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The main aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) and interobserver agreement in the identification of the comma sign. The second objective was to look for a correlation between the comma sign and the detachment of the superficial fascia of the subscapularis. Two radiologists, blinded to the arthroscopic findings, retrospectively assessed the magnetic resonance images of 110 shoulders and were asked to assess the presence of the comma sign and the intact subscapularis fascia. The inter-reader agreement and the MRI performance values for detection of the comma sign were calculated. In addition, the association between the intact superficial subscapularis fascia and the comma sign was evaluated. The agreement between the 2 radiologists was perfect. The following values were obtained: sensitivity, 90.9%; specificity, 98.8%; positive predictive value, 95.2%; negative predictive value, 97.7%; and accuracy, 97.2%. No association between the comma sign and subscapularis fascia lesions was found. MRI appears to be a reliable method for preoperative assessment of the comma sign. The comma sign appears not to be formed by the detached subscapularis fascia. [ABSTRACT FROM AUTHOR]

A thickened joint capsule is believed to be one of the most specific manifestations of and the primary restraint against range of motion (ROM) in frozen shoulders. The purpose of this study was to evaluate the relationship among ROMs under general anesthesia before surgery and the effects of each joint capsular release on ROM. ROM was measured using a goniometer with scapular fixation. Arthroscopic pan-capsular release was performed with the patient in the beach-chair position in the following order: (1) rotator interval, (2) coracohumeral ligament, (3) superior capsule, (4) middle glenohumeral ligament, (5) anterior inferior glenohumeral ligament, and (6) posterior inferior glenohumeral ligament. ROMs in forward flexion (FF), lateral elevation (LE), external rotation with the arm at the side (ER1), external rotation at 90° of LE (ER2), internal rotation at 90° of LE (IR2), horizontal flexion, external rotation at 90° of FF (ER3), and internal rotation at 90° of FF (IR3) were evaluated before and after each release. A total of 32 consecutive shoulders were included. After each capsular release, the ROM recovered; the final ROM was significantly greater on the affected side than on the unaffected side. Significant correlations were found between FF and LE, FF and ER1, ER1 and ER2, ER1 and ER3, ER2 and ER3, and IR2 and IR3 on both sides, regardless of surgery. Each segment of the joint capsule affected ROM in all directions, supporting the need for whole-joint capsular release; ROM was significantly greater on the affected side than on the unaffected side after surgery. [ABSTRACT FROM AUTHOR]

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Background Evaluation of range of motion (ROM) restriction before treatment of shoulder disorders is important for predicting the final functional outcomes. The purpose of this study was to investigate correlations of thickness of the coracohumeral ligament (CHL) and ROM restriction in patients with recurrent anterior glenohumeral instability. Methods Between January 2005 and March 2015, 181 shoulders (137 male and 44 female patients; mean age, 29.3 years) with recurrent anterior glenohumeral instability treated with an arthroscopic Bankart repair were enrolled in this study. We evaluated preoperative ROM, thickness of the CHL, and obliteration of the subcoracoid fat triangle on magnetic resonance arthrography. ROM measurements, including forward flexion (FF), external rotation with the arm at the side (ER), and hand behind the back (HBB), were made in a standing position. Results There were significant negative correlations between FF and age ( P  < .001) and between HBB and age ( P  < .001) but not between ER and age ( P  = .11). The thickness of the CHL significantly increased with age ( P  < .001). FF, ER, and HBB were significantly restricted in patients with obliteration compared with those without obliteration ( P  < .001, P  = .004, P  < .001, respectively). Conclusions Obliteration of the subcoracoid fat triangle and the thickness of the CHL positively correlated with ROM restrictions, and these changes were greater with age in patients with recurrent anterior glenohumeral instability. [ABSTRACT FROM AUTHOR]

Background Only a few reports describe the extension of the coracohumeral ligament to the subscapularis muscle. The purposes of this study were to histo-anatomically examine the structure between the ligament and subscapularis and to discuss the function of the ligament. Methods Nineteen intact embalmed shoulders were used. In 9 shoulders, the expansion of the ligament was anatomically observed, and in 6 of these 9, the muscular tissue of the supraspinatus and subscapularis was removed to carefully examine the attachments to the tendons of these muscles. Five shoulders were frozen and sagittally sectioned into 3-mm-thick slices. After observation, histologic analysis was performed on 3 of these shoulders. In the remaining 5 shoulders, the coracoid process was harvested to investigate the ligament origin. Results The coracohumeral ligament originated from the horizontal limb and base of the coracoid process and enveloped the cranial part of the subscapularis muscle. The superficial layer of the ligament covered a broad area of the anterior surface of the muscle. Laterally, it protruded between the long head of the biceps tendon and subscapularis and attached to the tendinous floor, which extended from the subscapularis insertion. Histologically, the ligament consisted of irregular and sparse fibers abundant in type III collagen. Conclusion The coracohumeral ligament envelops the whole subscapularis muscle and insertion and seems to function as a kind of holder for the subscapularis and supraspinatus muscles. The ligament is composed of irregular and sparse fibers and contains relatively rich type III collagen, which would suggest flexibility. [ABSTRACT FROM AUTHOR]

Background: Various findings in the lateral rotator interval to support the long head of the biceps tendon have been reported. The purpose of this study was to clarify the functional anatomy regarding the stabilization of the biceps tendon. Material and methods: Twenty embalmed shoulders were used for anatomic study, and 5 specimens of the anterosuperior part of the glenohumeral joint were histologically studied. Results: Anatomically, the most superior part of the subscapularis tendon was attached to the upper margin of the lesser tuberosity and extended as a thin tendinous slip to the fovea capitis of the humerus. The superior glenohumeral ligament ran spirally along the biceps tendon. Histologically, the superior glenohumeral ligament was attached to the tendinous slip. There was no clear boundary between the superior glenohumeral and coracohumeral ligament. Conclusion: To keep the biceps tendon in place and stabilized, tension in the superior glenohumeral ligament and the buttress support of the most superior insertion point of the subscapularis from behind the ligament may be necessary. Level of Evidence: Basic Science [Copyright &y& Elsevier]

The role of the rotator interval (RI) in maintaining stability of the shoulder joint remains controversial. Defined as the triangular-shaped space between the supraspinatus and subscapularis tendons, the RI is an area of complex anatomy that contains the superior and middle glenohumeral ligaments, the coracohumeral ligament, the long head of the biceps, and a thin layer of capsule. The RI has frequently been touted as an area that is important in preserving stability of the shoulder because an incompetent RI has been implicated in various conditions of shoulder instability. Biomechanical research suggests that surgical repair of the RI improves the overall stability of the shoulder joint predominantly in the anterior and potentially inferior directions. With the advent of arthroscopic techniques for the treatment of shoulder instability, the differences between an arthroscopic and open RI closure have been delineated. The purposes of this review were to investigate the anatomy and biomechanical function of the RI in shoulder instability, to review the techniques of surgical repair, and to describe the effect of RI closure on glenohumeral kinematics. Additionally, some of the controversies regarding the indications for RI closure will be discussed. [Copyright &y& Elsevier]

Summary: The triangular capsular space between the insertion tendons of the Mm. supraspinatus and subscapularis — the “rotator interval”, can be divided into lateral, medio-superior and medio-inferior parts. The lateral part of the capsule is strengthened by the “Lig. semicirculare humeri” and the anterior fibres of the M. supraspinatus tendon. The Ligg. coracohumerale and “coracolgenoidale” are the macroscopical elements of the medio-superior part. The medio-inferior part of the “rotator interval” is reinforced by the Ligg. glenohumeralia superius et medium. The key ligament of the “rotator interval” is the “Lig. semicirculare humeri”. Laterally it ensures the insertion of the anterior fibres of the M. supraspinatus tendon above the Lig. transversum humeri and on the Tubercula majus et minus. Medially it is the place of attachment of the Lig. coracohumerale and oblique fibres of the Lig. glenohumerale superius. The “rotator interval” is not a weak capsular region but a complex network of macroscopically recognizable tendinous and ligamentous structures. [Copyright &y& Elsevier]