Capsule Of The Glenohumeral Joint Research Articles

Podium Presentation Title: A Histological Analysis of the Superior Capsule of the Glenohumeral Joint and the Rotator Cuff

Podium Presentation Title: A Histological Analysis of the Superior Capsule of the Glenohumeral Joint and the Rotator Cuff

Does unilateral adhesive capsulitis also affect the healthy shoulder? Bilateral evaluation of shoulder kinematics and pain sensitivity using IMU sensors and algometer

Adhesive capsulitis (AC) is a generally unilateral condition caused by a pathological retraction of the capsule and ligaments of the glenohumeral joint. This results in progressive pain with a decrease of Pain Pressure Threshold (PPT), and in gradual loss of range of motion (ROM) in all planes of space [1]. The effectiveness of physical therapy treatments depends on the appropriate clinical management strategies, for this reason, the objective evaluation and treatment remain challenging [2]. In this observational study, clinical and kinematic differences between healthy and capsulitis shoulder before and after a conservative physiotherapy protocol are enquired. Humeral flexion/abduction motions of 10 patients with unilateral AC were investigated with inertial and magnetic (IMU) sensors. Specifically, ISEO protocol was used to assess the differences in humeral ROM between the pathological and healthy shoulder [3], and pain sensitivity was assessed by means of algometer. The acquisitions were performed, on both capsulitis (cS) and healthy shoulder (hS), twice: at the baseline (T0), and after 20 one-hour individual sessions of physiotherapy protocol (T1) [4]. Significant differences in the humeral ROM during both motion exercises were detected between cS and hS at T0 but not after physical therapy treatment (Fig. 1a). On the contrary PPT increased significatively at the cS level (not shown) and at the hS level ( Fig. 1 b). To date, no previous study has investigated the quality of movement with IMU sensors nor the differences between hS and cS in patients with AC. This study reveals that ISEO protocol is an efficient approach for quantitative evaluation of physical therapy efficacy in AC. Moreover, while physical therapy does not improve ROM in hS, it does ameliorate significantly bilateral patients’ pain sensitivity: since unilateral AC alters motor programs not only of the affected shoulder but also of dorsal and cervical elements [5], physical therapies treating and mobilitating these areas have a bilateral biomechanical effect that allows a reduction of pain sensitivity also at the level of hS.

Living with a frozen shoulder \u2013 a phenomenological inquiry

BackgroundFrozen shoulder (adhesive capsulitis) is an inflammatory condition affecting the capsule of the glenohumeral joint. It is characterised by a painful restricted range of passive and active movement in all planes of motion. The impact of frozen shoulder on affected individuals remains poorly characterised. In this study we sought to better understand the lived experience of people suffering from frozen shoulder to characterise the physical, psychological and socioeconomic impact of the condition.MethodsA qualitative study using a phenomenological approach was undertaken. Purposeful sampling was used to identify individuals for interview. Semi-structured interviews were performed and continued until saturation was achieved. A biopsychosocial framework was used during the analysis in order to generate themes which best described the phenomenon and reflected the lived experience of individuals’ suffering from this condition.ResultsTen interviews were conducted, and five main themes emerged including; the severity of the pain experience, a loss of independence, an altered sense of self, the significant psychological impact, and the variable experience with healthcare providers.ConclusionsThese findings offer an insight into the lived experience of individuals with frozen shoulder, both on a personal and sociocultural level. The pain endured has profound impacts on physical and mental health, with loss of function resulting in a narrative reconstruction and altered sense of self. Our findings illustrate that frozen shoulder is much more than a benign self-limiting musculoskeletal condition and should be managed accordingly.Trial registrationANZCTR 12620000677909 Registered 28/04/2020 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379719&isReview=true

Manual Therapy Interventions for Adhesive Capsulitis: A Review

Adhesive Capsulitis is a debilitating condition which causes the capsule of the Gleno-humeral joint to get thickened and contracted progressively. The prevalence of the disease is much higher in the middle aged and elderly community. It is characterized by pain in the shoulder, and advance towards the restriction of the active and passive glenohumeral motions and thereby obstructing the overall functional activities of the daily living. The effectiveness of various non-operative methods in the treatment of Adhesive Capsulitis has been demonstrated in the literature. Corticosteroid injections and the oral medications are known to be alleviating the pain levels and the inflammatory reactions but not the mobility of the affected joint. Joint mobilization techniques, electrotherapeutic modalities and other manual treatment methods are also found to be effective. In summary, this review focuses on the pathophysiology of the adhesive capsulitis, stages of the condition progress and various manual therapy interventions. Keywords: Gleno-humeral joint, frozen shoulder, rehabilitation, active and passive movements, functional activities.

An anatomical study of the fetal superior capsule of the glenohumeral joint

IntroductionThe superior part of the glenohumeral joint capsule has an intimate relationship with the tendons of the rotator cuff and the tendon of the long head of the biceps. One of the strategies currently proposed in the event of a massive cuff rupture is to reconstruct this superior capsule. The main objective of this anatomical study was to describe the superior joint capsule of the embryonic glenohumeral joint and its relationship to the tendons of the rotator cuff. HypothesisThe hypothesis was that this structure was an anatomical entity, morphologically identifiable from the embryogenesis of the joint (more pronounced tissue boundaries in the fetus). Material and methodsIn total, 101 continuous fetal anatomical sections (4 fetuses of 336mm), in the frontal plane, made it possible to identify and measure: diameters of the humeral head and glenoid, dimensions of the joint capsule insertion zone at the level of the greater tubercle, as well as the different thicknesses of this insertion zone. The ratios above the head of the biceps and against the superior labrum were also measured. ResultsAt the level of its distal insertion on the greater tuberosity, the thickness of the superior joint capsule varies on average between 0.8mm laterally and 1.2mm next to the tendons of the supraspinatus and infraspinatus; the thickness is 0.9mm next to the middle part of the supraspinatus tendon (the “rotator cable” zone). For its insertion at the level of the glenoid labrum, the superior capsule measures 0.6mm thick on average. The capsule around the tendon of the long head of the biceps is 1.5mm thick on average. DiscussionHere, we confirm the existence of this superior joint capsule, which can potentially be reconstructed. It is inserted on the greater tubercle covering 30 to 60% of its surface with variations in thickness. The joint capsule is fused to the supraspinatus tendon at the rotator cuff insertion area, preventing independent reinsertion of the tendon. Level of evidenceIV; anatomical study.

Arthroscopic Superior Capsular Reconstruction for Treatment of Massive Irreparable Rotator Cuff Tears: An Update of the Technique for 2020.

The treatment of massive, irreparable rotator cuff tears presents a substantial challenge to health-care professionals. Treatment options range from nonoperative to operative, including debridement, partial repair, biceps tenotomy, bridging patch grafts, muscle transfers, and reverse total shoulder arthroplasty. However, the results of such treatments are often mixed, and many carry a substantial risk of complications. Superior capsular reconstruction has been described as a surgical alternative to the aforementioned procedures. Superior capsular reconstruction is a technique that provides an anatomic reconstruction of the superior capsule of the glenohumeral joint, with the goal of restoring the normal restraint to superior translation that is lost with a deficient superior rotator cuff. The technique described in the present article highlights the pearls and pitfalls learned over the last several years of performing arthroscopic reconstruction of the superior capsule with dermal allograft.

The efficacy of physiotherapy interventions in the treatment of adhesive capsulitis: A systematic review.

Adhesive capsulitis is a debilitating condition which causes the capsule of the gleno-humeral joint to thicken and contract progressively. The effectiveness of various non-operative methods has been demonstrated to improve the pain, range of motion (ROM) and functional status of patients with adhesive capsulitis. This study aims to review recent evidence on the efficacy of physiotherapy interventions in the treatment of adhesive capsulitis. PubMed, Physiotherapy Evidence Database (PEDro), Science Direct and Cochrane databases were searched for studies published since 2013. The search terms included: Frozen shoulder, adhesive capsulitis, physical therapy, rehabilitation, manual therapy, mobilization, exercise, education, and electrotherapy. The search was limited to studies published in English and studies that used human subjects. Quality scores of 33 articles were reviewed according to the Sackett's critical appraisal criteria and the grades of recommendation were determined for physiotherapy interventions used in the studies. The empirical evidence suggests that certain physical therapy techniques and modalities are strongly recommended for pain relief, improvement of ROM, and functional status in patients with adhesive capsulitis, while others are either moderately or mildly recommended. However, the efficacy of one treatment modality over another is uncertain. The poor methodological rigors demonstrated in most of the reviewed studies emphasize the urgent need of properly conducted, adequately sampled randomized controlled trials with adequate follow up to determine the superior combination of treatment.

IDIOPATHIC UNILATERAL FROZEN SHOULDER

Introduction: Frozen shoulder or adhesive capsulitis is a condition affectingthe glenohumeral joint and leads to restricted painful shoulder. It is very debilitating. This notonly affects the activities of daily living of a person but job related chores too. The inflammationof the capsule of the glenohumeral joint causes pain and restriction of the motion. Adhesivecapsulitis can be characterized as primary or secondary. It can be secondary due to anyunderlying disease such as cervical spondylosis or diabetes mellitus. People affected seekdifferent treatment options for this debilitating condition such as taking non-steroidal antiinflammatorydrugs (NSAIDS), steroid injections, taking physical therapy and some even gofor surgical interventions. Objective: the objective of this research was to find out whetherKaltenborn mobilization technique alone improved the restricted shoulder abduction range ofmotion in better way or a combination of Kaltenborn mobilization and range of motion exerciseswas a better option. Study Design: randomized clinical trial (RCT). Setting: Fatima MemorialHospital (FMH) Shadman Lahore. Period: a period of 6 months. Material and Methods:Group I: Thirty patients participated in this group and were treated with Kaltenborn mobilizationtechnique along with range of motion exercises. Group II: The second group also consisted ofthirty patients and were treated with Kaltenborn mobilization technique without range of motionexercises. Sample Size: Sixty patients were included in the research by taking 30 patients ineach group. Systematic sampling was used in which all the odd ordered patients (1st, 3rd, 5th etc.)were included in group I while all the even ordered patients (2nd, 4th, 6th etc.) in group II. Results:For abduction the mean change was 29.33±10.65 in combination while for kaltenborn alone themean change was 12.30±4.06. The values obtained for shoulder abduction were significantlyhigher in Kaltenborn + ROM group, p-value < 0.05. Conclusion: A combination of Kaltenbornmobilization along with range of motion exercises showed better results in improving shoulderabduction range of motion.

Glenohumeral joint dissection: a new protocol

Objectives: The glenohumeral joint, as a component of the shoulder girdle, is one of the most frequently injured joints of the upper extremity. Typical dissection of the glenohumeral joint does not allow an intracapsular view without sacrificing the joint capsule and surrounding structures. Methods: A dissection method is presented which reveals the internal capsule of the glenohumeral joint, the glenoid labrum, the proximal insertion of the long head of the biceps tendon, and glenohumeral joint surfaces while preserving the posterior aspect of the capsule and surrounding supportive muscles and tendons of the joint. Results: The novel dissection technique allowed for preservation of glenohumeral joint structures and consideration or reexamination of the relationships and structures. Conclusion: The authors present an alternative protocol for dissection of the glenohumeral joint that minimizes destruction of the surrounding structures while allowing visualization of the internal capsule and maintains the relationships of the surrounding supporting structures of the pectoral girdle that may be used for study at a later time. Conclusion: The authors present an alternative protocol for dissection of the glenohumeral joint that minimizes destruction of the surrounding structures while allowing visualization of the internal capsule and maintains the relationships of the surrounding supporting structures of the pectoral girdle that may be used for study at a later time.

Superior capsule reconstruction

Superior capsule reconstruction (SCR) is a relatively new advancement in the realm of treating irreparable rotator cuff tears (RCTs). The surgery involves anchoring a graft between the superior glenoid and greater tuberosity, with the goal of restoring the continuity of the capsule and mechanical balance of the glenohumeral joint. Although the body of evidence surrounding SCR is in its infancy, it has been shown to be biomechanically superior to patch grafting procedures. Additionally, it provides the advantage over tendon transfers in that it does not burn bridges for subsequent interventions. A series of high-level biomechanical studies, which are highlighted in this review, have provided helpful information for the evolution and refinement of the SCR technique, including the importance of side-to-side suturing of the graft with the remnant cuff as well as the utility of concomitant acromioplasty. Early clinical results are promising for SCR, with both strong objective and subjective outcomes.

Effect of perfect anatomic repair, imperfect anatomic repair, and no repair of a 25% Hill-Sachs lesion on bony contact and capsular forces at the glenohumeral joint

Summary Background To compare the impact of a 25% Hill-Sachs lesion (defect condition, D) and perfect and imperfect anatomic repairs (PAR and IAR) of such lesions on glenohumeral bony contact and capsular forces in response to compressive and anterior loads. Material and methods A robotic/universal force-moment sensor testing system applied joint compression (22N) and an anterior load (44N) to cadaveric shoulders ( n =9) at three glenohumeral joint positions (abduction/external rotation): 0°/0°, 30°/30°, and 60°/60°. The 25% bony defect state, PAR state, and IAR state were created and the loading protocol was performed. Bony contact/capsular forces were measured in each position for each shoulder state. Results PAR had the least biomechanical impact on the bony surfaces and capsule of the glenohumeral joint. D had less impact on the bones and capsule compared to the IAR. The bony surfaces and capsule of the glenohumeral joint sustained the greatest forces in the IAR condition. Conclusions The PAR state had the least force applied to the bony surfaces and capsule of the glenohumeral joint. The defect shoulder had significantly less force applied to the bones and capsule of the glenohumeral joint compared to the IAR (greatest force applied). Performing an osteoallograft repair that does not fully restore normal anatomy may result in abnormal bony contact/capsular forces, resulting in joint wear, arthritis, and injury to the surrounding capsule. Clinical relevance The importance of performing an osteoallograft repair of a Hill-Sachs defect that closely matches the pre-injury state and restores normal humeral head anatomy.

Anatomical study of the coracoid process in Mongolian male cadavers using the Latarjet procedure.

BackgroundThe Latarjet procedure addresses recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid in coracoid transfer procedures has not yet been defined in Mongolian men. The aims of this study were to describe the soft tissue attachments of the coracoid regarding the bony anatomy, define the average amount of bone available for coracoid transfer, analyze the characteristics of the pectoralis minor and coracoid, and study the relationship between the bony dimensions of the coracoid and body length in Mongolian men.MethodsWe dissected 30 shoulders from 15 male Mongolian cadavers, exposing the coracoid process and attached anatomical structures including the lateral clavicle and acromion, then measured the bony dimensions of the coracoid and the locations and sizes of the coracoid soft tissue footprints.ResultsThe mean length of the coracoid available for transfer was 23.93 ± 2.32 mm. The mean length of the coracoid was 42.10 ± 2.3 mm, and the mean width and height of the coracoid midpoint were 15.29 ± 1.70 mm and 11.61 ± 1.98 mm, respectively. The pectoralis minor was part of the joint capsule and passed over the coracoid in some samples. The mutation rate of the pectoralis minor footprint, which was asymmetrical and irregular, was 23.33 %. Statistical analysis involved a multiple linear regression equation.ConclusionsThe average amount of bone available for use in coracoid transfer in Mongolian men was less than that of other populations. Mutation of the pectoralis minor may induce intraoperative capsule injury because this muscle passes over the coracoid deep to the joint capsule of the glenohumeral joint and constitutes part of the shoulder joint, strengthening the joint. Statistically, higher coracoids appeared in shorter patients and longer coracoids appeared in taller patients. Surgically, great care should be taken to consider a patient’s height to precisely implement the congruent-arc Latarjet technique.

Factors Affecting Capsular Volume Changes and Association With Outcomes After Bankart Repair and Capsular Shift

Background: Capsular laxity is a main contributing factor in recurrent shoulder instability and is suggested to be correlated with increased capsular volume. Arthroscopic capsular shift combined with Bankart repair can reduce the capsular volume and reinforce the redundant capsule; however, as the capsuloligamentous structure has viscoelastic properties, it is possible for the shifted and tensioned capsule of the glenohumeral joint to slowly stretch out again over time, resulting in an increase in capsular volume. Purpose: To analyze changes in capsular volume of the glenohumeral joint over time after arthroscopic Bankart repair and capsular shift, the factors associated with these changes, and their relevance to outcomes. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 105 patients (mean age, 25.8 ± 8.2 years) who underwent arthroscopic Bankart repair and capsular shift for anterior shoulder instability and computed tomography arthrography (CTA) at 3 months and 1 year postoperatively and whose various functional outcomes were evaluated preoperatively and at the last follow-up (>12 months). Among these patients, 27 also had preoperative CTA. These 27 patients were used to make comparisons between preoperative and 3-month postoperative CTA measurements, and all 105 patients were used for all other comparisons. Two raters measured the separate anterior and posterior capsular volume and cross-sectional area at the 5-o’clock position using 3-dimensional (3D) Slicer software. These measurements were subsequently adjusted for each glenoid size. The changes in capsular volume and cross-sectional area at the 5-o’clock position over time, the factors related to higher change in anterior capsular volume, and their correlation with outcomes were evaluated. Results: Three months postoperatively, the total and anterior capsular volume and anterior cross-sectional area significantly decreased; however, these values increased again at 1 year postoperatively (all P < .01). The inter- and intraobserver reliabilities of the measurements were excellent (interclass correlation coefficient = 0.717-0.945). Female sex, being an elite athlete, and more dislocations before surgery were related to a higher increase in anterior capsular volume at 1 year (all P < .05). Eight patients had redislocation, and 18 exhibited positive apprehension test postoperatively, and these patients showed significantly higher increases in anterior and total capsular volume at 1 year than did those without redislocation or positive apprehension sign (all P < .01). However, with the exception of Rowe score, a higher increase in anterior capsular volume was not related to functional outcome measures. Conclusion: Surgeons should be aware of the re-increase in anterior capsular volume or restretching trait of the anterior capsule over time, even after successful arthroscopic Bankart repair and capsular shift. In this study, women, elite athletes, and those with frequent dislocations were at high risk of capsular restretching. An increase in capsular volume was related to redislocation and positive apprehension sign as well as with Rowe score.

A Comparative Study to assess the effectiveness of Soft Tissue Mobilization Preceding Joint Mobilization Technique in the Management of Adhesive Capsulitis

Background: Adhesive capsulitis is a condition wherein the shoulder capsule of the glenohumeral joint becomes inflamed and stiff along with adhesion formation. Mobilisation techniques and soft tissue manipulations are important interventions in the management. Both, soft tissue manipulation and joint mobilisation are proven to be effective in treatment of adhesive capsulitis in the past. However logical thinking warranted the need to study the effects of prior use of soft tissue mobilisation of the periarticular structures, which primarily get affected in adhesive capsulitis, followed by joint mobilisation techniques around the glenohumeral joint. Thus our study compared the efficacy of treatment strategies to improve the extensibility of soft tissues i.e; Myofascial release Armpull technique and Maitland's joint mobilization technique in patients with adhesive capsulitis. Aim: To study the effects of Maitland's mobilization when preceded by Myofascial Release Arm pull technique in patients with Adhesive capsulitis. Methodology: 30 subjects fulfilling the inclusion criteria were selected and randomly allocated into 2 Groups, Group I: Control Group - Maitland's mobilization + Exercises, Group II: Experimental Group - MFR Arm pull + Maitland's mobilization + Exercises. Brief assessment of Pain, Disability and Range of motion was done by using Visual Analogue Scale, Goniometric measurements and Shoulder Pain And Disability Index. Results: Statistical analysis showed significant improvement in pain reduction, functional ability and ROM in both Group 1 and Group 2. However when all the outcome measures were compared between the 2 Groups, significant difference was observed in Myofascial release Arm pull technique preceding Maitland's mobilization with respect to pain, function and ROM. Conclusion: Soft tissue mobilization comprising of Myofascial release Arm pull technique when given prior to Maitland's mobilization showed significant results in reducing symptoms as well as improving functional abilities in Adhesive capsulitis.

An electrospun polydioxanone patch for the localisation of biological therapies during tendon repair

Rotator cuff tendon pathology is thought to account for 30-70% of all shoulder pain. For cases that have failed conservative treatment, surgical re-attachment of the tendon to the bone with a non-absorbable suture is a common option. However, the failure rate of these repairs is high, estimated at up to 75%. Studies have shown that in late disease stages the tendon itself is extremely degenerate, with reduced cell numbers and poor matrix organisation. Thus, it has been suggested that adding biological factors such as platelet rich plasma (PRP) and mesenchymal stem cells could improve healing. However, the articular capsule of the glenohumeral joint and the subacromial bursa are large spaces, and injecting beneficial factors into these sites does not ensure localisation to the area of tendon damage. Thus, the aim of this study was to develop a biocompatible patch for improving the healing rates of rotator cuff repairs. The patch will create a confinement around the repair area and will be used to guide injections to the vicinity of the surgical repair. Here, we characterised and tested a preliminary prototype of the patch utilising in vitro tools and primary tendon-derived cells, showing exceptional biocompatibility despite rapid degradation, improved cell attachment and that cells could migrate across the patch towards a chemo-attractant. Finally, we showed the feasibility of detecting the patch using ultrasound and injecting liquid into the confinement ex vivo. There is a potential for using this scaffold in the surgical repair of interfaces such as the tendon insertion in the rotator cuff, in conjunction with beneficial factors.

The Effect of Cyclic Loading Simulating Oscillatory Joint Mobilization on the Posterior Capsule of the Glenohumeral Joint: A Cadaveric Study

Experimental laboratory design. To examine the effect of force and repetition during oscillatory joint mobilizations on the posterior capsule of the glenohumeral joint. The optimal external force and frequency to be used during joint mobilization to elongate the posterior capsule of the glenohumeral joint has yet to be identified. Twenty-one posterior capsules were harvested from fresh-frozen shoulders. A cyclic loading test simulating oscillatory posterior joint mobilization on the shoulder specimens was performed with a material testing machine. The specimens were assigned to 3 different loading groups simulating joint mobilization in the toe (5 N), transition (20 N), and beginning of the linear regions (40 N) of the load displacement curve. Displacement of the humeral head at an applied load of 5 N was recorded at the 1st, 100th, 200th, 300th, 400th, 500th, and 600th cycles and at 1 hour after completion of the cyclic loading. Furthermore, stiffness was calculated after the 1st and 600th cycles and 1 hour after testing. Humeral head displacement was significantly greater for the 100th to 600th cycle, compared to the 1st cycle, for all 3 loading groups. Significant increases in displacement and stiffness were observed between the 1st cycle and 1 hour after completion of the cyclic tests for both the 20-N and 40-N loading groups. While oscillatory joint mobilization to a force of 5 N resulted in temporary elongation of the posterior capsule, mobilization to loads of 20 and 40 N resulted in sustained elongation of the capsule for up to 1 hour. Our findings also suggest that mobilization up to loads that represent the beginning of the linear region of the load displacement curve could be performed without serious damage to the posterior capsule.

Bilateral variation of the pectoralis minor muscle discovered during practical dissection

We describe a case of an original insertion of the pectoralis minor on the coracohumeral ligament, supraspinatus tendon and the capsule of the glenohumeral joint. This variation has been described in anatomy textbooks since the nineteenth century. The peculiarity of this case is that the right shoulder presented type 2 and the left type 1 of the three varieties described by Le Double in 1897. Le Double (1843-1913) was a French anatomist who wrote a treaty on anatomical variations, in particular those of the muscle. Lately, only three publications have reported this variation in anatomic studies. Some authors have described the rotator cuff syndrome caused by this variation and an ultrasound study has demonstrated a frequency of 9.57% for the detection of this variation. It is possible to try and find this variation while investigating in order to diagnose impingement, through ultrasound, CT arthrography or MRI. We believe that this variation should be taken into consideration by surgeons during surgical procedures and arthroscopy.

The Spiral Glenohumeral Ligament: An Open and Arthroscopic Anatomy Study

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

Unusual attachment of the pectoralis minor muscle

The authors report a presumably unusual bony attachment of the pectoralis minor muscle in an adult cadaver. The specimen's left pectoralis minor had no attachment to the coracoid process of the scapula but attached directly to the fibrous capsule of the glenohumeral joint. Some have theorized that the coracohumeral ligament represents fibers of the pectoralis minor that attach to this bone in some animals but that has degenerated in man. This case report seems to support this possibility.

Some peculiarities of the rotator cuff muscles

The authors studied the origin, course and insertion as well as some peculiarities of RC muscles on 25 cadaverous fixed limbs. They discovered that RC muscles exchange muscle bundles and are secured by synovial sheaths. They described the articular muscles in all of the observed muscles, including the deltoid muscle, which significantly stretch the capsule of the glenohumeral joint. They expressed the opinion that the subscapular bursa enhances motions in the shoulder joint. Due to the possibilities of arthroscopic diagnostic and treatment methods, they are convinced that more attention must directed to this issue from both the morphological and functional perspective.