah specifically evaluates in every shoulder assessment.
What is Subscapularis Tear?
The subscapularis is the largest and strongest of the four rotator cuff tendons. It attaches from the front of the scapula to the lesser tuberosity of the humerus and is primarily responsible for internal rotation of the arm. It also plays a critical role in stabilising the biceps tendon within the bicipital groove via the biceps pulley.
Subscapularis tears most commonly occur at the tendon’s upper insertion and are frequently associated with biceps pulley disruption, allowing the biceps tendon to become unstable or sublux out of the groove.
Types of Subscapularis Tear
Causes
Acute trauma, particularly forced external rotation of the arm or a direct anterior shoulder blow, can cause subscapularis tears. Degenerative tearing in older patients, and repetitive overhead loading in overhead athletes, are the other common mechanisms.
- Pain at the front of the shoulder, often confused with biceps tendinitis
- Weakness with internal rotation, such as difficulty turning the arm inward or tucking in a shirt
- A positive belly press test or lift-off test on clinical examination
- In some patients, a medially subluxed biceps tendon that can be palpated or felt to snap in the groove
Diagnosis
Specific clinical tests including the belly press, lift-off, and bear hug tests assess subscapularis integrity. MRI or MRI arthrogram provides the definitive imaging assessment and determines tear size and retraction.
Treatment
Arthroscopic Rotator Cuff Repair (subscapularis)
Subscapularis tears in active patients and those with significant functional deficit require surgical repair. Dr. Kushalappa performs arthroscopic repair of the subscapularis tendon, reattaching it to its footprint on the lesser tuberosity using suture anchors. Where the biceps pulley is disrupted, this is also addressed in the same procedure, either through pulley repair or biceps tenodesis. Recovery follows a similar course to other rotator cuff repairs, with a sling for 4 to 6 weeks and progressive physiotherapy.
Why Choose Dr. Kushalappa Subbiah in Bangalore?
Dr. Kushalappa Subbiah completed a Fellowship in Shoulder Surgery at the Sydney Shoulder Research Institute, where he trained in advanced arthroscopic shoulder procedures including labral repair and reconstruction. He holds the International Olympic Committee (IOC) Diploma in Sports Medicine, and has direct clinical experience managing shoulder injuries in Indian athletes across cricket, swimming, tennis, and contact sports. He is appointed as a Consultant Shoulder Surgeon at NH Hospital, Bangalore.