Arthroscopic Subscapularis Repair [chapter]

Ammar Anbari, Anthony A. Romeo
2008 Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine  
An all-arthroscopic repair of the subscapularis tendon has seen signifi cant interest in the past 10 years. As we refi ne our knowledge and arthroscopic techniques in repairing other rotator cuff tears, we are now more capable of addressing subscapularis tears in an all-arthroscopic fashion as well. Th e main advantages of an all-arthroscopic repair of the subscapularis tendon are smaller incisions, less postoperative pain, and the ability to better visualize and address coexisting pathologic
more » ... isting pathologic processes, including labral tears and posterior superior rotator cuff tears. Th is chapter addresses the preoperative considerations and the techniques involved in performing an arthroscopic subscapularis repair. Preoperative Considerations History In most cases, isolated high-grade subscapularis tears are a result of trauma. Most patients describe an event with excessive external rotation of the shoulder or with resistance to forceful external rotation. Some patients hear a "pop" and others feel the shoulder "slipping out of place." In older individuals, tears may be associated with shoulder dislocations. Presenting complaints include anterior shoulder pain and diffi culty reaching behind the back or tucking in a shirttail. Th ese complaints can be relatively nonspecifi c, and it is important to consider the multiple causes of anterior shoulder pain, including acromioclavicular joint arthrosis or dislocation, biceps tendon tears or infl ammation, anterior capsulolabral damage, and fractures of the lesser tuberosity. Physical Examination As with all shoulder conditions, physical examination begins with a thorough examination of the shoulder including observation, range of motion, and strength testing. Th e two most common physical examination fi ndings associated with subscapularis tears are increased external rotation compared with the opposite side and weakness of internal rotation. External rotation is evaluated with the arm at the side and compared with the opposite extremity. Because other muscles, such as the pectoralis major, are strong internal rotators of the shoulder, special tests can isolate the subscapularis for assessment of internal rotation strength. Th e belly press test is performed by asking the patient to press the ipsilateral hand on the abdomen, maintaining the elbow anterior to the body. If the patient is not able to keep the elbow anterior to the trunk or if the wrist is fl exed in attempting to press into the abdomen, the belly press test result is considered positive and the subscapularis is not functioning. Th e liftoff test requires the patient to be able to place the ipsilateral hand behind the back. Th e patient is asked to lift the hand off the back; if the patient is unable to do so, the test result is considered positive. A modifi cation to this test, also known as the subscapularis lag test, involves placing the ch018-X3447.indd 179 ch018-X3447.indd 179
doi:10.1016/b978-1-4160-3447-6.50020-x fatcat:r2ggorfsh5fntfxidighsitlwy