Anyway, okay, so good morning. I'm going to talk about subscap tears and bicep tendon pathology in athletes. So the subscap is somewhat the forgotten tendon. The incidence is much lower than the other ones, only 3.5%. And it's even more rare in athletes. So I've been in practice for 16 years and I can say, I think I've seen four acute subscap ruptures in athletes, two in football, I can think of them off the top of my head, one from water skiing and one from arm wrestling was my most recent one. Most frequently, they're traumatic tendon avulsion tears. Sometimes in the elderly patient, you're seeing a different pathology. Those are chronic degeneration and it can precede a sports-related trauma. So you'll see this in older patients and the clinical implications can be huge, particularly in these young athletes, if there's an acute rupture, you can get diminished athletic performance to serious disability. We know that the anatomy of the subscap is intimately related to the bicep tendon. So when you see bicep tendon pathology as well, you need to look for the subscap. The fibers of the subscap make the floor of your bicipital groove. Again, the most common things you'll see then, acute high-energy sports for an acute rupture, again, water skiing, baseball, arm wrestling, the typical mechanism is a violent hyperextension or combined adduction and external rotation maneuver. In skeletal immaturity, occasionally you'll see a rupture of the lesser tuberosity in a child. I've seen that once. And again, in older athletes, usually the tendon will rupture first. Again in these elderly patients, chronic overuse can precede them. You'll get microtrauma, I think from coracoid impingement. Sometimes anterior superior impingement as well can contribute. The sports that predispose that, golf, tennis, baseball pitchers and butterfly swimmers are most likely to get this coracoid impingement. So most patients will report acute trauma with this forcible hyperextension, external rotation is the mechanism. On physical exam they'll present with tenderness over the lesser tuberosity, increased passive external rotation, diminished internal rotation strength. They can have a positive bear hug, belly press or lift off. Sometimes those tests aren't positive so it's a little confusing. They're not always accurate. You can see positive apprehension, particularly if they've had a dislocation that caused this. And their bicep test can be positive. When there is an acute rupture, it is indicated to do surgery quickly, particularly these young athletes. So these aren't people that I sit on and try to rehab. I work on them, or will recommend surgery right away if they have only conservative management if they have an isolated partial tear. I try to fix them within one to two weeks, prevent scarring and tendon retraction. If partial tears involve over 50% of the tendon and they have impairment, then I will recommend surgery for them as well. Bicep tendon subluxation needs to be identified. My preferred method is to tenodese the bicep. I usually do an open subpectenodesis. And then with or without corcoplasty, you can look at the level of impingement. I think it's rare that I do a corcoplasty. Some people do more of them. Do you do them open versus arthroscopic? So most of the literature on these has reviewed open repair. My preferred technique is arthroscopic. But I think whatever is your best technique is fine. If you do it best open, that's fine, particularly if they're lower. So sometimes the tendinous part will stay intact, but the lower part will rupture. So when they're more inferior down the humerus, then I'm more likely to open that patient. Again, no substantial studies are out there. The largest case series is 13 patients. And that again looked at an open repair for isolated subscap tear, 12 of 13 were able to return to pre-injury level. So my tips and pearls when you have one of these, be prepared. Look at the axial cuts yourself. These are often missed by the radiologist when you're testing. So make sure you're looking at that. Any reed that discusses subluxation or dislocation of the bicep have a high suspicion for subscap tear. Again, look at these. You can see these wavy subscaps. These are partial thickness tears that often get missed on the reed. So be prepared to fix them. When I'm doing this arthroscopically, again use traction sutures. First you need to make sure you're identifying it. So make sure you get good visualization of the subscap with rotation of the arm. Some people use a 70-degree scope. I think that's unnecessary. I feel like if you get the 30-degree scope in, internally rotate the arm, you can see the insertion appropriately. I address the bicep tendon pathology first. If your bicep is subluxed out of the groove, I will plan on doing a tenodesis. I tag the bicep and truncate it, get it out of the way. I like to tag it so I can find it when I'm doing my tenodesis. I open the rotator interval. I open the... Sorry, the slides are a little slow. Expose the coracoid if necessary. I remember the first time I saw that, I was like, oh, it's sitting right there. It's very easy to do. Actually, it's right in front of you if you open up the Anter capsule. Assess your tear. If it's a side-to-side tear, you can put your sutures in. You can use bird peaks. You can use suture passers. Now with the different suture passing devices that are self-capture, I think it makes it easier to use a scorpion-like device. Again, develop your plane anterior to the subscap if you need to mobilize it. And put traction sutures in if necessary to pull it over. And sorry, my video is not going. Hang on. It's thinking. You can prepare your lesser tuberosity. I'll debride the lesser tuberosity. The bone is very dense up there. It's some of the densest bone in the proximal humerus. So in those patients, I'll put an anchor in. And I like to use a self-tapping lateral row type device. So I'll place my sutures in, shuttle the sutures through the tendon. You can do whichever way. Again, normally I'm using a scorpion-like device. I now use tape and place my sutures in a mattress fashion. And then I'll use the metal-tipped anchor to put that in. And it's nice because then you don't have to find your hole again if you're tapping. So these are just different partial tears that I've fixed. And then you can assess your subscap repair at the end. So in conclusion, you want to look for acute complete subscap tears. They're rare. If you see them, you should fix them sooner rather than later. Partial subscap tears are probably more common than we think in the aging athlete. Be prepared to address these when you go into surgery. Have the right tools on hand to fix them. Look for associated bicep pathology and be prepared to tinnitus the bicep if necessary. And then the coracoid as well. So thank you.

subscapularis tears

bicep tendon pathology

athletes

traumatic tendon avulsion tears

chronic degeneration