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The subscapularis: anatomy, injury, and imaging

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Abstract

The subscapularis is the largest and most powerful of the rotator cuff muscles and fulfills an important role in glenohumeral movement and stability. The spectrum and implications of subscapularis muscle or tendon injury differ from injury to other rotator cuff components because of its unique structure and function. Diagnosing subscapularis injury is clinically difficult and assessment of subscapularis integrity may be limited during arthroscopy or open surgery. Diagnostic imaging plays an important part in diagnosing and evaluating the extent of subscapularis injury. The radiologist should be aware of the anatomy of the subscapularis, the variations in muscle or tendon injury, and the potential implications for treatment and prognosis.

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References

  1. Sharkey NA, Marder RA, Hanson PB. The entire rotator cuff contributes to elevation of the arm. J Orthop Res. 1994;12(5):699–708.

    Article  CAS  PubMed  Google Scholar 

  2. Ward SR, Hentzen ER, Smallwood LH, Eastlack RK, Burns KA, Fithian DC, et al. Rotator cuff muscle architecture: implications for glenohumeral stability. Clin Orthop Relat Res. 2006;448:157–63.

    Article  PubMed  Google Scholar 

  3. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy. 2002;18(5):454–63.

    Article  PubMed  Google Scholar 

  4. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22(10):1076–84.

    Article  PubMed  Google Scholar 

  5. Sakurai G, Ozaki J, Tomita Y, Kondo T, Tamai S. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: cadaveric and clinical studies. J Shoulder Elbow Surg. 1998;7(5):510–5.

    Article  CAS  PubMed  Google Scholar 

  6. Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008;24(9):997–1004.

    Article  PubMed  Google Scholar 

  7. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Jt Surg Br. 1991;73(3):389–94.

    CAS  Google Scholar 

  8. Wright JM, Heavrin B, Hawkins RJ, Noonan T. Arthroscopic visualization of the subscapularis tendon. Arthroscopy. 2001;17(7):677–84.

    Article  CAS  PubMed  Google Scholar 

  9. Mansat P, Frankle MA, Cofield RH. Tears in the subscapularis tendon: descriptive analysis and results of surgical repair. Jt Bone Spine. 2003;70(5):342–7.

    Article  Google Scholar 

  10. Lo IK, Burkhart SS. The comma sign: an arthroscopic guide to the torn subscapularis tendon. Arthroscopy. 2003;19(3):334–7.

    Article  PubMed  Google Scholar 

  11. Clark JM, Harryman DT II. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Jt Surg Am. 1992;74(5):713–25.

    CAS  Google Scholar 

  12. Klapper RC, Jobe FW, Matsuura P. Subscapularis muscle and its glenohumeral ligament-like bands. A histomorphologic study. Am J Sports Med. 1992;20(3):307–10.

    Article  CAS  PubMed  Google Scholar 

  13. Symeonides PP. The significance of the subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder. J Bone Jt Surg Br. 1972;54(3):476–83.

    CAS  Google Scholar 

  14. MacDonald K, Bridger J, Cash C, Parkin I. Transverse humeral ligament: does it exist? Clin Anat. 2007;20(6):663–7.

    Article  CAS  PubMed  Google Scholar 

  15. Kadaba MP, Cole A, Wootten ME, McCann P, Reid M, Mulford G, et al. Intramuscular wire electromyography of the subscapularis. J Orthop Res. 1992;10(3):394–7.

    Article  CAS  PubMed  Google Scholar 

  16. O’Connell NE, Cowan J, Christopher T. An investigation into EMG activity in the upper and lower portions of the subscapularis muscle during normal shoulder motion. Physiother Res Int. 2006;11(3):148–51.

    Article  PubMed  Google Scholar 

  17. Kasper JC, Itamura JM, Tibone JE, Levin SL, Stevanovic MV. Human cadaveric study of subscapularis muscle innervation and guidelines to prevent denervation. J Shoulder Elbow Surg. 2008;17(4):659–62.

    Article  PubMed  Google Scholar 

  18. Halder A, Zobitz ME, Schultz E, An KN. Structural properties of the subscapularis tendon. J Orthop Res. 2000;18(5):829–34.

    Article  CAS  PubMed  Google Scholar 

  19. Jost B, Koch PP, Gerber C. Anatomy and functional aspects of the rotator interval. J Shoulder Elbow Surg. 2000;9(4):336–41.

    Article  CAS  PubMed  Google Scholar 

  20. Weishaupt D, Zanetti M, Tanner A, Gerber C, Hodler J. Lesions of the reflection pulley of the long biceps tendon. MR arthrographic findings. Invest Radiol. 1999;34(7):463–9.

    Article  CAS  PubMed  Google Scholar 

  21. Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001;17(2):173–80.

    Article  CAS  PubMed  Google Scholar 

  22. Gray H, Clemente CD. Anatomy of the human body. 30th American ed. Philadelphia: Lea & Febiger; 1985.

    Google Scholar 

  23. Kato K. Innervation of the scapular muscles and its morphological significance in man. Anat Anz. 1989;168(2):155–68.

    CAS  PubMed  Google Scholar 

  24. Blasier RB, Soslowsky LJ, Malicky DM, Palmer ML. Posterior glenohumeral subluxation: active and passive stabilization in a biomechanical model. J Bone Jt Surg Am. 1997;79(3):433–40.

    Article  CAS  Google Scholar 

  25. Perry J. Anatomy and biomechanics of the shoulder in throwing, swimming, gymnastics, and tennis. Clin Sports Med. 1983;2(2):247–70.

    CAS  PubMed  Google Scholar 

  26. Kronberg M, Nemeth G, Brostrom LA. Muscle activity and coordination in the normal shoulder. An electromyographic study. Clin Orthop Relat Res. 1990;257:76–85.

    PubMed  Google Scholar 

  27. Codman EA. Rupture of the supraspinatus tendon. 1911. Clin Orthop Relat Res. 1990;(254):3–26.

  28. Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;(267):45–56

  29. Aluisio FV, Osbahr DC, Speer KP. Analysis of rotator cuff muscles in adult human cadaveric specimens. Am J Orthop. 2003;32(3):124–9.

    PubMed  Google Scholar 

  30. Moseley HF. The basic lesions of recurrent anterior dislocation. Surg Clin North Am. 1963;43:1631–4.

    CAS  PubMed  Google Scholar 

  31. Araghi A, Prasarn M, St Clair S, Zuckerman JD. Recurrent anterior glenohumeral instability with onset after forty years of age: the role of the anterior mechanism. Bull Hosp Joint Dis. 2005;62(3–4):99–101.

    Google Scholar 

  32. Itoi E, Tabata S. Rotator cuff tears in anterior dislocation of the shoulder. Int Orthop. 1992;16(3):240–4.

    Article  CAS  PubMed  Google Scholar 

  33. McLaughlin HL. Trauma. Philadelphia: Saunders; 1959.

    Google Scholar 

  34. Simank HG, Dauer G, Schneider S, Loew M. Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients. Arch Orthop Trauma Surg. 2006;126(4):235–40.

    Article  PubMed  Google Scholar 

  35. Craig EV. The posterior mechanism of acute anterior shoulder dislocations. Clin Orthop Relat Res. 1984;(190):212–6.

  36. DePalma AF, Cooke AJ, Prabhakar M. The role of the subscapularis in recurrent anterior dislocations of the shoulder. Clin Orthop Relat Res. 1967;54:35–49.

    Article  CAS  PubMed  Google Scholar 

  37. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res. 1993;(291):103–6.

  38. Li XX, Schweitzer ME, Bifano JA, Lerman J, Manton GL, El-Noueam KI. MR evaluation of subscapularis tears. J Comput Assist Tomogr. 1999;23(5):713–7.

    Article  CAS  PubMed  Google Scholar 

  39. Kaltsas DS. Comparative study of the properties of the shoulder joint capsule with those of other joint capsules. Clin Orthop Relat Res. 1983;(173):20–6.

  40. Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF. Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med. 1997;25(1):13–22.

    Article  CAS  PubMed  Google Scholar 

  41. MacMahon PJ, Taylor DH, Duke D, Brennan DD, O’Brien J, Eustace SJ. Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement. Clin Radiol. 2007;62(6):556–63.

    Article  CAS  PubMed  Google Scholar 

  42. Bergin D, Parker L, Zoga A, Morrison W. Abnormalities on MRI of the subscapularis tendon in the presence of a full-thickness supraspinatus tendon tear. AJR Am J Roentgenol. 2006;186(2):454–9.

    Article  PubMed  Google Scholar 

  43. Gerber C, Sebesta A. Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: a preliminary report. J Shoulder Elbow Surg. 2000;9(6):483–90.

    Article  CAS  PubMed  Google Scholar 

  44. Lo IK, Burkhart SS. The etiology and assessment of subscapularis tendon tears: a case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. Arthroscopy. 2003;19(10):1142–50.

    Article  PubMed  Google Scholar 

  45. Giaroli EL, Major NM, Lemley DE, Lee J. Coracohumeral interval imaging in subcoracoid impingement syndrome on MRI. AJR Am J Roentgenol. 2006;186(1):242–6.

    Article  PubMed  Google Scholar 

  46. Nove-Josserand L, Boulahia A, Levigne C, Noel E, Walch G. Coraco-humeral space and rotator cuff tears. Rev Chir Orthop Reparatrice Appar Mot. 1999;85(7):677–83.

    CAS  PubMed  Google Scholar 

  47. Sano H, Uhthoff HK, Backman DS, Brunet JA, Trudel G, Pham B, et al. Structural disorders at the insertion of the supraspinatus tendon. Relation to tensile strength. J Bone Jt Surg Br. 1998;80(4):720–5.

    Article  CAS  Google Scholar 

  48. Nove-Josserand L, Levigne C, Noel E, Walch G. Isolated lesions of the subscapularis muscle. Apropos of 21 cases. Rev Chir Orthop Reparatrice Appar Mot. 1994;80(7):595–601.

    CAS  PubMed  Google Scholar 

  49. Shibuya S, Ogawa K. Isolated avulsion fracture of the lesser tuberosity of the humerus. A case report. Clin Orthop Relat Res. 1986;(211):215–8.

  50. Scheibel M, Martinek V, Imhoff AB. Arthroscopic reconstruction of an isolated avulsion fracture of the lesser tuberosity. Arthroscopy. 2005;21(4):487–94.

    Article  PubMed  Google Scholar 

  51. Gamulin A, Pizzolato G, Stern R, Hoffmeyer P. Anterior shoulder instability: histomorphometric study of the subscapularis and deltoid muscles. Clin Orthop Relat Res. 2002;(398):121–6.

  52. Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop Relat Res. 2002;(400):32–9.

  53. Ovesen J, Sojbjerg JO. Lesions in different types of anterior glenohumeral joint dislocation. An experimental study. Arch Orthop Trauma Surg. 1986;105(4):216–8.

    Article  CAS  PubMed  Google Scholar 

  54. Bokor DJ, Conboy VB, Olson C. Instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament. A review of 41 cases. J Bone Jt Surg Br. 1999;81(1):93–6.

    Article  CAS  Google Scholar 

  55. Bui-Mansfield LT, Taylor DC, Uhorchak JM, Tenuta JJ. Humeral avulsions of the glenohumeral ligament: imaging features and a review of the literature. AJR Am J Roentgenol. 2002;179(3):649–55.

    PubMed  Google Scholar 

  56. Coates MH, Breidahl W. Humeral avulsion of the anterior band of the inferior glenohumeral ligament with associated subscapularis bony avulsion in skeletally immature patients. Skeletal Radiol. 2001;30(12):661–6.

    Article  CAS  PubMed  Google Scholar 

  57. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Jt Surg Am. 1981;63(8):1208–17.

    CAS  Google Scholar 

  58. Tuoheti Y, Itoi E, Minagawa H, Wakabayashi I, Kobayashi M, Okada K, et al. Quantitative assessment of thinning of the subscapularis tendon in recurrent anterior dislocation of the shoulder by use of magnetic resonance imaging. J Shoulder Elbow Surg. 2005;14(1):11–5.

    Article  PubMed  Google Scholar 

  59. Schoenfeld AJ, Lippitt SB. Rotator cuff tear associated with a posterior dislocation of the shoulder in a young adult: a case report and literature review. J Orthop Trauma. 2007;21(2):150–2.

    Article  PubMed  Google Scholar 

  60. Bhatia DN, de Beer JF, van Rooyen KS, du Toit DF. The reverse terrible triad of the shoulder: circumferential glenohumeral musculoligamentous disruption and neurologic injury associated with posterior shoulder dislocation. J Shoulder Elbow Surg. 2007;16(3):e13–7.

    Article  PubMed  Google Scholar 

  61. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Jt Surg Am. 2007;89(6):1184–93.

    Article  Google Scholar 

  62. Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23(1):73–80.

    Article  PubMed  Google Scholar 

  63. Uno A, Bain GI, Mehta JA. Arthroscopic relationship of the axillary nerve to the shoulder joint capsule: an anatomic study. J Shoulder Elbow Surg. 1999;8(3):226–30.

    Article  CAS  PubMed  Google Scholar 

  64. De Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study. J Bone Jt Surg Br. 1994;76(3):381–3.

    Google Scholar 

  65. Tung GA, Yoo DC, Levine SM, Brody JM, Green A. Subscapularis tendon tear: primary and associated signs on MRI. J Comput Assist Tomogr. 2001;25(3):417–24.

    Article  CAS  PubMed  Google Scholar 

  66. Warner JJ, Higgins L, Parsons IM IV, Dowdy P. Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2001;10(1):37–46.

    Article  CAS  PubMed  Google Scholar 

  67. Lyons RP, Green A. Subscapularis tendon tears. J Am Acad Orthop Surg. 2005;13(5):353–63.

    PubMed  Google Scholar 

  68. Kreuz PC, Remiger A, Erggelet C, Hinterwimmer S, Niemeyer P, Gachter A. Isolated and combined tears of the subscapularis tendon. Am J Sports Med. 2005;33(12):1831–7.

    Article  PubMed  Google Scholar 

  69. Gerber C, Meyer DC, Schneeberger AG, Hoppeler H, von Rechenberg B. Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: an experimental study in sheep. J Bone Jt Surg Am. 2004;86-A(9):1973–82.

    CAS  Google Scholar 

  70. Galatz LM, Connor PM, Calfee RP, Hsu JC, Yamaguchi K. Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency. J Shoulder Elbow Surg. 2003;12(1):1–5.

    Article  PubMed  Google Scholar 

  71. Pfirrmann CW, Zanetti M, Weishaupt D, Gerber C, Hodler J. Subscapularis tendon tears: detection and grading at MR arthrography. Radiology. 1999;213(3):709–14.

    CAS  PubMed  Google Scholar 

  72. Walch G, Boileau P, Noel E, Liotard JP, Dejour H. Surgical treatment of painful shoulders caused by lesions of the rotator cuff and biceps, treatment as a function of lesions. Reflections on the Neer’s concept. Rev Rhum Mal Osteoartic. 1991;58(4):247–57.

    CAS  PubMed  Google Scholar 

  73. Nerot C, Jully JL, Gerard Y. Rotator cuff ruptures with predominant involvement of the subscapular tendon. Chirurgie. 1993;119(8):404–10.

    PubMed  Google Scholar 

  74. Flury MP, John M, Goldhahn J, Schwyzer HK, Simmen BR. Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): when is a repair indicated? J Shoulder Elbow Surg. 2006;15(6):659–64.

    Article  PubMed  Google Scholar 

  75. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78–83.

  76. Studler U, Pfirrmann CW, Jost B, Rousson V, Hodler J, Zanetti M. Abnormalities of the lesser tuberosity on radiography and MRI: association with subscapularis tendon lesions. AJR Am J Roentgenol. 2008;191(1):100–6.

    Article  PubMed  Google Scholar 

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The authors thank Anne Phillips for her work on the illustrations.

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Morag, Y., Jamadar, D.A., Miller, B. et al. The subscapularis: anatomy, injury, and imaging. Skeletal Radiol 40, 255–269 (2011). https://doi.org/10.1007/s00256-009-0845-0

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