Visualization of the anatomy of the rotator interval and bicipital sheath

A systematic evaluation of the glenohumeral joint should be routinely performed with all shoulder arthroscopy and include all anatomic areas. However, to date, less attention has been given to the insertion of the subscapularis tendon, superior glenohumeral ligament (SGHL), and medial head of the coracohumeral ligament (MCHL). This article outlines arthroscopic techniques that may aid in the evaluation of the anatomy of the rotator interval and bicipital sheath. In this apical region, the CHL contributes fibers to the SGHL (forming the internal reflection of the bicipital groove-SGHL/CHL complex), the subscapularis tendon, and the joint capsule. The CHL is more anterior to the SGHL. There is a distinct anatomic difference between the SGHL/CHL insertion complex and the subscapularis insertion. The normal insertion of the subscapularis tendon is into a small trough on the lesser tuberosity. Together, these structures make up the medial wall of the superior biceps pulley. With the arthroscope advanced to the anterior portion of the joint, the shoulder is elevated from 60 degrees to 90 degrees and a neuroprobe is advanced through the anterior cannula. By internally rotating the arm, the subscapularis tendon insertion and SGHL/CHL complex slacken. A neuroprobe can be placed under the insertion of the subscapularis tendon and SGHL/CHL complex. A 70 degrees arthroscope can aid in visualization with less shoulder elevation. These techniques allow for a thorough visualization of the structures of the rotator interval and medial bicipital sheath.