The intra-articular component of the subscapularis tendon: anatomic and histological correlation in reference to surgical release in patients with frozen-shoulder syndrome

Decreased rotator cuff muscle cross-sectional areas in subjects with adhesive capsulitis: a study comparing male and female subjects

OBJECTIVE

To compare rotator cuff (RC) muscle cross-sectional areas (CSA) in subjects with adhesive capsulitis (AC) to age- and sex-matched controls.

MATERIALS AND METHODS

We retrospectively analyzed 97 shoulder MRIs or MR arthrography studies, of which 42 were clinically diagnosed with AC (27 female, 15 male) and 55 were age- and sex-matched controls (38 female, 17 male). All AC subjects underwent imaging ≥ 6 months after symptom onset. All imaging was examined to exclude RC full-thickness tears and prior surgery. A standardized T1 sagittal MR image was segmented in each subject to obtain the CSA of subscapularis (SSC), supraspinatus (SSP), and infraspinatus (ISP) muscles. Differences in CSAs between AC and control subjects were analyzed by sex (females and males separately) and all subjects combined.

RESULTS

AC females had significantly decreased SSC (P = 0.002) and total (P = 0.006) CSAs compared to controls. Male AC subjects showed decreased SSC (P = 0.044), SSP (P = 0.001), and total (P = 0.005) CSAs. Across all subjects, male and female, the AC cohort had significantly decreased SSC (P = 0.019) and total (P = 0.029) CSAs compared to controls.

CONCLUSION

Decreased RC muscle CSAs were present in AC subjects with ≥ 6 months of symptom duration, with decreased SSC and total CSAs in male and female subjects, and decreased SSP CSA in males.

The subscapularis muscle: A meta-analysis of its variations, prevalence, and anatomy

BACKGROUND

The subscapularis (SSC) is the largest rotator cuff muscle and is involved in the medial rotation, abduction, adduction, and anterior stabilization of the shoulder. It is anatomically variable, as is the morphology and prevalence of the accessory SSC (aSSC), a rare muscle slip attached to the SSC. There is no current review investigating the prevalence and morphometrics of the SSC and aSSC.

PURPOSE

To investigate the prevalence of the morphological variants of the SSC and aSSC via meta-analysis and review the relevant literature involving cadaveric, magnetic resonance imaging, and ultrasonographic studies.

STUDY DESIGN

Meta-analysis.

MATERIALS AND METHODS

Literature data reporting the prevalence rates and morphometrics of the SSC and aSSC and their variants were pooled. Literature searches and data analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Anatomical Quality Assurance guidelines.

RESULTS

Forty-six studies, totaling 2166 shoulders, were assessed. The SSC showed an overall length, thickness, cross-sectional area, and volume of 152.2 mm (95% confidence interval, CI, 103.8-200.5 mm), 5.6 mm (95% CI, 4.6-6.6 mm), 18.1 cm² (95% CI, 14.2-22.0 cm² ), and 126.9 cm³ (95% CI, 87.2-166.5 cm³ ), respectively. The SSC displayed substantial variations in its origin and insertion points and in the composition of its tendon. The aSSC had an overall pooled prevalence of 24.6% (95% CI, 0.0%-76.9%).

CONCLUSIONS

The SSC and aSSC have been implicated in multiple shoulder pathologies, including muscle and tendon ruptures and neurovascular compromise. A better understanding of SSC and aSSC variants when diagnosing and treating their related pathologies will reduce patient morbidity and improve treatment regimens.

Comparison of Gene Expression of Inflammation- and Fibrosis-Related Factors Between the Anterior and Posterior Capsule in Patients With Rotator Cuff Tear and Shoulder Stiffness

Background

Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness, yet there are no basic studies that can explain the extent of the release.

Purpose

This study aimed to compare the genetic expression of inflammation- and fibrosis-related factors between the anterior and posterior capsules in patients with shoulder stiffness and rotator cuff tear.

Study Design

Descriptive laboratory study.

Methods

Enrolled in this study were 35 patients who underwent arthroscopic capsular release for shoulder stiffness along with the rotator cuff repair. Anterior and posterior glenohumeral joint capsular tissues were obtained during the capsular release. For the control tissue, anterior capsule was obtained from 40 patients without stiffness who underwent arthroscopic rotator cuff repair. The gene expression of collagen types I and III, fibronectin, extracellular matrix, basic fibroblast growth factor, transforming growth factor-β, connective tissue growth factor, matrix metalloproteinase (MMP)-1, MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, TIMP-2, intercellular adhesion molecule 1, interleukin 1, and tumor necrotizing factor-α were analyzed using real-time reverse transcription polymerase chain reaction. Differences in gene expression between the anterior capsule, the posterior capsule, and the control tissue were compared with the Kruskal-Wallis test.

Results

The expression levels of collagen types I and III were significantly higher in the anterior capsule with stiffness com (pared with both the posterior capsule with stiffness (P = .010 for both) and the control (P = .038 and .010, respectively). The levels of fibronectin, MMP-2, and MMP-9 in the anterior capsule were significantly higher than in both the posterior capsule (P = .013, .003, and .006, respectively) and the control (P = .014, .003, and .005, respectively).

Conclusion

Genetic analysis of the shoulder capsule revealed that more fibrogenic processes occur in the anterior capsule compared with the posterior capsule in patients with shoulder stiffness.

Clinical Relevance

Capsular release for shoulder stiffness should be more focused on the anterior capsule than on the posterior capsule.

Frozen Shoulder 360° Release

Arthroscopic capsular release has emerged as a safe and reliable method for treating severe frozen shoulder in patients with significant loss of range of motion. This article describes a reproducible technique for arthroscopic 360° release of the shoulder performed in the lateral decubitus position.

Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies

Adhesive capsulitis of the shoulder (ACS) is a condition with significant clinical and economic implications. The etiology of adhesive capsulitis is not clearly understood and there remains lack of consensus in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of ACS are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences, and can range from conservative options to surgical intervention. The aim of this review is to summarize the pathophysiology and clinical presentation of ACS and to discuss the evidence base for various management strategies employed today.

Frozen shoulder (FS) is a relatively common condition characterized by pain and stiffness of the shoulder joint. The exact cause of primary FS is unknown and in some patients the condition can persist for several years. Treatment strategies vary depending on stage of presentation, patient factors and clinician preferences. This review gives a summary of the clinical presentation of FS and an overview of the current evidence for both surgical and conservative treatment options for the condition.

Ultrasound-Guided Hydrodilatation of the Shoulder Capsule at the Rotator Interval: Technical Tips and Tricks

Adhesive capsulitis and disorders of the intra-articular portion of the long head of the biceps brachii tendon are common causes of shoulder pain. Sonographic findings, coupled with clinical evaluation and medical history, are paramount for prompt diagnosis. Herewith, either to precisely confirm the pain generator(s) or to appropriately treat relevant cases, ultrasound-guided interventions are often required in daily clinical practice. Targeting the anatomical structures involved in the aforementioned pathological conditions, we briefly describe some technical tips and tricks as regards ultrasound-guided hydrodilatation of the shoulder capsule at the rotator interval.

Rotator cuff tear with joint stiffness: a review of current treatment and rehabilitation

Repair of the rotator cuff tear is a joint-tightening procedure that can worsen joint stiffness. This paradoxical phenomenon complicates treatment of rotator cuff tear with joint stiffness. As a result, there is controversy about how and when to treat joint stiffness. As many treatments have been published, this review discusses the latest findings on treatment of rotator cuff tear with joint stiffness.

Editorial Commentary: Precise Repair of Partial Subscapularis Tendon Tears Is Essential

The subscapularis is a very important anatomic structure that is essential for maintaining proper glenohumeral joint mechanics and shoulder function. It establishes a force couple with the infraspinatus and teres minor to stabilize the glenohumeral joint in the transverse plane. The subscapularis muscle also opposes the deltoid with humerus abduction and elevation. Recent advances in imaging and arthroscopy techniques have led to greater detection of subscapularis tendon tears. Furthermore, there have been detailed descriptions of the subscapularis insertional anatomy showing that the subscapularis tendon has 4 different facets of insertion to the lesser tuberosity. The tear patterns of the subscapularis are also different from that of the supraspinatus tendon where the complete isolated subscapularis tendon tear is not common. However, the subscapularis partial tear combined with supraspinatus or 3 tendon tears is more common, with most being first-facet tears. Clinically, upper-portion subscapularis partial tendon tears may be considered relatively benign, but biomechanically these tears result in increased external rotation and altered glenohumeral kinematics. Therefore, in my opinion, it is very important to precisely repair these partial subscapularis tendon tears for anatomic, structural, and functional restoration of the shoulder.

Arthroscopic Management of the Stiff Shoulder

Shoulder stiffness affects a diverse population of patients suffering a decrease in function and shoulder pain. Arthroscopic management of this debilitating spectrum of pathology is a safe and effective course of action in cases recalcitrant to nonoperative therapy. Arthroscopic management of the stiff shoulder has been reported to be effective in the treatment of stiffness due to adhesive capsulitis, birth palsy, stiffness in the setting of rotator cuff tears, and osteoarthritis in the posttraumatic patient, in the postoperative patient, and in the throwing athlete. Arthroscopic management is most effective in treating the stiff shoulder in the setting of adhesive capsulitis recalcitrant to nonoperative therapy or posttraumatic stiffness. Results are more guarded in the treatment of postoperative stiffness. Excessive force and trauma to the shoulder, including fracture of the humerus, can be avoided with a 360[degrees] capsular release for shoulder stiffness rather than manipulation under anesthesia.

Subscapularis tendon tears: Management and arthroscopic repair

Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.Due to the tendency of the tendon to retract medially, acute and traumatic full-thickness tears should be repaired. Chronic tears without significant degeneration should be considered for repair if no contraindication exists.Arthroscopic repair can be performed using a 30-degree arthroscope and a laterally-based single row repair; one anchor for full thickness tears ⩽ 50% of tendon length and two anchors for those ⩾ 50% of tendon length.Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.Timing of post-operative rehabilitation is dictated by the size of the repair and the security of the repair construct. The stages of rehabilitation typically involve a period of immobilisation followed by range of movement exercises, with a delay in active internal rotation (IR) and strengthening in IR. Cite this article: EFORT Open Rev 2017;2:484-495. DOI: 10.1302/2058-5241.2.170015.

The relationship of the anterior articular capsule to the adjacent subscapularis: An anatomic and histological study

INTRODUCTION

The purpose of this study was to delineate the anatomic relationship between the anterior articular capsule and the adjacent subscapularis by measuring the dimensions of the anterior articular capsule attachment and the subscapularis footprint on the humerus, as well as investigating the interface between the two structures.

MATERIALS AND METHODS

Three shoulder specimens underwent histological analysis; for histological analysis, cross-sections through the subscapularis-capsule complex were harvested at the tendinous and muscular insertion sites. The dimensions of the anterior articular capsule attachment and the subscapularis footprint (including the tendinous and muscular insertions) were measured in thirteen cadaveric shoulder specimens.

RESULTS

Histologically, the articular capsule has thin and loosely arranged collagen fibers with many interspersing fibroblast nuclei, whereas the outer layer of the articular capsule blends into a layer of more loosely spaced and less organized collagen fibers. This interface between the subscapularis and the underlying articular capsule is filled with more loosely spaced and less organized collagen fibers. The macroscopic evaluation showed that the minimum articular capsule width (4.2mm, SD 2.2mm) was located at its initiation 4.9mm (SD, 2.1mm) inferior to the superior margin of the subscapularis; the corresponding subscapularis footprint width measured 10.1mm (SD, 4.9mm). The maximum articular capsule width was11.1 mm (SD, 3.7mm) and was located 5mm distal to the inferior margin of the tendinous footprint. The maximum subscapularis footprint width was 15.8mm (SD, 2.9mm); the corresponding articular capsule attachment measured 5.2mm (SD, 1.8mm).

CONCLUSIONS

Our results suggest that the anterior articular capsule attachment of the glenohumeral joint complements the footprint of the subscapularis and occupies a larger area of the lesser tubercle and metaphysis of the humerus than previously documented. The histological study confirms the presence of a demarcation between the subscapularis and articular capsule, specifically more significant at the region medial to the tendon insertion and at the muscular insertion of the subscapularis.

Midterm Outcomes After Arthroscopic Anteroinferior Capsular Release for the Treatment of Idiophatic Adhesive Capsulitis

PURPOSE

The purpose of this study is to report the early and midterm functional outcomes and complications of a consecutive series of patients with primary adhesive capsulitis who were treated with isolated anteroinferior arthroscopic capsular release after they did not respond to conservative treatment.

METHODS

Thirty-two consecutive patients with idiopathic adhesive capsulitis who did not respond to conservative physiotherapy were included in the study. Arthroscopic anteroinferior capsular release was performed in all cases. The primary outcome was improvement in range of motion in the short- and midterm follow-up. We also evaluated pain relief with the visual analog scale, functional outcomes with the Constant-Murley score, and we registered postoperative complications.

RESULTS

The mean age was 49.6 years (range, 33-68 years) and the mean follow-up was 63 months (range, 18-84). Overall, there was significant improvement in the Constant-Murley score from 42.4 to 86 points (P < .001). The visual analog scale decreased by approximately 6.3 points compared with the preoperative value (P < .001). All parameters improved significantly the first 6 months and then remained stable until the end of follow-up (P < .001). There was an additional minor improvement in both parameters between the sixth month and the final follow-up; however, this improvement was less than in the first 6 months and it was not statistically significant.

CONCLUSIONS

In patients who don't respond to conservative treatment for primary adhesive capsulitis, isolated anteroinferior capsular release provides a reliable improvement in pain and range of motion that is maintained in the mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic, case series study.

Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis

PURPOSE

To present the clinical results of arthroscopic extended rotator interval release with a stretching program for treating refractory adhesive capsulitis.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

Arthroscopy-assisted extended rotator interval tissue release including anterior capsular was performed in 26 patients with refractory adhesive capsulitis. All rotator interval tissues, except the medial sling of the biceps, were excised and the excursion of the subscapularis tendon was restored and freely mobilized. The preoperative mean passive forward flexion was 101°, whereas external rotation at the side was 10°. Patients were followed for a minimum of 2 years and their visual analog scale for pain, muscle power, range of motion, Constant score, modified American Shoulder and Elbow Surgeons Shoulder Evaluation Form score, and modified University of California at Los Angeles score were recorded.

RESULTS

Visual pain scale and the aforementioned clinical scores improved postoperatively. The patients exhibited a significant postoperative difference in forward flexion, external rotation, and internal rotation. Postoperative mean passive forward flexion was 172°, whereas external rotation at the side was 58°. There was no difference in the muscle power postoperatively including abduction, internal rotation, and external rotation.

CONCLUSIONS

Our study revealed satisfactory subjective and objective clinical results after a 2-year follow-up. Arthroscopy-assisted extended rotator interval release with a stretching program could be an alternative treatment for refractory adhesive capsulitis.

Measurement of Coracohumeral Distance in 3 Shoulder Positions Using Dynamic Ultrasonography: Correlation With Subscapularis Tear

PURPOSE

To detect differences between the values of dynamic coracohumeral distance (CHD) measured using ultrasonography (USG) in different shoulder rotations and to investigate its correlation with subscapularis tear.

METHODS

We prospectively enrolled consecutive patients (n = 168) who were scheduled to have arthroscopic rotator cuff repair. Patients with a history of previous shoulder surgery or shoulder fracture and patients with external rotation less than 30° were excluded from the study. Dynamic CHD was measured using USG in 3 different shoulder positions: external rotation, neutral and internal rotation. We evaluated the intrarater reliability with 3 times repetition of measurement. Patients were divided into 1 of 3 groups according to arthroscopic findings: intact subscapularis, partial-thickness tear, and full-thickness tear of the subscapularis. The control group (n = 23) included patients without rotator cuff tears from the outpatient clinic. Subgroup analysis-according to the presence of dynamic subcoracoid stenosis, defined as a CHD less than 6 mm measured in internal rotation-was performed to find the clinical effect of dynamic subcoracoid stenosis.

RESULTS

A partial-thickness tear of the subscapularis tendon was present in 60 patients (35.7%) and a full-thickness tear in 26 patients (15.4%) among 168 patients. The CHD was maximum in external rotation and the narrowest in internal rotation. There were no statistical differences in the CHDs between groups with different subscapularis tear status. According to the presence of dynamic subcoracoid stenosis, patients with dynamic subcoracoid stenosis had a significantly higher incidence of partial-thickness subscapularis tear than those without stenosis (P = .022).

CONCLUSIONS

The CHD values were narrowest in shoulder internal rotation, which is thought to be the pathogenic position. We could not confirm the correlation between CHD and subscapularis tear. However, patients who have dynamic subcoracoid stenosis had significantly higher incidence of subscapularis tear than others without dynamic stenosis.

LEVEL OF EVIDENCE

Level II, prospective prognostic cohort study.

Shoulder Stiffness: Current Concepts and Concerns

Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome.

LEVEL OF EVIDENCE

Level V, evidence-based review.

Primary Frozen Shoulder Syndrome: Arthroscopic Capsular Release

Idiopathic adhesive capsulitis, or primary frozen shoulder syndrome, is a fairly common orthopaedic problem characterized by shoulder pain and loss of motion. In most cases, conservative treatment (6-month physical therapy program and intra-articular steroid injections) improves symptoms and restores shoulder motion. In refractory cases, arthroscopic capsular release is indicated. This surgical procedure carries several advantages over other treatment modalities. First, it provides precise and controlled release of the capsule and ligaments, reducing the risk of traumatic complications observed after forceful shoulder manipulation. Second, release of the capsule and the involved structures with a radiofrequency device delays healing, which prevents adhesion formation. Third, the technique is straightforward, and an oral postoperative steroid program decreases pain and allows for a pleasant early rehabilitation program. Fourth, the procedure is performed with the patient fully awake under an interscalene block, which boosts the patient's confidence and adherence to the physical therapy protocol. In patients with refractory primary frozen shoulder syndrome, arthroscopic capsular release emerges as a suitable option that leads to a faster and long-lasting recovery.

Essential Surgical Technique for Arthroscopic Capsular Release in the Treatment of Shoulder Stiffness

Introduction

Among many treatments for shoulder stiffness, which is a common debilitating condition, arthroscopic capsular release is an effective surgical method for patients who have not responded to conservative treatment, as it provides visual control of the capsular release with a lower risk of potential traumatic damage than manipulation under anesthesia.

Step 1: Position the Patient

Place the patient either in the lateral decubitus position or in the beach-chair position, depending on one’s preference.

Step 2: Portal Placement

Create a standard posterior viewing portal, an anterior portal, and a lateral portal for approaching the glenohumeral joint and the subacromial space.

Step 3: Remove Rotator Interval Tissue

Begin the capsular release with the rotator interval and middle glenohumeral ligament using a 3.0-mm 90° electrocautery device through the anterior portal.

Step 4: Release the Anterior Capsule

Begin the anterior capsular release below the long head of the biceps tendon origin and preserve the glenoid labrum.

Step 5: Release the Inferior Capsule

As the electrocautery device may not reach the inferior portion of the inferior glenohumeral ligament, switch the working portal to the posterior portal for an easier approach to the inferior portion.

Step 6: Release the Coracohumeral Ligament and the Subscapularis

Begin this procedure with the camera in the lateral portal viewing the anterior portion of the subdeltoid space.

Step 7: Postoperative Rehabilitation

The goal for the patient is to achieve an immediate range of motion by performing active-assisted and passive range-of-motion exercises including pendulum circumduction or the pulley exercise.

Results

In our recently reported series of seventy-five patients who had a rotator cuff tear with simultaneous shoulder stiffness, treatment with an anterior and inferior capsular release showed favorable results.

What to Watch For

Indications

Contraindications

Pitfalls & Challenges

The influence of partial subscapularis tendon tears combined with supraspinatus tendon tears

BACKGROUND

With the advent of arthroscopy, more partial subscapularis tears are being recognized. The biomechanical effects of partial subscapularis tears are unknown, and there is no consensus as to their treatment. Therefore, the objective of this study was to evaluate and to quantify the changes in range of motion and glenohumeral kinematics for isolated subscapularis partial tears, combined subscapularis and supraspinatus tears, supraspinatus repair, and combined supraspinatus and subscapularis repair.

METHODS

Six cadaveric shoulders were tested in the scapular plane with 0°, 30°, and 60° shoulder abduction under 6 conditions: intact; ¼ subscapularis tear; ½ subscapularis tear; ½ subscapularis and complete supraspinatus tear; supraspinatus repair; and supraspinatus and subscapularis repair. Maximum internal and external rotation and glenohumeral kinematics were measured under physiologic muscle loading condition. A repeated measures analysis of variance with a Tukey post hoc test was used for statistical analysis.

RESULTS

Maximum external rotation was significantly increased after ¼ subscapularis tear at 30° abduction and in all abduction angles with ½ subscapularis tear (P < .05). The 2 repair conditions did not restore external rotation to the intact level. At maximum internal and external rotation, there was a significant superior shift in the humeral head apex position with ¼ subscapularis tear at 30° abduction and with ½ subscapularis tear at 60° abduction (P < .05). Repair of the supraspinatus tendon partially corrected abnormal kinematics; however, neither repair restored abnormal kinematics to intact.

CONCLUSION

Additional repair of the partial subscapularis tear with supraspinatus tear did not affect external rotation or glenohumeral kinematics. Further studies are needed to evaluate different subscapularis repair techniques.

LEVEL OF EVIDENCE

Basic science study, biomechanics.

Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study

BACKGROUND

Arthroscopic capsular release is an effective treatment for shoulder stiffness, yet its extent is controversial.

PURPOSE

To compare the clinical outcomes of arthroscopic capsular release in patients with and without posterior extended capsular release for shoulder stiffness.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Between January 2008 and March 2011, 75 patients who underwent arthroscopic capsular release for shoulder stiffness were enrolled and randomized into 2 groups. In group I (n = 37), capsular release was performed, including release of the rotator interval and anterior and inferior capsule. In group II (n = 38), capsular release was extended to the posterior capsule. The American Shoulder and Elbow Surgeons score, Simple Shoulder Test, visual analog scale for pain, and range of motion (ROM) were used for the evaluation before surgery and at 3, 6, and 12 months after surgery and at the last follow-up.

RESULTS

Preoperative demographic data of age, sex, symptom duration, and clinical outcomes showed no significant differences (P > .05). The average follow-up was 18.4 months. Both groups showed significantly increased ROM at the last follow-up compared with preoperative ROM (P < .05). At the last follow-up, no statistical differences were found (P > .05) between groups I and II in American Shoulder and Elbow Surgeons score (91.3 vs. 79.5), Simple Shoulder Test (83.3 vs. 83.3), and visual analog scale (1.5 vs. 2.2). There were also no statistical differences between the 2 groups at the last follow-up (P > .05) in ROM: forward flexion, 145.2° vs. 143.3°; external rotation with 90° of abduction, 88.1° vs. 86.2°; external rotation at side, 88.9° vs. 82.9°; and internal rotation, 9.1° vs. 8.3°.

CONCLUSION

Posterior extended capsular release might not be necessary in arthroscopic surgery for shoulder stiffness.

Arthroscopic anatomy of the subdeltoid space

From the first shoulder arthroscopy performed on a cadaver in 1931, shoulder arthroscopy has grown tremendously in its ability to diagnose and treat pathologic conditions about the shoulder. Despite improvements in arthroscopic techniques and instrumentation, it is only recently that arthroscopists have begun to explore precise anatomical structures within the subdeltoid space. By way of a thorough bursectomy of the subdeltoid region, meticulous hemostasis, and the reciprocal use of posterior and lateral viewing portals, one can identify a myriad of pertinent ligamentous, musculotendinous, osseous, and neurovascular structures. For the purposes of this review, the subdeltoid space has been compartmentalized into lateral, medial, anterior, and posterior regions. Being able to identify pertinent structures in the subdeltoid space will provide shoulder arthroscopists with the requisite foundation in core anatomy that will be required for challenging procedures such as arthroscopic subscapularis mobilization and repair, biceps tenodesis, subcoracoid decompression, suprascapular nerve decompression, quadrangular space decompression and repair of massive rotator cuff tears.

RESULTS FROM ARTHROSCOPIC REPAIR OF ISOLATED TEARS OF THE SUBSCAPULARIS TENDON

OBJECTIVE

To evaluate the functional and clinical outcomes and identify prognostic factors in patients undergoing arthroscopic repair of isolated tears of the subscapularis tendon.

METHODS

Between January 2003 and May 2009, we identified 18 shoulders with isolated tears or deinsertions that were complete or affected at least one third of the subscapularis tendon and underwent arthroscopic repair.

RESULTS

Three shoulders (17%) showed lesions in the upper third of the subscapularis; nine shoulders (50%) showed lesions in the upper two thirds; and six shoulders (33%) presented complete tears. In comparing the range of lateral rotation of the injured shoulder between before surgery and the time of the reevaluation, there was no statistical difference (p = 0.091). The LHBT was damaged in 11 shoulders (61%). According to the Constant score validation, we had excellent and good results in 83% of the cases and 17% were reasonable. The reevaluations on three patients showed re-tearing on MRI. Acromioplasty was performed on ten patients and this procedure did not represent statistical differences in the final results (p = 0.57).

CONCLUSIONS

There was no statistically significant difference in relation to preoperative lateral rotation between the injured shoulder and the contralateral side. There was no significant loss of lateral rotation after surgery. The LHBT may be normal in deinsertions of the subscapularis tendon. Acromioplasty did not influence the results. The re-tearing rate for arthroscopic repair of the subscapularis tendon was 16.6%.

Adhesive capsulitis: a review of current treatment

Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule. Variable nomenclature, inconsistent reporting of disease staging, and a multitude of different treatments have created a confusing and contradictory body of literature about this condition. Our purpose is to review the evidence for both nonsurgical and surgical management of adhesive capsulitis with an emphasis on level I and II studies when available. Significant deficits in the literature include a paucity of randomized controlled trials, failure to report response to treatment in a stage-based fashion, and an incomplete understanding of the disease's natural course. Recognition that the clinical stages reflect a progression in the underlying pathological changes should guide future treatments.

Subscapularis tendon tears: identifying mid to distal footprint disruptions

We present an arthroscopic technique used to identify mid to distal subscapularis tendon disruptions. These tears can be easy to miss and require a thorough arthroscopic evaluation of the medial biceps sling and the medial side wall of the bicipital groove to detect. The arthroscopic procedure is performed with the patient in the lateral decubitus position, and the same portals used for standard subscapularis repair are used for this technique. If a high degree of clinical suspicion exists for subscapularis pathology and no tendon disruption is initially identified, an inspection of the medial biceps sling and medial side wall of the bicipital groove may show mid to distal subscapularis tendon disruptions. A 70 degrees arthroscope is essential in visualizing the medial sling, the subscapularis tendon, the biceps tendon, and the proximal 2 cm of the bicipital groove. Any disruptions or rents in the medial sling or medial side wall are suggestive of a subscapularis tear. Once a tear is identified, we proceed with a biceps tenodesis and then take down the medial sling from the lesser tuberosity to better delineate the subscapularis footprint. The subscapularis may then be repaired in standard fashion.

Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder?

PURPOSE

The aims of our study were to assess effects of the extent of capsular release and to define the benefit of additional release of the inferior glenohumeral ligament (IGHL) from inferior to posterior in frozen shoulder.

METHODS

Seventy-four consecutive patients with refractory frozen shoulder underwent arthroscopic capsular release and were divided into 2 groups randomly. The release of anterior capsular structures, including the anterior band of the IGHL, was performed in group 1. In group 2 the release extended inferiorly and posteriorly. Constant functional scores were used to assess the outcome. The range of motion (ROM) in various directions was also recorded preoperatively and postoperatively.

RESULTS

Follow-up was obtained in 41 patients in group 1 and 29 patients in group 2, and it averaged 28 months. At the last follow-up, there was a significant improvement in Constant score (P < .01) postoperatively in all patients. There was a significant and rapid reduction in the visual analog scale score in both groups postoperatively. No statistical difference in the visual analog scale score was found between the 2 groups at the corresponding time points. Overall, patients had restored shoulder ROM at the last follow-up without difference between group 1 and group 2. Abduction, flexion, external rotation at 90 degrees of abduction, internal rotation at 0 degrees of abduction, and internal rotation at 90 degrees of abduction recovered more rapidly in group 2 within 3 months after surgery; however, there was no significant difference in ROM after 6 months.

CONCLUSIONS

In this broad group of patients with recalcitrant adhesive capsulitis, the addition of the posterior capsular release did not improve patient function or ROM over anterior capsular release alone at 6 months. The extended release of the inferior and posterior IGHL would improve ROM more rapidly within the first 3 months postoperatively.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial.

Frozen shoulder: evidence and a proposed model guiding rehabilitation

Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion. The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic. We also propose another classification system based on the patient's irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention. Nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes. However, there is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment. A rehabilitation model based on evidence and intervention strategies matched with irritability levels is proposed. Exercise and manual techniques are progressed as the patient's irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release.

LEVEL OF EVIDENCE

Level 5.

Posterior arthroscopic capsular release in frozen shoulder

PURPOSE

The aims of our study were to assess the overall effectiveness of arthroscopic capsular release and to determine if the addition of a posterior capsular release had any benefit, particularly in relation to internal rotation.

METHODS

Forty-eight consecutive patients with primary or secondary frozen shoulder in whom conservative physiotherapy had failed were included in the study. Arthroscopic capsular release was performed in all cases. Group 1 had an anterior and inferior release only; group 2 included a posterior release. All data were collected prospectively. Constant-Murley functional scores were used to assess outcome. Overall satisfaction and patient reported outcomes were also measured.

RESULTS

The mean patient age was 51 years (range, 28 to 65 years), with no difference between the 2 groups. There were 27 patients in group 1 and 21 patients in group 2. The mean follow-up was 5 months. Etiology of the frozen shoulder was primary (22), diabetic (7), post-traumatic (7), and postoperative (11). Overall across both groups, there was a highly significant improvement in Constant score (P < .001) postoperatively. A similar pattern was noted in the range of motion (P < .001). The mean satisfaction score was 7 of 10 postoperatively. The patients reported overall outcome as much better (24), better (15), the same (1), and worse (4). There was no significant difference in Constant score between the 2 groups, and no significant difference in the improvement of the range of motion, in particular internal rotation.

CONCLUSIONS

We have shown an overall rapid significant improvement following arthroscopic capsular release for primary and secondary frozen shoulder. There was no significant difference in the overall outcome with the addition of a posterior release.

LEVEL OF EVIDENCE

Level III, therapeutic, retrospective comparative study.

The spiral glenohumeral ligament: an open and arthroscopic anatomy study

PURPOSE

The purpose of this study was to visualize arthroscopically and to describe the micro- and macroscopic anatomy of the poorly known ligament of the anterior capsule of the glenohumeral joint: the so-called ligamentum glenohumerale spirale (spiral GHL).

METHODS

Twenty-two fresh shoulder joints were dissected, and the anatomy of the anterior capsular structures (the spiral GHL, the middle glenohumeral ligament [MGHL], and the anterior band as well as the axillary part of the inferior glenohumeral ligament [AIGHL and AxIGHL, respectively]) was investigated. For arthroscopic visualization, 30 prospective arthroscopic clinical cases and 19 retrospective video clips of the patients who had an arthroscopic shoulder procedure with a normal subscapularis tendon, labrum, and anterior joint capsule were evaluated.

RESULTS

The spiral GHL and the AxIGHL were present in all 22 shoulder specimens. The AIGHL was not recognizable on the extra-articular side of the joint capsule. The MGHL was absent in 3 shoulder specimens (13.6%). Arthroscopically, the spiral GHL was found in 22 (44.9%), the MGHL in 43 (87.8%), and the AIGHL in 46 (93.9%) of the cases. The spiral GHL arose from the infraglenoid tubercle and the triceps tendon and inserted together with subscapularis tendon onto the lesser tubercle of the humerus.

CONCLUSIONS

Our results suggest that extra-articular structure of the spiral GHL is consistently recognizable, the upper part of which can be arthroscopically identified.

CLINICAL RELEVANCE

Advanced anatomic knowledge of the spiral GHL helps the clinician better understand the normal anatomy of the shoulder joint and also helps to differentiate it from pathologic findings of the patient. The biomechanical importance of the spiral GHL and its connection with shoulder pathology remains to be determined in further studies.

The influence of arthroscopic subscapularis tendon and capsule release on internal rotation strength in treatment of frozen shoulder

BACKGROUND

Arthroscopic release of the capsule is a popular treatment option for chronic refractory frozen shoulder. Additional release of the intra-articular part of the subscapularis is controversial regarding possible impairment of subscapularis function.

HYPOTHESIS

Arthroscopic release of the intra-articular part of the subscapularis produces good clinical results and does not lead to reduced internal rotation strength.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-two patients were retrospectively evaluated 53 months (range, 12-106) after undergoing arthroscopic anterior capsular release, including release of the intra-articular portion of the subscapularis. Clinical outcome was evaluated using the American Shoulder and Elbow Surgeons score and the Constant score. Isometric and isokinetic strength for internal and external rotation were determined at the time of follow-up in both shoulders using a Cybex dynamometer.

RESULTS

The Constant score was improved significantly from 17.7 points to 82.8 points (P < .0001) and the American Shoulder and Elbow Surgeons score increased significantly from 23.5 points to 76.8 points (P < .0001). The mean range of motion was significantly improved for external rotation from 16 degrees to 58 degrees , from 66 degrees to 142 degrees for abduction, and from 76 degrees to 155 degrees for forward flexion. Isometric and isokinetic strength in the standard abduction position of the Cybex dynamometer showed no significant side-to-side difference.

CONCLUSION

Arthroscopic capsular release combined with a release of the intra-articular portion of the subscapularis tendon revealed good clinical results in the arthroscopic treatment of adhesive capsulitis without significant loss of internal rotation strength.

Adhesive capsulitis

Adhesive capsulitis is a common problem seen in the general population by orthopedic surgeons. It is a problem that causes patients pain and disability, and symptoms can last up to 2 years and longer. The questions of when and how to treat the frozen shoulder can present challenges. Most treatments are conservative; however, indications for surgery do exist. Arthroscopic capsular release has gained popularity over the years and offers a predictably good treatment in patients with adhesive capsulitis. The purpose of this paper is to review the orthopedic literature on adhesive capsulitis, to provide background information on this topic, and to describe our technique in arthroscopic capsular release.

Variations in the superior capsuloligamentous complex and description of a new ligament

Although the rotator cuff interval and the adjacent ligaments are gaining interest because of their importance for glenohumeral instability and adhesive capsulitis, there seems to be some confusion about their anatomy. This study reinvestigates the superior capsular structures in 110 cadaveric shoulders by a combination of arthroscopy, dissection, histology, and functional analysis. The structure of the superior capsule was found to be more complex than suspected until now. The coracohumeral, coracoglenoid, and superior glenohumeral ligaments joined with a circular transverse band to form the anterior limb of a suspension sling. This was 9 to 26 mm wide at its midportion. In 90% of the specimens, there also was a posterior limb composed of a broad fibrous sheet, 6 to 26 mm wide at its midportion. This hitherto unrecognized posterosuperior glenohumeral ligament joined posterolaterally with the circular transverse band. Four types of configuration for the superior complex could be identified. The suspension sling formed by the superior complex functions in the same way as the hammock formed by the inferior glenohumeral ligament complex. The posterior limb seems to restrict internal rotation, like the anterior limb restricts external rotation. The expanded knowledge of the superior capsular complex increases the understanding of the pathology involved in anterosuperior and posterosuperior impingement, as well as articular-sided rotator cuff tears. It also has clinical implications for rotator cuff interval and biceps pulley lesions, because these areas are bordered by the anterior limb of the superior complex, as well as for adhesive capsulitis, where we can now understand why internal rotation is limited and why the release needs to be extended posterosuperiorly.

The subscapularis footprint: an anatomic study of the subscapularis tendon insertion

PURPOSE

Arthroscopic repair of the subscapularis tendon has become more prevalent in recent years. Tears of the subscapularis insertion can be measured arthroscopically when the size of the average subscapularis tendon insertion is known. This anatomic study was performed to measure the dimensions and describe the anatomy of the subscapularis footprint.

METHODS

A total of 6 male and 6 female shoulders were dissected down to the insertion of the subscapularis tendon. The insertion was demarcated, the tendon was detached, and the dimensions of the insertion site were measured.

RESULTS

The footprint is the insertion of the subscapularis tendon onto the lesser tubercle. The shape of the footprint was characterized as resembling a human ear. The insertion is broad proximally and tapered distally and has a straight medial border that is almost parallel to the longitudinal axis of the humerus. The total average cephalocaudal height of the footprint was 25.8 mm (+/-3.2 mm). The total average width was 18.1 mm (+/-1.6 mm). Average male cephalocaudal height was 26.7 mm (range, 22 to 32 mm), and width was 18.3 mm (range, 16 to 21 mm). Average female cephalocaudal height was 24.8 mm (range, 22 to 29 mm), and width was 17.8 mm (range, 15 to 19 mm). Although the male footprint was slightly larger than the female footprint, differences were not statistically significant (P = .18 and .31 for height and width, respectively).

CONCLUSIONS

An anatomic study was performed to determine the size of the footprint of the subscapularis tendon. We found that the average cephalocaudal height of the footprint was 25.8 mm, and the average width was 18.1 mm.

CLINICAL RELEVANCE

Subscapularis tears are now more frequently addressed arthroscopically. This anatomic study was performed to characterize the anatomy of the subscapularis footprint so that the surgeon can achieve a more anatomic repair.

The influence of arthroscopic subscapularis tendon and anterior capsular release on glenohumeral translation: a biomechanical model

The effect of an arthroscopic release of the intraarticular portion of the subscapularis tendon and the anterior capsule on glenohumeral translation was investigated in a cadaveric model. Ten human cadaveric shoulders with a mean age of 63.5 years (range, 52-79 years) were tested in a robot-assisted shoulder simulator. Joint translation was measured before and after an arthroscopic release of the intraarticular portion of the subscapularis tendon and a subsequent release of the anterior capsule at 0 degrees , 30 degrees , 60 degrees , and 90 degrees of glenohumeral elevation. Translation was measured in the anterior, anterior-inferior, and inferior directions under 20 N of applied load. Testing of the specimen revealed that the release of the intraarticular portion of the subscapularis tendon and the anterior capsule increased translation in all directions. Significant increases in translation were observed after release of the intraarticular portion of the subscapularis tendon in the midrange of motion. The influence of the arthroscopic capsular release, in conjunction with the release of the subscapularis tendon, was very high above 60 degrees of elevation. The study indicates that the intraarticular component of the subscapularis tendon functions as a restraint to anterior-inferior translation primarily in the midrange of glenohumeral motion, whereas the anterior capsule adds anterior-inferior stability to the glenohumeral joint mainly above 60 degrees of elevation.

An evaluation of the effects of the extent of capsular release and of postoperative therapy on the temporal outcomes of adhesive capsulitis

PURPOSE

To evaluate effects of the extent of surgical release and of postoperative physiotherapy on the outcomes of this procedure.

TYPE OF STUDY

Case-controlled cohort study.

METHODS

Pain and range of motion scores were compared preoperatively, operatively, and at 1, 6, 12, 24, 52, and 104 weeks postoperatively, in 2 temporal cohorts of patients with adhesive capsulitis. The first cohort (n = 18) underwent a 155 degrees +/- 40 degrees (mean +/- SEM) standard anteroinferior arthroscopic capsule release of the shoulder (ACR-S) and rehabilitation. The second cohort (n = 22) underwent capsular release that was extended an additional 65 degrees +/- 65 degrees posteriorly, a portion of the intra-articular part of the subscapularis tendon was divided, and the patients had a modified earlier, supervised postoperative physical therapy program (ACR-M).

RESULTS

In both cohorts, there was a significant reduction in pain 1 week after surgery, which was maintained at all time-points (P < .05). More gains in intraoperative range of forward flexion (121 degrees v 150 degrees), abduction (114 degrees v 146 degrees) and external rotation (55 degrees v 68 degrees) were obtained in the ACR-M cohort (P < .001). Six weeks after surgery, external and internal rotation regressed to preoperative levels in the ACR-S cohort; 2 of them required a re-release. This regression was not observed in the ACR-M cohort. There was no instability or weakness in lift-off power in either cohort.

CONCLUSIONS

This is a level IV study of 2 nonrandomized cohorts where simultaneous changes in surgical technique and rehabilitation were introduced to the ACR-M cohort. Arthroscopic capsular release for adhesive capsulitis resulted in significant reductions in pain by 1 week in both cohorts. A more extensive capsular release with division of the intra-articular portion of subscapularis improved intraoperative motion. Gains in internal and external rotation were lost postoperatively in the ACR-S cohort, but were preserved when an extended surgical release and an early, supervised postoperative physical therapy program was initiated in the ACR-M cohort.

LEVEL OF EVIDENCE

Level IV.

Subscapularis tendon tears

Pathology of the subscapularis tendon is both infrequently identified and not commonly considered as a major source of shoulder pain and dysfunction. Subscapularis tendon pathology can present as isolated tears; partial-thickness tears; anterosuperior tears, also involving the supraspinatus tendon; complete rotator cuff avulsion; and rotator interval lesions, in which instability of the long head of the biceps tendon may dominate the clinical presentation. Although an accurate physical examination is paramount, modalities such as arthroscopy, magnetic resonance imaging, and ultrasound have advanced knowledge of the spectrum of abnormalities involving the subscapularis tendon. Nonsurgical management may be effective for most partial tears. Surgically, open repair is more frequent than use of arthroscopic techniques. Tears of the subscapularis tendon portend a different prognosis than do supraspinatus tendon tears, especially when the injury is acute and diagnosis is delayed.

Complete subscapularis tendon visualization and axillary nerve identification by arthroscopic technique

The authors explain how one can view the greatest part of the subscapularis tendon from the subacromial aspect. From the articular aspect, it is possible to see only about one third of its entire surface. We also describe the standardized surgical technique used to obtain this visualization. To visualize the greatest possible surface of the tendon, it is necessary to make a trip to the subacromial space starting from the coracoacromial ligament, which leads us to the key structure: the coracoid. Having reached the coracoid, one goes further, following the conjoined tendon under which the subscapularis tendon is located. This last part of the trip takes place in a dark and potentially dangerous area because of its proximity to noble structures. In fact, the axillary nerve is easily identified on the way. Arthroscopic visualization of the greatest part of the subscapularis tendon is possible from the subacromial space. The technique is standard and follows a well-defined path. The exploration and conquest of this dark space through arthroscopy can open new frontiers both in knowledge and treatment.

Quantitative assessment of thinning of the subscapularis tendon in recurrent anterior dislocation of the shoulder by use of magnetic resonance imaging

It is known that thinning and lengthening of the subscapularis tendon occur in shoulders with recurrent anterior dislocation. However, no studies have been performed to quantify the morphologic changes of the subscapularis tendon under such conditions. We retrospectively measured the thickness and cross-sectional area of the subscapularis tendon by use of magnetic resonance imaging in 22 shoulders in 11 patients with unilateral recurrent anterior dislocation of the shoulder. The contralateral shoulder in each patient served as a control. The thickness and cross-sectional area of the subscapularis on the affected side were smaller than those on the normal side (6.5 +/- 1.7 mm vs 8.0 +/- 1.9 mm, P = .001, and 388.6 +/- 120.0 mm 2 vs 547.9 +/- 128.5 mm 2 , P = .0001, respectively). We conclude that the subscapularis tendon undergoes an 18.7% decrease in thickness and a 29.1% decrease in cross-sectional area in shoulders with recurrent anterior dislocation.

Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia

The aim of this study was to find intraarticular lesions after manipulation under general anesthesia in patients with primary frozen shoulder. In a prospective trial conducted between 2001 and 2003 in 30 patients with primary frozen shoulder, the affected shoulders were manipulated while the patients were under general anesthetia. Exclusion criteria were secondary stiffness caused by rotator cuff tears and glenohumeral arthritis. After manipulation, each patient was examined by arthroscopy, and any intraarticular lesions were documented. In all patients, during manipulation, a significant improvement in the range of motion was achieved. Under anesthesia, flexion improved on average from 70 degrees +/- 33 degrees to 180 degrees +/- 15 degrees, abduction from 50 degrees +/- 20 degrees to 170 degrees +/- 25 degrees, and external rotation from -5 degrees +/- 10 degrees to +40 degrees +/- 20 degrees. Arthroscopy revealed hemarthrosis in all patients after manipulation. In 22 patients, localized synovitis was detected in the area of the rotator interval, whereas in 8 patients, disseminated synovitis was observed as a feature of adhesive capsulitis. After manipulation, the capsule was seen to be ruptured superiorly in 11 patients, the anterior capsule was ruptured up to the infraglenoid pole in 24 patients, and 16 patients each had a capsular lesion located posteriorly. In 18 patients no additional joint damage was found after manipulation. In 4 patients, iatrogenic superior labrum anterior-posterior lesions were observed. Further injuries detected were 3 fresh partial tears of the subscapularis tendon, 4 anterior labral detachments (1 with a small osteochondral defect), and 2 tears of the middle glenohumeral ligament. Even though manipulation under anesthesia is effective in terms of joint mobilization, the method can cause iatrogenic intraarticular damage.

Arthroscopic release of adhesive capsulitis

Twenty-five patients with primary adhesive capsulitis underwent an arthroscopic release of the capsule of the shoulder joint. They were reviewed after a mean of 14.8 months (range, 3-40 months). Night pain and awakening were a feature in all 25 patients preoperatively but were only found in 3 postoperatively. There was marked improvement in pain from a preoperative visual analog scale score of 3.1 to a postoperative visual analog scale score of 12.6 on a scale of 15. Passive movement of the joint improved significantly, with mean passive elevation changing from 73.7 degrees preoperatively to 163 degrees postoperatively, mean passive external rotation changing from 10.6 degrees preoperatively to 46.8 degrees postoperatively, and passive internal rotation improving by a mean of 9 levels. The mean preoperative Constant score of 25.3 improved to 75.5 postoperatively, and the Constant score adjusted for age and gender averaged 91%. All patients completed the Short Form-36 questionnaire at their review, revealing a norm-based physical summary score of 48.7, falling within 1 SD of a normal population sample. This arthroscopic surgical technique is derived from the open surgical release. It is founded upon an understanding of the pathology of this condition. It appears to yield rapid relief of pain and dramatic improvement in movement and function in this painful and otherwise protracted condition.

The etiology and assessment of subscapularis tendon tears: a case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis

With the advent of arthroscopy and arthroscopic repair techniques, the diagnosis and treatment of subscapularis tears have been significantly advanced. The precise etiologic factors related to subscapularis tears remain unclear. We propose that subcoracoid stenosis and subcoracoid impingement cause a "roller-wringer effect" on the subscapularis tendon. This effect increases the tensile loads on the articular surface of the subscapularis tendon that may lead to tensile undersurface fiber failure (TUFF) of the subscapularis insertion. Collectively, these factors may in part contribute to the pathogenesis of subscapularis tears.

Subscapularis tears: arthroscopic repair techniques

The subscapularis is an essential component of normal shoulder function. An intact subscapularis muscle provides the anterior moment for the transverse plane force couple. Any disruption of the subscapularis disrupts normal glenohumeral biomechanics. If this occurs the shoulder functions abnormally, leading to pain and disability. A thorough history and physical examination lead the surgeon to the diagnosis of a torn subscapularis. Radiographs and MRI are helpful in delineating the rotator cuff tear pattern and other intra-articular lesions and in determining subcoracoid stenosis. Advancements with arthroscopic techniques have enabled surgeons to deal with subscapularis tears arthroscopically. There are seven key points to arthroscopic subscapularis repair: (1) portal placement (posterior portal, anterior portal, anterolateral portal, and accessory anterolateral portal), (2) visualization of the pathology by using a 30 degree and a 70 degree arthroscope, (3) manipulating the arm into maximal internal rotation to assist in assessing the tendon's relationship to its footprint, (4) appropriate anchor placement, (5) suture passage through the tendon, (6) tying secure arthroscopic knots, and (7) appropriate rehabilitation that minimizes stress on the repair. With these principles in mind, the shoulder surgeon can address disruptions of the anterior rotator cuff by repairing the subscapularis, thus alleviating the disability associated with this overlooked and under-appreciated pathology.

Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases

BACKGROUND

Prevalence and clinical significance of partial tears of the subscapularis tendon have not been widely studied.

PURPOSE

To determine prevalence of and clinical factors associated with partial tears of the subscapularis tendon at arthroscopy.

STUDY DESIGN

Case control study.

METHODS

During arthroscopic procedures on 314 consecutive shoulders, the arthroscopically visible portion of the subscapularis tendon was probed. Patients with and without partial tears were compared for prospectively identified variables.

RESULTS

Partial tears were found in 60 of the 314 patients (19%). Increasing age and dominant arm involvement were significant variables for partial tears. Significantly associated factors included supraspinatus tendon tears (54 of 60; 90%), rotator cuff disease (44 of 60, 73%), and posterosuperior labral fraying (34 of 47, 72%). Increasing age, dominant arm involvement, and coexisting infraspinatus tendon tears were strong independent risk factors for partial tears.

CONCLUSION

Partial tears of the subscapularis tendon are not uncommon findings during shoulder arthroscopic procedures and are associated with extensive rotator cuff disease. They do not appear to be associated with glenohumeral instability, but a possible association with atypical forms of instability (subclinical or superior instability) cannot be excluded by this study. The absence of a significant association between the lesion and specific subjective symptoms or physical findings suggests that caution should be taken when attributing a specific symptom to this condition.

Releases of subscapularis contracture: an anatomic and clinical study

Correction of anterior subscapularis contracture is an important step in soft-tissue balancing at the time of total shoulder replacement (TSR). An anatomic and clinical investigation was undertaken to investigate the effect of steps involved in subscapularis release. In 14 cadaveric shoulders studied, the subscapularis insertion consisted of three regions: a thick superior tubular tendon (STT), a flat middle tendon, and an inferior portion where the muscle fibers insert directly into the humerus. In 16 consecutive patients undergoing primary TSR for osteoarthritis, measurements of subscapularis length were taken after different releases. An average of 0.9 cm (confidence interval, 0.7-1.1 cm) of excursion was added after anterior capsular release, and an additional 0.7 cm (confidence interval, 0.5-0.9 cm) of excursion was obtained after STT release. Incision of the STT is an alternative means of gaining subscapularis length when balancing the soft tissues in patients with osteoarthritis undergoing TSR.

Loss of subscapularis function after total shoulder replacement: A seldom recognized problem

Little attention has focused on subscapularis integrity after total shoulder replacement (TSR). We have noted that several patients have loss of internal rotation and subscapularis function on follow-up, leading to our review of success in restoring subscapularis function after TSR. A retrospective review was done of the records of 41 patients after TSR performed between 1995 and 2000. Mean follow-up was 1.9 years. Terminal internal rotation was evaluated by the lift-off and belly-press examinations. Subscapularis function was assessed by the patients' ability to tuck in a shirt. The subscapularis was repaired anatomically in 9 cases and through bone tunnels in 32 patients. Abnormal results were found for 25 of 37 lift-off examinations (67.5%) and 24 of 36 belly-press examinations (66.6%). Of 25 patients with an abnormal lift-off finding, 92% reported reduced subscapularis function (Fisher exact test, P <.01). Despite meticulous attention to subscapularis repair, suboptimal return of function was found on clinical examination and assessment of activities of daily living.