Difficult and Unusual Rotator Cuff Tears

INTRODUCTION

Rotator cuff tears represent the most common condition treated by the shoulder arthroscopist. While common, these tears can present a variety of unique challenges or conundra. One size does not fit all, and one repair technique cannot address the myriad of tear patterns. Therefore, the advanced shoulder arthroscopist must possess a large armamentarium to address these challenges. In the setting of these challenges, the principles of recognition, order of steps, and matching the repair pattern to the tear pattern will guide the surgeon to a successful repair.

PARTIAL ROTATOR CUFF TEARS

Partial rotator cuff tears occur in three varieties: partial articular-sided tears (PASTA), bursal tears, and interstitial tears. Each comes with its own set of conundra.

PASTA Tears

The treatment of PASTA tears is controversial, with debates about both when to repair (based on the size of the lesion) and when to preserve or take down the lateral rotator cuff attachment. We strongly believe in anatomic preservation. As such, we err on the side of repairing PASTA tears and nearly always preserve the lateral cuff insertion by performing a transtendon repair. This repair maintains the length-tension relationship of the rotator cuff and preserves the healthy lateral tissue. The simplest way to measure the size of the PASTA tear is to compare it to a known instrument width. We use a 5.0-mm shaver to debride the nonviable rotator cuff and then measure the exposed footprint with this shaver. If after debridement the shaver fits between the articular margin and the rotator cuff, then the tear is at least 5 mm and we proceed with repair. The one exception is a patient over the age of 70 in whom we have greater tolerance for debridement alone. We also frequently perform a biceps tenodesis during repair of PASTA lesions because the lateral sling of the biceps tendon is often disrupted. In the setting of a young patient with a central PASTA lesion (within the crescent) and an intact lateral biceps sling, the biceps can be preserved. However, in most cases, the sling is disrupted and tenodesis facilitates visualization and repair.

Several options exist for a transtendon repair. If the tear is located anteriorly and the infraspinatus is intact, a single-anchor technique can be used. In this setting, the biceps can be tenodesed and the sutures from the interference screw can be shuttled through the rotator cuff and tied in a mattress fashion subacromially. If the biceps is intact, preservation is an option but care must be taken during suture passage to not constrain the biceps. If the tear is wide from anterior to posterior, we use a two-anchor technique with two 4.5-mm BioComposite Corkscrew anchors placed in a transtendon fashion. A medial double-pulley technique is then used to secure the tendon down to the bone. The sutures may then be cut. Or, if the tear extends medial to lateral, the suture limbs from the medial anchors are preserved (after tying the medial double pulley), crisscrossed, and secured laterally to two lateral knotless SwiveLock C anchors for a doublerow PASTA Bridge repair.

FIGURE 1-1 MRI coronal cut showing a PASTA lesion of the supraspinatus.

History:

A 42-year-old male orthopaedic surgeon
Six-month history of pain in the dominant right shoulder after awkwardly pushing up the weight stack while doing a bench press in the gym

Physical Exam:

Full range of motion.
4/5 strength with resisted external rotation.
Examination was otherwise normal.

FIGURE 1-2 Right shoulder, posterior intra-articular viewing portal. There is a PASTA lesion of the supraspinatus with some residual tendon remnants on the bone footprint. A ring curette is useful for removing soft tissue.

FIGURE 1-3 A: Right shoulder, posterolateral subacromial viewing portal. Four-anchor PASTA Bridge repair has been completed. B: Right shoulder, posterior intra-articular viewing portal. The capsule has been brought into anatomic apposition with the bone footprint, which is no longer visible.

Imaging:

X-rays were normal.
MRI showed a partial articular surface tear of the supraspinatus tendon (PASTA lesion) (Fig. 1-1).

Arthroscopic Findings:

There was a typical PASTA lesion with exposure of ˜50% of the width of the footprint of the supraspinatus (Fig. 1-2).
A trans-tendon four-anchor PASTA Bridge repair was performed (Fig. 1-3).

FIGURE 1-4 A: Schematic illustration of a completed PASTA Bridge repair. Mattress knots tied between two medial anchors (BioComposite Corkscrew FT; Arthrex, Inc., Naples, FL) seal off the rotator cuff footprint from synovial fluid. Blue suture limbs have been crisscrossed and secured laterally to two lateral BioComposite SwiveLock C anchors (Arthrex, Inc., Naples, FL). B: Aerial view demonstrates the double medial mattress, as well as the crisscross pattern.

Pearls, Pitfalls, and Decision-Making:

We prefer a double-pulley repair to create a double-mattress suture between the two trans-tendon anchors. Then, in active patients whose PASTA lesion is 50% of the width of the cuff footprint or more, we crisscross the sutures and fix them laterally to two more anchors in order to compress the entire tear (Fig. 1-4).
Two medial anchors are placed trans-tendon (4.5-mm BioComposite Corkscrew FT; Arthrex, Inc., Naples, FL) (Fig. 1-5).
Two sets of double-mattress sutures are created by means of the double-pulley technique, in which the
eyelets of the anchors serve as pulleys during delivery of the first knot, which is tied extracorporeally. The second knot is a static knot tied arthroscopically (Figs. 1-6 and 1-7).
Two BioComposite SwiveLock C suture anchors (Arthrex, Inc., Naples, FL) are used to anchor the suture limbs laterally, thereby compressing the tendon to the footprint (Fig. 1-4).

FIGURE 1-5 Schematic of transtendon anchor placement for a PASTA-bridge rotator cuff repair. A: A metal cannula is bluntly passed through the rotator cuff and a bone socket is created with a punch. Note: Prior to creating the bone socket, it is important to “past point” during cannula insertion so that the rotator cuff is not captured underneath the cannula. B: An anchor is inserted through the metal cannula.

FIGURE 1-5 (Continued) C: Appearance after transtendon placement of two medial anchors.

FIGURE 1-6 Schematic illustration of the double-pulley technique to create a medial mattress knot during a PASTA Bridge rotator cuff repair in a left shoulder. Two medial anchors have been placed transtendon. A single suture limb of the same color (in this case white) is retrieved from each anchor. Extracorporeally, a static Surgeon’s knot is tied over an instrument.

History:

A 38-year-old active male with 9-month history of left shoulder pain.
No specific injury, but he played competitive sports including football throughout high school.
Has failed trials of NSAIDs, injections, and physical therapy.
He is active in sports with his kids, and his shoulder interferes with this as well as with his sleep.

Physical Exam:

He has full ROM and only slight weakness with resisted external rotation.
However, external rotation against resistance does cause significant shoulder and arm pain.

Imaging:

X-rays are essentially normal, and MRI demonstrates tendinopathy of the cuff with a possible articularsided tear of the supraspinatus—although subtle (Fig. 1-8).

Arthroscopy Findings:

After debridement of the articular-sided supraspinatus tear, a significant portion of the bone footprint of the rotator cuff was exposed (Fig. 1-9).
Utilizing the percutaneous insertion kit (Fig. 1-10), the spinal needle from the kit is inserted lateral to the acromion and through the position of the cuff felt best for repair to the medial bone footprint. The posterior anchor is placed first (Fig. 1-11A, B) followed by the anterior anchor (Fig. 1-11C).
The suture from the anterior anchor is then loaded into the splice locking mechanism of the posterior anchor. Similarly, the posterior suture is loaded into the anterior anchor locking mechanism (Fig. 1-12).
The sutures are then pulled thus pulling the cuff down against the articular margin (Fig. 1-13).
Finally, the two limbs are compressed into a lateral SwiveLock site thus accomplishing the final repair (Fig. 1-14).

Pearls, Pitfalls, and Decision-Making:

PASTA lesions frequently generate some debate. What is the magic number for repair versus debridement? Is
it 50%—or does the actual number change depending on the patient or activity level? Do you repair PASTA lesions in overhead throwers? All these questions are hot topics in the shoulder world. But for this patient with a 50% PASTA lesion, arthroscopic repair was felt to be most appropriate. He is very active and also very young, and those factors made the decision relatively easy in this case.

FIGURE 1-7 A: After a knot is tied extracorporeally, pulling on the opposite corresponding suture limbs delivers the knot into the subacromial space using the two medial anchor eyelets as pulleys. B: The medial double-mattress knot is completed by tying the static knot with the opposite suture limbs using a Surgeons’ Sixth Finger Knot Pusher (Arthrex, Inc., Naples, FL). These suture limbs will be cut. Then, the process will be repeated for the other colored suture, but the tails will be preserved for incorporation into a lateral row. Note: A static knot must be tied for the second knot since linking the anchors prevents a sliding knot. Also note that the second knot is tied opposite the first so that there is maximal spread between the two knots.

FIGURE 1-8 Sagittal cut of the T2 MRI demonstrates possible articular sided tearing of the supraspinatus.

FIGURE 1-9 Intra-articular view of the left shoulder demonstrates articular-sided tear of the supraspinatus. H, humeral head; BT, biceps tendon.

FIGURE 1-10 A 17-gauge spinal needle from the Arthrex percutaneous insertion kit is placed off the lateral margin of the acromion and through the cuff at a position felt appropriate for soft tissue fixation. BT, biceps tendon; H, humeral head.

FIGURE 1-11 A: The insertion guide is advanced over the dilator (from the percutaneous insertion kit) and positioned at the posterior articular margin of the humeral head. The bone is punched, and an anchor is inserted all without moving the insertion guide. B: Once the anchor is placed, the insertion guide is removed. C: Both the anteromedial and posteromedial anchors are visualized in this photo. H, humeral head; BT biceps tendon.

FIGURE 1-12 Schematic illustration of the “cross-threading” of the two medial anchors. The anterior anchor working suture will be loaded into the splice of the posterior anchor. The posterior anchor working suture will be loaded into the splice of the anterior anchor.

FIGURE 1-13 After securing the medial row, the footprint is reestablished as visualized from the intra-articular perspective. BT, biceps tendon; H, humeral head.

Transtendon repair can be difficult, however. Trying to get an anchor through the tendon without doing major additional damage to the tendon can be difficult. One huge advantage of utilizing the percutaneous kit and the 3.0 Knotless SutureTak for this purpose is that the anchor can be inserted through the guide, which can be inserted over the dilator of the percutaneous insertion kit. Thus, once the spinal needle is in place, it is simply a series of sequential steps to get the anchor in place (see Video). No additional suture passage is necessary, and once the anchors are in place, the case is nearly over.

FIGURE 1-14 Subacromial view from the lateral portal. The suture limbs are then brought laterally and compressed into the bone with a 5.5 SwiveLock anchor thus completing the repair. RC, rotator cuff.

However, a potential pitfall in such a case is anchor pullout. The SutureTak family of anchors does not have as much resistance to pullout as most threaded anchors. Thus, we typically reserve using the Knotless SutureTaks (in rotator cuff cases) for younger patients with good bone. Another pearl is to utilize the anchor punch rather than drilling for the anchor. This will allow no bone to be removed but rather the bone will be compressed during bone socket preparation.

With attention to the above pearls and pitfalls, this technique has been a tremendously successful advancement for the treatment of PASTA lesions in a completely knotless fashion. This eliminates the potential for knot impingement or similar issues postoperatively.

Interstitial Tears

The decision of whether or not to repair an interstitial tear of the rotator cuff is one of the most controversial subjects in treatment of partial cuff tears. True interstitial tears represent delamination of the layers of the rotator cuff with preservation of both the medial and lateral cuff attachments. As we have outlined previously, we use a combination of MRI and arthroscopy findings (probing and the bubble sign) to diagnose an interstitial tear. These tears require takedown of the lateral cuff attachment followed by repair.

History:

A 47-year-old computer technician who had undergone an arthroscopic acromioplasty and biceps tenotomy at another institution 1 year earlier. He says that his shoulder pain never improved after the surgery.
He thinks that his shoulder is becoming progressively weaker.
He does not like the appearance of the Popeye deformity that developed after his biceps tenotomy.

FIGURE 1-15 MRI Scan. A: T2 axial cut shows a tear of the upper subscapularis. B: T2 coronal section shows an interstitial defect in the supraspinatus tendon consistent with an interstitial cuff tear.

Physical Exam:

4/5 weakness with resisted external rotation
Positive bear-hug and belly-press tests
Popeye deformity of biceps

Imaging:

MRI scan shows:
- A tear of the upper subscapularis (Fig. 1-15A)
- An interstitial tear of the supraspinatus tendon (Fig. 1-15B)

FIGURE 1-16 Bubble Test. A spinal needle is used to perforate the outer layer of the interstitial tear. Then, sterile saline is injected until resistance is felt, and the cuff can be seen to “bubble up” as a dome-shaped fluid-filled “bubble.” A: Before injection of saline. B: After injection of saline. Note the full dome-shaped appearance of the part of the cuff where the fluid was injected.

Arthroscopic Findings:

There was a tear of the upper 50% of the subscapularis.
An interstitial tear of the supraspinatus was identified by means of a positive “Bubble test” (Fig. 1-16) and a positive “Probe Push test” (Fig. 1-17).
The subscapularis was repaired with a FiberTape and SwiveLock C suture anchor, comprising a modified SpeedFix configuration (Fig. 1-18).
The interstitial tear of the supraspinatus was converted to a bursal surface tear that was repaired
with a SpeedFix configuration (inverted mattress FiberTape secured with a SwiveLock C suture anchor) (Fig. 1-19).

FIGURE 1-17 A metal probe is used to puncture into the “bubble,” confirming the location of the interstitial cuff tear.

Pearls, Pitfalls, and Decision-making:

This revision case points out the importance of identifying and addressing all the pathology when doing a shoulder arthroscopy. This patient likely had symptomatic tears of the subscapularis and the supraspinatus at the time of the first surgery that were missed and continued to be symptomatic.
A long-standing Popeye sign often cannot be improved with surgery, due to continued degeneration and degradation of the biceps tendon, with loss of tendon substance. Therefore, we typically do not offer biceps tenodesis for a Popeye deformity that has been present for more than 3 months.
Subscapularis tears that are not retracted, as in this case, can easily be missed if a 70° arthroscopic is not used in conjunction with a posterior lever push to show the footprint of the subscapularis.
Interstitial tears of the supraspinatus are often overlooked. The surgeon must have a strong index of suspicion when he or she sees an interstitial defect on MRI scan. He or she then confirms the existence of a contained interstitial cuff defect by injection of saline into the defect until resistance is felt and observing the dome-shaped bubble of cuff tissue that has formed (bubble sign). A probe can then be pushed into the “bubble” to confirm the defect. Then, an arthroscopic scissors or shaver is used to convert the interstitial tear to a bursal surface tear that can easily be repaired with a SpeedFix technique.

FIGURE 1-18 A FiberTape suture and a SwiveLock C suture anchor have repaired the subscapularis by means of a SpeedFix construct.

Bursal Tears

As with PASTA tears, our repair technique for bursal-sided tears centers on preservation of anatomy. The simplest technique for repair of a high-grade bursal tear is a knotless repair using an inverted mattress suture with FiberTape and a lateral-based SwiveLock C anchor. Since these tears are often associated with impingement, an acromioplasty should always be performed prior to repair of these tears.

FIGURE 1-19 Final repair of supraspinatus with an inverted mattress FiberTape and a SwiveLock C suture anchor in a SpeedFix configuration.

FIGURE 1-20 Preoperative imaging. A: Plain radiograph demonstrates a normal glenohumeral joint and lateral overhang of the acromion, which may predispose to a rotator cuff tear. B: Coronal T2 MRI demonstrates a high-grade bursal surface tear (blue arrow) of the supraspinatus tendon.

History:

A 33-year-old right-hand dominant man has activityrelated lateral shoulder pain
He failed to improve with NSAIDs, home therapy, and two subacromial injections

Physical Exam:

Active forward flexion is 120° with full passive motion
4/5 supraspinatus strength
Markedly positive impingement maneuvers

FIGURE 1-21 Right shoulder, posterior subacromial viewing portal demonstrate (A) a high-grade bursal surface rotator cuff tear, followed by (B) a knotless SpeedFix repair. RC, rotator cuff.

Imaging:

Plain radiographs demonstrate lateral overhang of the acromion (Fig. 1-20A).
MRI demonstrates a high-grade bursal surface tear of the supraspinatus tendon (Fig. 1-20B).

Arthroscopy Findings:

A high-grade bursal surface tear of the supraspinatus is confirmed (Fig. 1-21A).
Repair is performed with a knotless SpeedFix technique (Fig. 1-21B).

Pearls, Pitfalls, and Decision-Making:

Following the principle of preservation of anatomy, the articular attachment is left intact and lateral-based fixation is used to restore anatomy.
The bone bed should be cleared to facilitate healing, and we frequently create bone vents in the tuberosity prior to repair to facilitate healing since anchors are not placed directly in the bone bed.
A 70° arthroscope is helpful for visualization of the bone bed from the posterior subacromial portal, as well as for lateral anchor placement.

History:

A 62-year-old male with persistent pain and weakness in his dominant right shoulder
No history of traumatic event
Enjoys lifting weights in the gym but cannot perform overhead exercises due to pain and weakness
Attempted 2 months of physical therapy with no relief of his symptoms

Physical Exam:

Range of motion:
- Slight restriction in active elevation, external and internal rotation compared to the other shoulder
Strength:
- 4/5 strength with resisted elevation and external rotation
- Normal internal rotation strength
Special tests:
- Pain with Neer impingement test
- Pain and weakness with supraspinatus test

FIGURE 1-22 Right shoulder, posterior viewing portal with a calibrated probe demonstrating a high-grade bursal tear of the supraspinatus tendon. GT, greater tuberosity; RC, rotator cuff.

Imaging:

Plain radiographs were unremarkable.
MRI suggested a supraspinatus bursal surface tear.

Arthroscopy Findings:

Intra-articular evaluation revealed no tear of rotator cuff, labrum, or biceps.
Subacromial evaluation revealed a tear of 50% of the supraspinatus tendon on the bursal side (Fig. 1-22).
After passage of a TigerTape (Arthrex, Inc., Naples, FL) suture in an inverted mattress fashion, both suture limbs were pulled out of the same percutaneous portal (Fig. 1-23A) to prevent a soft tissue bridge during anchor insertion (Fig. 1-23B).
Arthroscopic subacromial decompression and SpeedFix (Arthrex, Inc., Naples, FL) repair of the supraspinatus tendon (Fig. 1-24).

FIGURE 1-23 Right shoulder, posterior viewing portal in the same patient (A) using a FiberTape retriever (Arthrex, Inc., Naples, FL) to remove both sutures at the same time through the same percutaneous portal prior to (B) anchor insertion. RC, rotator cuff.

FIGURE 1-24 Right shoulder, posterior viewing portal in the same patient after completing SpeedFix (Arthrex, Inc., Naples, FL) bursal repair of the supraspinatus tendon. RC, rotator cuff.

Pearls, Pitfalls, and Decision-Making:

In a symptomatic patient, a tear of >30% of the thickness of the tendon on the bursal side warrants a repair versus a debridement of the supraspinatus tendon.
Knotless versus knotted repair of the supraspinatus tendon is up to surgeon discretion.
With a percutaneous approach (no cannula), care must be taken to grab both sutures at the same time (see Fig. 1-23A) prior to loading the sutures into the knotless anchor (or tying the sutures if a knotted repair is chosen) to avoid a soft tissue bridge.

SUBSCAPULARIS TEARS

Subscapularis tears are frequently overlooked both radiographically and arthroscopically. Therefore, the first key to arthroscopic repair of the subscapularis tendon is recognition. Just as tears of the posterosuperior rotator cuff present in a variety of tear patterns, so do tears of the subscapularis tendon. Similarly, the tear pattern of the subscapularis tear dictates the repair pattern.

Many subscapularis tears are PASTA lesions of the upper subscapularis tendon. These tears are easily repaired with a medial-based anchor as we have previously described. The major conundrum with partial tears of the subscapularis is the type of fixation. For most of these tears, we use a knotless technique with a FiberTape suture and a SwiveLock anchor. However, in the setting of a small footprint, such as that often seen in small females, we perform the repair with the sutures from the biceps tenodesis construct. This is the one exception to our usual order of steps in which the tenodesis is usually completed after the subscapularis has been repaired.

More complex patterns of subscapularis tears include a large PASTA, which extends from superior to inferior; retracted tears, occult tears, and bursal-sided tears.

Regardless of the tear pattern, subscapularis repair should be performed prior to repair of an associated supraspinatus tear in order to maximize visualization. The repair proceeds in the following steps:

1. Diagnostic arthroscopy

2. Biceps tenotomy in preparation for tenodesis

3. Make a window in the rotator interval

4. Clear the subcoracoid space

5. Perform a coracoplasty if indicated (i.e., if coracohumeral interval <7 mm)

6. Mobilize the subscapularis tendon if needed

7. Repair the subscapularis tendon

8. Complete the biceps tenodesis

9. Repair the posterosuperior rotator cuff

History:

A 20-year-old healthy female recreational body builder.
One-year history of shoulder pain when she lifts weights.
Failed conservative measures and underwent previous diagnostic arthroscopy at an outside facility
- Operative report said they performed limited labral debridement, decompression, and arthroscopic distal clavicle excision.
She did well in therapy, but once she resumed weight lifting activities had recurrence of anterior shoulder pain.

Physical Exam:

Thin and healthy female.
Full range of motion and normal cuff strength exam.
No weakness; however, she did have pain with bearhug exam and with Speed test.

Imaging:

Plain films are normal.
Repeat MR arthrogram demonstrates no obvious shoulder pathology.

Arthroscopic Findings:

Diagnostic arthroscopy reveals apparent pathology of the superior edge of the subscapularis tendon.
A cordlike glenohumeral ligament is constricting the upper subscapularis and with internal rotation is cutting into the upper subscapularis (Fig. 1-25).
Arthroscopic scissors are utilized through the anterior portal, and the middle glenohumeral ligament (MGHL) is transected (Fig. 1-26).
Removing the impinging lesion allows the subscapularis to move freely (Fig. 1-27).

FIGURE 1-25 A: Posterior view of a right shoulder demonstrates abnormality/tearing of the upper subscapularis. B: With internal rotation and flexion, the cordlike middle glenohumeral ligament (MGHL) cuts into the upper subscapularis. H, humeral head; SSc, subscapularis.

FIGURE 1-26 Arthroscopic scissors are utilized to transect the cordlike MGHL. H, humeral head; SSc, subscapularis.

Pearls, Pitfalls, and Decision-Making:

The most difficult decision process with this patient was the decision to proceed with surgery. Her previous surgery had not offered her any relief of her symptoms. Her repeat MR arthrogram was entirely benign. Her clinical exam elicited some pain in various maneuvers, but it was difficult to pinpoint where her pain was coming from preoperatively.

FIGURE 1-27 Once the MGHL is excised, the subscapularis moves freely without constriction. H, humeral head; SSc, subscapularis.

Dr. Stephen Snyder described an entity of a frayed upper subscapularis with impingement. Although this case is not exactly like those Dr. Snyder described, the pathology of anterior capsular tissue causing damage to the upper subscapularis is similar. Our patient did not have obvious impingement…thus, it could be called just an FUSS lesion!

With debridement of the cordlike MGHL, this patient had complete relief of her symptoms. She was able to rehabilitate immediately, and she was back to weight lifting in just a few weeks.

History:

A 44-year-old healthy and active male with 6-month history of left shoulder pain. No history of traumatic event.
Has failed trials of NSAIDs, injections, and physical therapy.
Pain that interferes with sleep is his primary complaint.

Physical Exam:

He has full ROM and a mildly positive bear-hug sign
Positive impingement signs as well as AC joint signs (cross body adduction and tenderness to palpation)

FIGURE 1-28 A: Posterior view of the left shoulder demonstrates pathology of the upper subscapularis. B: With internal rotation of the arm and a posterior lever push maneuver, the upper subscapularis pathology is even more apparent. H, humeral head; MGHL, middle glenohumeral ligament; SSc, subscapularis.

Imaging:

X-rays are normal, and MRI shows minimal obvious pathology other than subacromial bursitis and mild AC joint arthritis.

Arthroscopy Findings:

Diagnostic arthroscopy revealed apparent pathology with partial tearing of the upper subscapularis (Fig. 1-28).
The medial sling of the biceps and the biceps tendon itself both looked normal (Fig. 1-29).
The subcoracoid space was also assessed and felt to be adequate.
After the lesser tuberosity bone bed was prepared, a 3.0 Knotless SutureTak anchor was placed in the upper portion of the footprint (Fig. 1-30).
The FiberWire suture was then shuttled through the upper subscapularis with a spinal needle and monofilament suture (Fig. 1-31).
The looped end of the nitinol wire and the FiberWire suture were then grasped together and brought out of the ASL (anterosuperolateral) portal (Fig. 1-32). NOTE: It is beneficial to grasp and deliver both of these together thus eliminating potential twists in the construct.
The FiberWire was then shuttled back into the splice locking mechanism of the anchor and the suture tightened onto the subscapularis (Fig. 1-33).

Pearls, Pitfalls, and Decision-Making:

While upper subscapularis tears are quite common, they are usually associated with some form of biceps pathology
(or subluxation) or at least subcoracoid impingement. This case had neither. Nonetheless, the patient had upper subscapularis pathology, which became more evident with internal rotation and posterior lever push of the humerus.

FIGURE 1-29 The medial sling and the biceps both look normal. BT, biceps tendon; MS, medial sling; SSc, subscapularis.

The Knotless SutureTak was utilized in this case for several reasons. First of all, the patient was a younger male and his bone quality was excellent. This anchor is a push-in anchor rather than a thread-in anchor, but with such good bone quality we were satisfied with the fixation strength of a push-in anchor. The second reason this anchor was chosen is its ability to be progressively tensioned. It can be advantageous to perform initial tensioning and then before cutting the suture to take the patient through moderate range of motion and then to retension once again. The third reason for utilizing this anchor is that a knotless anchor in this location may be beneficial. As all shoulder surgeons experience, often patients can
have some residual anterior shoulder pain that lasts for 4 to 6 months postoperatively. Eliminating the potential contribution of a knot stack is just one small step in potentially diminishing the severity and occurrence of this residual anterior shoulder pain.

FIGURE 1-30 The 3.0 Knotless SutureTak anchor is inserted into the upper portion of the lesser tuberosity bone bed through the inserter guide. BT, biceps tendon; H, humeral head.

FIGURE 1-31 The FiberWire suture from the anchor is then shuttled through the upper subscapularis utilizing a spinal needle and monofilament suture as a shuttle. H, humeral head; SSc, subscapularis.

FIGURE 1-32 The FiberWire and the looped end of the nitinol are then pulled out the ASL portal together. They are both grasped and retrieved in the same pull. H, humeral head; SSc, subscapularis.

FIGURE 1-33 The FiberWire is then loaded back into the splice locking mechanism of the anchor (via the nitinol wire) and the suture is tensioned thus compressing the subscapularis down to the prepared bone bed. BT, biceps tendon; H, humeral head; MS, medial sling; SSc, subscapularis.

History:

A 52-year-old woman had 5 years of anterior shoulder pain that was not responsive to nonoperative treatment.

Physical Exam:

Active range of motion was equal bilaterally with 160° forward elevation, 60° external rotation, and internal rotation to L2.
O’Driscoll dynamic labral shear test, bear-hug and belly-press tests, and Hawkins test were all positive.

Imaging:

X-rays were unremarkable.
MRI arthrogram demonstrated irregularity of the upper subscapularis tendon with possible medial biceps displacement (Fig. 1-34).

FIGURE 1-34 Axial MRI demonstrates irregularity of the upper subscapularis tendon insertion and possible medial biceps instability.

Arthroscopy Findings:

The long head of the biceps tendon was unstable medially and had split into the upper subscapularis tendon causing a partial bursal-sided tear (Fig. 1-35).

Pearls, Pitfalls, and Decision-Making:

Use a 70° arthroscope to adequately view and treat the subscapularis tendon, long head of the biceps tendon, and associated structures.
When the biceps tendon has become unstable and leads to subscapularis tearing, biceps tenodesis (preferred for most patients over tenotomy) is indicated.
Arthroscopic biceps tenodesis high in the groove not only allows the surgeon to both complete the tenodesis in a safe and efficient manner but also to place an anchor in a good location for rotator cuff repair.
Once the biceps has been tenodesed so that it causes no further tearing, the surgeon may be tempted to leave the partial subscap tear unrepaired. However, we repair all subscapularis tears, even smaller partial tears, because of the importance of this tendon for shoulder function.
In this case, suture passage was accomplished using a percutaneous shuttling technique (Fig. 1-36), which can be helpful to place sutures in “tight” locations without having to make an accessory portal:
- First, a spinal needle is placed at the correct angle (Fig. 1-36) through the tendon.
- An “O” PDS suture is passed through the spinal needle and retrieved out of the cannula with one of the suture limbs (Fig. 1-37A). The FiberWire suture limb is tied with the PDS, and then the PDS is pulled out percutaneously, thus passing the FiberWire suture through the tendon and through the skin (Fig. 1-37B).
- The passed sutures are then tied as simple sutures using a Sixth Finger Knot Pusher.
- The completed repair of the partial subscapularis tear is seen using 70° and 30° scopes (Fig. 1-38).

FIGURE 1-35 After biceps tenotomy (whipstitch sutures present in preparation for tenodesis), the partial, bursal-sided subscapularis tear (black arrow) is seen. H, humeral head; SSc, subscapularis; BT, biceps tendon.

FIGURE 1-36 The correct angle of approach for suture passage is demonstrated here with the spinal needle. The spinal needle will subsequently be placed through the tendon replicating this angle. SSc, subscapularis; H, humeral head; black arrow notes the placement of the biceps tenodesis interference screw slightly medially at the top of the groove for the subscapularis repair.

FIGURE 1-37 A: One FiberWire suture limb has been retrieved out of the cannula with the PDS and tied to the loop of the PDS suture (white arrow). When the other end of the PDS is pulled (blue arrow), the FiberWire suture will be shuttled back through the tendon and through the skin (white arrow) (B). SSc, subscapularis; H, humeral head.

History:

A 57-year-old male with persistent pain and weakness in his dominant right shoulder for about 6 months
No history of traumatic event
Significant pain with washing under the contralateral arm and tucking in his shirt in the back
Attempted 1 month of physical therapy and a cortisone injection with only temporary relief of his symptoms

FIGURE 1-38 Final repair as seen with 70° (A) and 30° (B) scopes from a posterior portal. H, humeral head; SSc, subscapularis.

Physical Exam:

Range of motion:
- Slight restriction in active elevation and external rotation and moderate restriction of internal rotation compared to the other shoulder
Strength:
- 4+/5 strength with resisted elevation and external rotation
- 4-/5 internal rotation strength
Special tests:
- Pain with Neer impingement test
- Pain with supraspinatus empty can test
- Pain and weakness with bear-hug and belly-press tests

Imaging:

Plain radiographs revealed minimal glenohumeral arthritis.
MRI revealed tendinosis of supraspinatus and subscapularis tendons without an obvious tear.

Arthroscopy Findings:

Arthroscopic evaluation did not reveal a tear of the supraspinatus or infraspinatus tendons.
Posterior lever push revealed a tear of the upper 30% to 40% of the subscapularis tendon (Fig. 1-39).
A Scorpion suture passer (Arthrex, Inc., Naples, FL) is used to pass a TigerTape (Arthrex, Inc., Naples, FL) suture in a simple fashion through the upper subscapularis tendon just medial to the comma tissue (Fig. 1-40A).
Both of the suture limbs are then pulled out a percutaneous anterior portal with a FiberTape retriever (Arthrex, Inc., Naples, FL) (Fig. 1-40B) to prevent a soft tissue bridge during anchor insertion (Fig. 1-40C).
Completed arthroscopic SpeedFix (Arthrex, Inc., Naples, FL) repair of the subscapularis tear (Fig. 1-41).

FIGURE 1-39 Right shoulder, posterior viewing portal with the assistant applying a posterior lever push the upper subscapularis tendon (SSc) tear is revealed. LT, lesser tuberosity; H, humeral head; blue comma symbol, “comma sign.”

FIGURE 1-40 Right shoulder, posterior viewing portal in the same patient (A) using a Scorpion suture passer (Arthrex, Inc., Naples, FL) to pass a TigerTape (Arthrex, Inc., Naples, FL) suture in a simple fashion through the upper subscapularis tendon (SSc) just medial to the comma tissue (blue comma symbol). B: Both of the suture limbs are then pulled out a percutaneous anterior portal with a FiberTape retriever (Arthrex, Inc., Naples, FL) (C) to prevent a soft tissue bridge during anchor insertion. LT, lesser tuberosity; H, humeral head.

FIGURE 1-41 Right shoulder, posterior viewing portal in the same patient after the completed SpeedFix (Arthrex, Inc., Naples, FL) repair of the upper supraspinatus tendon (SSc). H, humeral head; blue comma symbol, “comma sign.”

Pearls, Pitfalls, and Decision-Making:

Many subscapularis tendon tears are missed from the radiology reports.
In a symptomatic patient, a torn subscapularis generally is best treated by repair rather than debridement.
We typically repair all symptomatic partial-thickness subscapularis tendon tears with at least one anchor for tears <50% of the cephalad to caudal length and at least two anchors for tears >50%.
The anterosuperolateral portal with its working cannula is made in line with the subscapularis tendon.
The sutures for the upper anchor are passed through the subscapularis tendon medial to the comma tissue, which acts as a rip-stop to decrease the chance of suture cutout.
With an anterior percutaneous approach (no cannula), care must be taken to grab both sutures at the same time (see Fig. 1-40B) prior to loading the sutures into the knotless anchor (or tying the sutures if a knotted repair is chosen) to avoid a soft tissue bridge.

History:

A 63-year-old male with persistent pain and weakness in his dominant right shoulder for about 1 year
No history of traumatic event
Pain and weakness with CrossFit and tennis
Attempted 3 months of physical therapy with no relief

Physical Exam:

Range of motion:
- Slight restriction in active elevation and internal and external rotation
Strength:
- 4+/5 strength with resisted elevation and external rotation
- 4-/5 internal rotation strength
Special tests:
- Pain with palpation anterior shoulder
- Pain with Neer impingement test
- Pain with supraspinatus test
- Pain and weakness with bear-hug and belly-press tests

FIGURE 1-42 Right shoulder, posterior viewing portal with 70° arthroscope. The upper subscapularis has pulled away from its insertion on the lesser tuberosity. LT, lesser tuberosity; SSc, subscapularis.

Imaging:

Plain radiographs revealed minimal glenohumeral arthritis.
MRI revealed tendinosis of supraspinatus and question of a small upper subscapularis tendon tear.

FIGURE 1-43 (A) The surgery is accomplished by means of a posterior viewing portal and a single anterosuperolateral working portal, which is placed adjacent to the anterosuperolateral corner of the acromion. (B) The biceps tendon is exteriorized through the anterosuperolateral portal, and a whipstitch is placed. (C) A FiberTape is passed in antegrade fashion through the subscapularis by means of a Scorpion FastPass suture passer (Arthrex, Inc.; Naples, FL). H, humeral head; LT, lesser tuberosity; SSc, subscapularis.

Arthroscopy Findings:

Arthroscopic evaluation revealed no tear of the supraspinatus or infraspinatus tendons.
Evaluation of upper subscapularis revealed a tear of upper 20% to 30% of subscapularis tendon (Fig. 1-42).
A single portal/cannula technique was used to repair the subscapularis tendon and perform a biceps tenodesis (Fig. 1-43A).
A biceps tenotomy and whipstitch are placed to secure the biceps tendon (Fig. 1-43B).
A FiberTape (Arthrex, Inc., Naples, FL) is passed in a simple fashion through the upper subscapularis tendon (Fig. 1-43C).
The subscapularis FiberTape (Arthrex, Inc., Naples, FL) and biceps tenodesis whipstitch sutures are both placed through the eyelet of the same Biceps Tenodesis SwiveLock (Arthrex, Inc., Naples, FL) anchor (Fig. 1-44).

Pearls, Pitfalls, and Decision-Making:

Most subscapularis tendon tears are missed or underestimated in terms of size from the MRI scan.
A subscapularis repair and a biceps tenodesis can be performed through a single cannula if the portal is properly placed and the assistant uses internal and external rotation of the patient’s arm to obtain the correct angle of approach depending on the structure that is being addressed.
When exteriorizing the biceps tendon to perform a whipstitch, additional excursion of the biceps tendon can be achieved by flexing the patient’s shoulder and elbow.
With a concomitant subscapularis repair and biceps tenodesis, the sutures from the biceps tenodesis anchor can be passed and tied to repair a subscapularis tear, or a braided tape suture (FiberTape; Arthrex, Inc., Naples, FL) can be passed and secured with the same tenodesis anchor as seen in this case.
The sutures for the upper anchor are passed through the subscapularis tendon medial to the comma tissue, which acts as a rip-stop to decrease the chance of suture cutout.

FIGURE 1-44 Subscapularis repair and biceps tenodesis have been accomplished with a single implant (Biceps Tenodesis SwiveLock; Arthrex, Inc.; Naples, FL). H, humeral head; SSc, subscapularis.

History:

A 54-year-old university professor with 9-month history of increasing right shoulder pain
Failed conservative management

Physical Exam:

Positive bear-hug exam, mildly positive belly-press, and negative Napoleon
4/5 external rotation strength, positive empty can sign
Positive Speed test exam

Imaging:

X-rays were normal.
MRI demonstrates full-thickness supraspinatus and likely upper subscapularis tear.

Arthroscopic Findings:

Diagnostic arthroscopy reveals
- Upper subscapularis tear
- Incompetent biceps sling
- Full-thickness supraspinatus tear (Fig. 1-45)
An anterosuperolateral portal is created for tenodesis of the biceps (Fig. 1-46).
The biceps is secured (Fig. 1-47), tenotomized, exteriorized, and a Krackow suture placed in the biceps.
The biceps is dunked into a prepared bone socket along with a FiberTape suture (Fig. 1-48).
The half-racking suture (white) is passed through the upper subscapularis tear and tied (Fig. 1-49)—thus repairing the subscapularis down to the prepared lesser tuberosity bone bed (Fig. 1-50).
The FiberTape suture is utilized as the anteromedial suture of a SpeedBridge cuff repair of the supraspinatus (Fig. 1-51).
The SpeedBridge supraspinatus repair is then completed (Fig. 1-52).

Pearls, Pitfalls, and Decision-Making:

Frequently when multiple pathologies are encountered, the surgeon must think closely about “real estate.” Too

many anchors in a close space can result in the pitfall of an iatrogenic bone fracture or other problem.
Using a single biceps tenodesis anchor for a combined upper subscapularis and supraspinatus repair is commonplace in our practice.
This case represents utilizing this single anchor for three purposes.
- The biceps tenodesis
- The upper subscapularis repair
- The supraspinatus repair

FIGURE 1-45 A: Right shoulder, posterior view of upper subscapularis tear. B: Same tear with flexion and internal rotation of the arm. C: The cuff tear also involves the entire supraspinatus tendon. H, humeral head; BT, biceps tendon; GT, greater tuberosity; SSc, subscapularis.

FIGURE 1-46 The anterosuperolateral portal must be made in a position that will allow an appropriate angle to the top of the bicipital groove for placement of the bone socket for the biceps tenodesis. H, humeral head; BT, biceps tendon; ASL, anterosuperolateral portal.

FIGURE 1-47 The biceps tendon is provisionally secured with a half-racking suture from the ASL portal. H, humeral head; BT, biceps tendon.

FIGURE 1-48 The biceps tenodesis screw is being advanced securing the biceps tendon within the bone socket via interference fixation. Note a FiberTape suture is also dunked into the bone socket for later use in the SpeedBridge supraspinatus repair. The white suture is the half-racking suture, which was also compressed into the bone socket.

FIGURE 1-49 The white FiberWire suture is then passed through the upper subscapularis. H, humeral head.

FIGURE 1-50 The white FiberWire suture is tied thereby securing the subscapularis to the prepared bone bed of the lesser tuberosity. H, humeral head; SSc, subscapularis; blue comma, “comma sign.”

FIGURE 1-51 Lateral view of the supraspinatus tear. The FiberTape as well as the biceps whipstitch are shuttled through the supraspinatus for the anteromedial fixation point of the SpeedBridge. H, humeral head; GT, greater tuberosity; RC, rotator cuff.

FIGURE 1-52 The completed SpeedBridge as visualized from the lateral portal.

History:

A 43-year-old man who was doing a bench press in the gym when he felt a tearing sensation in the anterior aspect of the left shoulder 6 months earlier.
He has had persistent pain and weakness of the left shoulder.

Physical Exam:

Full active and passive range of motion
Positive bear-hug and belly-press tests

Imaging:

X-rays were normal.
MRI shows a tear of the upper subscapularis.

Arthroscopic Findings:

There was a retracted tear of the upper subscapularis, along with medial subluxation of the biceps.
A three-sided release of the subscapularis was performed in order to gain maximal excursion of the subscapularis.
A biceps tenodesis was performed at the top of the bicipital groove and sutures from the tenodesis construct were used to repair the subscapularis (Fig. 1-53).

FIGURE 1-53 Biceps tenodesis was performed at the top of the bicipital groove, and sutures from the tenodesis construct were used to repair the subscapularis.

Pearls, Pitfalls, and Decision-Making:

In order to repair the subscapularis under the least possible amount of tension, a three-sided release was performed in this case. This produced enough excursion of the tendon to allow it to be repaired to its anatomic footprint on the lesser tuberosity.

History:

A 47-year-old man has had years of shoulder pain in his dominant arm that has been unresponsive to conservative treatment

FIGURE 1-54 Preoperative MRI of a right shoulder. A: Axial T2 image demonstrates a subscapularis tear with medial bicep tendon subluxation. B: Sagittal T1 image demonstrates mild fatty degeneration of the upper subscapularis.

Physical Exam:

Tenderness over the biceps.
Active forward flexion is 40°, but he can hold his arm against gravity at 90°.
Bear-hug test is positive.

Imaging:

Plain radiographs are normal.
MRI demonstrates a tear of the subscapularis tendon with medial biceps tendon subluxation and mild fatty degeneration of the upper subscapularis (Fig. 1-54).

Arthroscopy Findings:

The biceps was partially torn and subluxed medially.
The supraspinatus tendon was intact (Fig. 1-55).
The subscapularis tendon had a partial articular tear inferiorly and was completely torn superiorly (Fig. 1-56A).
The medial footprint of the subscapularis was repaired with a transtendon technique using two medial anchors, and the superior portion was repaired with a double-row technique by preserving the medial sutures and securing these to a lateral SwiveLock anchor in a modified double-row repair (Fig. 1-56B).

Pearls, Pitfalls, and Decision-Making:

Medial biceps tendon subluxation on MRI virtually always indicates a tear of the subscapularis tendon.
Medial abrasion of the biceps at the level of the medial sling is typically associated with a tear of the subscapularis tendon.
As with the posterosuperior rotator cuff, the tear pattern for anterior and anterosuperior tears dictates the repair pattern.
- This tear has disruption of the medial footprint inferiorly but preservation of the lateral attachment inferiorly. Therefore, a transtendon anchor is required for restoration of the inferior footprint.
- Following placement of the superomedial anchor, a medial double pulley between the two anchors is effective for restoring the medial footprint.
- When the superior portion of the subscapularis tendon is completely torn, a double-row repair of this portion of the tear restores anatomy and reinforces the anterior rotator cable attachment.

FIGURE 1-55 Right shoulder, posterior glenohumeral viewing portal demonstrates an intact supraspinatus tendon. H, humeral head; RC, rotator cuff.

FIGURE 1-56 Right shoulder, posterior glenohumeral viewing portal with a 70° arthroscope. A: A tear of the subscapularis tendon is seen, which extends inferiorly. An anchor is being placed in a transtendon fashion for restoration of the inferomedial footprint. B: Final repair. H, humeral head; SSc, subscapularis tendon; LT, lesser tuberosity.

History:

A 58-year-old carpenter has pain and weakness in his dominant shoulder for several months.
He reports substantial weakness with overhead and has intermittent inability to raise his arm above shoulder level.

Physical Exam:

Range of motion:
- Forward flexion: 90° active, 160° passive (equal to opposite side)
- External rotation: 60° (equal to the opposite side)
- Internal rotation: L2 (equal bilaterally)
Strength:
- 4/5 external rotation at the side
- 3/5 supraspinatus
- Positive bear-hug and belly-press tests

Imaging:

Plain radiographs are normal (Fig. 1-57).
MRI shows complete tears of the subscapularis, supraspinatus, and infraspinatus tendons. Sagittal images show Goutallier stage II fatty degeneration in the supraspinatus and stage III changes in the infraspinatus and upper subscapularis (Fig. 1-58).

FIGURE 1-57 Preoperative Grashey view of a right shoulder demonstrates an intact glenohumeral joint and preservation of the normal contour of the greater tuberosity.

FIGURE 1-58 Preoperative MRI of a right shoulder. A: Axial T2 image demonstrates a tear of the subscapularis tendon. B: Coronal T2 image demonstrates a massive tear retracted to the level of the glenoid. C: Sagittal T1 image demonstrates fatty degeneration of the supraspinatus, infraspinatus, and upper subscapularis.

Arthroscopy Findings:

A massive rotator cuff tear was identified involving the subscapularis, supraspinatus, and infraspinatus tendons (Fig. 1-59).
A complete repair was achieved with a knotless SpeedBridge of the subscapularis tendon and singlerow repair of the supraspinatus and infraspinatus tendons (Fig. 1-60).

Pearls, Pitfalls, and Decision-Making:

Despite the advanced fatty degeneration, this patient is too active to consider arthroplasty, and he has preservation of the greater tuberosity, indicating a repairable tear.
Subscapularis tears can be difficult to detect on MRI, and atrophy of the upper subscapularis tendon is one indicator that should key the surgeon into diagnosing this tear.
Repair of the subscapularis tendon first facilitates and decreases subsequent tension on the posterosuperior rotator cuff.
A double-row repair can be performed when there is sufficient tendon mobility.
A knotless SpeedBridge repair is used for the subscapularis tendon based on the good tissue quality.
A single-row repair of the posterosuperior rotator cuff is used with multiple anchors based on limited mobility of the portion of the rotator cuff.

FIGURE 1-59 Arthroscopic view of a right shoulder. A: Posterior glenohumeral viewing portal with a 70° arthroscope demonstrates a tear of the majority of the subscapularis tendon. B: Posterior subacromial viewing portal demonstrates a massive tear of the supraspinatus and infraspinatus with retraction to the glenoid. G, glenoid; H, humeral head; RC, rotator cuff; SSc, subscapularis tendon; LT, lesser tuberosity.

FIGURE 1-60 Arthroscopic view of a right shoulder. A: Posterior glenohumeral viewing portal with a 70° arthroscope demonstrates a repaired subscapularis tendon. B: Posterior subacromial viewing portal demonstrates a single-row repair of the supraspinatus and infraspinatus tendons. G, glenoid; H, humeral head; RC, rotator cuff; SSc, subscapularis tendon; GT, greater tuberosity; Black Comma Symbol, comma sign.