Editorial Commentary: Subscapularis Tears With Advanced Fatty Infiltration: When Every Option Is Imperfect.

Full-thickness subscapularis tears with advanced fatty infiltration represent one of the most challenging problems in shoulder surgery, in large part because every available treatment option is imperfect. Reverse total shoulder arthroplasty in older patients and tendon transfer in younger individuals without glenohumeral arthritis are effective but often perceived by patients as extreme, while nonoperative management frequently leaves persistent symptoms. New literature suggests that perhaps a modification of a traditional open approach, in the form of open antegrade muscle advancement, is a viable joint-preserving alternative. Despite high structural failure rates, the authors show meaningful improvements in patient-reported outcomes and physical function, reinforcing both the value of necessity-driven surgical innovation and the persistent gaps in our understanding of shoulder pain.