Hidden Long Head of the Biceps Tendon Instability and Concealed Intratendinous Subscapularis Tears

Abstract

Background: Few studies have described the characteristics of a concealed intratendinous subscapularis tear (CIST), and there is a lack of research on the preoperative predictability of such lesions. Purpose: To describe the characteristics of a CIST as seen on magnetic resonance imaging (MRI) and intraoperatively and to develop a scoring system for predicting such lesions. Study Design: Case series; Level of evidence, 4. Methods: Retrospectively, we identified 43 patients with CISTs among 442 consecutive patients who had undergone rotator cuff repair from July 2014 to June 2016. Range of motion, visual analog scale results for pain and function, and patient-reported outcome scores were evaluated preoperatively and at 1 and 2 years postoperatively. CISTs were classified arthroscopically as small (<5 mm), medium (5-10 mm), and large (>10 mm). We performed repair (≥50%) or debridement (<50%) depending on the total subscapularis tendon tear size including the CIST. Preoperative MRI findings were analyzed by 2 observers and were correlated with the arthroscopic findings. A 10-point scoring system was developed based on characteristics during the physical examination (anterior tenderness, bear hug sign), MRI (biceps tendon displacement and subluxation, subscapularis signal change just lateral to the lesser tuberosity), and arthroscopic surgery (medial biceps tendon lesion, combined subscapularis tendon tear), with a cutoff value of ≥7 predicting a CIST. After the retrospective study, we prospectively enrolled 95 patients to validate the 10-point CIST scoring system. Results: All 43 patients diagnosed with a CIST during the retrospective study improved both range of motion and functional scores at 1 year postoperatively. The interrater agreement of the 2 observers was substantial for the evaluation of all parameters except for subscapularis tear classification, which was moderate. On arthroscopic surgery, 11 small, 19 medium, and 13 large CISTs were detected. The preliminary prospective study showed a sensitivity of 61.9%, specificity of 94.3%, positive predictive value of 89.0%, negative predictive value of 75.7%, and accuracy of 80.0% when the cutoff value was set at ≥7 on the CIST scoring system. Conclusion: A CIST can be suspected using a combination of preoperative MRI and intra-articular diagnostic arthroscopic findings, but a definitive diagnosis requires an arthroscopic view. On the 10-point CIST scoring system, a score of ≥5 can be suggestive of a CIST, and a score of ≥7 is most likely to predict a CIST.

Risk factors of chronic subscapularis tendon tear

“…Several MR studies have reported that medial subluxation or dislocation of the LHBT is associated with SBT [ 47 , 49 ]. Hidden biceps tendon instability has also been reported as a factor associated with SBT [ 50 ]. One study reported a sentinel sign, in which biceps tendon scuffing, abrasion, or partial tear of the anterior portion can serve as a warning to clinicians about the presence of SBT [ 51 ].…”

Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear

“…When a concealed intratendinous subscapularis tear was highly suspected by a scoring system consisting of physical examination, MRI, and arthroscopic findings, we opened the bicipital transverse ligament and a part of the rotator interval after the biceps procedure (biceps tenotomy or tenodesis) and inspected the upper lateral insertion of the subscapularis tendon in the subacromial arthroscopic view. 8…”

“…When a concealed intratendinous subscapularis tear was highly suspected by a scoring system consisting of physical examination, MRI, and arthroscopic findings, we opened the bicipital transverse ligament and a part of the rotator interval after the biceps procedure (biceps tenotomy or tenodesis) and inspected the upper lateral insertion of the subscapularis tendon in the subacromial arthroscopic view. 8 The size of the subscapularis tendon tear was described according to the Yoo and Rhee classification as follows: type 1, fraying or longitudinal split tear of the leading edge of the subscapularis tendon; type 2A, \50% detachment of the subscapularis tendon from the first facet; type 2B, .50% detachment, corresponding to approximately one-fourth to one-third of the total superior-inferior length of the subscapularis tendon; type 3, the entire first facet with a full-thickness tear (lateral hood tear); type 4, exposure of the first and second facets with significant medial retraction of the tendon; and type 5, complete subscapularis tendon with involvement of the muscular portion (Figure 3). 55 After classification of the subscapularis tears was done, surgical repair was performed for subscapularis tears of type 2B or greater.…”

The long head of biceps at the shoulder: a scoping review

“…Concomitant rotator cuff pathology associated with LHB tendinopathy includes rotator cuff tears, Supraspinatus and Subscapularis tears, Supraspinatus tendinopathy and rotator cuff tendinopathy. A high association was observed between LHBT instability and rotator cuff pathology in twelve articles, inclusive of Subscapularis tears in eight articles [ 61 , 98 , 137 , 152 , 178 , 195 , 196 , 203 ], isolated Supraspinatus tears and Subscapularis tears in two studies [ 24 , 227 ] and rotator cuff tears in two studies [ 45 , 75 ]. A lower association was observed between the incidence of biceps pulley lesions and rotator cuff tears, SLAP lesions, anterosuperior impingement and increasing age [ 89 ].…”