What is the recommended treatment for a subsacapularis tendon avulsion?

Subscapularis Tendon Avulsion Treatment

Acute traumatic subscapularis tendon avulsions should be surgically repaired, particularly in young athletes and when the tear is full-thickness, as the tendon has a strong tendency to retract medially and conservative management is inadequate for restoring function and stability. 1, 2

Surgical Repair: The Definitive Treatment

Surgical intervention is the recommended treatment for subscapularis tendon avulsions because:

• Acute and traumatic full-thickness tears require repair due to the tendon's tendency to retract medially, making delayed repair technically more difficult and potentially compromising outcomes 1
• Isolated avulsion fractures and complete tears in skeletally immature athletes also warrant surgical intervention to prevent prolonged symptoms and restore function 3, 4
• The subscapularis functions as one of the main internal rotators and anterior stabilizers of the glenohumeral joint—loss of this function has serious consequences for shoulder stability and strength 5

Surgical Technique

• Arthroscopic repair is the preferred approach using a 30-degree arthroscope with laterally-based single row repair 1
• Use one anchor for full-thickness tears ≤50% of tendon length and two anchors for tears ≥50% of tendon length 1
• Address associated biceps pathology (invariably present) with tenotomy or tenodesis 1
• Arthroscopic repair in experienced hands restores previous levels of function and activity, particularly important for adolescent athletes 4

Conservative Management: Limited Role

Conservative treatment is only appropriate for mild fraying involving the upper third of the tendon 5. For substantive tears causing pain or functional impairment, surgery is necessary 5.

If attempting conservative management for partial tears:

• Implement relative rest while maintaining some movement to prevent muscle atrophy 6
• Use NSAIDs (topical preferred to eliminate gastrointestinal hemorrhage risk) for acute pain relief 6
• Apply ice therapy for short-term pain relief and swelling reduction 6
• Avoid corticosteroid injections as they may reduce tensile strength and predispose to tendon rupture 6

Post-Operative Rehabilitation

Phased progression is essential to avoid premature stress on healing tissue while enabling early return to activities 5:

• Initial immobilization period (duration dictated by tear size and repair security) 1
• Gradual introduction of range of motion exercises 1
• Delayed active internal rotation and strengthening in internal rotation to protect the repair 1
• Progressive return to sport and activity based on tissue healing 5

Critical Diagnostic Considerations

High index of suspicion is essential as subscapularis tears are frequently under-recognized 1:

• Perform directed physical examination including lift-off test, belly-press test, and assessment for increased passive external rotation 1
• Evaluate all planes on MRI to identify tears, retraction, atrophy, and biceps pathology 1
• Early diagnosis prevents prolonged symptoms and allows timely surgical intervention 3

Key Pitfalls to Avoid

• Do not delay diagnosis—special tests should be performed early in primary care or emergency settings to prevent weeks of ineffective physical therapy 3
• Do not attempt conservative management for full-thickness tears—these require surgical repair to restore stability and function 1, 2
• Do not ignore associated biceps pathology—it is invariably present and must be addressed surgically 1