Subscapularis Disruption

Description

Subscapularis disruption is characterized by pain and weakness in the shoulder as a result of partial or complete tearing of the subscapularis muscle and tendon from the upper arm (humerus). The subscapularis is one of the four rotator cuff muscles that surround the ball of the shoulder (humeral head); it is the muscle in the front of the humeral head and is the strongest of the four rotator cuff muscles. The subscapularis attaches directly to the humerus in the lower quarter of the muscle and via a tendon for the rest. The main function of the subscapularis is to help maintain the humeral head in the center of the socket and to provide strength for rotating the arm inward. This is an uncommon injury that may occur as part of a rotator cuff tear.

Common signs and symptoms

• Pain around the shoulder, often in the front of the shoulder and upper arm

• Pain that is worse with shoulder function, especially when reaching overhead or lifting

• Tenderness, swelling, warmth, or redness over the front of the shoulder (occasionally)

• Loss of strength, especially on inward rotation of the shoulder and arm

• Increased outward rotation of the shoulder

• Crepitation (a crackling sound) when the shoulder is moved

• Biceps tendon pain and inflammation in the front of the shoulder that is worse with bending the elbow or lifting

• Recurrent shoulder dislocation if a rupture is associated with or caused by initial dislocation

Causes

• Violent outer rotation of the shoulder or arm

• Hyperextension of the shoulder

• A direct blow to the shoulder or a fall

• Resumption of activity too soon after shoulder surgery, especially shoulder stabilization surgery

• Shoulder dislocation

Factors that increase risk

• Contact sports such as football, wrestling, and basketball

• Previous injury to the rotator cuff

• Poor physical conditioning (strength, flexibility)

• Inadequate warm-up before practice or play

• Inadequate protective equipment

• Shoulder dislocation

• Surgery that requires moving the subscapularis

Preventive measures

• Appropriately warm up and stretch before practice and competition.

• Maintain appropriate conditioning that includes cardiovascular fitness, shoulder flexibility, and strength and endurance training.

• Use proper sports technique.

Expected outcome

Subscapularis tears do not heal without treatment. Surgery is often recommended to optimize shoulder strength, alleviate pain, improve function, and help prevent recurrent dislocation.

Possible complications

• Persistent pain

• Shoulder stiffness, frozen shoulder, or loss of motion (uncommon)

• Persistent weakness

• Recurrence of symptoms, especially if treated without surgery

• Inability to return to the same level of sports performance

• Recurrent shoulder dislocation

• Risks of surgery, including infection, bleeding, injury to nerves, shoulder stiffness, weakness, retearing of the subscapularis, and persistent pain

General treatment considerations

Initial treatment consists of medication and ice to relieve pain and stretching and strengthening exercises. These all can be carried out at home, although referral to a physical therapist or athletic trainer may be prescribed. Surgery to reattach the tendon to the humerus is almost always recommended. Surgery performed after 6 months has a poorer result than surgery performed within the first 3 months following an injury. Surgery is performed through an open incision, and return to full activity usually requires 6 to 12 months.

Medication

• Nonsteroidal antiinflammatory medications, such as aspirin and ibuprofen (do not take for 7 days before surgery), or other over-the-counter pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician, and contact your doctor immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

• Stronger pain relievers may be prescribed as necessary. Use these only as directed, and take only as much as you need.

Heat and cold

• Cold is used to relieve pain and reduce inflammation. It should be applied for 10 to 15 minutes every 2 to 3 hours as needed and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

• Heat may be used before performing stretching and strengthening activities prescribed by your physician, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

When to call your doctor

• Symptoms get worse or do not improve in 2 to 4 weeks despite treatment.

• You experience pain, numbness, or coldness in your hand.

• A blue, gray, or dusky color appears in your fingernails.

• Any of the following occur after surgery: increased pain, swelling, redness, drainage, bleeding in the surgical area, or signs of infection such as headache, muscle aches, dizziness, or a general ill feeling with fever.

• New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

Figure 1

From Rockwood CA Jr, Matsen FA III: The shoulder, ed 2, Philadelphia, 1998, W.B. Saunders, p 17.

Range of Motion and Stretching Exercises

Subscapularis Disruption

These are some of the initial exercises you may use to start your rehabilitation program, until you see your physician, physical therapist, or athletic trainer again, or until your symptoms resolve. Please remember:

• Flexible tissue is more tolerant of the stresses placed on it.

• A gentle stretching sensation should be felt.

Range of motion scapular elevation, shrugs

1. Stand in a good, erect posture with your arms at your sides.

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