A Cadaveric Study of the Rotator Cable: Interrogating the Suspension Bridge Model

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Methods: In 30 formaldehyde-fixed shoulders from 20 cadavers, the rotator cuff and rotator cable were dissected and the glenohumeral joint opened. The orientation and attachments of the rotator cable to the rotator cuff muscles were studied and the severity of any osteoarthritis, labral pathology, and rotator cuff pathology present was documented. The width and thickness of the infraspinatus attachments to the rotator cable were measured. Results: The infraspinatus muscle was noted to be more loosely adherent to the rotator cable, while the supraspinatus and teres minor were tightly adherent to the cable. Specifically, the superior-most portion of the infraspinatus was found to be less tightly adherent than the inferior-most portion in 26 of the 30 shoulders studied. There was a correlation between increased thickness of the inferior-most portion of infraspinatus and more-than-minimal osteoarthritis and labral pathology (p=0.0477, p=0.0409, respectively). Conclusions: While the supraspinatus and teres minor muscles were tightly adherent to the cable in all shoulders, the degree of attachment of the superior-most portion of the infraspinatus muscle was notably less in 26 of the 30 shoulders studied. This could mean that only the inferior portion of the infraspinatus participates in stress shielding through the cable or be a compensatory response to increased load on the tendon. This work is expected to provide insight into the function of the rotator cable and the different functions of the infraspinatus. rotator cable rotator cuff infraspinatus Figures Figure 1 Figure 2 Introduction While the morphology of the rotator cuff is well described in literature, less is known about the morphology of the rotator cable. The rotator cable has been described as a semicircular, fibrous, band-like thickening of the glenohumeral joint capsule that runs between the tubercles of the humerus, lacing together the capsular attachment of the supraspinatus, infraspinatus, and teres minor muscles (Figs. 1 and 2 ) [ 2 , 8 ]. Because of its orientation and thickness, the cable is believed to function as a suspension bridge, helping to evenly distribute the forces generated by the supraspinatus and infraspinatus muscles along the superior and posterior rotator cuff [ 8 ]. More specifically, it is analogous to a cable connecting two pillars of a suspension bridge as it transfers the tension generated along the rotator cuff muscles to the rotator cable’s bony attachments [ 16 ]. Therefore, the rotator cable is believed to preserve rotator cuff tendon function in the event of a tear, limiting tear progression and protecting the rotator crescent, an avascular, injury-prone area formed by the tendinous insertion of the infraspinatus and supraspinatus (Fig. 1 ) [ 4 ]. However, a study by Yuri et al. found a variable attachment pattern between the rotator cuff muscles and the glenohumeral capsule [ 21 ]. This indicates a need to revisit the suspension bridge model. Pathological conditions of the shoulder are known to alter the morphology of the shoulder. Previous studies have shown that the rotator cuff can atrophy in response to glenohumeral osteoarthritis, and that the progression of osteoarthritis is higher in patients with rotator cuff retears [ 1 , 11 ]. Changes in shoulder mechanics secondary to rotator cuff tears have been shown to play a significant role in pathologic changes of the superior labrum [ 9 ]. Furthermore, the rotator cuff atrophies in response to tendon tears [ 22 ]. More in-depth studies of the supraspinatus have shown that in addition to atrophy of both type 1 and 2 muscle fibers, there is also a shift towards type 2 fibers, leading to a loss of muscle endurance and increased fatigability in the presence of rotator cuff tears [ 19 ]. Increased rotator cuff fatigability alters shoulder kinematics, possibly leading to increased stress on neighboring structures [ 20 ]. Additionally, the rotator cable itself has been shown to increase in thickness in the presence of glenohumeral capsule tears [ 17 ]. Characterization of the morphological changes in the rotator cable in the presence of rotator cuff and glenohumeral pathology may lead to a better understanding of its role in shoulder function and improve upon the suspension bridge model. This study aims to further our knowledge of the anatomical and structural characteristics of the rotator cable by studying its attachments to the supraspinatus, infraspinatus, and teres minor on cadaveric specimens and to investigate the correlation between the morphology of the rotator cuff-cable attachment in the presence of shoulder pathology. Methods Following a gross anatomy course, institutional approval was granted to perform anatomical studies on the cadaveric shoulders (the cadavers were donated with prior informed consent for research and education purposes and institutional IRB policies and guidelines governing the ethical conduct of research involving human cadavers were observed). All formaldehyde-fixed cadaveric shoulders were initially included in the study. Shoulders were excluded from the study if dissections were unable to be completed due to desiccation or if prior dissection of the rotator cuff or glenohumeral joint had been performed. 30 formaldehyde-fixed shoulders from 20 cadavers (11 female, 9 male, average age of 79.65 years) were dissected. Dissections were performed by removing the deltoid from its distal and proximal attachments. The trapezius was detached from the clavicle and scapula and was reflected medially. After removing all neurovascular structures connecting the shoulder to the neck and thorax, an oscillating autopsy saw was used to make a vertical cut through the medial clavicle just lateral to the sternoclavicular joint and a horizontal cut at the midshaft of the humerus such that the glenohumeral joint and scapula could be completely separated from the rest of the cadaver. An additional cut was made at the lateral aspect of the scapular spine, allowing the acromion to be removed so that there was an unobstructed view of the posterior glenohumeral joint. The supraspinatus, infraspinatus, and teres minor were identified, dissected, and reflected from medial to lateral such that their attachments to the rotator cable and glenohumeral capsule could be clearly seen from both the superficial and deep capsule surface. The attachments of the supraspinatus, infraspinatus, and teres minor muscles in relation to the cable were noted, the width and thickness of the superior- and inferior-most portions of the infraspinatus attachments to the rotator cable were measured with a digital caliper (Mitutoyo CD-600 CSX, Aurora, IL, USA) three times by the same person blinded to previous measurements, and the mean was calculated. A vertical incision superficial to the posterior glenohumeral joint was then made in the glenohumeral joint capsule from proximal to distal and the joint capsule was opened. After opening the glenohumeral joint capsule posteriorly, the severity of any grossly visible osteoarthritis, labral pathology, and rotator cuff pathology was documented. In the absence of a standardized way to classify grossly visible cadaveric joint pathology, we developed a rubric for classifying labral pathology, osteoarthritis, and rotator cuff pathology. Labral and osteoarthritis pathology classification was based on the approximate percentage of total surface area of the glenohumeral joint or glenoid labrum that demonstrated anything abnormal, including but not limited to fraying, osteophytes, erosion, and calcifications. Glenohumeral joints with any bony or labral abnormalities present covering approximately less than one-third of the total glenohumeral joint or labrum surface area were classified as none/minimal. Joints with bony or labral abnormalities covering approximately more than one-third of the total surface area were classified as more-than-minimal. If present, rotator cuff pathology, including but not limited to fraying, tearing, and calcifications, was classified as none/minimal if affecting approximately less than one-third of the total thickness of the tendon or muscle and as more-than-minimal if affecting approximately more than one-third of the tendon or muscle thickness. To account for the size difference between cadavers, the thickness/width ratio was calculated for the superior and inferior portion of the infraspinatus’ attachment to the rotator cable for each shoulder. All classifications of pathology were documented and correlated with infraspinatus dimensions. Analyses began by calculating sample mean and sample standard deviation thickness/width ratio to measure central location and dispersion of the ratio variable. These calculations were conducted by group. Due to the small sample size and lack of ability to adequately judge the assumptions of normality, all tests were conducted using the Exact Wilcoxon Rank Sum test. All analyses were conducted using SAS 9.4. Results During dissection, it was apparent that the infraspinatus had varying degrees of attachment to the rotator cable. The superior-most portion of the infraspinatus had a different degree of attachment than the inferior-most portion of the infraspinatus when viewing the cable with the supraspinatus, infraspinatus, and teres minor muscles reflected laterally. While the supraspinatus and teres minor uniformly attached to the rotator cable in every shoulder, the superior-most portion of the infraspinatus was significantly less adherent to the rotator cable and the inferior-most portion of the infraspinatus was significantly more adherent to the rotator cable in 26 of the 30 (86%) shoulders dissected (pictures 1–4). Out of the 30 shoulders, more-than-minimal (MTM) labral pathology was noted in 11, MTM osteoarthritis in 10, and MTM rotator cuff pathology in 4 (Table 1 ). A statistically significant difference was noted in the inferior infraspinatus thickness/width ratio in the more-than-minimal osteoarthritis and labral pathology groups compared to the none/minimal groups (Table 2 ). Table 1 Number of shoulders in each category of pathology More-than-Minimal None/Minimal Cuff Pathology 4 26 Osteoarthritis 10 20 Labral Pathology 11 19 Table 2 Ratio variable of the superior and inferior portions of infraspinatus compared between two groups of pathology. Group = More-than-Minimal Group = None/Minimal Position N Mean ± SD N Mean ± SD p-value Cuff pathology: Superior infraspinatus 4 0.32 ± 0.13 26 0.21 ± 0.05 0.0769 Cuff pathology: Inferior infraspinatus 4 0.30 ± 0.13 26 0.17 ± 0.05 0.1795 Osteoarthritis: Superior infraspinatus 10 0.24 ± 0.05 20 0.23 ± 0.09 0.2714 Osteoarthritis: Inferior infraspinatus 10 0.24 ± 0.12 20 0.17 ± 0.04 0.0477 Labral pathology: Superior infraspinatus 11 0.24 ± 0.05 19 0.23 ± 0.09 0.1066 Labral pathology: Inferior infraspinatus 11 0.24 ± 0.11 19 0.17 ± 0.05 0.0409 Discussion During our dissections, we noted an interesting pattern in the infraspinatus-rotator cable attachment that has not been previously described. This could shed light on the role the cable plays within the function of the rotator cuff. Specifically, the attachment pattern found could signify that only the inferior portion of the infraspinatus participates in stress shielding through the cable, or it could be a compensatory response to increased load on the tendon, such as that from glenohumeral pathology [14, 16]. Alternatively, the difference in attachment could simply be the effect of the different partitions of the infraspinatus muscle belly [8]. In fact, a recent study by Yuri et al. found variation in how the infraspinatus attached to the rotator cable, specifically in the middle partition, which was firmly attached with dense connective tissue while the rest of the infraspinatus had loose, less dense connective tissue [21]. While we didn’t note three separate partitions of the infraspinatus at the rotator cable, the variation we found may be attributed to different partitions of the infraspinatus and described differently by Yuri et al. Regardless of the nomenclature, the statistically significant increase in the thickness/width ratio of the inferior portion of the infraspinatus in the presence of more-than-minimal osteoarthritis or labral pathology could be a sign of an increased stress load being transferred through the muscle, tendon, and rotator cable at its inferior attachment. It is also possible that with a larger sample size (n>4), there would have been a statistically significant relationship between the inferior infraspinatus in the two rotator cuff pathology groups. This pattern of increased thickness in the presence of significant pathology is consistent with what has been observed previously in the presence of glenohumeral capsule tears [17]. However, Mura et al.’s biomechanical infraspinatus model introduces another possibility. Their findings, which showed that the infraspinatus could generate abduction torque even when the entire superior infraspinatus was torn, suggest the cable could play a role in keeping the infraspinatus engaged with the rest of the cuff during abduction, even in the setting of large tears [11]. Our previously unexplored infraspinatus-rotator cable attachment pattern could offer valuable insight into the potentially multifaceted role the rotator cable plays within the intricate dynamics of the rotator cuff. Similar observations to our infraspinatus-cable attachment findings have already been made about the cable’s superior-anterior attachment at the supraspinatus. Detailed dissections have shown that the coracohumeral and posterosuperior glenohumeral ligaments merge with the rotator cable, providing the cable with additional anchoring and support superiorly and anteriorly [12, 15]. Therefore, large anterior cable tears have been shown to cause a disproportionate amount of strain across the supraspinatus when compared to tears localized to the crescent area [10]. While the supraspinatus has received more attention in previous studies, we think our findings suggest a similar pattern would be seen if the inferior portions of the cable were disrupted, which would presumably cause an increased amount of strain on the infraspinatus and teres minor muscles. Our observed attachment pattern, which is consistent with previous supraspinatus-cable patterns observed, potentially confirms the cable's coupling role in the inferior part of the rotator cuff, where it has stronger attachments to the infraspinatus. This study is limited in several ways. Besides being a descriptive study, the attachment pattern observed in the infraspinatus could have been artificially augmented by the manner of dissection since the reflection of the rotator cuff muscles from medial to lateral could have separated some of the tissue connecting the infraspinatus to the rotator cable. Furthermore, there is no standardized way to classify gross cadaveric glenohumeral or rotator cuff pathology, so our pathology classification is somewhat arbitrary. With a different cut-off for disease severity, we may have found different relationships between rotator cable-infraspinatus attachment dimensions and disease severity. The cadavers’ medical history regarding the shoulder was unknown, and while no signs of prior shoulder surgery or injury on any of the dissected shoulders were noted, such signs could have been missed by visual inspection. Given the advanced age of the cadavers and their unknown prior physical activity history, the implications of our results could be limited to an older patient population and confounded by an uneven distribution of rotator cuff health. Finally, without knowing previous medical history and physical activity ability, we are unable to examine the relationship between the rotator cable's presence and rotator cuff functionality. In conclusion, our study of the morphology of the rotator cable-rotator cuff attachments sheds light on the dynamics of the rotator cable in relation to rotator cuff function. Our findings, consistent with observed supraspinatus-cable attachment patterns, suggest that the rotator cable may play a coupling role in the inferior rotator cuff. Future study of the rotator cable should include histologic analysis of the rotator cable, particularly the inferior portion, and should aim to assess the relationship between the rotator cable’s presence and rotator cuff functionality. While there are surgical techniques that focus on repairing the anterior-superior rotator cable, our study suggests that repairing tears of the inferior rotator cable might improve surgical outcomes and might warrant consideration [4, 9]. While our study elucidates the intricate dynamics of the rotator cable-rotator cuff attachments and proposes potential surgical considerations for the inferior rotator cable, further investigations are necessary to enhance our understanding of the therapeutic potential of these findings in a more diverse patient population. Declarations Statements and Declarations : No authors have any conflicts of interests to disclose. Funding : No authors received any funding for this work. Human Ethics, Consent to Participate, and Ethics Declaration : The U.S. Department of Health and Human Services does not define cadaver research as human subject research. This anatomical cadaveric study was performed in compliance with Edward Via College of Osteopathic Medicine institutional IRB policies and guidelines governing the ethical conduct of research involving human cadavers. The cadavers were donated with prior informed consent for research and education purposes. Data Availability Statement : All data is available with the corresponding author and can be shared openly upon request. Acknowledgements : I’d like to thank Bill Pearson for mentoring this project, Michael Sims for providing assistance with images, David Redden for statistical analysis, and Jessica Muller for reviewing and editing the manuscript. Author Contribution Statements: Timothy Kanne: data collection or management, data analysis, manuscript writing/editing John Lusk: data collection or management, manuscript writing/editing Cassidy Clark: data collection or management, manuscript writing/editing Cody Jones: data collection or management, manuscript writing/editing Leanna Kanne: Other (creating/drawing figures) Daniel Cawley: protocol/project development, data collection or management, manuscript writing/editing References Aleem AW, Chalmers PN, Bechtold D, Khan AZ, Tashjian RZ, Keener JD (2019) Association Between Rotator Cuff Muscle Size and Glenoid Deformity in Primary Glenohumeral Osteoarthritis. J Bone Joint Surg 101(21):1912–1920. https://doi.org/10.2106/jbjs.19.00086 Asghar A, Ghosh S, Narayan Ravi. Revisiting the Anatomy of Rotator Cuff Relevant to Rotator Cuff Injury. Natl J Clin Anat 9. 10.1055/s-0040-1709029 Burkhart SS (1992) Fluoroscopic Comparison of Kinematic Patterns in Massive Rotator Cuff Tears. 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Anat Sci Int 94(1):53–57. 10.1007/s12565-018-0447-9 Pouliart N, Somers K, Eid S, Gagey O (2007) Variations in the Superior Capsuloligamentous Complex and Description of a New Ligament. J Shoulder Elb Surg 16(6):821–836. 10.1016/j.jse.2007.02.138 Ravn MK, Ostergaard TI, Schroeder HD, Nyengaard JR, Lambertsen KL, Frich LH (2020) Supraspinatus and Deltoid Muscle Fiber Composition in Rotator Cuff Tear Conditions. JSES Int 4(3):431–437. https://doi.org/10.1016/j.jseint.2020.04.016 Teyhen DS, Miller JM, Middag TR, Kane EJ (2008) Rotator Cuff Fatigue and Glenohumeral Kinematics in Participants Without Shoulder Dysfunction. Journal of Athletic Training . ;43(4):352–358. Accessed February 13, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2474814/ Yuri T, Kobayashi H, Takano Y et al (2019) Capsular Attachment of the Subregions of Rotator Cuff Muscles. Surg Radiol Anat 41(11):1351–1359. https://doi.org/10.1007/s00276-019-02288-7 Zumstein MA, Lädermann A, Raniga S, Schär MO (2017) The Biology of Rotator Cuff Healing. Orthop Traumatology: Surg Res 103(1):S1–S10. https://doi.org/10.1016/j.otsr.2016.11.003 Picture Picture 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files floatimage3.png Picture 1. SSP=Supraspinatus, Sup.=Superior portion of infraspinatus, Inf.=inferior portion of infraspinatus, TM=Teres Minor, Red line overlay=Approximate superficial surface of rotator cable floatimage4.png Picture 2. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable floatimage5.png Picture 3. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable floatimage6.png Picture 4. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4102467","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280933035,"identity":"7dbe5255-e06d-4c57-b390-8bd3e1bd701a","order_by":0,"name":"Timothy Kanne","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYDACHjBpw8AggSmKQwdEMo10LYdJ0GLPc/jZ44KK8/IGt3vMPhcwHJbnFzvA+OBtGx5beNvMjWecuW244c4Z49kzGA4bzpydwGw4F58WfgYzad6224wbbuQYM/MwpCUY3E5gA4rg08L+TZr33zl7ZC3sv/Fq4e0B2tJwIBGqxQZsCzNeLWfOlEnzHEtOnnnnWDEzj4EN0C+JzZJzzuHWwt6Tvk2ap8bOtu9282ZmngoJeX7p5IMf3pTh1oIGDEAEYwPR6kfBKBgFo2AUYAcAs7pGFGlcFA0AAAAASUVORK5CYII=","orcid":"","institution":"Edward Via College of Osteopathic Medicine","correspondingAuthor":true,"prefix":"","firstName":"Timothy","middleName":"","lastName":"Kanne","suffix":""},{"id":280933038,"identity":"ec378c9e-0399-4910-b684-6d73ae8e350f","order_by":1,"name":"John Lusk","email":"","orcid":"","institution":"Edward Via College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Lusk","suffix":""},{"id":280933039,"identity":"f09c6e86-b4af-4f44-8197-11b198dfc868","order_by":2,"name":"Cassidy Clark","email":"","orcid":"","institution":"Edward Via College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Cassidy","middleName":"","lastName":"Clark","suffix":""},{"id":280933040,"identity":"d0a190c6-4e74-407a-b68d-e1894169f8a5","order_by":3,"name":"Cody Jones","email":"","orcid":"","institution":"Edward Via College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Cody","middleName":"","lastName":"Jones","suffix":""},{"id":280933041,"identity":"50fb9c33-28ea-42fc-b47b-721a3bdd95c6","order_by":4,"name":"Leanna Kanne","email":"","orcid":"","institution":"Truett-McConnell College","correspondingAuthor":false,"prefix":"","firstName":"Leanna","middleName":"","lastName":"Kanne","suffix":""},{"id":280933043,"identity":"a8206ce3-54b5-47e7-b995-77596bc2050c","order_by":5,"name":"Daniel Cawley","email":"","orcid":"","institution":"Edward Via College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Cawley","suffix":""}],"badges":[],"createdAt":"2024-03-14 16:50:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4102467/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4102467/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53082329,"identity":"fbf10037-65eb-42c6-99f6-b4addae693d1","added_by":"auto","created_at":"2024-03-20 11:00:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":930934,"visible":true,"origin":"","legend":"\u003cp\u003ePosterior view of the right rotator cuff showing the rotator cable’s location as described by [4, 16]. Figure drawn by author (based on [2])\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/375d88a092ab9dd9d1aba7b3.png"},{"id":53082330,"identity":"e1d2100e-b693-4ae6-84d3-193cf6d27e93","added_by":"auto","created_at":"2024-03-20 11:00:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3465042,"visible":true,"origin":"","legend":"\u003cp\u003eSuperior view of the glenohumeral joint depicting how the rotator cable transmits abduction force as described by [4, 16]. Figure drawn by author (based on [16])\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/3bed586fa9c5262d18f64110.png"},{"id":57090284,"identity":"8a212a21-91b9-40c0-b0fc-7962d5969ba5","added_by":"auto","created_at":"2024-05-24 12:50:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3759775,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/e229f7d8-bcba-47a1-ab12-ab644dfdd91d.pdf"},{"id":53082332,"identity":"867c2c21-e559-4959-80f3-9b4bca65c51f","added_by":"auto","created_at":"2024-03-20 11:00:03","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1859666,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 1. \u0026nbsp;SSP=Supraspinatus, Sup.=Superior portion of infraspinatus, Inf.=inferior portion of infraspinatus, TM=Teres Minor, Red line overlay=Approximate superficial surface of rotator cable\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/f3c507a942cbe908dd2b6319.png"},{"id":53082331,"identity":"b8959b50-474d-4b93-b568-456a64f5d47e","added_by":"auto","created_at":"2024-03-20 11:00:03","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2171900,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 2. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/5703b6e6cbe46048a32dba64.png"},{"id":53082730,"identity":"800f0c74-e39d-4b38-9287-b9cacdd5d575","added_by":"auto","created_at":"2024-03-20 11:08:03","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1741091,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 3. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/4e56193a5c154729257c9070.png"},{"id":53082333,"identity":"00fdf8ea-6165-44c5-ab2a-eb696d95ae21","added_by":"auto","created_at":"2024-03-20 11:00:03","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":1474671,"visible":true,"origin":"","legend":"\u003cp\u003ePicture 4. Sup.=Superior portion of infraspinatus, Inf.=Inferior portion of infraspinatus, Red line overlay=Approximate superficial surface of rotator cable\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-4102467/v1/ab3e65b7218c1a53547c3eb1.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Cadaveric Study of the Rotator Cable: Interrogating the Suspension Bridge Model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhile the morphology of the rotator cuff is well described in literature, less is known about the morphology of the rotator cable. The rotator cable has been described as a semicircular, fibrous, band-like thickening of the glenohumeral joint capsule that runs between the tubercles of the humerus, lacing together the capsular attachment of the supraspinatus, infraspinatus, and teres minor muscles (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Because of its orientation and thickness, the cable is believed to function as a suspension bridge, helping to evenly distribute the forces generated by the supraspinatus and infraspinatus muscles along the superior and posterior rotator cuff [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. More specifically, it is analogous to a cable connecting two pillars of a suspension bridge as it transfers the tension generated along the rotator cuff muscles to the rotator cable\u0026rsquo;s bony attachments [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, the rotator cable is believed to preserve rotator cuff tendon function in the event of a tear, limiting tear progression and protecting the rotator crescent, an avascular, injury-prone area formed by the tendinous insertion of the infraspinatus and supraspinatus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, a study by Yuri et al. found a variable attachment pattern between the rotator cuff muscles and the glenohumeral capsule [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This indicates a need to revisit the suspension bridge model.\u003c/p\u003e \u003cp\u003ePathological conditions of the shoulder are known to alter the morphology of the shoulder. Previous studies have shown that the rotator cuff can atrophy in response to glenohumeral osteoarthritis, and that the progression of osteoarthritis is higher in patients with rotator cuff retears [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Changes in shoulder mechanics secondary to rotator cuff tears have been shown to play a significant role in pathologic changes of the superior labrum [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, the rotator cuff atrophies in response to tendon tears [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. More in-depth studies of the supraspinatus have shown that in addition to atrophy of both type 1 and 2 muscle fibers, there is also a shift towards type 2 fibers, leading to a loss of muscle endurance and increased fatigability in the presence of rotator cuff tears [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Increased rotator cuff fatigability alters shoulder kinematics, possibly leading to increased stress on neighboring structures [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, the rotator cable itself has been shown to increase in thickness in the presence of glenohumeral capsule tears [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Characterization of the morphological changes in the rotator cable in the presence of rotator cuff and glenohumeral pathology may lead to a better understanding of its role in shoulder function and improve upon the suspension bridge model.\u003c/p\u003e \u003cp\u003eThis study aims to further our knowledge of the anatomical and structural characteristics of the rotator cable by studying its attachments to the supraspinatus, infraspinatus, and teres minor on cadaveric specimens and to investigate the correlation between the morphology of the rotator cuff-cable attachment in the presence of shoulder pathology.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Following a gross anatomy course, institutional approval was granted to perform anatomical studies on the cadaveric shoulders (the cadavers were donated with prior informed consent for research and education purposes and institutional IRB policies and guidelines governing the ethical conduct of research involving human cadavers were observed). All formaldehyde-fixed cadaveric shoulders were initially included in the study. Shoulders were excluded from the study if dissections were unable to be completed due to desiccation or if prior dissection of the rotator cuff or glenohumeral joint had been performed. 30 formaldehyde-fixed shoulders from 20 cadavers (11 female, 9 male, average age of 79.65 years) were dissected.\u003c/p\u003e \u003cp\u003eDissections were performed by removing the deltoid from its distal and proximal attachments. The trapezius was detached from the clavicle and scapula and was reflected medially. After removing all neurovascular structures connecting the shoulder to the neck and thorax, an oscillating autopsy saw was used to make a vertical cut through the medial clavicle just lateral to the sternoclavicular joint and a horizontal cut at the midshaft of the humerus such that the glenohumeral joint and scapula could be completely separated from the rest of the cadaver. An additional cut was made at the lateral aspect of the scapular spine, allowing the acromion to be removed so that there was an unobstructed view of the posterior glenohumeral joint. The supraspinatus, infraspinatus, and teres minor were identified, dissected, and reflected from medial to lateral such that their attachments to the rotator cable and glenohumeral capsule could be clearly seen from both the superficial and deep capsule surface.\u003c/p\u003e \u003cp\u003eThe attachments of the supraspinatus, infraspinatus, and teres minor muscles in relation to the cable were noted, the width and thickness of the superior- and inferior-most portions of the infraspinatus attachments to the rotator cable were measured with a digital caliper (Mitutoyo CD-600 CSX, Aurora, IL, USA) three times by the same person blinded to previous measurements, and the mean was calculated.\u003c/p\u003e \u003cp\u003eA vertical incision superficial to the posterior glenohumeral joint was then made in the glenohumeral joint capsule from proximal to distal and the joint capsule was opened. After opening the glenohumeral joint capsule posteriorly, the severity of any grossly visible osteoarthritis, labral pathology, and rotator cuff pathology was documented.\u003c/p\u003e \u003cp\u003eIn the absence of a standardized way to classify grossly visible cadaveric joint pathology, we developed a rubric for classifying labral pathology, osteoarthritis, and rotator cuff pathology. Labral and osteoarthritis pathology classification was based on the approximate percentage of total surface area of the glenohumeral joint or glenoid labrum that demonstrated anything abnormal, including but not limited to fraying, osteophytes, erosion, and calcifications. Glenohumeral joints with any bony or labral abnormalities present covering approximately less than one-third of the total glenohumeral joint or labrum surface area were classified as none/minimal. Joints with bony or labral abnormalities covering approximately more than one-third of the total surface area were classified as more-than-minimal. If present, rotator cuff pathology, including but not limited to fraying, tearing, and calcifications, was classified as none/minimal if affecting approximately less than one-third of the total thickness of the tendon or muscle and as more-than-minimal if affecting approximately more than one-third of the tendon or muscle thickness. To account for the size difference between cadavers, the thickness/width ratio was calculated for the superior and inferior portion of the infraspinatus\u0026rsquo; attachment to the rotator cable for each shoulder. All classifications of pathology were documented and correlated with infraspinatus dimensions.\u003c/p\u003e \u003cp\u003eAnalyses began by calculating sample mean and sample standard deviation thickness/width ratio to measure central location and dispersion of the ratio variable. These calculations were conducted by group. Due to the small sample size and lack of ability to adequately judge the assumptions of normality, all tests were conducted using the Exact Wilcoxon Rank Sum test. All analyses were conducted using SAS 9.4.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring dissection, it was apparent that the infraspinatus had varying degrees of attachment to the rotator cable. The superior-most portion of the infraspinatus had a different degree of attachment than the inferior-most portion of the infraspinatus when viewing the cable with the supraspinatus, infraspinatus, and teres minor muscles reflected laterally. While the supraspinatus and teres minor uniformly attached to the rotator cable in every shoulder, the superior-most portion of the infraspinatus was significantly less adherent to the rotator cable and the inferior-most portion of the infraspinatus was significantly more adherent to the rotator cable in 26 of the 30 (86%) shoulders dissected (pictures 1\u0026ndash;4).\u003c/p\u003e\n\u003cp\u003eOut of the 30 shoulders, more-than-minimal (MTM) labral pathology was noted in 11, MTM osteoarthritis in 10, and MTM rotator cuff pathology in 4 (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). A statistically significant difference was noted in the inferior infraspinatus thickness/width ratio in the more-than-minimal osteoarthritis and labral pathology groups compared to the none/minimal groups (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNumber of shoulders in each category of pathology\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMore-than-Minimal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNone/Minimal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCuff Pathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLabral Pathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRatio variable of the superior and inferior portions of infraspinatus compared between two groups of pathology.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup\u0026thinsp;=\u0026thinsp;More-than-Minimal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup\u0026thinsp;=\u0026thinsp;None/Minimal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCuff pathology: Superior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCuff pathology: Inferior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis: Superior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis: Inferior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0477\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLabral pathology: Superior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLabral pathology: Inferior infraspinatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0409\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuring our dissections, we noted an interesting pattern in the infraspinatus-rotator cable attachment that has not been previously described. \u0026nbsp;This could shed light on the role the cable plays within the function of the rotator cuff. \u0026nbsp;Specifically, the attachment pattern found could signify that only the inferior portion of the infraspinatus participates in stress shielding through the cable, or it could be a compensatory response to increased load on the tendon, such as that from glenohumeral pathology [14, 16]. \u0026nbsp;Alternatively, the difference in attachment could simply be the effect of the different partitions of the infraspinatus muscle belly [8]. \u0026nbsp;In fact, a recent study by Yuri et al. found variation in how the infraspinatus attached to the rotator cable, specifically in the middle partition, which was firmly attached with dense connective tissue while the rest of the infraspinatus had loose, less dense connective tissue [21]. \u0026nbsp;While we didn\u0026rsquo;t note three separate partitions of the infraspinatus at the rotator cable, the variation we found may be attributed to different partitions of the infraspinatus and described differently by Yuri et al. \u0026nbsp;Regardless of the nomenclature, the statistically significant increase in the thickness/width ratio of the inferior portion of the infraspinatus in the presence of more-than-minimal osteoarthritis or labral pathology could be a sign of an increased stress load being transferred through the muscle, tendon, and rotator cable at its inferior attachment. \u0026nbsp;It is also possible that with a larger sample size (n\u0026gt;4), there would have been a statistically significant relationship between the inferior infraspinatus in the two rotator cuff pathology groups. \u0026nbsp;This pattern of increased thickness in the presence of significant pathology is consistent with what has been observed previously in the presence of glenohumeral capsule tears [17]. \u0026nbsp;However, Mura et al.\u0026rsquo;s biomechanical infraspinatus model introduces another possibility. \u0026nbsp;Their findings, which showed that the infraspinatus could generate abduction torque even when the entire superior infraspinatus was torn, suggest the cable could play a role in keeping the infraspinatus engaged with the rest of the cuff during abduction, even in the setting of large tears [11]. \u0026nbsp;Our previously unexplored infraspinatus-rotator cable attachment pattern could offer valuable insight into the potentially multifaceted role the rotator cable plays within the intricate dynamics of the rotator cuff.\u003c/p\u003e\n\u003cp\u003eSimilar observations to our infraspinatus-cable attachment findings have already been made about the cable\u0026rsquo;s superior-anterior attachment at the supraspinatus. Detailed dissections have shown that the coracohumeral and posterosuperior glenohumeral ligaments merge with the rotator cable, providing the cable with additional anchoring and support superiorly and anteriorly [12, 15]. Therefore, large anterior cable tears have been shown to cause a disproportionate amount of strain across the supraspinatus when compared to tears localized to the crescent area [10]. While the supraspinatus has received more attention in previous studies, we think our findings suggest a similar pattern would be seen if the inferior portions of the cable were disrupted, which would presumably cause an increased amount of strain on the infraspinatus and teres minor muscles. Our observed attachment pattern, which is consistent with previous supraspinatus-cable patterns observed, potentially confirms the cable\u0026apos;s coupling role in the inferior part of the rotator cuff, where it has stronger attachments to the infraspinatus. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study is limited in several ways. \u0026nbsp;Besides being a descriptive study, the attachment pattern observed in the infraspinatus could have been artificially augmented by the manner of dissection since the reflection of the rotator cuff muscles from medial to lateral could have separated some of the tissue connecting the infraspinatus to the rotator cable. \u0026nbsp;Furthermore, there is no standardized way to classify gross cadaveric glenohumeral or rotator cuff pathology, so our pathology classification is somewhat arbitrary. \u0026nbsp;With a different cut-off for disease severity, we may have found different relationships between rotator cable-infraspinatus attachment dimensions and disease severity. \u0026nbsp;The cadavers\u0026rsquo; medical history regarding the shoulder was unknown, and while no signs of prior shoulder surgery or injury on any of the dissected shoulders were noted, such signs could have been missed by visual inspection. \u0026nbsp; Given the advanced age of the cadavers and their unknown prior physical activity history, the implications of our results could be limited to an older patient population and confounded by an uneven distribution of rotator cuff health. \u0026nbsp;Finally, without knowing previous medical history and physical activity ability, we are unable to examine the relationship between the rotator cable\u0026apos;s presence and rotator cuff functionality. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, our study of the morphology of the rotator cable-rotator cuff attachments sheds light on the dynamics of the rotator cable in relation to rotator cuff function. \u0026nbsp; Our findings, consistent with observed supraspinatus-cable attachment patterns, suggest that the rotator cable may play a coupling role in the inferior rotator cuff. \u0026nbsp;Future study of the rotator cable should include histologic analysis of the rotator cable, particularly the inferior portion, and should aim to assess the relationship between the rotator cable\u0026rsquo;s presence and rotator cuff functionality. \u0026nbsp;While there are surgical techniques that focus on repairing the anterior-superior rotator cable, our study suggests that repairing tears of the inferior rotator cable might improve surgical outcomes and might warrant consideration [4, 9]. \u0026nbsp; While our study elucidates the intricate dynamics of the rotator cable-rotator cuff attachments and proposes potential surgical considerations for the inferior rotator cable, further investigations are necessary to enhance our understanding of the therapeutic potential of these findings in a more diverse patient population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements and Declarations\u003c/strong\u003e: No authors have any conflicts of interests to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No authors received any funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics, Consent to Participate, and Ethics Declaration\u003c/strong\u003e: The U.S. Department of Health and Human Services does not define cadaver research as human subject research. This anatomical cadaveric study was performed in compliance with Edward Via College of Osteopathic Medicine institutional IRB policies and guidelines governing the ethical conduct of research involving human cadavers. \u0026nbsp;The cadavers were donated with prior informed consent for research and education purposes. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e: All data is available with the corresponding author and can be shared openly upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: I\u0026rsquo;d like to thank Bill Pearson for mentoring this project, Michael Sims for providing assistance with images, David Redden for statistical analysis, and Jessica Muller for reviewing and editing the manuscript.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statements: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTimothy Kanne: data collection or management, data analysis, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eJohn Lusk: data collection or management, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eCassidy Clark: data collection or management, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eCody Jones: data collection or management, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eLeanna Kanne: Other (creating/drawing figures)\u003c/p\u003e\n\u003cp\u003eDaniel Cawley: protocol/project development, data collection or management, manuscript writing/editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAleem AW, Chalmers PN, Bechtold D, Khan AZ, Tashjian RZ, Keener JD (2019) Association Between Rotator Cuff Muscle Size and Glenoid Deformity in Primary Glenohumeral Osteoarthritis. 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Orthop Traumatology: Surg Res 103(1):S1\u0026ndash;S10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.otsr.2016.11.003\u003c/span\u003e\u003cspan address=\"10.1016/j.otsr.2016.11.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Picture ","content":"\u003cp\u003ePicture 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"rotator cable, rotator cuff, infraspinatus","lastPublishedDoi":"10.21203/rs.3.rs-4102467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4102467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThe objective of this cadaveric study was to study the anatomic relationships between the rotator cuff muscles and the rotator cable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eIn 30 formaldehyde-fixed shoulders from 20 cadavers, the rotator cuff and rotator cable were dissected and the glenohumeral joint opened. The orientation and attachments of the rotator cable to the rotator cuff muscles were studied and the severity of any osteoarthritis, labral pathology, and rotator cuff pathology present was documented. The width and thickness of the infraspinatus attachments to the rotator cable were measured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe infraspinatus muscle was noted to be more loosely adherent to the rotator cable, while the supraspinatus and teres minor were tightly adherent to the cable. Specifically, the superior-most portion of the infraspinatus was found to be less tightly adherent than the inferior-most portion in 26 of the 30 shoulders studied. There was a correlation between increased thickness of the inferior-most portion of infraspinatus and more-than-minimal osteoarthritis and labral pathology (p=0.0477, p=0.0409, respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWhile the supraspinatus and teres minor muscles were tightly adherent to the cable in all shoulders, the degree of attachment of the superior-most portion of the infraspinatus muscle was notably less in 26 of the 30 shoulders studied. This could mean that only the inferior portion of the infraspinatus participates in stress shielding through the cable or be a compensatory response to increased load on the tendon. This work is expected to provide insight into the function of the rotator cable and the different functions of the infraspinatus.\u003c/p\u003e","manuscriptTitle":"A Cadaveric Study of the Rotator Cable: Interrogating the Suspension Bridge Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-20 10:59:58","doi":"10.21203/rs.3.rs-4102467/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8754a08-fb40-4a15-a68f-42ca419148d2","owner":[],"postedDate":"March 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-24T12:42:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-20 10:59:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4102467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4102467","identity":"rs-4102467","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}