Orthopaedics & Traumatology: Surgery & Research (2012) 98S, S186—S192

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ORIGINAL ARTICLE

New endoscopic classification for subscapularis

lesions
B. Toussaint a,∗, J. Barth b, C. Charousset c, A. Godeneche d, T. Joudet e,
Y. Lefebvre f, L. Nove-Josserand d, E. Petroff g, N. Solignac h, P. Hardy h,
C. Scymanski i, C. Maynou i, C.-E. Thelu j, P. Boileau j, N. Graveleau k,
S. Audebert l , The French Arthroscopy Society (SFA)1

a
Clinique Générale, 4, chemin Tour-de-la-Reine, 74000 Annecy, France
b
Clinique des Cèdres, 48, avenue de Grugliasco, 38130 Échirolles, France
c
60, rue de Courcelles, 75008 Paris, France
d
Centre Paul-Santy, 24, rue Paul-Santy 69008 Lyon, France
e
Clinique du Libournais, 119, rue de la Marne, 33500 Libourne, France
f
16, allée de la Robertsau, 67000 Strasbourg, France
g
48, rue de l’Abbe-Choquet, 59140 Dunkerque, France
h
Hôpital Ambroise-Paré, 9, avenue Charles-De-Gaulle, 92100 Boulogne-Billancourt, France
i
Hôpital Salengro, hôpital B CHR Lille cité hospitalière, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
j
Service chirurgie orthopédique, hôpital Archet-2, CHU de Nice, 151, route Saint-Antoine-Ginestière, BP 3079, 06200 Nice, France
k
Centre Vauban, 2, avenue de Ségur, 75007 Paris, France
l
ZAC du Bois de la Chocque, rue Paul-Emile-Victor, 02100 Saint-Quentin, France

Accepted: 25 September 2012

KEYWORDS Summary
Subscapularis tears; Background: The absence of a coherent classification system has hampered communication
Classification; about the treatment and outcomes of the various types of subscapularis tendon lesions. In
Anatomical lesions addition, a reliable classification system allows comparisons of epidemiological and therapeutic
data. The classification systems used until now fail to incorporate the radiological and intraop-
erative abnormalities of the bicipital sling, and they do not consider the degree of subscapularis
tendon cleavage. Here, we describe a new arthroscopy-based classification system intended for
therapeutic and prognostic purposes.
Methods: A prospective multicentre study sponsored by the French Society for Arthroscopy was
conducted from March 2010 to January 2011 in 150 isolated subscapularis lesions with or without
limited anterosuperior involvement. The bicipital sling and insertion of the deep subscapularis

∗ Corresponding author.
E-mail address: bruno.toussaint10@wanadoo.fr (B. Toussaint).
1 18, rue Marbeuf, 75008 Paris, France.

1877-0568/$ – see front matter © 2012 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2012.10.003
New endoscopic classification for subscapularis lesions S187

layer were routinely investigated by arthroscopy with video recording. Each lesion was classified
after a consensus was reached among four surgeons.
Results: We identified four lesion types based on the bicipital sling findings. Type I was defined
as partial separation of the subscapularis tendon fibres from the lesser tuberosity with a normal
bicipital sling. Type II consisted of a partial subscapularis tear at the lesser tuberosity attach-
ment combined with partial injury to the anterior wall of the bicipital sling, without injury to
the superior glenohumeral ligament. Type III was complete separation of the subscapularis fibres
from the lesser tuberosity with extensive cleavage of the bicipital sling. Finally, in Type IV, all
the subscapularis fibres were detached and, in some cases, conjunction of the subscapularis and
supraspinatus fibres produced the comma sign. Nearly all the lesions identified intraoperatively
during the study fit one of these four types.
Discussion: A reproducible classification system that allows different surgeons to establish
comparable homogeneous patient groups is useful for both therapeutic and prognostic purposes.
We defined four types of subscapularis lesions that are easy to identify as either isolated lesions
or combined with anterosuperior rotator cuff tears. Long head of biceps tendon abnormalities
and fatty degeneration of the shoulder muscles can be added to our classification system. Stud-
ies of intraobserver and interobserver reproducibility are needed to complete the process of
validating the diagnostic and/or prognostic usefulness of this new classification scheme.
Level of evidence: II.
© 2012 Elsevier Masson SAS. All rights reserved.

Introduction superficial supraspinatus fibres [4,12,13] (Fig. 2). Finally, the

uppermost part of the tendon does not attach to the lesser
tuberosity but instead forms the floor of the most proximal
Recent anatomic studies have produced new information on portion of the bicipital sling.
subscapularis muscle anatomy, particularly regarding ten- During open surgery, adequate visualization of the sub-
don attachment to the lesser tuberosity and relationships scapularis is difficult to achieve, and the frequency of
of the tendon with the other components of the rotator subscapularis tendon lesions was consequently underesti-
interval. The anatomic characteristics of the subscapularis mated for many years [14,15]. Initial studies by Walch et al.
tendon differ markedly from those of the other rotator cuff [16] identified hidden lesions of the subscapularis that were
tendons, i.e., the supraspinatus and infraspinatus tendons. covered by intact superficial fibres. Only after the bicipital
The rotator interval is composed of the superior sling and rotator interval are opened can these lesions be
glenohumeral ligament, the two coracohumeral ligament visualised and repaired. The introduction of arthroscopic-
bundles, and the glenohumeral joint capsule [1—5]. Jost assisted procedures for rotator cuff surgery improved the
et al. [6] identified three layers: the deep layer, composed of diagnosis of subscapularis tendon lesions [17]. In a study of
the superior glenohumeral ligament; the intermediate layer,
composed of the two bundles of the coracohumeral liga-
ment; and the superficial layer, formed by the supraspinatus
fibres posteriorly and the subscapularis fibres anteriorly
[6—8]. The superficial layer overlies the uppermost part
of the bicipital sling, as well as the transverse humeral
ligament that extends between the two edges of the bicip-
ital groove in the humerus. Arai et al. [9,10] described
a tendinous slip composed of the uppermost fibres of the
subscapularis tendon extending to the anterior wall of the
bicipital sling, formed by the proximal portion of the lesser
tuberosity. A depression in these fibres produces a fibrous
groove (anterior portion of the proximal bicipital sling) with
the superior glenohumeral ligament and medial bundle of
the coracohumeral ligament (Fig. 1) [8,11]. The inferior
portion of the subscapularis tendon contains a contingent
of muscle fibres that attach directly to the distal lesser
tuberosity, along a narrow vertical footprint. The superior
portion of the subscapularis tendon attachment is com-
posed of a main contingent having a roughly triangular Figure 1 Anatomy of the rotator interval. A: coracohumeral
downwards-pointing footprint and of a secondary contingent ligament; B: long head of biceps tendon (red); C: superior
that attaches directly to the transverse humeral ligament glenohumeral ligament (green); D: tendinous slip (yellow); E:
over the roof of the bicipital sling and coalesces with the transverse humeral ligament (beige); F: subscapularis muscle.
S188 B. Toussaint et al.

Table 1 Anatomic structures studied and possible

descriptions.

Anatomic structure Possible descriptions

1 Anterior wall of the Normal, partial tear,

bicipital sling complete tear
2 Anterior and superior Normal, distended, torn
pulley of the biceps
3 Comma sign Present, absent
4 Connection between Present, absent
supraspinatus and
subscapularis fibres
without rotator interval
disruption
6 Biceps tendon position Normal, subluxation,
luxation, absent

Figure 2 Arthroscopic view of the rotator interval. SSC: sub- 7 Subscapularis tendon None, upper third, upper
scapularis tendon; LGHS: superior glenohumeral ligament; Lgt detachment from the two-thirds, > upper
Hum Transverse: transverse humeral ligament. lesser tuberosity two-thirds

8 Depth of detachment None, partial, total

348 rotator cuff tears by Garavaglia et al. [18], subscapularis
tendon lesions were found in 37% of cases.
Classification systems for subscapularis tendon lesions
have been developed by Lafosse et al. [19], Garavaglia et al.
[18], and Fox et al. [20]. All three systems use descrip-
tions derived from those of supraspinatus tendon lesions.
The tears are described in the superior-to-inferior direction,
without taking into account the anterior part of the bicipi-
tal sling or the thickness of the tears, even in the modified
versions of these classification systems [20,21]. Garavaglia
et al. [18] defined six grades with a distinction, among grade
I lesions, of minor fraying of the upper tendon edge (grade
Ia) and of partial tears in the deep tendon fibres (grade Ib).
This system gives considerable importance to the comma
sign seen when the upper two-thirds of the tendon are torn,
as initially described by Lo and Burkhart [22].
Here, our objective was to develop a new classifica-
tion system for subscapularis tendon lesions that takes
into account the anatomic abnormalities at both the lesser
tuberosity and the bicipital sling, as identified during the
diagnostic step of shoulder arthroscopy.
Materials and method
A prospective study sponsored by the French Society for
Arthroscopy (Société française d’arthroscopie [SFA]) was
conducted from March 2010 to January 2011 in 12 surgical
centres in 176 consecutive patients with subscapularis ten-
don lesions that were either isolated or combined with deep
supraspinatus tendon tears or minor full-thickness tears. We
excluded patients with extensive full-thickness tears and
patients undergoing revision rotator cuff surgery.
Video recordings of the arthroscopic procedures per-
formed in the 176 study patients were reviewed by four
senior surgeons working in three different centres. The sur-
geons worked independently of one another and used a
standardised form to describe the lesions.
9 Subscapularis tendon Absent, intermediate, to
retraction the glenoid labrum
10 Trophicity of the Good, fair, poor
subscapularis tendon
11 Lamellar dissection of the Present, absent
tendon
12 Type of tear Isolated + deep aspect of
supraspinatus + full-
thickness tear in
supraspinatus
The diagnostic step of the arthroscopy procedure was
standardised. The posterior approach and a 30◦ arthroscope
were used. The upper portion of the subscapularis was
explored first, with the arm in neutral rotation. The arm
was then rotated internally to visualise the most medial
part of the subscapularis footprint on the lesser tuberos-
ity, by opening up the angle between the tendon fibres and
humeral head. The size and height of the footprint were
evaluated according to Wright et al. [23]. The bicipital sling
and its upper opening were then examined, followed by the
biceps tendon and components of the rotator interval. The
condition and position of the biceps tendon were assessed
using the criteria of Walch et al. [24]. Special attention was
given to the condition of the anterior wall of the bicipi-
tal sling, where complete or incomplete tears were sought.
After debridement and division of the superior glenohumeral
ligament, which were the first steps of the repair proce-
dure [10], complete exploration of the lesions was possible.
In particular, the height and extent of the lesions were
assessed, most notably at the lesser tuberosity. If needed,
an anterosuperior portal was created for introduction of the
arthroscope along the axis of the tendon. Table 1 lists the 12
New endoscopic classification for subscapularis lesions
Figure 3 Arthroscopic view of the comma sign. SSP:
supraspinatus tendon; SSC: subscapularis tendon.
criteria that were assessed during arthroscopic exploration
and during interpretation of the video recordings.
Results
Bicipital sling and associated lesions
In 36 cases, examination of the bicipital sling was consid-
ered to contribute no information to the evaluation of the
anterior sling wall.
The sling was classified as normal in 14 cases. In 12 of
these cases, partial separation of the subscapularis tendon
from the lesser tuberosity was noted. In the remaining two
cases, the subscapularis was completely detached, leaving
the bicipital sling intact but resulting in complete disappear-
ance of the anterior portion of the sling, which was replaced
by a comma sign.
In 72 cases, a partial tear was seen in the anterior
sling wall. The concomitant subscapularis tears were full-
thickness in ten cases and partial-thickness in 62 cases. In 14
of these 62 last cases, the subscapularis was detached over
more than one-third of the height of the lesser tuberosity. In
these cases, examination of the anterior sling (composed of
the tendinous slip medially, superior glenohumeral ligament
and medial coracohumeral ligament anteriorly, and superfi-
cial rotator interval fibres laterally) showed no lesions in 24
cases, distension with no risk of biceps tendon subluxation
in 32 cases, and tears in two cases.
Finally, in 54 cases, there was a complete tear in the
anterior wall of the bicipital sling. In 52 of these 54 cases,
the subscapularis was completely detached, over more than
one-third of the height of the tuberosity in 39 cases and over
the full height in 13 cases.
The comma sign was seen in 62 cases. In all these
cases, there was a complete tear in the anterior sling, with
disappearance of the superior glenohumeral ligament and
coracohumeral ligament (Fig. 3).
S189
Long head of biceps tendon (LHBT) and associated
lesions
The condition and position of the long head of biceps tendon
(LHBT) could be adequately determined in 162 of the 176
cases.
The LHBT was torn in 22 cases and was permanently dis-
located medially in 17 cases.
The LHBT was subluxed in the sling in 56 cases with dis-
tension of the front of the pulley. The LHBT was centered in
the sling in 67 cases.
The appearance of the LBHT was normal in 39 cases
(three LHBT dislocated, seven LHBT subluxed, 29 LHBT cen-
tered in the sling) and pathologic in 113 cases.
In the 67 cases of LHBT centered in the sling, the anterior
wall of the sling could not be evaluated in 50 cases. The sling
was normal in 11 cases, with a partial tear in 30 cases, and
a complete tear in nine cases.
In the 39 normal LHBT, the anterior wall of the sling was
normal in 10 cases, with a partial tear in 17 cases and with
a complete tear in nine cases (the anterior wall of the sling
could not be evaluated in three cases).
In 113 damaged LHBT, the anterior wall of the sling was
normal in two cases, with a partial sling tear in 48 cases,
and with a complete tear in 35 cases (the anterior wall of
the sling could not be evaluated in 28 cases).
Other features
Tendon quality could not be assessed in a reproducible man-
ner.
The shape of the coracoid process and the space between
the conjoined tendon and subscapularis were classified as
normal in every case.
Anterosuperior subluxation of the humeral head was not
found in any of the cases.
Lesion patterns
A systematic analysis of the individual lesions allowed us to
identify four patterns:
• type 1 (n = 14) was defined as a normal anterior sling wall
with partial subscapularis tendon detachment;
• type 2 (n = 72) combined partial subscapularis separation
from the lesser tuberosity and a partial tear in the anterior
sling wall;
• type 3 (n = 54) was a complete subscapularis tendon
detachment and a complete tear in the anterior sling wall,
with the most superficial fibres remaining continuous with
the sling;
• in type 4 (n = 36), was a complete detachment of the sub-
scapularis tendon from the humerus by a full-thickness
tear, leaving a free lateral edge.
Discussion
This study rests on systematic descriptions of lesions found
during arthroscopy. We were able to define four main lesion
types in a large patient population. Although lesion severity
S190 B. Toussaint et al.

Figure 4 Type 1 lesion. On the left, the subscapularis tendon fibres are frayed and partially separated from the humerus. On the
right, note the intact bicipital sling and the erosion in the superior glenohumeral ligament and tendinous slip (arrow).

Figure 5 Type 2 lesion. On the left, tear in the bicipital sling. On the right, the probe introduced into the tear is lifting the
superficial subscapularis fibres. 1: biceps: long head of biceps tendon; 2: coracohumeral ligament; 3: tear in the bicipital sheath;
4: humeral head.

would seem to increase from Type 1 to Type 4, we cannot
state with confidence that a continuum exists across the four
lesion types.
Subscapularis tendon lesions, including severe forms, can
exist in the absence of damage to the LHBT or bicipital sling,
indicating that the biceps does not play a predominant role
in the genesis of subscapularis lesions [24]. Subscapularis
tendon damage is likely to be secondary only when delam-
ination is found, with a complete tear in the anterior sling
wall and LHBT luxation between the two layers [25,26].
Thus, although subscapularis lesions are consistently present
in patients with LHBT luxation or subluxation, the reverse
is not true, as subscapularis lesions may exist without LHBT
luxation. Our results confirm that subscapularis lesions can
antedate biceps lesions and that the two can progress inde-
pendently of each other [17].
Current classification systems describe the size of the
lesion relative to the height of the subscapularis footprint on
the lesser tuberosity, without taking into account the thick-
ness of the tear or the presence of bicipital sling lesions
[18—20]. Lafosse et al. [19] described five grades: I, partial
tear in the upper third; II, complete tear in the upper third;
III, complete tear in the upper two-thirds; IV, complete
tear with a normally centred humerus and a fatty degen-
eration grade no greater than 3; and V, superior humeral
head subluxation and fatty degeneration grade grater than
3. Intraoperative evaluation of muscle trophicity has proven
highly subjective and difficult to quantify and, consequently,
contributes little to the diagnosis. The size and degree of
fatty degeneration of the muscles are best assessed by com-
puted tomography-arthrography and magnetic resonance
imaging with intra-articular gadolinium injection. Finally, in
our opinion, the articular layer concept introduced in a 2010
classification system modification is a source of additional
complexity. The classification systems devised by Fox et al.
[20] and Garaviglia et al. [18] fail to substantially improve
the description of lesions other than those strictly confined
to the tendons.
The classification system with four lesion types devel-
oped in our study relies both on the lesions at the lesser
tuberosity and on those affecting the bicipital sling. Indeed,
connections exist between the subscapularis and supraspina-
tus fibres and the components of the rotator interval. Given
that the potential for lesion progression remains unclear,
we used the term ‘‘type’’ instead of ‘‘stage’’ or ‘‘grade’’.
Type 1 is defined as subscapularis tendon separation from the
lesser tuberosity — usually partial — with no abnormalities of
the bicipital sling or superior glenohumeral ligament. The
anatomical condition of the bicipital tendon varies, as does
the vertical extent of the lesion (Fig. 4).
New endoscopic classification for subscapularis lesions
Figure 6 Type 3 lesion. On the left, the probe is in the bicipital sheath tear. On the right, note the complete separation of the
subscapularis tendon from the humerus. SSC: subscapularis tendon; LGHS becomes SGHL: superior glenohumeral ligament.
Figure 7 Type 4 lesion. On the left, intra-articular view of the lesions. On the right, subacromial view after section of the biceps:
note the free edge of the subscapularis tendon (arrow).
In Type 2 lesions, the subscapularis tendon is sepa-
rated from the lesser tuberosity and there is a partial
lesion of the bicipital sling that spares the anterior LHBT
pulley and the tendinous slip. The superior glenohumeral
ligament is intact. A probe introduced through the par-
tial sling tear (usually located in the anterior wall) can
be used to lift the superficial layer of the subscapu-
laris, which is no longer attached to the lesser tuberosity
(Fig. 5).
Type 3 lesions combine complete subscapularis ten-
don separation and a complete tear in the anterior sling
wall. The anterior bicipital pulley may be normal, dis-
tended or, in a minority of cases, completely torn. Tendon
retraction is minimal, because the superficial tendon layer
remains normally attached to the bicipital sling and con-
nected to the superficial supraspinatus fibres. The vertical
extent of the lesion varies and may be difficult to assess,
since the middle glenohumeral ligament may be difficult to
differentiate intraoperatively from the subscapularis ten-
don. The superior glenohumeral ligament may be torn,
exposing the medial part of the coracohumeral ligament
(Fig. 6).
Finally, in Type 4 lesions, the subscapularis tendon is com-
pletely detached, leaving a free edge, which may remain
continuous with the fibrous scar tissue adhering either to
the humerus or to the subacromial bursa. The degree of
tendon retraction is variable, and the stump may reach the
S191
level of the glenoid labrum. When the supraspinatus ten-
don is detached also, the comma sign is readily seen and
links the subscapularis to the supraspinatus. During arthro-
scopic dissection, care should be taken to individualise the
free edge of the subscapularis tendon and the comma sign,
to allow an assessment of reducibility followed by reduc-
tion of the subscapularis to the lesser tuberosity (Fig. 7).
The vertical extent of the lesion is difficult to assess, as the
level of attachment of the middle glenohumeral ligament on
the humerus varies and the subscapularis muscle fibres are
difficult to identify, although the upper edge of the latis-
simus dorsi muscle is visible during the extraarticular step
[27].
This new classification system seems more appropri-
ate for the lesions seen during arthroscopic exploration
of the subscapularis, allowing them to be described in
greater detail. It takes into account the anatomic difference
between the subscapularis and supraspinatus footprints on
the humerus. Using these data to interpret radiological
images, including those obtained by computed tomography-
arthrography and magnetic resonance imaging, may improve
the diagnosis and classification of subscapularis lesions dur-
ing the imaging workup. In this initial descriptive study,
we did not evaluate intraobserver or interobserver repro-
ducibility. However, the assessments of the four observers
seemed concordant. Reproducibility will be validated in a
subsequent study.
S192
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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