Isolated subscapularis tendon tears are rare, accounting for approximately 3% to 8% of rotator cuff tears. Delayed diagnosis may lead to tendon retraction, complicating surgical management and postoperative recovery. Pectoralis major tendon transfer has been reported in the academic literature since the late 1990s and is associated with pain relief and improved upper extremity function. A variety of techniques can be used for pectoralis major tendon transfer. The main differences between these techniques include transfer of the entire pectoralis major tendon versus a tendon-splitting approach and the passage of the pectoralis major tendon above versus below the conjoint tendon. Pectoralis major tendon transfer is well tolerated; however, a 1% rate of axillary and musculocutaneous nerve dysfunction has been reported. The primary complication associated with pectoralis major tendon transfer is re-rupture, which occurs in approximately 12.8% of patients.

This video demonstrates the technique for open rotator cuff repair and pectoralis major transfer for the management of subscapularis insufficiency. The video discusses the case presentation of a 58-year-old man with right shoulder pain after a fall that occurred 2 months ago. Evidence of a small anterior supraspinatus tear with an associated subscapularis tendon rupture is observed on radiographs and MRIs. The patient was scheduled for surgery on initial presentation, but never underwent surgery because of medical risk factors. The patient presented 7 months later after a course of failed nonsurgical treatment and reported persistent pain. Repeat MRI revealed marked enlargement of the anterosuperior rotator cuff tear and a massive subscapularis tendon tear with retraction to the glenoid and substantial fatty atrophy. Approximately 9 months after initial presentation, the patient underwent right shoulder arthroscopy with open biceps tenodesis, open transfer of the sternal head of the pectoralis major tendon, and open supraspinatus and infraspinatus tendon repair. An overview of the surgical techniques is described.

Long-term outcomes after pectoralis major tendon transfer for the management of subscapularis insufficiency are continually improving, most notably with regard to decreased pain and increased internal rotation. Positive outcomes up to 10 years postoperatively have been reported in the academic literature. This procedure is associated with a low rate of revision to reverse shoulder arthroplasty.