The population of Hawai\'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai\'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

Anterior cable reconstruction (ACR) using the long head of the biceps tendon (LHBT) was developed to place at the native superior capsule attachment site for large to massive rotator cuff tears (LMRCTs) with anterior cable disruption. In this study, we investigated whether ACR for reinforcement before ARCR prevented retear after arthroscopic rotator cuff repair (ARCR), especially in cases of LMRCTs with anterior cable disruption. A total of 125 patients who underwent arthroscopic rotator cuff repair (ARCR) for LMRCTs were retrospectively enrolled. To assess the benefit of ACR with LHBT, all data were compared with those after ARCR alone. As a result, ACR with LHBT showed satisfactory clinical and radiologic outcomes in comparison with conventional ARCR only technique. ACR with LHBT prevented retear after ARCR and improved the AHD, although There was no difference of clinical outcomes between two groups.

BACKGROUND: This study evaluated the presence of the rotator cable intraoperatively and compared its prevalence according to both patient age and rotator cuff integrity. The study hypothesis was that the cable would be more prevalent in older patients and patients with partial-thickness tears.
METHODS: Patients who were undergoing shoulder arthroscopy and were aged at least 16 years were included in this study, whereas those who had a cuff tear of more than 1 tendon or who had a video with poor visualization of the rotator cuff insertion were excluded. Intraoperative videos were collected, deidentified, and distributed to 7 orthopedic surgeons to define rotator cable and cuff tear characteristics.
RESULTS: A total of 58 arthroscopic videos (average patient age, 46 years; range, 16-75 years) were evaluated. The observers were in the most agreement on identifying the presence of a cable, with a κ coefficient of 0.276. Patients with the rotator cable were significantly older than those without it (mean age, 52.1 years vs. 42.5 years; P = .008), and a positive and significant correlation was found between rotator cable presence and increasing patient age (r = 0.27, P = .04). A significant association was noted between tear degree and cable presence (P = .002). There was no significant association with cable presence in patients with a full-thickness tear.
CONCLUSIONS: In this study, an intraoperative analysis was performed to define the presence of the rotator cable and correlate this with both patient age and rotator cuff integrity. The hypothesis was confirmed in that patients older than 40 years had a significantly higher rotator cable prevalence.

OBJECTIVE: The purpose of this study was to compare clinical and radiological outcomes after arthroscopic repair of two different rotator cuff tear configurations: anterosuperior rotator cuff tear and rotator cuff tears with subscapularis involvement. It was hypothesized that, although both tear configurations would show significant improvement in clinical outcomes after arthroscopic repair, the rotator cuff tears with subscapularis involvement where the anterior rotator cable maintains its integrity would have better clinical outcomes and structural integrity.
METHODS: This study included 226 patients who underwent arthroscopic repair of anterosuperior rotator cuff tears (n = 107, group A) and rotator cuff tears with subscapularis involvement (n = 119, group B). The visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and active range of motion (ROM) were assessed. Modified belly press test was performed to assess the strength of the subscapularis muscle. Cuff integrity was evaluated using magnetic resonance arthrography or computed tomographic arthrography at 6 months after operation.
RESULTS: At 3-year follow-up, the VAS score, SSVs, ASES scores, UCLA shoulder scores, active ROM, and modified belly press test showed significant improvement in both groups (p < 0.001). However, these improvements showed no statistical significance between the two groups. On follow-up radiologic evaluations, no significant difference in re-tear rates between group A (25 of 107, 23.4%) and group B (23 of 119, 19.3%) was observed.
CONCLUSIONS: The presence of anterior cable involvement of the anterosuperior rotator cuff tear did not affect postoperative clinical outcomes and re-tear rate compared to rotator cuff tears with subscapularis involvement where the anterior cable integrity was maintained, although the anterosuperior rotator cuff tear was associated with more significant preoperative supraspinatus fatty infiltration. Therefore, the present study determined that it would not be necessary to differentiate treatment protocols between these patterns.
METHODS: Level III.

UNASSIGNED: Partial articular supraspinatus tendon avulsion (PASTA) lesions are often seen in shoulders of throwing athletes. PASTA lesions in anterior instability are also found in recurrent anterior glenohumeral instability.
UNASSIGNED: To investigate the prevalence and location of rotator cuff tears (RCTs), including PASTA lesions, in shoulders with recurrent anterior instability.
UNASSIGNED: Case series; Level of evidence, 4.
UNASSIGNED: A total of 842 shoulders in 801 patients with recurrent anterior instability (647 men, 154 women; mean age, 24 years; age range, 13-40 years) who underwent arthroscopic surgery at the age of 40 years or younger were enrolled. During surgery, the thickness and the sites of RCTs as well as patient factors associated with RCTs were examined.
UNASSIGNED: RCTs were found in 57 shoulders (7%) in 56 patients. There were 4 shoulders with full-thickness RCTs and 54 shoulders with PASTA lesions. All lesions but 1 involved the anterior border of the supraspinatus (SSP). Participation in high-level athletics and older age at injury were associated with RCTs.
UNASSIGNED: The incidence of RCTs was 7% in shoulders with recurrent anterior instability at age 40 years or younger. Most RCTs were PASTA lesions that involved the anterior border of the SSP.

The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a \'suspension bridge\'. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature. Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.

The rotator cable is a semicircular thickening of the glenohumeral joint capsule. It travels between tubercles of the humerus and interweaves with the supra- and infraspinatus muscle tendons. The rotator cable anchors these tendons to the tubercles, playing the role of a suspension bridge. However, little is known about the modifications of this cable that result from pathologies to the rotator cuff tendons. Thus, we aim to compare the morphology of the normal rotator cable with cables in specimens with rotator cuff injuries. The glenohumeral joint was dissected in 30 cadaveric shoulders. The supra-, infraspinatus and teres minor muscles were inspected for injuries and the rotator cable was visualised. The cables course was determined and the width, length and thickness were measured. The rotator cable was found present in all cadavers dissected. In three specimens there was a partial injury of the supraspinatus tendon (two from capsular side and one from bursal side). The rotator cable was thickened in the cases of capsular tears. In another two specimens the supraspinatus and infraspinatus muscles were torn completely and in these cases the rotator cable was blended with retracted stumps and elongated to the level of the glenoid rim. The rotator cable creates a functional complex with the supra- and infrasinatus muscles. The morphology of the cable differs in cases of rotator cuff injury.

BACKGROUND: The anterior rotator cable is critical in force transmission of the rotator cuff. However, few clinical studies have examined the correlation between the integrity of the anterior supraspinatus tendon and surgical outcomes in patients with rotator cuff tears.
OBJECTIVE: To compare the clinical and structural outcomes of the arthroscopic repair of full-thickness rotator cuff tears with and without anterior disruption of the supraspinatus tendon.
METHODS: Cohort study; Level of evidence, 3.
METHODS: One hundred eighty-one shoulders available for magnetic resonance imaging (MRI) at least 6 months after arthroscopic rotator cuff repair, with a minimum 1-year follow-up, were enrolled. The anterior attachment of the rotator cable was disrupted in 113 shoulders (group A) and intact in 68 shoulders (group B). The mean age at the time of surgery in groups A and B was 59.6 and 59.2 years, respectively, and the mean follow-up period was 24.2 and 25.1 months, respectively.
RESULTS: There were statistically significant differences in the preoperative tear size and pattern and muscle fatty degeneration between the 2 groups ( P = .004, P = .008, and P < .001, respectively). At final follow-up, the mean visual analog scale (VAS) for pain score during motion was 1.31 ± 0.98 and 1.24 ± 0.90 in groups A and B, respectively ( P = .587). The mean Constant score was 77.5 ± 11.2 and 78.0 ± 11.9 points in groups A and B, respectively ( P = .875). The mean University of California, Los Angeles score was 30.5 ± 4.1 and 31.0 ± 3.0 points in groups A and B, respectively ( P = .652). In assessing the repair integrity on postoperative MRI, the retear rate was 23.9% and 14.7% in groups A and B, respectively ( P = .029).
CONCLUSIONS: Irrespective of involvement in the anterior attachment of the rotator cable, the mean 24-month follow-up demonstrated excellent pain relief and improvement in the ability to perform activities of daily living after arthroscopic rotator cuff repair. However, tears with anterior disruption of the rotator cable showed a significantly larger and more complex tear pattern and more advanced fatty degeneration. Additionally, the retear rate was significantly higher in patients with a tear involving the anterior attachment of the rotator cable.

OBJECTIVE: The objective of this study was to determine the biomechanical function of the rotator cable when a partial-thickness (>50%) tear is present. We compared intact specimens with partial tears of the anterior cable followed by partial anterior and posterior tears in regard to glenohumeral kinematics and translation. The hypothesis was that partial-thickness tears will lead to abnormal glenohumeral biomechanics, including glenohumeral translation and path of glenohumeral articulation.
METHODS: Five fresh frozen cadaveric shoulders with intact labrum, rotator cuff, and humerus were tested using a custom shoulder testing system in the scapular plane. Glenohumeral translation was measured after applying an anterior load of 30 N at different angles of external rotation. The path of glenohumeral articulation was measured by calculating the humeral head center with respect to the glenoid articular surface at 30°, 60°, 90°, and 120° of external rotation.
RESULTS: With an anterior force of 30 N, there was a significant increase in anterior and total translation at 30° of external rotation after the anterior cable was cut (P < .05). When the tear was extended to the posterior cable, there was a significant increase in anterior, inferior, and total translation at 30° and 120° of external rotation (P < .05). With respect to the path of glenohumeral articulation , the humeral head apex was shifted superiorly at 90° and 120° of external rotation after the posterior cable was cut (P < .05).
CONCLUSIONS: Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model.

BACKGROUND: The purpose of this study was to examine the baseline function and results of arthroscopic cuff repair in shoulders with small and medium-sized full-thickness cuff tears with complete supraspinatus disruption compared with those with an intact anterior supraspinatus tendon.
METHODS: The study evaluated 112 subjects with small and medium-sized cuff tears. Subjects were grouped according to anterior supraspinatus integrity (83 shoulders intact, group 1; and 29 shoulders with anterior supraspinatus tendon disruption, group 2). Functional assessments included visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and Constant score. Repair integrity was assessed by ultrasound examination.
RESULTS: Group 2 shoulders had greater mean tear width, length, and area (P < .0001) and greater supraspinatus muscle degenerative changes (P < .0001) compared with shoulders with an intact anterior supraspinatus tendon. There were no differences in demographics or baseline function (ASES score: 45 group 1 vs 46 group 2, P = .79; Constant score: 56 group 1 vs 52 group 2, P = .29) before surgery. There were no differences in any functional parameter (ASES score: 92 group 1 vs 93 group 2, P = .71; Constant score: 84 group 1 vs 85 group 2, P = .84) after surgery. There was no difference in tendon healing rates (93% group 1 vs 86% group 2; P = .26).
CONCLUSIONS: In the setting of painful small and medium-sized rotator cuff tears, disruption of the anterior supraspinatus tendon was associated with greater tear size and more advanced supraspinatus muscle degeneration. However, anterior supraspinatus tendon integrity had no influence on the clinical presentation or the functional and structural results of cuff repair surgery.