Passive range of motion exercises are started the third day after surgery and limited to 30 degrees of flexion and 80 degrees of internal rotation for 6 weeks, with progressive increase in range of motion in each week. External rotation is permitted until neutral position. Then, after 6 weeks, active range of motion is allowed, including external rotation. At 3 months after surgery, strengthening of rotator cuff muscles is started, with a minimum of additional 2 months of rehabilitation.

The proposed technique, with the two alternative fixation methods (with and without bone chips), are suitable for irreparable ruptures of the subscapularis muscle as well as for anterosuperior defects of the cuff (Bateman III-IV, AB Patte) [10, 11]. In literature, reported results show satisfactory results in terms of improvement of function and reduction of pain, especially in those cases with isolated subscapularis rupture [7, 8, 12]. The pectoralis tendon transfer certainly provides a safe and promising method for the treatment of irreparable ruptures of the subscapularis tendon. A secure method of fixation that avoids secondary ruptures is of high importance. Jost et al. [8] reported that patients with pain localized in the insertion area (60 %) could have an insufficient insertion, and for this reason, the authors changed their fixation method from suture anchor to transosseus. The fixation method is of essential importance because the pectoralis muscle exhibits a high level of traction. The alternative technique with bony fixation was proposed to address it, with osseous healing more stable and predictable. This is supported by the finding that lesser tuberosity osteotomy compared to subscapularis tenotomy has lower rate of tear and higher functional scores [13, 14].

Another point of debate is the pathway of the transferred tendon. A recent biomechanical investigation has shown that rerouting the conjoined tendon is a good way to imitate the natural force vector and function of an intact subscapularis tendon [15]. Specifically, a transfer underneath the conjoint tendon better mimics glenohumeral kinematics (the maximum abduction angle as well as the external rotation angle and humeral translations at maximum abduction) that are closer to those in the intact shoulder than a transfer above the conjoint tendon.

The main reported complication of the pectoralis major tendon transfer is injury to the musculocutaneous nerve [8, 16]. In a recent study, it is shown that the anatomical variation in the musculocutaneous nerve branches may compromise the nerve integrity and function in approximately half of cases when a subcoracobrachialis pectoralis major transfer is performed [17]. Moreover, in 21 % of cases, there is not even enough space between the coracoid and the nerve branches to accommodate the transferred sternal portion of the pectoralis major muscle [17]. Authors of the latter study conclude that it might be unsafe to perform a subcoracobrachialis transfer in many shoulders [17]. To avoid iatrogenic injuries to the nerve, it is essential that the musculocutaneous nerve and its branches are identified since local variations may produce undesired contact between the transferred muscle and the nerve.