Abstract
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The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.
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The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a ‘suspension bridge’. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.
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Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.
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Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature.
Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.
Introduction
Rotator cuff problems are a common cause of shoulder pain and represent a significant expense and burden on the healthcare system. Despite the high rate of radiological prevalence of rotator cuff tears in elderly patients, many patients continue their lives with minimal symptoms. Several studies investigated asymptomatic shoulders in the general population and found that rotator cuff tears are relatively common, in the range of 6% to 34% in all age groups. 1,2 A recent study by Yamamoto et al reported that nearly 20% of the general population have rotator cuff tears, with an increasing prevalence in elderly patients. They found that 50% of patients who are in their 80s have rotator cuff tears regardless of whether they are symptomatic or asymptomatic. Even patients without any shoulder symptoms accounted for 13.5% of the rotator cuff tears in the general population. 3 Understanding the contribution of the rotator cable (RC) or rotator interval (RI) could be the answer to those.
In his first publication about supraspinatus tears in 1934, Codman presented two cases of surgical repair and defined an avascular crescentic area at the insertion site of the supra and infraspinatus. 4 He identified this insertion site in rotator cuff tear patients. Nearly 60 years later, Clark and Harryman published a detailed anatomical study of the rotator cuff and described a fibrous tissue which originates from the deep layer of coracohumeral ligament and moves along the perpendicular axis of supraspinatus and infraspinatus tendon fibres. 5 Later, Burkhart et al named this anatomical structure the ‘rotator cable’ and described the biomechanical role of this ligament as a stress shielder of the rotator crescent, which is an avascular crescentic area at the insertion site of the supra and infraspinatus. 6 They compared the RC to a ‘suspension bridge’ that works to keep load stress out of the rotator crescent, which tends to be more vulnerable to tears. More studies of the gross anatomic and arthroscopic appearance of the RC were published after the abovementioned publications. 7,8
The RI is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the RC. This close relationship with the joint capsule and nearby anatomical structures, such as the long head of biceps tendon and coracohumeral ligament, etc., increases its importance. Ignoring the RI causes many misdiagnoses in clinical routine and can explain some ‘refractory’ shoulder pains. The RI’s role in biceps tendinopathy, SLAP lesions and glenohumeral instability has been recently popularized in shoulder literature. 9
The aim of this paper is to recall the importance of the RC and RI and summarize their anatomical, biomechanical and radiological features. Awareness of these important structures should be raised among shoulder surgeons in the interest of proper diagnosis and treatment of shoulder pathologies.
Anatomy and function
Understanding the anatomy of the rotator cuff is essential for a shoulder surgeon in order to apply the appropriate surgical repair. Recent research has helped to advance our understanding of the complexity of the shoulder anatomy. The coracohumeral ligament (CHL) arises from the lateral side of the coracoid process and orientates obliquely to the humeral head. It divides into two layers (superficial and deep), surrounds the rotator cuff and inserts into lesser and greater tuberosities. The superficial layer of the CHL covers the articular surface of the supraspinatus and infraspinatus tendons. The deeper part of the CHL is thicker and inserts into the greater tuberosity. Here, the deep layer forms a crescent-shaped structure, running posteriorly from the anterior insertion site of the supraspinatus to the inferior border of the infraspinatus, perpendicular to the axis of tendon fibres (Fig. 1). Kolts et al contributed to the anatomy literature and named this structure the ligamentum semicirculare humeri. 10 This arch showed variable thickness in ultrasonographic and cadaveric studies. 11 It is approximately 2.59 times thicker than the rotator crescent. Burkhart et al found that younger cadaveric specimens have a thicker rotator crescent compared to the cable. They proposed that two categories can be defined. 6 One of these categories is cable-dominant, which is seen in older specimens, and the other is crescent-dominant. Their data suggested that as a person gets older, his/her RC becomes thicker and the rotator crescent thinner. Therefore, it can be said that the cable/crescent ratio is bigger in older shoulders and the crescent area becomes thinner. This implies that the integrity of the superior rotator cuff is more dependent on RC integrity in older patients. Despite these findings, some researchers found that the RC is more detectable with ultrasound (US) in younger patients. 10,12
Arthroscopic view of the rotator cable (black arrows) (courtesy of Nickolas Garbis).
Citation: EFORT Open Reviews 4, 2; 10.1302/2058-5241.4.170071
Understanding which muscles are suspended by the RC is crucial to making a proper diagnosis and surgical repair. The supraspinatus tendon has two parts: a superficial part which reaches more anteriorly and attaches to the lesser tuberosity, whereas the deeper and major part fuses into the RC in conjunction with the CHL. The anterior insertion area of the RC mainly consists of supraspinatus tendon fibres. The posterior insertion area is shared by the supraspinatus, infraspinatus and partly the teres minor tendons. 9
In addition to rotator cuff insertion, there has been some recent interest in studying the anatomy and function of the RI. The RI was presumed to be a semi-functional and relatively empty area in the rotator cuff. There are two different RIs in shoulder anatomy: the anterior and posterior RIs. 13 Here, we will discuss only the anterior RI. In 2002, Kolts et al identified the borders of the RI in a cadaver study on 19 shoulder joints. 7 It is described as a triangular-shaped space instead of a two-dimensional ‘area’, whose borders are drawn superiorly by the supraspinatus, inferiorly by the subscapularis tendon and by the joint capsule as a ceiling. The floor of this space is the articular surface of the humeral head (Fig. 2). It is strengthened by the CHL laterally and by the superior glenohumeral ligament (SGHL) medially (Fig. 3a). 14 The long head of the biceps tendon lies on the base of the RI space and is covered by a fibrous sheet of capsule. 15 The coracoid process constitutes the medial edge of this triangular space (Fig. 3b). Microscopically, the RI consists of four layers, as described by Jost et al. 16 The first layer consists of superficial CHL fibres which originate from the coracoid process and insert into the greater and lesser tuberosities following the supraspinatus and subscapularis tendons, respectively. The second layer is a blend of the CHL and rotator cuff tendons. The third layer consists of deep CHL fibres and the fourth layer is a mesh of the SGHL and capsule. 17 Another important structure in the RI is the coracoglenoid ligament (CGL) which forms the anterosuperior ligament complex with the CHL and SGHL. It runs from the coracoid process to the supraglenoid tubercle, extra-articularly. Its function is still not fully understood, but a few studies suggest the contribution of stability to the shoulder. 18
a) Arthroscopic view of the rotator interval (courtesy of Gazi Huri). b) Arthroscopic view of the rotator interval (courtesy of Nickolas Garbis).
Citation: EFORT Open Reviews 4, 2; 10.1302/2058-5241.4.170071
a) Important ligamentous structures around the glenohumeral joint. b) Schematic drawing of anatomic location of the rotator interval.
Citation: EFORT Open Reviews 4, 2; 10.1302/2058-5241.4.170071
Wilson et al described how the capsular anatomy in the RI can be variable. They stated that most of the patients (59%) have a RI capsular opening (RICO) that is superolateral to the middle glenohumeral ligament (MGHL). 19 A shoulder surgeon should also be aware of how close the RI and anterior portion of the RC (or supraspinatus tendon) are. This variability and proximity can give us a clue about why the RI and its associated structures (ligaments and biceps tendon, etc.) are involved in some cuff tears. 20
Radiological manifestation
The RC and RI structures are not visible on plain radiographs. MRI or US is widely used in the screening of these anatomical structures. The RC can be observed in routine shoulder MRI screening in patients with rotator cuff symptoms in all planes. Some authors state that the abduction, external rotation (ABER) is the best position for viewing the rotator cuff and cable pathologies. This is attributed to the decreased tension of ruptured rotator cuff fibres and avoidance of adherence to adjacent intact cuff tissue. 21 However, evaluation of this imaging technique requires experience and can be complicated for some radiologists and orthopaedic surgeons. A routine oblique coronal plane MRI often offers a good view of the RC (Fig. 4). On the fat-suppressed T2 view, the RC can be visualized as a hypo-intense region 2 mm to 5 mm wide on the articular side of the supraspinatus tendon. Even in the best-case scenario, visualization of the RC is limited up to nearly 75% in asymptomatic patients on MRI due to its small diameter and the difficulty in distinguishing it in crescent-dominant younger patients. 6,22 In addition, it is hard to distinguish the RC from a small anterior supraspinatus tear. Using axial images may help identify the RC for the clinician. On the axial plane, hypo-intensity of the RC runs from the greater tuberosity to its posterior attachment next to the infraspinatus tendon, the same as its anatomical shape. Coronal and axial images provide sufficient visibility in most cases, whereas ABER and sagittal planes may also be used to confirm the previous commonly used planes. 23
MRI, coronal section, T2-weighted image of rotator cable. SS, supraspinatus; RC, rotator cable.
Citation: EFORT Open Reviews 4, 2; 10.1302/2058-5241.4.170071
Ultrasound is another screening technique used to assess the RC. Some studies report improved identification of RI structures compared to MRI screening, in the range of 77% to 99%. 24,25 Sconfienza et al reported more frequent detection of the RC in elderly patients. This finding is consistent with the findings by Burkhart, in which elderly patients have cable-dominant anatomy. Another explanation for this relationship is the concomitant subclinical tendinosis in elderly patients, which makes the cable more visible. 26
Because the RI is an intra-articular structure, it can only be seen on MRI if synovial fluid is prominent (Fig. 5). 27 For this reason, a MR arthrogram is suggested in the presence of any injury of RI structures. The oblique sagittal MRI plane is the most useful sequence in evaluating the RI. On the sagittal plane, the RI capsule lies over the biceps pulley as a hypo-intense band. More medially, the CHL is visualized running from the coracoid process to the humeral head covering the long head of biceps tendon. Conversely, the SGHL is harder to visualize than the other structures of the RI. In an MRI study by Chung et al, the SGHL is not seen at all in all routine MRI views, and the CHL is observed only in 60% of cases. 28 The CGL can also be observed by experienced radiologists as a part of the anterosuperior capsuloligamentous complex. 29
MRI, coronal section, T2-weighted image of the rotator interval. SS, supraspinatus tendon; IS, infraspinatus tendon; LHBT, long head of the biceps tendon; RI, rotator interval.
Citation: EFORT Open Reviews 4, 2; 10.1302/2058-5241.4.170071
Tamborrini et al reported that musculoskeletal US is another superior technique used to visualize the RI. Many pathologies of the anatomic structures within the RI (including tendinosis, tears and capsulitis) can be imaged using US with a better resolution than any other techniques. The only limiting factor is the decreased visualization while observing the soft tissue beneath any bony structure such as the acromion. 30 Also, US is dependent on the ability of radiologists’ diagnostic experience; decisions on appropriate imaging techniques should be made taking this into consideration.
Biomechanical and clinical importance of the rotator cable and rotator interval
The relationship of cuff tear type and size with patients’ clinical presentation has been discussed for a long time. Early studies suggested a correlation between the tear size and symptomatic disease with decreased muscle strength, pre- and post-operatively; 30 however, some researchers contradicted this idea, stating that post-operative outcomes and tear size have no relationship. 17 After the RC concept was introduced, there have been studies specifically evaluating the biomechanics. In 2013, Mesiha et al published the biomechanical properties of the RC in a cadaveric shoulder model. 31 They compared crescent- and cable-involving tears and proved that the cable-involved tears which are located at the anterior insertion site of the supraspinatus tendon are more relevant with bigger tear size, reduced tendon stiffness and increased tendon stress. These findings may explain increased fatty degeneration in anterior supraspinatus tendon ruptures and give us a clue about why some rotator cuff tears are more likely to be symptomatic. Using this concept, the treatment strategy for full thickness rotator cuff ruptures involving the anterior portion of the supraspinatus tendon is more often surgical.
Our knowledge continued to evolve with the findings of Pinkowski et al about partial thickness ruptures involving the RC. Using five frozen cadavers, they demonstrated partial thickness cable rupture and found out that even partial thickness rupture would be enough to change the glenohumeral kinematics. The simulated tear in the anterior cable increases the anterior translation of humeral head by 38.6% in 30° external rotation. They concluded that these results can explain why orthopaedic surgeons sometimes fail to treat overhead athletes with partial thickness cuff rupture and their shoulder pain if they only perform debridement without repair in surgery. 32
Besides the more complex pattern and inherent risk for fatty degeneration and disrupted glenohumeral kinematics, re-tears occur more frequently in the setting of the rotator cuff ruptures involving the RC. 33 Additionally, Denard et al laid emphasis upon the relation of the cable integrity and pseudoparalysis. They compared the integrity of the RC in two different patient groups that underwent arthroscopic repair with massive rotator cuff tear, retrospectively. The first group, in which all patients had pseudoparalysis pre-operatively, had more disrupted RC attachment than the other group, in which patients had more active forward flexion > 90°. 34 This shows us the importance of the cable integrity in shoulder biomechanics.
The RI plays an important role in stabilizing the glenohumeral joint. Harryman et al proved this relationship in a cadaveric study, in which they measured the motion of glenohumeral joint in three conditions: in the normal state; after capsule dissection; and imbrication. The capsular and ligamentous components of the RI limit the inferior translation of the glenohumeral joint in an adducted position. Sectioning increases the range of passive flexion, external rotation and adduction. Imbrication causes a decrease in these motions. 35 A second function of the RI is the stabilization of the long head of the biceps tendon via the CHL and SGHL. Both of these ligaments form a U-shaped cover around the biceps tendon, named the ‘biceps pulley’. The superior part of the subscapularis tendon also contributes to this stabilization with a buttress effect. 36 Many studies reveal the biomechanical and clinical effects of RI closure. Daly et al suggested that an additional RI closure improves the biomechanical strength of the repaired subscapularis tendon. 37 Furthermore, Mologne et al put forward the idea that anterior shoulder stability increases with the same closure. 38 A study by Tsai et al showed good clinical results with arthroscopic release of the RI in adhesive capsulitis patients. They declared that the technique does not increase the risk of instability and avoids injury of the axillary nerve and fluid extravasation. 39
Adhesive capsulitis (frozen shoulder) is another pathologic condition that the RI plays a fundamental role in. It was first described by Nevasier et al in 1945 and is seen in patients aged > 40 years. 40 To put it all in simple terms, we can describe it as a thickening or rigidification of the glenohumeral capsule around the RI, as we mentioned above that the deepest layer of the RI consists of the capsule. Histological studies revealed that higher cytokine levels and lack of metalloproteinases could be the cause of the pathology. 41 Although CHL thickening and autoimmune response are also accused of being the cause, we still do not know the exact mechanism. Synovitis in adhesive capsulitis involves all of the anatomical parts of the RI, such as the sheath of long head of the biceps, the CHL and the capsule. Thus, these findings prove to us that whatever the exact mechanism adhesive capsulitis has, it can be said that adhesive capsulitis is a disease of the RI, specifically. The diagnosis is based mainly on clinical findings: pain and loss of range of the motion around the shoulder circle. MRI findings such as obliteration of the RI fat pad and increased signal density of the inferior glenohumeral ligament are diagnostic. 42 Imaging is helpful to exclude other pathologies such as rotator cuff tears, etc. Ultrasound can also be used for diagnosis but it is more difficult to view than in MRI. Treatment is mainly conservative, as most of the cases resolve by themselves. If physiotherapy fails to succeed, manipulation under general anaesthesia or arthroscopic release of the capsule is indicated.
Anatomical proximity of the anterior RC and RI lead to a new definition: ‘anterior superior lesions’. This distinct type of rotator cuff tear involves the subscapularis and anterior portion of the supraspinatus tendon and adjacent RI structures: SGHL, CHL and biceps tendon. 43 Case-control clinical studies and further investigation are needed to better define the clinical importance of this new concept.
Conclusion
The RC is one of the most important contributors to glenohumeral biomechanics. Even in cases of partial thickness rotator cuff tear involving the RC, there are significant changes in joint translation. This knowledge may help shoulder surgeons to clarify the indication for repairing versus debridement based on the involvement of the RC rather than the traditional percentage of medial to lateral thickness involvement. Biomechanical studies have been transforming into clinical prospective trials; the benefits of repairing the RC will be studied further as we develop longer-term results. 32 Our understanding of the RI can help us treat the shoulder during arthroscopic intervention in conditions such as adhesive capsulitis or shoulder instability. 39,44 The relatively new finding of an anatomical structure in the RI like the CGL may continue to change our knowledge about shoulder biomechanics and further clarify identification and clinical management of pathologic processes. Additional studies are needed to clarify the role of the RI and RC and its associated structures in the setting of shoulder instability to better define indications and improve surgical techniques.
Open access
This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.
Special thanks to Aysen Dincer for drawings.
The author or authors choose not to respond.
N. Garbis declares payment for lectures from DJO and Wright Medical, activity outside the submitted work.
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