Dr. Ticker Explains His Approach to the Subscapularis Including Arthroscopic Techniques

Subscapularis Tendon Tears: Imaging Recognition and Arthroscopic Correlation

Overview:

In this in-depth instructional lecture, Jonathan Ticker, MD shares over two decades of clinical, surgical, and academic experience focused on the subscapularis tendon. This tendon is frequently overlooked,  but is a critically important component of the rotator cuff. The lecture, delivered to more than 1,000 musculoskeletal radiologists worldwide, bridges the gap between MRI interpretation and arthroscopic findings, helping clinicians better identify, understand, and treat subscapularis pathology.

Dr. Ticker emphasizes that subscapularis tears are far more common than historically appreciated, often occurring alongside biceps instability and posterosuperior rotator cuff tears, and that early recognition directly impacts reparability, surgical success, and long-term shoulder function.

Why the Subscapularis Matters:

The subscapularis plays a central role in anterior shoulder stability, internal rotation strength, and rotator cuff force coupling. Failure to identify and repair subscapularis tears can compromise outcomes, even when supraspinatus or infraspinatus repairs appear technically successful.

Key clinical implications include:

  • Increased risk of biceps tendon subluxation or dislocation
  • Higher likelihood of rotator cuff re-tear
  • Progressive tendon retraction and irreparable tears with delayed diagnosis
  • Persistent pain, weakness, and dysfunction despite posterior cuff repair

Historical Perspective and Evolution of Understanding:

Dr. Ticker reviews the evolution of subscapularis recognition, from early descriptions by Smith, Codman, and McLaughlin, to modern clinical and arthroscopic emphasis led by Gerber, Warner, and others. His own academic contributions, spanning early open repairs to advanced arthroscopic techniques, have helped shape contemporary understanding of anterior rotator cuff pathology.

Arthroscopic Anatomy and Key Intraoperative Landmarks:

A major focus of the lecture is arthroscopic identification of subscapularis tears and their associated structures:

  • Comma tissue: A critical soft-tissue landmark connecting the subscapularis to the supraspinatus
  • Middle glenohumeral ligament (MGHL): Used as a guide to determine the extent of subscapularis involvement
  • Lesser tuberosity footprint: Assessment of exposed bone guides repair strategy
  • Biceps pulley system: Frequently disrupted in subscapularis tears

Dr. Ticker demonstrates how mobilizing and repairing the subscapularis first helps laterally translate the posterosuperior cuff, creating a more secure and anatomic repair. He uses an  analogy where he likens the repair to “closing the zipper all the way.”

MRI Findings Radiologists Should Not Miss:

Dr. Ticker provides detailed guidance for radiologists evaluating MRI studies, emphasizing pattern recognition over isolated findings.

High-Value MRI Signs of Subscapularis Tears:

  • Medial retraction or absence of tendon anterior to the coracoid (“medial coracoid sign”)
  • Exposed or cystic changes at the lesser tuberosity footprint
  • Vertically oriented or medially displaced long head of the biceps tendon
  • Fluid tracking medially along the subscapularis
  • Disruption of the comma tissue on axial and sagittal views

He highlights that axial images alone are insufficient, advocating for careful review of sagittal and coronal sequences, especially when biceps pathology is present.

Hidden and Partial Subscapularis Tears:

A critical teaching point is the concept of “hidden lesions.” These are partial or deep-surface subscapularis tears that may appear subtle on MRI and during an arthroscopy unless specifically sought out. These are:

  • Often located beneath the biceps tendon in the groove
  • May appear benign until internal rotation or dynamic probing reveals the defect
  • Tend to progress if untreated, rather than remain stable

Dr. Ticker stresses the importance of actively inspecting the biceps groove arthroscopically to avoid missed diagnoses.

Surgical Principles and Repair Strategy:

While acknowledging that open repair remains a valid option, Dr. Ticker outlines his arthroscopic-first approach, emphasizing visualization, mobilization, and secure fixation.

Key Surgical Principles Include:

  • Early diagnosis improves reparability
  • Complete mobilization beneath the coracoid is essential
  • Single-row anchor fixation provides reliable healing when properly executed
  • Retrograde suture shuttling allows controlled tendon reduction
  • Internal rotation during knot tying improves footprint restoration
  • Associated pathology, especially biceps and posterosuperior cuff tears, must be addressed

Prevalence and Clinical Correlation:

Based on Dr. Ticker’s consecutive surgical series:

  • 30–40% of arthroscopic posterosuperior cuff repairs involved subscapularis pathology
  • Over 50% of those subscapularis tears required repair
  • Biceps pathology was present in nearly half of cases, frequently associated with subscapularis injury

These findings reinforce the importance of routine anterior cuff assessment in both imaging and surgery.

Clinical Examination and Patient Evaluation:

Dr. Ticker correlates imaging with physical examination findings, including:

  • Increased passive external rotation
  • Weakness on belly-press testing
  • Positive lift-off or modified lift-off tests

He emphasizes that imaging interpretation is most powerful when combined with direct patient examination and surgical correlation.

Key Takeaways for Radiologists and Surgeons:

  • Subscapularis tears are common, clinically significant, and frequently underdiagnosed
  • MRI sensitivity continues to improve, but pattern recognition remains essential
  • Biceps pathology is often the clue that leads to diagnosis
  • Early identification improves surgical options and outcomes
  • Collaboration between radiologists and surgeons strengthens patient care

Final Thoughts:

Dr. Ticker concludes by underscoring the value of cross-specialty collaboration, noting that shared understanding between radiologists and surgeons leads to better diagnosis, better surgery, and better patient outcomes. As awareness of subscapularis pathology continues to grow, so too does the opportunity to improve shoulder care through earlier recognition and thoughtful treatment.