A Histological Analysis of the Superior Capsule of the Glenohumeral Joint and the Supraspinatus Tendon.

Abstract

Background: Complete understanding of rotator cuff pathology relies on a comprehensive knowledge of the anatomic relationships between the supraspinatus tendon (ST) and the superior capsule (SC) of the glenohumeral joint. However, the native anatomy of these structures across the glenohumeral joint and at their attachment sites remains incompletely understood.

Purpose: To (1) determine the histological anatomy and absolute and relative thicknesses of the SC compared with the ST across the glenohumeral joint at the anterior, midpoint, and posterior portions of the ST; (2) quantify the percentage of the humeral footprint occupied by the SC versus the ST; and (3) measure the width of the SC insertion on the glenoid.

Study design: Descriptive laboratory study.

Methods: Fourteen right cadaveric shoulders were dissected, fixed in formalin, embedded in plastic, and sectioned into 3 sections encompassing the anterior, middle, and posterior portions of the ST. Sections were then surface-stained with toluidine blue and basic fuchsin. The SC and ST thicknesses at the medial, midpoint, and lateral aspects of the ST; the medial-lateral width of the humeral insertions of the SC and ST; and the width of the SC insertion on the glenoid were measured. Measurements at each location were compared using 1-way analysis of variance with post hoc Bonferroni corrections.

Results: There was no statistically significant variation in the relative thickness of the SC versus the ST at the medial, midpoint, or lateral aspects of the tendon. The SC and ST were histologically distinct at their insertions on the humeral footprint. The SC comprised 15.2% to 16.2% of the total footprint width. The ST was consistently thicker at its humeral insertion than at its medial-lateral midpoint (P < .05). The anterior and posterior humeral insertions of the SC were significantly thicker than the corresponding midpoints (P = .015 anteriorly; P = .042 posteriorly). The SC was consistently thicker at its glenoid insertion than at its midpoint (P < .05).

Conclusion: The humeral insertions of the ST and SC were generally thicker than their midpoints. The SC was also thicker at its glenoid insertion compared with its midpoint. The SC occupied approximately 15% of the width of the native rotator cuff insertion, which is smaller than previously defined.

Clinical relevance: By providing improved clarity on the histological differences between the SC and ST, these data may allow for a better understanding of rotator cuff pathology, particularly delaminated tears. These results suggest that, when present, the deepest 1 to 2 mm of tissue in the articular layer may represent the SC, while articular-sided layers >2 mm in thickness likely include portions of the supraspinatus musculotendinous unit. This knowledge may serve to enhance intraoperative understanding of tear anatomy, especially in cases of poor tissue quality and retraction. Furthermore, this study demonstrates that the native insertion of the SC covers the medial 15% of the tuberosity. Surgeons should be aware of this anatomic detail when attempting to repair delaminated rotator cuff tears that may involve the underlying SC.