Repair of Acute-on-Chronic Subscapularis Insufficiency in an Adolescent Athlete.

A 13-year-old right-hand-dominant skeletally immature boy presented to the authors' clinic after being blocked during an overhead dodgeball throw and hearing an abrupt "pop" in the shoulder. He had pain in the subdeltoid region that was most prominent during sports-related activity, particularly throwing. The patient had nonoperative management of a lesser tuberosity avulsion fracture 1 year earlier after a similar injury that occurred during a basketball game. He had returned to normal sporting activity 2 months before the most recent injury. Repeat advanced imaging showed an avulsion fracture of the subscapularis tendon, with a significantly retracted 2-cm component as well as a less retracted component, suggesting acute-on-chronic injury. Given this retraction and the symptoms during throwing, the patient was counseled that surgical management would best facilitate an asymptomatic return to sports-related activity. This case showed acute-on-chronic subscapularis tendon insufficiency with avulsion of the lesser tuberosity and significant retraction of the subscapularis tendon without tearing, a rare injury pattern in adolescents. For fixation of the avulsed lesser tuberosity fracture, an open approach technique was used in which SpeedBridge (Arthrex, Naples, Florida) sutures were passed behind the bone fragment. Four anchors were placed medial and lateral to the subscapularis insertion points to create a knotless double-row footprint. Compared with the published literature, this method of subscapularis fixation offered secure anatomic repair in a time-efficient, user-friendly manner.