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Distribution of the axillary nerve to the subacromial bursa and the area around the long head of the biceps tendon

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Purpose Patients with a shoulder disorder often complain of pain on the anterior or lateral aspect of the shoulder. Such pain has been thought to originate from the suprascapular nerve. However, taking into consideration the distinctive course of the axillary nerve, the axillary nerve is likely to supply branches to the structure around the shoulder joint. This study was conducted to clarify the division, course, and distribution of the branches which originate from the axillary nerve and innervate structures around the shoulder joint. Methods The division, course, and distribution of the branches which originate from the axillary nerve and innervate structures around the shoulder joint were examined macroscopically by dissecting 20 shoulders of 10 adult Japanese cadavers. Results The thin branches from the anterior branch of the axillary nerve were distributed to the subacromial bursa and the area around the long head of the biceps tendon. The branches from the main trunk of the axillary nerve or the branch to the teres minor muscle were distributed to the infero-posterior part of the shoulder joint. Conclusion The pain on the anterior or lateral aspect of the shoulder, which has been thought to originate from the suprascapular nerve, might be related to the thin branches which originate from the axillary nerve and innervate the subacromial bursa and the area around the long head of the biceps tendon. Clinical relevance These results would be useful to consider the cause of the shoulder pain or to prevent the residual pain after the biceps tenodesis.
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SHOULDER
Distribution of the axillary nerve to the subacromial bursa
and the area around the long head of the biceps tendon
H. Nasu A. Nimura K. Yamaguchi
K. Akita
Received: 2 December 2013 / Accepted: 29 May 2014
ÓSpringer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Patients with a shoulder disorder often complain
of pain on the anterior or lateral aspect of the shoulder.
Such pain has been thought to originate from the supra-
scapular nerve. However, taking into consideration the
distinctive course of the axillary nerve, the axillary nerve is
likely to supply branches to the structure around the
shoulder joint. This study was conducted to clarify the
division, course, and distribution of the branches which
originate from the axillary nerve and innervate structures
around the shoulder joint.
Methods The division, course, and distribution of the
branches which originate from the axillary nerve and
innervate structures around the shoulder joint were exam-
ined macroscopically by dissecting 20 shoulders of 10
adult Japanese cadavers.
Results The thin branches from the anterior branch of the
axillary nerve were distributed to the subacromial bursa
and the area around the long head of the biceps tendon. The
branches from the main trunk of the axillary nerve or the
branch to the teres minor muscle were distributed to the
infero-posterior part of the shoulder joint.
Conclusion The pain on the anterior or lateral aspect of
the shoulder, which has been thought to originate from the
suprascapular nerve, might be related to the thin branches
which originate from the axillary nerve and innervate the
subacromial bursa and the area around the long head of the
biceps tendon.
Clinical relevance These results would be useful to
consider the cause of the shoulder pain or to prevent the
residual pain after the biceps tenodesis.
Keywords Axillary nerve Subacromial bursa
Long head of the biceps Capsule Distribution
Macroscopic anatomy
Introduction
Patients with a shoulder disorder often complain of pain on
the lateral aspect of the shoulder. Such lateral shoulder pain
has been proposed to originate from some lesions on the
subacromial bursa, rotator cuff, or capsule [18,19]; it is
considered as a referred pain. However, the mechanism
how the lateral shoulder pain is referred to the lesions has
not been elucidated. Further, the division and courses of
nerve fibres that are distributed to the lateral aspect of the
shoulder have not been clarified.
Some patients also complain of pain on the anterior
aspect of the shoulder. The anterior shoulder pain is usually
caused by a lesion of the long head of the biceps tendon
[16,24,30]. Recently, the origin of the pain has been
considered to be due to biochemical substances interacting
with nociceptors in and around the tendon. Therefore, the
sympathetic innervation of the long head of the biceps
tendon has been investigated histochemically [2,13,25].
However, the manner of division and course of nerve fibres
innervating the structures around the long head of the
biceps tendon have not been clarified macroscopically.
The suprascapular nerve provides sensory fibres to 70 %
of the shoulder joint [21]. The suprascapular nerve is typ-
ically distributed to the posterior shoulder joint capsule,
coracoclavicular ligament, coracohumeral ligament,
H. Nasu A. Nimura K. Yamaguchi K. Akita (&)
Department of Clinical Anatomy, Graduate School of Medical
and Dental Sciences, Tokyo Medical and Dental University,
1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
e-mail: akita.fana@tmd.ac.jp
123
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3112-4
subacromial bursa, and acromioclavicular joint capsule [3].
Therefore, lateral or anterior shoulder pains have been
thought to mainly originate from the suprascapular nerve.
The axillary nerve extends to the lateral and anterior
aspect of the shoulder, and has the distinctive characteristic
of surrounding the humerus from posterior to anterior. It
originates from the posterior cord of the brachial plexus,
divides into the anterior branch and the posterior branch,
and is distributed to the deltoid muscle, teres minor muscle,
and the skin on the posterolateral aspect of the shoulder [1,
4,8,14,26]. The axillary nerve also has an articular
branch. The articular branch arises from the origin of the
axillary nerve and enters the inferior part of the shoulder
joint capsule [10,29]. With regard to surgical exposure,
innervation patterns of the axillary nerve to the inferior
joint capsule have been discussed in depth [3,9]. However,
taking into consideration the course of the axillary nerve,
we hypothesized that it has the potential to supply other
branches to the humerus or structures around the shoulder
joint. This was a new viewpoint on branches of the axillary
nerve. The presence of these branches might provide
insight into the correct diagnosis of the pain on the lateral
or anterior aspects of the shoulder.
The aim of this study was to clarify the division, course, and
distribution of the branches which originate from the axillary
nerve and innervate structures around the shoulder joint.
Materials and methods
All of the cadavers used in this study were donated to
Tokyo Medical and Dental University. Before death, all of
the donors had voluntarily expressed their will of donating
their own body for anatomical education and study. This
system is established in Act on Body Donation for Medical
and Dental Education in Japan. Our study completely
complied with the law.
A total of 20 shoulders of 10 adult Japanese cadavers (eight
male and two female cadavers) were dissected in this study.
The age range was 70–91-year old (average age: 82-year old).
Cadavers were fixed in 8 % formaldehyde and preserved in
30 % ethanol. This study was conducted under a stereomi-
croscope (magnification: 129, Operation Microscope
OLYMPUS OME-1000, Olympus Optical, Tokyo). Findings
were recorded by drawings and photographs in each case.
First, the brachial plexuses in the neck and muscles around
the shoulder joint were identified. The anterior part of the
deltoid muscle, which originated from the clavicle, was
dissected from the clavicle and carefully reflected laterally.
Then, the pectoralis major muscle, the trapezius muscle, the
pectoralis minor muscle, the coracobrachialis muscle, the
short head of the biceps brachii muscle, the latissimus dorsi
muscle, the teres major muscle, and the long head of the
triceps brachii muscle were removed. The clavicle was cut at
the middle third. The posterior cord of the brachial plexus
was identified, and the origin of the axillary nerve was
exposed. Then, the branches of the axillary nerve were
identified as follows: the branch to the posterior part of the
deltoid muscle, the branch to the teres minor muscle, the
superior lateral brachial cutaneous nerve, the articular
branch, and the anterior branch which was usually distrib-
uted to the middle and anterior part of the deltoid muscle. The
branching pattern of the axillary nerve was examined.
Second, a thin branch from the anterior branch of the
axillary nerve was identified, while the connective tissue
was removed between the reflected anterior part of the
deltoid muscle and the humerus. An identified thin branch
was pursued to both the origin of the anterior branch and
the distributed area. The origin, course, and distribution of
the thin branch were investigated. In addition, the origin,
course, and distribution of the articular branch, which
originated from a main trunk of the axillary nerve or a
branch to teres minor, were also examined.
The distribution of the thin branch was categorized into
three areas: the subacromial bursa, the connective tissue
around the long head of the biceps tendon, and the int-
ertubercular sulcus. The number of shoulders in which the
thin branch was distributed to each area was counted and
summarized in a table. In the same manner, the distribution
of the articular branch was also categorized into three
areas: the inferior capsule, the posterior capsule, and the
long head of the triceps tendon. The number of shoulders in
which the articular branch was distributed to each area was
counted and summarized in a table.
Results
The axillary nerve bifurcated into an anterior branch and a
posterior branch at the infero-lateral part of the subscapu-
laris muscle. The anterior branch went around the humerus
from posterior to anterior and gave off numerous branches
which supplied to the middle and anterior parts of the
deltoid muscle. The posterior branch trifurcated into the
branch to the teres minor muscle, the branch to the pos-
terior part of the deltoid muscle, and the superior lateral
brachial cutaneous nerve in the quadrilateral space (Fig. 1).
In addition to these muscular or cutaneous branches, the
axillary nerve divided into some branches which were
distributed to the following structures around the shoulder
joint in all specimens.
Distribution to the subacromial bursa
In 12 of 20 shoulders, the anterior branch gave off a thin
branch to the subacromial bursa (Fig. 2). As the anterior
Knee Surg Sports Traumatol Arthrosc
123
branch ran through the middle part of the deltoid muscle, it
gave off the thin branch. This thin branch ran in the
direction towards the humerus rather than entering the
deltoid muscle. It ascended on the surface of the humerus,
pierced a thin fascia, and was distributed to the
subacromial bursa on the lateral or anterolateral aspect of
the shoulder.
Distribution around the long head of the biceps
In 8 of 20 shoulders, a thin branch originated from the
anterior branch and was distributed around the long head of
the biceps tendon. The thin branch bifurcated into an
ascending twig and a descending twig along the lateral
border of the long head of the biceps tendon. It was dis-
tributed to the connective tissue of the long head of the
biceps tendon such as the tendon sheath or the transverse
humeral ligament (Fig. 3a, b). In 3 out of 8 shoulders, the
thin branch ascended and pierced the cortical bone of the
humerus at the superolateral portion of the intertubercular
sulcus (Fig. 3c, d).
Distribution around the infero-posterior part
of the shoulder joint
In 16 of 20 shoulders, a branch was distributed to the
inferior part of the joint capsule. In 15 shoulders, it origi-
nated from the main trunk of the axillary nerve on the
surface of the subscapularis muscle (Fig. 4a). In one
specimen, it originated from the branch to the teres minor
muscle.
In three shoulders, a branch innervated the posterior part
of the joint capsule in addition to the inferior part. The
branch was given off by the branch of the teres minor
muscle, ascended beneath the teres minor muscle, and
entered the posterior part of the joint capsule (Fig. 4b).
In another three shoulders, the branch also supplied to the
posterolateral aspect of the long head of the triceps tendon
(Fig. 4c). It originated from the branch to the teres minor
muscle, passed along the lateral border of the long head of
the triceps tendon, and entered its the posterolateral aspect.
In the dissection series of the current study, the distri-
bution patterns of all specimens to the areas described
above are summarized in Table 1.
Discussion
The most important finding of the present study was that
the anterior branch of the axillary nerve was distributed to
the subacromial bursa, the connective tissue around the
long head of the biceps tendon, and the cortical bone of the
humerus at the superolateral portion of the intertubercular
sulcus. This result supports our hypothesis that the axillary
nerve has branches to the humerus or the structures around
the shoulder joint.
Some histochemical studies on the subacromial bursa
showed that the subacromial bursa had more free nerve
Fig. 1 Overall view of the division of the axillary nerve in an anterior
view of the right shoulder. The deltoid muscle (DEL) is detached and
reflected laterally. The axillary nerve (Ax) bifurcated into the anterior
branch (Ant) and the posterior branch (Pos) at the infero-lateral part of
the subscapularis muscle (SSC). The anterior branch ran anterior-
wards from behind the humerus and supplied branches to the anterior
and middle parts of DEL. The posterior branch trifurcated into the
branch to the teres minor muscle (black circle), the branch to the
posterior part of the deltoid muscle (black triangle), and the superior
lateral brachial cutaneous nerve (black square)
Fig. 2 Distribution to the subacromial bursa. The region surrounded
by the white outline in the anterolateral view of the left shoulder is
magnified. The deltoid muscle (DEL) is reflected laterally. The
anterior branch (black arrow) gave off a thin branch (open
arrowhead) to supply the subacromial bursa (SAB)
Knee Surg Sports Traumatol Arthrosc
123
endings than proprioceptors [12,17,23]. These sensory
branches have been considered to come from the supra-
scapular nerve [3,6,27]. However, we found that the
axillary nerve was distributed to the subacromial bursa.
This result suggests that the axillary nerve is involved with
sensation in the subacromial bursa, like the suprascapular
nerve. Further, the distribution area of the axillary nerve in
the subacromial bursa was located on the lateral or anter-
olateral aspect of the shoulder. We suppose that the pain of
the lateral aspect of shoulder from the subacromial bursitis
might originate from both the suprascapular nerve and the
axillary nerve.
Alpantaki et al. [2] showed that the sensory and sym-
pathetic fibres innervating the long head of the biceps
tendon were distributed to its origin predominantly. How-
ever, we observed that the axillary nerve was widely dis-
tributed to the connective tissue around the long head of the
biceps tendon. Rauber [20] and Wrete [29] also showed
that a branch of the axillary nerve was distributed around
the long head of the biceps tendon. The branch, which
originated from the main trunk of the axillary nerve, passed
deep to the long head of the biceps tendon from the medial
side to the lateral side. In the present study, we observed
that the branch originated from the anterior branch and ran
along the lateral side of the long head of the biceps tendon.
This is a new finding about the distribution of the axillary
nerve in a macroscopic study. As a clinical relevance, the
wide distribution of the axillary nerve might contribute to
the anterior shoulder pain with a lesion of the long head of
the biceps tendon.
Additionally, we observed that the branch from the
anterior branch of the axillary nerve pierced the cortical
bone of the humerus at the superolateral portion of the
intertubercular sulcus. Many studies have reported cases of
the persistent post-operative pain after biceps tenodesis [5,
7,11,16,28]. In particular, the proximal fixation led to
more persistent post-operative pain at the intertubercular
sulcus than the distal fixation [15,22]. The proximal part
might correspond to the area in which the branch pierced
into the cortical bone. We suppose that the branch could be
Fig. 3 Distribution around the
long head of the biceps tendon.
The region surrounded by the
white outline in the anterolateral
view of the right shoulder is
magnified. The deltoid muscle
(DEL) is reflected laterally. aA
thin branch (open arrowhead)
originated from the anterior
branch and ascended or
descended along the lateral
border of the long head of the
biceps tendon (asterisk). The
thin branch was distributed to
the connective tissue around the
long head of the biceps tendon
such as the tendon sheath
(circles) or the transverse
humeral ligament (star).
bIllustration of the findings of
a.cThe transverse ligament
was cut and opened bilaterally
(stars) at the approach point of
the long head of the biceps
tendon (asterisk) to the
intertubercular sulcus. The thin
branch originated from the
anterior branch and ascended to
pierce the cortical bone of the
humerus at the superolateral
portion of the intertubercular
sulcus (circles). dIllustration of
the findings of c
Knee Surg Sports Traumatol Arthrosc
123
related to the residual pain after the biceps tenodesis, and
knowledge about the course and distribution of the branch
might be helpful for the prevention of the residual pain.
Although the main nerve distributed to the posterior part
of the joint capsule was the suprascapular nerve, Aszmann
et al. [3] reported that a small branch from the branch to the
Fig. 4 Distribution around the infero-posterior part of the shoulder
joint. The region surrounded by white outline in each view is
magnified. aInferior view of the right shoulder is shown. The main
trunk of the axillary nerve (arrow) gave off a branch (open
arrowheads) which supplied the inferior part of the joint capsule
(star). bPosterior view of the right shoulder is shown. The teres
minor muscle (TMI) and the infraspinatus muscle (ISP) were detached
from the scapula and reflected laterally. The long head of the triceps
tendon was cut at its insertion (asterisk). A branch (open arrowheads)
that was gave off by the branch to the teres minor muscle (black
arrowhead) was distributed to the posterior part of the joint capsule
(star). cPosterior view of the left shoulder is shown. TMI was
reflected laterally. The long head of the triceps tendon was cut at its
insertion (asterisk). A thin branch (open arrowheads) that originated
from the branch to the teres minor muscle (black arrowhead) was
distributed to the long head of the triceps tendon. Ant anterior branch,
SSC subscapularis muscle
Table 1 Distribution areas of the branch from the axillary nerve and the number of shoulders in which the branch was observed
From anterior branch From main trunk of axillary nerve or branch to teres
minor muscle
Subacromial bursa Area around LHB Intertubercular sulcus Inferior capsule Posterior capsule LHT
Number of shoulders 12 8 3 16 3 3
LHB long head of the biceps tendon, LHT long head of the triceps tendon
Knee Surg Sports Traumatol Arthrosc
123
teres minor muscle entered the long head of the triceps
tendon and the adjacent capsule in 28 %. We also found
that a branch from the branch to the teres minor muscle was
distributed to the posterior part of the joint capsule or the
long head of the triceps tendon in 30 %. This finding was
consistent with the result reported by Aszmann et al. [3].
Gardner [10] proposed that if one articular branch did not
exist, other articular branches would develop. We also
speculate that the axillary nerve, in addition to the supra-
scapular nerve, might play dominant roles in innervation of
structures around the shoulder joint and that the supra-
scapular and the axillary nerve could compensate for each
other for lack of distribution area.
This study is limited by the fact that it analysed only a
macroscopic approach. Although we have mainly dis-
cussed the pain based on the past histochemical studies, a
histochemical study is necessary to demonstrate which
receptors are present in the terminal of the thin branches
from the axillary nerve. In addition, we investigated only
the axillary nerve. If the thin branch from the axillary nerve
is poor or empty, other nerves will compensate for the
region. Further macroscopic study about other nerves is
necessary to show shoulder innervation in full detail.
Conclusion
The thin branches from the anterior branch of the axillary
nerve were distributed to the subacromial bursa and the
area around the long head of the biceps tendon. We con-
clude that the pain on the anterior or lateral aspect of the
shoulder, which has been considered to originate from the
suprascapular nerve, might be related to the thin branches
originating from the axillary nerve.
Acknowledgements This study was partly supported by a Grant-in-
Aid for Young Scientists (B) from the Ministry of Education, Culture,
Sports, Science and Technology (No. 90622556).
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... The posterior division accompanies the posterior humeral circumflex artery as it emerges from the quadrangular space (bounded by the teres minor, teres major, long head of the triceps, and surgical neck of humerus). As the AN passes through the quadrangular space, the anterior division (which innervates the midanterior deltoid) sends articular branches deep to the subscapularis tendon, innervating the anterior-inferior GH capsule [12,17,18]. Additionally, branches from the anterior division wrap posteriorly to anterolaterally around the humerus [12,17], sometimes inserting in the transverse humeral ligament and long head of the biceps tendon [17]. ...
... As the AN passes through the quadrangular space, the anterior division (which innervates the midanterior deltoid) sends articular branches deep to the subscapularis tendon, innervating the anterior-inferior GH capsule [12,17,18]. Additionally, branches from the anterior division wrap posteriorly to anterolaterally around the humerus [12,17], sometimes inserting in the transverse humeral ligament and long head of the biceps tendon [17]. The posterior division of the AN innervates the teres minor and posterior deltoid muscles [19] while sending articular branches to the medial-inferior GH ligament and the posterior-inferior GH capsule [12,14,19]. ...
... As the AN passes through the quadrangular space, the anterior division (which innervates the midanterior deltoid) sends articular branches deep to the subscapularis tendon, innervating the anterior-inferior GH capsule [12,17,18]. Additionally, branches from the anterior division wrap posteriorly to anterolaterally around the humerus [12,17], sometimes inserting in the transverse humeral ligament and long head of the biceps tendon [17]. The posterior division of the AN innervates the teres minor and posterior deltoid muscles [19] while sending articular branches to the medial-inferior GH ligament and the posterior-inferior GH capsule [12,14,19]. ...
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Shoulder pain is prevalent, burdensome, and functionally limiting, with diverse pathology and associated treatments. This narrative review provides a summary of relevant neuroanatomy, proposed ablation targets, safety and efficacy concerns for ablation targets, and current research gaps. Radiofrequency ablation (RFA) of peripheral sensory nerves is a well-established treatment for chronic joint and spine pain, but it is relatively nascent for shoulder pain. Cadaveric studies demonstrate the shoulder joint is innervated by articular branches of the suprascapular nerve, axillary nerve, lateral pectoral nerve, and upper and lower subscapular nerves. Shoulder articular branch RFA appears to be a safe and effective treatment for chronic shoulder pain, but there are currently no widely accepted protocols for ablation targets. There are also no randomized controlled trials (RCT) assessing safety and efficacy of proposed targets or the prognostic value of articular blocks. Future research studies should prioritize categorical data, use appropriate functional measures as primary endpoints, and would ideally include a large-scale RCT.
... Its anterior branch has distributions into the subacromial bursa, the connective tissue around the LHBT, and pierces the cortical bone of the humerus at the superolateral portion of the bicipital groove (Nasu, Nimura, Yamaguchi, & Akita, 2015). It has been suggested that the distribution of these branches explains the anterior or lateral shoulder pain associated with LHBT lesions (Nasu et al., 2015). ...
... Its anterior branch has distributions into the subacromial bursa, the connective tissue around the LHBT, and pierces the cortical bone of the humerus at the superolateral portion of the bicipital groove (Nasu, Nimura, Yamaguchi, & Akita, 2015). It has been suggested that the distribution of these branches explains the anterior or lateral shoulder pain associated with LHBT lesions (Nasu et al., 2015). ...
... Sanders reported that a proximal tenodesis site does not necessarily solve the problem of persistent tenosynovitis of the LHBT and therefore results in higher revision rates (Sanders et al., 2012). Owing to the wide distribution of the anterior branch of the axillary nerve around the bicipital groove, a proximal tenodesis could injure or irritate this branch and cause residual shoulder pain, in contrast to a more distal tenodesis site (Nasu et al., 2015). Alternatively, a suprapectoral LHBT tenodesis located below the bicipital groove could be favored because it avoids the bottleneck in the bicipital groove, provides the advantage of an arthroscopic technique, and adds the possibility of performing a release of the THL (Figure 4). ...
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Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words “bicipital” and “groove” and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two‐thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.
... Saltzman et al., 10 in a retrospective study comparing open subpectoral versus arthroscopic tenodeses, reported a higher revision rate when diseased tendon was left within the groove. In an anatomic study, Nasu et al. 25 described an abundance of nociceptive receptors along the entire bicipital groove and transverse ligament from the ascending branch of the anterior axillary nerve. However, in a retrospective series of 1,083 arthroscopic articular margin repairs performed by 7 surgeons, Brady et al. 26 reported a low revision rate of 4.1%, a low rate of residual pain with the VAS score improving from 6.47 to 1.08 postoperatively, and significant improvement in objective shoulder outcome scores. ...
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Purpose: To determine whether there is a difference in clinical results among open subpectoral (SB), arthroscopic low-in-groove suprapectoral (SP), and arthroscopic top-of-groove (TOG) locations in terms of patient-reported outcome measures for biceps tenodesis (BT) procedures using a global, self-reporting registry. Methods: We identified patients who underwent BT surgery in the Surgical Outcomes System registry. The inclusion criteria were isolated primary surgical procedures for BT, excluding patients with rotator cuff and labral repairs. Additional search requirements included repair location and 100% compliance with pretreatment and 2-year follow-up surveys. This study measured clinical outcomes comparing the 3 aforementioned techniques using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and Single Assessment Numeric Evaluation (SANE) score before treatment and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, postoperative VAS pain scores were collected at 2 and 6 weeks. Statistical analysis was conducted using analysis of variance (Kruskal-Wallis test) and the Wilcoxon test. Results: A total of 1,923 patients from the Surgical Outcomes System registry qualified for the study; of these, 879 underwent the SB technique, 354 underwent the SP technique, and 690 underwent the TOG technique. There was no statistically significant difference in the demographic characteristics among the groups except that the TOG group was older: 60.76 years versus 54.56 years in the SB group and 54.90 years in the SP group (P < .001). In all groups, the ASES score statistically improved from before treatment (mean, 49.29 ± 0.63) to 2 years postoperatively (mean, 86.82 ± 0.80; P < .05). There were no statistically significant differences among the 3 groups in the VAS, ASES, and SANE scores at all time points (P > .12) except for the VAS score at 1 year (P = .032) and the ASES score at 3 months (P = .0159). At 1 year, the mean VAS score in the SB group versus the TOG group was 1.146 ± 1.27 versus 1.481 ± 1.62 (P = .032), but the minimal clinically important difference (MCID) was not met. The 3-month ASES Index scores in the SB, SP, and TOG groups were 68.991 ± 18.64, 66.499 ± 17.89, and 67.274 ± 16.9, respectively (P = .0159), and similarly, the MCID was not met. At 2 years, the ASES scores in the SB, SP, and TOG groups improved from 49.986 ± 18.68, 49.54 ± 16.86, and 49.697 ± 7.84, respectively, preoperatively to 86.00 ± 18.09, 87.60 ± 17.69, and 86.86 ± 16.36, respectively, postoperatively (P > .12). Conclusions: The SB, SP, and TOG BT procedures each resulted in excellent clinical improvement based on patient-reported outcome measures from a global registry. On the basis of the MCID, no technique was clinically superior to the other techniques in terms of VAS, ASES, or SANE scores at any time point up to 2 years. Level of evidence: Level III, retrospective comparative study.
... This was followed by a large lack of interest for almost a century. Afterwards, new interest by different authors, who had described the contribution of the lateral pectoral nerve, axillary, sub-scapular and the supra-scapular nerve for shoulder innervation [1,3,4,9,10,14]. The available studies did not focus on the issue of pain or on surgical approaches for resecting these articular branches. ...
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Purpose To assess the feasibility of total shoulder denervation through two proposed incisions. Methods Total shoulder denervation was performed through an extended delta-pectoral approach and a transverse dorsal approach at the spine of the scapula. The study involved six cadavers. Course and number of articular branches from the lateral pectoral, axillary and supra-scapular nerve were documented. Results All shoulder joint articular branches were accessible through the proposed anterior and posterior approaches. The articular branch of the lateral pectoral nerve and supra scapular nerve were present in all the specimen. Axillary nerve articular branches were variable in number but when present anteriorly were proximal to the deltoid muscular branches and posteriorly proximal to the muscular branches to the teres minor. Conclusion Total glenohumeral denervation was feasible through our proposed anterior and posterior approaches. Enhanced knowledge of articular nerve branches could provide interventional targets for joint and ligament pain, with low risk of muscle weakness.
Chapter
Chronic joint pain (>3 months) affects 63 million of Americans with 18.7 million reported shoulder (glenohumeral) joint pain, and 11.4 million reported wrist (radiocarpal) joint pain. Osteoarthritis (OA) is the most common cause of joint pain. With an aging population, the prevalence of joint pain is expected to rise. Mild to moderate symptoms can be managed with pharmacologic and physical therapy. For patients with moderate to advanced pain and disabilities, clinicians usually resort to more invasive therapy (injection or surgery). Various shoulder injections are available but the efficacy decreases with advanced disease when shoulder arthroplasty is usually considered. Unlike the hip and knee arthroplasties, the outcome of shoulder arthroplasty is not as promising and the risk of post-arthroplasty persistent pain is up to 22%.This chapter discussed in details the innervation of shoulder and the pertinent image-discernable landmarks that can be adopted for shoulder denervation.KeywordsSuprascapular nerveAxillary nerveLateral pectoral nerveSubscapular nerveRotator cuff tendinopathyDegenerative tears and impingementGlenohumeral and acromioclavicular joint osteoarthritisAdhesive capsulitisLabral tears
Article
The proximal long head of the biceps tendon (LHBT) has been recognized as a well-known cause of anterior shoulder pain. Previous studies have identified a heterogeneous distribution of nerve fibers in the tendon, with a higher abundance of fibers in the proximal and distal thirds of the tendon. This suggests that the proximal portion of the long head biceps tendon may have a different source of innervation than the distal portion. The purpose of this study was to review the innervation of the superior shoulder and identify the proximal source of sensory innervation of the LHBT. The relevant hypothesis was that the suprascapular nerve (SSN) was the proximal source of sensory innervation to the LHBT. Gross and microdissection of eight fresh human cadaver shoulders were performed, with a focus on the distal articular branches of suprascapular nerve (SSN). Utilizing 3.5× magnification loupes, the medial subacromial branch (MSAb), lateral subacromial branch (LSAb), and posterior glenohumeral branch (PGHb) were identified and followed distally to their terminal branches. In all specimens, terminal branches of the lateral subacromial branch supplied the proximal LHBT and the superior labrum. Terminal branches of the posterior glenohumeral branch supplied the posterosuperior labrum and, to a lesser extent, the labral attachment of the LHBT. These findings confirm branches of the suprascapular nerve as the proximal source of sensory innervation to the LHBT. Identification of the suprascapular nerve as a source of proximal innervation of the LHBT may influence clinical decisions related to nonsurgical and surgical intervention, nerve blocks, and nerve ablation procedures.
Article
Detailed understanding of the course and location of articular nerves supplying the shoulder joint is paramount to the successful utilization of image-guided radiofrequency ablation to manage chronic shoulder pain. In this article, the origin, course, and relationship to anatomic landmarks of articular nerves supplying the shoulder and acromioclavicular joints are discussed. The shoulder joint capsule was consistently reported to receive innervation from multiple sources including the suprascapular, axillary, subscapular, and lateral pectoral nerves. The acromioclavicular joint received innervation from suprascapular and lateral pectoral nerves. The consistent relationship of articular branches to anatomic landmarks provides the basis for specific image-guided targeting.
Article
Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.
Article
Purpose To evaluate the functional outcomes and structural integrity of primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for long head of the biceps tendon (LHBT) pathology. Methods A retrospective case series with prospectively collected data of patients who underwent primary, isolated subpectoral biceps tenodesis with a single all-suture anchor onlay fixation between March 2017 and March 2019 was conducted. Outcomes were recorded at a minimum follow-up of 12 months based on assessments of the American Shoulder and Elbow Surgeons (ASES) score, long head of the biceps (LHB) score, and elbow flexion and supination strength measurements. Integrity of the tenodesis construct was evaluated using ultrasound. Results Thirty-four patients were available for clinical and ultrasound examination at a mean follow-up of 18 ± 5 months. Mean ASES score significantly improved from 51.0 ± 14.2 points preoperatively to 89.8 ± 10.5 points postoperatively (P < .001). The MCID was 8.7 for ASES, which was exceeded by 31 patients (91.2%). Mean postoperative LHB score was 92.2 ± 8.3 points. Regarding subcategories, an average of 47.2 ± 6.3 points was reached for “pain/cramps”, 26.4 ± 6.1 points for “cosmesis”, and 18.6 ± 2.6 points for “elbow flexion strength”. Both, elbow flexion and supination strength were similar compared to the non-operated side (PFlex = .169; PSup = .210). In 32 patients ultrasound examination showed an intact tenodesis construct, while two patients (5.9 %) sustained failure of the all-suture anchor fixation requiring revision. Conclusions Primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for pathology of the LHBT provides reliable clinical results and a relatively low failure rate (5.9 %).
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Background Painful shoulders (PS) create a substantial socioeconomic burden and significant diagnostic challenge for shoulder surgeons. Consensus with respect to the anatomic location of sensory nerve branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches (AB) (1) innervating the shoulder joint, and (2) the distribution of sensory receptors about its capsule and bursae. Materials & methods Four electronic databases were queried, between January 1945 and June 2019. Thirty original articles providing a detailed description of the distribution of sensory receptors about the shoulder joint capsule (13) and its articular branches (22) were reviewed. Results The suprascapular, lateral pectoral, axillary, and lower subscapular nerves were found to provide AB to the shoulder joint. The highest density of nociceptors was found in the sub-acromial bursa. The highest density of mechanoreceptors was identified within the insertion of the glenohumeral ligaments. The most frequently identified innervation pattern was comprised of three nerve bridges (consisting of AB from suprascapular, axillary, and lateral pectoral nerves) connecting the trigger and the identified pain generators areas rich in nociceptors. Conclusion Current literature supports the presence of a common sensory innervation pattern for the human shoulder joint. Anatomic studies have demonstrated that the most common parent nerves supplying AB to the shoulder joint are the suprascapular, lateral pectoral, and axillary nerves. Further studies are needed to assess both the safety and efficacy of selective denervation of the PS, while limiting the loss of proprioceptive function. Level of evidence Anatomy Study; Literature Review
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Purpose: The goal of this study is to compare the cartilage of anterior cruciate ligament (ACL)-reconstructed and uninjured contralateral knees using T 1ρ MRI 12-16 months after ACL reconstructions. Methods: Eighteen patients with ACL-reconstructed knees (10 women, 8 men, mean age = 38.3 ± 7.8 years) were studied using 3T MRI. Injured and contralateral knee MR studies were acquired 12-16 months post-operatively. Cartilage sub-compartment T 1ρ values of each injured knee were compared with the contralateral knee's values. Subgroup analysis of sub-compartment T 1ρ values in both knees was performed between patients with and without meniscal tears at the time of ACL reconstruction using a paired Student's t test. Results: In ACL-injured knees, the T 1ρ values of the medial tibia (MT) and medial femoral condyle (MFC) were significantly elevated at 12-16 months follow-up compared to contralateral knees. Patients with a medial meniscal tear had higher MFC and MT T 1ρ values compared to respective regions in contralateral knees. Patients with lateral meniscal tears had higher lateral femoral condyle and LT T 1ρ values compared to respective regions in contralateral knees. There were no differences between the injured and contralateral knees of patients without meniscal tears. Conclusions: T 1ρ MRI can detect significant changes in the medial compartments' cartilage matrix of ACL-reconstructed knees at 1 year post-operatively compared to contralateral knees. The presence of a meniscal tear at the time of ACL reconstruction is a risk factor for cartilage matrix degeneration in the femorotibial compartments on the same side as the meniscal tear.
Article
Tenotomy and tenodesis are both effective for the treatment of long head biceps lesions. The aim of this study was to compare the clinical outcomes of the two procedures in patients older than 55 years of age affected by reparable rotator cuff tears with concomitant long head biceps pathologies. Patients older than 55 years of age with long head biceps lesions and reparable rotator cuff tears were selected for this study. A total of 151 patients were randomly assigned to the tenotomy group (77 patients) or the tenodesis group (74 patients). Arthroscopic rotator cuff repair was performed in all the patients. Before surgery, physical and radiological examinations were performed; the constant score was measured as well. After the operation, the surgical time, cost, pain (VAS scores), Popeye sign, cramping pain, constant scores, satisfaction level and the elbow flexion and forearm supination strength indices were recorded. Patients were followed for an average of 24 months. No significant differences in the clinical results for the constant scores, the forearm supination and elbow flexion strength indices, Popeye sign, cramping pain and satisfaction level were found between the groups. However, tenotomy required a shorter surgical time (40.4 ± 4.0 vs. 50.4 ± 5.9 min, P < 0.001) and resulted in faster pain relief (3.1 ± 1.8 vs. 4.8 ± 1.9, P < 0.001). Both tenotomy and tenodesis are effective and equal for the treatment of long head biceps lesions. However, because tenotomy requires a shorter surgical time and results in faster pain relief, tenotomy may be more suitable for the treatment of long head biceps lesions in patients older than 55 years of age with reparable rotator cuff tears. Therapeutic studies, Level I.
Article
Background: The primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology. Methods: We investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells. Results: A strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions. Conclusion: Our results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.
Article
Reports place the frequency of axillary nerve injury at 6% for all brachial plexus injuries, emphasizing the importance of an accurate anatomic description of this nerve within the deltoid in order to reduce iatrogenic injury. The aim of the present study was to explore the anatomic variations of the axillary nerve within the deltoid muscle. Fifty human cadavers were dissected, resulting in 100 nerve specimens. The anterior and posterior branches of the axillary nerve were identified and their length measured from their point of origin (split from the axillary nerve) to their termination in the deltoid muscle. In 65% of cases, the axillary nerve split into two branches (anterior and posterior) within the quadrangular space, and in the remaining 35% split within the deltoid muscle. The posterior branch of the deltoid muscle irrespectively of origin gave off a branch to the teres minor and the superior lateral brachial cutaneous nerve in 100% of cases. The branch to the posterior part of the deltoid muscle was present in 90% of cases, and the branch to the middle part of the deltoid was present in 38% of cases. The anterior branch of the deltoid muscle provided a branch to the joint capsule, a branch to the anterior part of the deltoid muscle and the middle part of the deltoid in 100% of cases. In 18% of the cases, the anterior branch of the axillary nerve provided a branch to the posterior part of the deltoid muscle. The middle part of the deltoid muscle received dual innervation in 38% of cases and the posterior part of the deltoid muscle in 8% of the cases.
Article
Lesions of the long head biceps tendon (LHB) are frequent causes of shoulder pain and disability. Biceps tenotomy and tenodesis have gained widespread acceptance as effective procedures to manage both isolated LHB pathology and combined lesions of the rotator cuff and biceps-labral complex. The function of the LHB tendon and its role in glenohumeral kinematics presently remain only partially understood because of the difficulty of cadaveric and in vivo biomechanical studies. The purpose of this article is to offer an up-to-date review of the anatomy and biomechanical properties of the LHB and to provide an evidence-based approach to current treatment strategies for LHB disorders.