Abstract
Rotator cuff disease is among the most prevalent musculoskeletal disorders treated by orthopedic surgeons. While supraspinatus tears are far more prevalent, subscapularis tears comprise between 3.5 and 8 % of all rotator cuff tears (Codman EA, Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: The shoulder. Thomas Todd Co, Boston, pp 65–67, 1934; Deutsch et al., Am J Sports Med 25:13–22, 1997; Frankle and Cofield, Rotator cuff tears involving the subscapularis tendon. Techniques and results of repair. In: Proceedings of the fifth international conference on Shoulder Surgery, International Shoulder and Elbow Society, Paris, p 52, 1992) and frequently go undiagnosed (Bennett, Arthroscopy 17:173–80, 2001; Gerber and Krushell, J Bone Joint Surg Br 73:389–394, 1991). Normal shoulder biomechanics depend heavily upon a functional subscapularis for dynamic stability of the glenohumeral joint. Patients with subscapularis insufficiency tend to present with anterior shoulder pain, weakness with internal rotation, increased passive external rotation, and sometimes with anterior glenohumeral instability. Physical examination tests designed to elucidate subscapularis pathology include the lift-off test, internal rotation lag sign, the belly-press test, the belly-off sign, and the bear-hug test. MRI remains the most useful and widely utilized imaging modality to confirm and characterize subscapularis disease. The majority of subscapularis tears can be treated with either arthroscopic or open primary repair. Significant muscle atrophy, fatty infiltration, tendon retraction, and large tear size reduce the chance of successful primary repair, and in extreme cases make such tears irreparable. Management of these tears remains a challenge, with musculotendinous transfer of the pectoralis major being the most commonly employed treatment option. General indications are pain, anterior instability, and/or significant functional limitations after failure of nonoperative management in the setting of an irreparable subscapularis tear. Contraindications include concomitant irreparable supraspinatus tear, advanced patient age, severe glenohumeral joint arthrosis, fixed anterior joint subluxation, an inability to comply with postoperative measures and rehabilitation, and pectoralis major dysfunction/insufficiency. Several techniques have been described and vary primarily upon the amount of tendon transferred as well as the location of tendon passage as it relates to the coracoid process and conjoined tendon. Postoperative rehabilitation protocols generally call for 6 weeks of immobilization with early pendulum exercises and gentle passive external rotation, progressing to active range of motion at 6 weeks, and strengthening beginning at 12 weeks. Robust outcomes data for this procedure is largely lacking in the current orthopedic literature, but many smaller clinical series suggest improvement in pain and incremental functional gains. As such, pectoralis major tendon transfer remains the workhorse salvage procedure for the management of the irreparable subscapularis tear.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Codman EA. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: The shoulder. Boston: Thomas Todd Co; 1934. p. 65–7.
Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF. Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med. 1997;25:13–22.
Frankle MA, Cofield RH. Rotator cuff tears involving the subscapularis tendon. Techniques and results of repair. In: Proceedings of the fifth international conference on Shoulder Surgery; 12–15 Jul 1992; Paris. International Shoulder and Elbow Society; 1992. p. 52.
Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy: arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001;17:173–80.
Ticker JB, Burkhart SS. Why repair the subscapularis? A logical rationale. Arthroscopy. 2011;27:1123–8.
Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73:389–94.
Warner JJ, Higgins L, Parsons 4th IM, Dowdy P. Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2001;10:37–46.
Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and post-operative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.
Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12:550–4.
Mellado JM, Calmet J, Olona M, Esteve C, Camins A, Perez Del Palomar L, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. Am J Roentgenol. 2005;184:1456–63.
Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop Relat Res. 1997;344:275–83.
Elhassan B, Ozbaydar M, Massimini D, Diller D, Higgins L, Warner JJ. Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work? J Bone Joint Surg Br. 2008;90:1059–65.
Galatz LM, Connor PM, Calfee RP, Hsu JC, Yamaguchi K. Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency. J Shoulder Elbow Surg. 2003;12:1–5.
Gavriilidis I, Kircher J, Magosch P, Licthenberg S, Habermeyer P. Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. Int Orthop. 2010;34:689–94.
Jost B, Puskas GJ, Lustenberger A, Gerber C. Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears. J Bone Joint Surg Am. 2003;85-A:1944–51.
Lederer S, Auffarth A, Bogner R, Tauber M, Mayer M, Karpik S, Matis N, Resch H. Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques. J Shoulder Elbow Surg. 2011;20:1155–62.
Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am. 2000;82:372–82.
Wirth MA, Rockwood Jr CA. Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am. 1997;79:722–73.
DePalma AF. Surgery of the shoulder. Philadelphia: Lippincott; 1950. p. 209–20.
Li XX, Schweitzer ME, Bifano JA, Lerman J, Manton GL, El-Noueam KI. MR evaluation of subscapularis tears. J Comput Assist Tomogr. 1999;23:713–7.
Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008;24:997–1004.
Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22:1076–84.
Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am. 2007;89:1184–93.
Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am. 1988;70:1308–11.
Nove-Josserand L, Levigne C, Noel E, Walch G. Isolated lesions of the subscapularis muscle. Apropos of 21 cases. Rev Chir Orthop Reparatrice Appar Mot. 1994;80:595–601. French.
Walch G, Boileau P. Rotator cuff tears associated with anterior instability. In: Warner JPJ, Iannotti JP, Gerber C, editors. Complex and revision problems in shoulder surgery. Philadelphia: Lippincott-Raven; 1997. p. 65–70.
Garavaglia G, Ufenast H, Taverna E. The frequency of subscapularis tear in arthroscopic rotator cuff repair: a retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int J Should Surg. 2001;5:91–4.
Ulrich L, Fullick R, Bongiorno V, Saintmard B, Campens C, Lafosse L. Arthroscopic repair of large subscapularis tendon tears: 2- to 4-year clinical and radiographic outcomes. Arthroscopy. 2013;29:1471–8.
Bennett WF. Arthroscopic repair of isolated subscapularis tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003;19:131–43.
Toussaint B, Audebert S, Barth J, Charousset C, Godeneche A, Joudet T, Lefebvre Y, Nove-Josserand L, Petroff E, Solignac N, Hardy P, Scymanski C, Maynou C, Thelu C-E, Boileau P, Pitermann M, Graveleau N, French Arthroscopy Society (SFA). Arthroscopic repair of subscapularis tears: preliminary data from a prospective multicentre study. Orthop Traumatol Surg Res. 2012;98(8 Suppl):S193–200.
Gray H. The muscles and fasciae of the shoulder. In: Goss CM, editor. Gray’s anatomy of the human body. 28th ed. Philadelphia: Lea and Febiger; 1968. p. 458–9.
Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Joint Surg Br. 1993;75:137–40.
Richards DP, Burkhart SS, Tehrany AM, Wirth MA. The subscapularis footprint: an anatomic description of its insertion site. Arthroscopy. 2007;23:251–4.
Kato K. Innervation of the scapular muscles and its morphological significance in man. Anat Anz. 1989;168:155–68.
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992;74:491–500.
Burkhart SS. Arthroscopic treatment of massive rotator cuff tears: clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;267:45–56.
Burkhart SS. Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model. Clin Orthop Relat Res. 1992;(284):144–52.
David G, Magarey ME, Jones MA, Dvir Z, Türker KS, Sharpe M. EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint. Clin Biomech (Bristol, Avon). 2000;15:95–102.
Denard PJ, Lädermann A, Burkhart SS. Arthroscopic management of subscapularis tears. Sports Med Arthrosc. 2011;19:333–41.
Inman VT, Saunders JB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg. 1944;26:1–30.
Thompson WO, Debski RE, Boardman 3rd ND, Taskiran E, Warner JJ, Fu FH, et al. A biomechanical analysis of rotator cuff deficiency in a cadaveric model. Am J Sports Med. 1996;24:286–92.
Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. Results of operative repair. J Bone Joint Surg Am. 1996;78:1015–23.
Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta‐analysis of individual tests. Br J Sports Med. 2012;46:964–78.
Hertel R, Ballmer FT, Lambert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307–13.
Pennock AT, Pennington WW, Torry MR, Decker MJ, Vaishnav SB, Provencher MT, Millett PJ, Hackett TR. The influence of arm and shoulder position on the bear‐hug, belly‐press, and lift‐off tests: an electromyographic study. Am J Sports Med. 2011;39:2338–46.
Scheibel M, Magosch P, Pritsch M, Lichtenberg S, Habermeyer P. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy. 2005;21:1229–35.
Ballmer FT, Lambert SM, Hertel R. Napoleon’s sign: a test to assess subscapularis function. J Shoulder Elbow Surg. 1997;6:193.
Scheibel M, Tsynman A, Magosch P, Schroeder RJ, Habermeyer P. Postoperative subscapularis muscle insufficiency after primary and revision open shoulder stabilization. Am J Sports Med. 2006;34:1586–93.
Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: technique and preliminary results. Arthroscopy. 2002;18:454–63.
Schwamborn T, Imhoff AB. Diagnosis and classification of rotator cuff lesions. In: Imhoff AB, Konig U, editors. Schulterinstabilitat-Rotatorenmanschette. Darmstadt: Steinkopff Verlag; 1999. p. 193–5. German.
Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical tests for subscapularis lesions. Knee Surg Sports Traumatol Arthrosc. 2010;18:1712–7.
Rigsby R, Sitler M, Kelly JD. Subscapularis tendon integrity: an examination of shoulder index tests. J Athl Train. 2010;45:404–6.
Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff: a comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000;82A:498–504.
Hodler J, Kursunoglu-Brahme S, Snyder SJ, Cervilla V, Karzel RP, Schweitzer ME, et al. Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthroscopic confirmation. Radiology. 1992;182:431–6.
Palmer EW, Brown JH, Rosenthal DI. Rotator cuff: evaluation with fat-suppressed MR arthrography. Radiology. 1993;188:683–7.
Jung JY, Yoon YC, Cha DI, Yoo JC, Jung JY. The “bridging sign”: a MR finding for combined full-thickness tears of the subscapularis tendon and the supraspinatus tendon. Acta Radiol. 2013;54:83–8.
Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8:599–605.
Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21:492–501.
Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect. 2001;50:63–71.
Levy O, Mullett H, Roberts S, Copeland S. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. J Shoulder Elbow Surg. 2008;17:863–70.
Cofield R, Parvizi J, Hoffmeyer P, Lanzer W, Ilstrup D, Rowland C. Surgical repair of chronic rotator cuff tears: a prospective long-term study. J Bone Joint Surg Am. 2001;83:71–7.
Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505–15.
Keener J, Wei A, Kim H, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009;91:1405–13.
Melillo AS, Savoie 3rd FH, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am. 1997;28:117–24.
Burkart S, Nottage W, Ogilvie-Harris D, Kohn H, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10:363–70.
Flatow E, Connor P, Levine W. Coracoacromial arch reconstruction for anterosuperior subluxation after failed rotator cuff surgery. J Shoulder Elbow Surg. 1997;6:228.
Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92:2544–56.
Flatow E, Bigliani LU, April EW. An anatomic study of the musculocutaneous nerve and its relationship to the coracoid. Clin Orthop Relat Res. 1989;244:166–71.
Klepps SJ, Goldfarb C, Flatow E, Galatz L, Yamaguchi K. Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers. J Shoulder Elbow Surg. 2001;10:453–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer Science+Business Media New York
About this chapter
Cite this chapter
Boatright, J.D., Crow, A.J., Brockmeier, S.F. (2015). Pectoralis Major Tendon Transfer. In: Gulotta, L., Craig, E. (eds) Massive Rotator Cuff Tears. Springer, Boston, MA. https://doi.org/10.1007/978-1-4899-7494-5_8
Download citation
DOI: https://doi.org/10.1007/978-1-4899-7494-5_8
Published:
Publisher Name: Springer, Boston, MA
Print ISBN: 978-1-4899-7493-8
Online ISBN: 978-1-4899-7494-5
eBook Packages: MedicineMedicine (R0)