Dr. Ticker Speaks on Tips and Techniques for Arthroscopic Subscapularis Repair at the 40th Annual AANA Meeting

Dr. Jonathan Ticker on Subscapularis Repair

Practical Surgical Insights for Recognizing and Treating the Subscapularis Tendon

In this educational presentation, Jonathan Ticker, MD focuses on one of the most commonly missed and misunderstood structures in shoulder surgery: the subscapularis tendon. His goal is simple and practical. He wants surgeons to leave with a few clear techniques they can immediately apply in the operating room, along with a stronger understanding of how recognizing subtle anatomy can dramatically improve repair quality and outcomes.

Why the Subscapularis Matters:

Dr. Ticker emphasizes that subscapularis tears are often overlooked, particularly when attention is drawn to more obvious posterosuperior rotator cuff pathology. However, missing these tears can compromise overall shoulder stability and repair success.

A key theme of the talk is the importance of identifying the comma sign, a reliable arthroscopic landmark that helps surgeons locate retracted or hidden subscapularis tears.

Understanding the Comma Sign:

The comma tissue represents a connection between the subscapularis and supraspinatus tendons. Dr. Ticker explains that recognizing this tissue both on MRI and during arthroscopy can make the difference between an incomplete repair and a more accurate anatomic repair.

Key points he highlights include:

• The comma sign is often visible on MRI just anterior to typical posterosuperior cuff tears
• Fluid medial to the coracoid can be a clue to underlying subscapularis pathology
• Pulling on the comma tissue brings the subscapularis laterally into a more normal position
• Repairing the subscapularis also improves positioning of the supraspinatus

Surgical Techniques That Improve Repair Quality

Throughout the presentation, Dr. Ticker shares practical techniques that help achieve secure, reproducible repairs.

Some of the most valuable technical pearls include:

• Using traction sutures to improve visualization and mobilization
• Performing careful soft tissue releases around the subscapularis to allow proper reduction
• Using the middle glenohumeral ligament as a guide for how far the tendon should be brought laterally
• Placing anchors based on where the tendon naturally reduces with the arm in neutral position

He also discusses anchor placement options, including percutaneous techniques and approaches through the rotator interval, depending on access and visualization.

Efficient Suture Management and Passage

Dr. Ticker describes his preference for retrograde suture passing, which aligns with the natural fiber orientation of the subscapularis tendon. This approach allows for strong fixation while minimizing tissue trauma.

Additional tips include:

• Passing all sutures from a single anchor before tying
• Managing multiple suture pairs within a cannula using a spinal needle technique
• Using luggage-tag style sutures in select cases for smaller tears or biceps involvement

These strategies help reduce confusion, save time, and maintain control during complex repairs.

Clinical Impact and Outcomes

Dr. Ticker demonstrates how proper recognition and repair of the subscapularis can positively affect the entire shoulder repair construct. In several examples, repairing the subscapularis improved the position of the anterosuperior supraspinatus and allowed large tears to be addressed effectively using single-row techniques.

Postoperative examples showed stable repairs and strong functional outcomes at follow-up, reinforcing the value of attention to detail and anatomy-driven technique.

A Takeaway Surgeons Can Use Immediately

The central message of Dr. Ticker’s presentation is clear. Subscapularis tears are common, often subtle, and critically important. By learning to recognize the comma sign, respecting key anatomical landmarks, and applying deliberate surgical technique, surgeons can achieve more anatomic repairs and better long-term outcomes for their patients.

This practical, experience-based approach makes subscapularis repair more predictable and more successful in  arthroscopic shoulder surgery.