What is the best treatment option for a subscapularis injury?

Best Treatment Options for Subscapularis Injury

For subscapularis tendon tears, mild fraying involving the upper third of the tendon can be treated non-operatively; however, more substantive tears usually require surgical repair in cases of pain or functional impairment. 1

Initial Assessment and Conservative Management

Conservative Treatment (First-Line for Mild Injuries)

• Indicated for:
  • Mild fraying of the upper third of the tendon 1
  • Partial tears, especially in elderly patients 2
  • Initial management before considering surgical options

Conservative Treatment Components

1. Medication Management:

   • Regular acetaminophen as a safer first-line option
   • NSAIDs for pain relief and anti-inflammatory effects 3
   • Topical NSAIDs for fewer systemic side effects

2. Physical Therapy:

   • Rotator cuff and scapular stabilizer strengthening
   • Gentle stretching exercises
   • Correction of scapular dyskinesis 3
   • Avoidance of complete immobilization
   • Activities that don't worsen pain are permitted

3. Injections:

   • Intra-articular corticosteroid injections for significant pain 3
   • Note: The use of perioperative subacromial corticosteroid injections remains inconclusive 4

Surgical Management

Indications for Surgery

• Full-thickness tears
• Failed conservative management after 3-6 months
• Significant pain or functional impairment
• Tears that have become retracted 2

Surgical Approaches

1. Arthroscopic Repair:

   • Most subscapularis repairs can now be accomplished with arthroscopic techniques 2
   • Double-row transosseous equivalent repair shows promising results for full-thickness tears 5
   • Advantages: Less invasive, faster recovery, lower complication rates

2. Open Repair:

   • Historically considered the gold standard 5
   • Still indicated for complex or severely retracted tears
   • May be necessary for irreparable tears requiring complex reconstruction

3. Augmentation Techniques:

   • For at-risk patients or complex tears
   • "Biceps-Subscap Sling" technique using long head biceps tendon can provide additional structural integrity 6

Rehabilitation Following Repair

Post-Operative Protocol

• Phased progression to avoid premature stress on healing tissue 1
• Early phase: Protection of repair, passive range of motion within safe limits
• Middle phase: Progressive strengthening of rotator cuff and scapular stabilizers
• Late phase: Return to functional activities and sport-specific training

Prognosis and Outcomes

• Approximately 80% of patients recover completely within 3-6 months with appropriate treatment 3
• Early surgical repair after acute injury is an option with some evidence suggesting better outcomes when repair is performed within 3 weeks of injury 4
• Age is a factor in outcomes, with increasing age potentially correlating with less favorable results 4

Important Considerations

• Imaging assessment should begin with standard radiographs (AP views in internal and external rotation, axillary or scapula-Y view) 4
• MRI is preferred for evaluating rotator cuff quality, fatty degeneration, and muscle atrophy 3
• Subscapularis tears are less common than other rotator cuff tears but have serious consequences given its function as a main internal rotator and anterior stabilizer 1
• Timing of surgery may affect outcomes, with some evidence suggesting better results with earlier intervention 4