This critical analysis review synthesizes the diagnosis and treatment of subscapularis tendon tears. It covers the relevant surgical anatomy, physical exam tests, imaging, classification systems, and open versus arthroscopic repair. The goal is to raise clinical suspicion for a tear that older open-surgery literature systematically underdiagnosed.
When you see biceps instability or a positive bear-hug in a patient with anterior shoulder pain, actively look for a subscapularis tear. The older teaching that these tears are rare came from open surgery, which missed partial and upper ("hidden") lesions.
Remember the sensitivity trap: lift-off, belly-press, and bear-hug tests are specific but can be falsely negative even with half the tendon torn. A clean exam does not rule out a tear, so pursue MRI when suspicion is high.
The comma sign is your intraoperative anchor. When the tendon is retracted and scarred to anterior structures, following the medial biceps sling leads you back to the torn subscapularis border.
Set realistic expectations. Even after a healed repair, internal rotation strength tests frequently remain positive because fatty infiltration usually does not reverse. This is why acute traumatic tears warrant earlier repair before atrophy sets in.
This critical analysis review synthesizes the diagnosis and treatment of subscapularis tendon tears. It covers the relevant surgical anatomy, physical exam tests, imaging, classification systems, and open versus arthroscopic repair. The goal is to raise clinical suspicion for a tear that older open-surgery literature systematically underdiagnosed.
When you see biceps instability or a positive bear-hug in a patient with anterior shoulder pain, actively look for a subscapularis tear. The older teaching that these tears are rare came from open surgery, which missed partial and upper ("hidden") lesions.
Remember the sensitivity trap: lift-off, belly-press, and bear-hug tests are specific but can be falsely negative even with half the tendon torn. A clean exam does not rule out a tear, so pursue MRI when suspicion is high.
The comma sign is your intraoperative anchor. When the tendon is retracted and scarred to anterior structures, following the medial biceps sling leads you back to the torn subscapularis border.
Set realistic expectations. Even after a healed repair, internal rotation strength tests frequently remain positive because fatty infiltration usually does not reverse. This is why acute traumatic tears warrant earlier repair before atrophy sets in.