SHOULDER
Shoulder arthroscopy,
anatomy and variants - part 1
Simon Boyle
Manuel Haag
David Limb
Laurent Lafosse
Abstract
Arthroscopy is increasingly the modality of choice for interventional
procedures in shoulder surgery. It is often learned after a basic grounding
in knee arthroscopy, but the wide variation in normal anatomy and unfa-
miliarity with the 3D arrangement of the joint can easily confuse. This
article therefore describes the technicalities of shoulder arthroscopy
and introduces the many structures that are encountered. In part 1 we
will discuss the indications for arthroscopy and the process of setting
up and performing the procedure in a clinical setting, with useful concepts
and technical tips. In part 2 we will move on to discuss the range of find-
ings that can be encountered, both normal and pathological, as correct
recognition is critical to safe subsequent management.
Keywords arthroscopy; patient positioning; portals; shoulder anatomy
Introduction
Since the early 1980’s there has been an exponential rise in the
use of the arthroscope in shoulder surgery. The minimally
disruptive nature of arthroscopic surgery along with the benefit
of magnification, has resulted in an improved understanding of
shoulder anatomy, its variants and the pathophysiology of
shoulder dysfunction. This, combined with developments in
instruments, pumps and cameras, has led to a natural increase in
the proportion of therapeutic procedures that can be performed
arthroscopically, and therefore an expansion in the indications
for shoulder arthroscopy.
History
The first shoulder arthroscopy is generally credited to the
American Dr Michael Burman in 1931.1 He performed his initial
arthroscopies on cadaveric shoulders, although evidence of the
Simon Boyle MSc FCRS(Tr&Orth) Shoulder Fellow, Alps Surgery Institute,
Annecy, France.
Manuel Haag MD Shoulder Fellow, Alps Surgery Institute, Annecy, France.
David Limb BSc FRCSEd(Orth) Consultant Orthopaedic Surgeon Leeds
General Infirmary, Leeds, UK.
Laurent Lafosse MD Shoulder Surgeon, Alps Surgery Institute, Annecy,
France.
ORTHOPAEDICS AND TRAUMA 23:4
earlier use of the arthroscope has been reported by the Danish
surgeon Nordentoft (1912),2 Takagi in Japan (1918),3 Dr Eugen
Bircher (1922)4 and Dr Phillip Kreuscher (1925).5 These pio-
neering arthroscopists however, performed these early proce-
dures primarily on knee joints. In addition, Burman also defined
several arthroscopic principles in his work that are still applied
today. These include joint distension (using fluid or air), the use
of traction and the importance of positioning.
The advent of World War II slowed progression, and it was
not until the 1950’s, when the work of Takagi was revived by Dr
Masaki Watanabe, that arthroscopy began to move forward
again. Watanabe modified existing arthroscopic equipment, and
in 1958 he introduced the Watanabe 21, which led to the
complete revision of the Atlas of Arthroscopy. Further advances
in the 1970’s and 80’s included the introduction of smaller
diameter arthroscopes, higher quality lenses, the use of fibre
optic light sources and later, the introduction of the charge
coupled device (CCD) camera.
The development of shoulder arthroscopy remained slow, its
first recorded clinical use being by Andren and Lundberg in
19656 for the treatment of frozen shoulder. Watanabe subse-
quently described the posterior portal in 19787 and through this
he began to describe shoulder pathology as viewed through the
arthroscope.8 Conti shortly after described the anterior portal
which he used to perform brisement (capsular distension) and
capsular release in 18 patients with frozen shoulders.9 The first
documented use of the arthroscopic shaver in the shoulder
appeared in 1980.10
Thereafter shoulder arthroscopy became increasingly popular,
especially in the management of dynamic gleno-humeral joint
and sub-acromial disorders. More recently, the arthroscope has
been used to perform acromio-clavicular joint stabilisations and
excision, suprascapular nerve releases, bone block transfers and
even latissimus dorsi transfers. These developments are beyond
the scope of this article and innovative techniques continue to be
introduced with regularity.
Indications
The indications for shoulder arthroscopy are continually
expanding. Its early use was as a diagnostic tool but this role now
encompasses many complex procedures. Both intra- and extra-
articular shoulder girdle structures are seen as being accessible to
the arthroscope and a combination of approaches can be adopted.
The arthroscope has the advantage of causing minimal
disruption to the existing joint anatomy and its use has led to
a better appreciation of several pathological entities, most
notably the Superior Labrum Anterior Posterior (SLAP) lesion.
The gleno-humeral joint (GHJ), sub-acromial space, acromio-
clavicular joint (ACJ) and scapulo-thoracic articulation are all
accessible to the arthroscope. Furthermore, neurovascular
structures such as the axillary nerve, supra-scapular nerve,
brachial plexus and axillary vessels are all within reach of the
skilled (or clumsy!) arthroscopist (Table 1).
Anaesthesia for shoulder arthroscopy
As shoulder surgery has advanced, so has the familiarity and
enthusiasm for regional nerve blockade for both anaesthesia and
postoperative pain control. Consequently, shoulder arthroscopy
291 Ó 2009 Published by Elsevier Ltd.
 SHOULDER

The indications for shoulder arthroscopy

Diagnostic

Therapeutic Gleno-humeral joint Instability Bankart repair

Capsular plication
Capsular shrinkage
Latarjet procedure
Cuff pathology Calcific tendinitis
Rotator cuff tears
Capsular pathology Adhesive capsulitis
Biceps tendon SLAP lesions
Subluxing/dislocating tendon
Biceps tendinopathy
Synovial disorders Synovitis
Synovial chondromatosis
PVNS
Septic arthritis Washout
Ganglia/cysts Decompression
Cartilage lesions (OA) Graft procedures
Sub-acromial space (Bursoscopy) Impingement
Cuff pathology Calcific tendinitis
Rotator cuff tears
Acromio-clavicular joint Instability
Dislocation
Degeneration
Supra-scapular nerve Entrapment Nerve release
Scapulo-thoracic articulation Snapping scapula Bursitis
Osteochondromas
Muscle transfers Large irreparable cuff tears Arthroscopic Latissimus dorsi transfer

Table 1

is now routinely performed under inter-scalene block, general
anaesthesia, or both. A basic knowledge of these anaesthetic
techniques is essential for shoulder surgeons, especially with
regard to their risks and complications and these will be dis-
cussed in a forthcoming issue of Orthopaedics and Trauma.
Patient positioning11,12
Shoulder arthroscopy is performed in either the lateral decubitus
or beach chair positions. The choice often comes down to
surgeon familiarity and this is usually a reflection of experience
and exposure to a particular setup during training. There are,
however, practical differences to consider when determining the
optimal position for the patient. As with any surgical procedure,
correct positioning is vital and many intra-operative difficulties
can be avoided if time and diligence are taken at this stage of the
setup.
components to improve access to the posterior part of the
shoulder. We insist on being able to place two fingers medial to
the medial aspect of the scapula to ensure adequate access.
The arm is prepared and draped, after which it can either be
placed in traction, rested on a custom support or on a Mayo
table. We prefer to use 2e3.5 kg of traction with the shoulder
flexed to 60 and 20 abduction (see Figure 1).
Advantages of the beach chair position
- familiar anatomic upright position
- easier to convert to an open procedure without re-posi-
tioning or re-draping
- regional anaesthesia alone is better tolerated in this position

Beach chair
Positioning begins with the patient in the supine position on
a table equipped with a suitable back, neck and headrest. A
cushion is placed behind the patients knees, which are flexed to
approximately 30 . The table is then adjusted to bring the
patients trunk into a more upright position with their hips flexed
to 60 . Most modern tables allow the removal of different Figure 1 Beach chair position.

ORTHOPAEDICS AND TRAUMA 23:4 292 Ó 2009 Published by Elsevier Ltd.

 SHOULDER
- this position permits easier access for the anaesthetist should
conversion to general anaesthesia be necessary
- allows greater mobility of the arm and shoulder during
surgery
- the option of not using traction means less distortion of the
soft tissues This is especially important during stabilisation
procedures.
Disadvantages
- bubbles can accumulate superiorly in the subacromial space
or the joint after using diathermy
- increased risk of cardiovascular complications
- increased risk of air embolus.
Lateral decubitus
In this position, the patient is placed laterally on the operating
table and supports are placed behind the upper lumbar spine and
anterior to the anterior superior iliac spine. Alternatively, a bean
bag type support can be used. An axillary roll is used to help
protect the neurovascular structures of the non-operated side.
The head is supported in a neutral position and the lower
ear protected. A pillow is placed between the knees and these
are flexed to 30 . The operative arm is placed in traction at
approximately 30 abduction and 15 forward flexion, although
this can be varied according to the procedure being performed
(see Figure 2). Additional lateral traction can be added with
a sling around the upper humerus. Finally, the table can be tilted
laterally to bring the plane of the glenoid more horizontal,
parallel to the floor.
Advantages
- familiarity if trained in this technique
- traction improves the view in the subacromial space and
glenohumeral joint
- lower cardiovascular and cerebrovascular risk
- an assistant may not be needed.
Disadvantages
- more difficult to convert to an open procedure
- it is necessary to reach forwards and around for the anterior
portals
- patients do not tolerate isolated regional anaesthesia well in
this position
- the use of traction is associated with decreased limb perfu-
sion and brachial plexus neuropraxia
- peroneal nerve neuropraxia
- increased risk of nerve injury with antero-inferior portal.
Figure 2 Lateral position.12
ORTHOPAEDICS AND TRAUMA 23:4
In both positions, care must be taken to support the head,
neck and airway in conjunction with the anaesthetist. All pres-
sure points should be well padded and the eyes protected. The
amount of traction applied depends on surgeon preference, the
procedure being performed and the body habitus of the patient.
Examination under anaesthesia
The majority of diagnoses regarding shoulder pathology are made
through good history taking, clinical examination and supplemen-
tary radiology. However, an examination under anaesthesia (EUA)
can yield valuable information that may even lead to a change in the
surgical management plan eg. unmasking unrecognised instability
that was not detected on awake examination due to pain.
Passive range of movement
This is assessed with particular attention to the point at which
scapulo-thoracic motion commences. Passive range of movement
is recorded in all planes and referenced against the pre-operative
examination and in comparison to the opposite shoulder. This is
particularly relevant in cases of adhesive capsulitis.
It is useful to use the forearm as a goniometer for this
assessment.
Gleno-humeral stability
Anterior and posterior translation should be performed and graded.
We prefer to use the Load and Shift test13 in which the examiner
stands behind the patient and with one hand stabilises the scapula
whilst the other hand centres the humeral head with an axial load
applied to the humeral shaft. Humeral translation is then applied in
an anterior and posterior direction and graded as follows:
Grade I - the humeral head can be translated to the glenoid rim
Grade II - the head can be felt riding over the glenoid rim but
reduces spontaneously with the release of the
translating force
Grade III - the head rides over the glenoid rim and remains
dislocated on release of the translating force.
This test is then repeated in increasing the degrees of abduction
and rotation of the arm where occult subluxation is suspected and
also allows assessment of any engaging Hill-Sachs lesion.
Inferior translation is then assessed with inferior traction force
applied to the arm. When a hollow or sulcus appears below the
acromion, it can be graded as follows
I - less than 1 cm
II - 1e2 cm
III - >2 cm
If a sulcus is seen, then the test is repeated with the shoulder
in external rotation. A persistent sulcus sign in external rotation
suggests laxity of the rotator interval.14
The shoulder as a house
Before introducing the arthroscope and proceeding to a formal
joint evaluation, it is important for the surgeon to have a clear
understanding of the anatomy of the shoulder. To improve
spatial awareness and to gain a better appreciation of the 3
dimensional nature of the shoulder, the Alps Surgery Institute
find it useful to create an analogy of the shoulder as a house (see
Figure 3), with a ground floor, a first floor and a basement.
293 Ó 2009 Published by Elsevier Ltd.
 SHOULDER
The ground floor
The glenohumeral joint is the main room on the ground floor. It’s
ceiling is formed by the supraspinatus tendon, the anterior wall
by the subscapularis tendon, and the posterior wall by the
infraspinatus and teres minor tendons. The rotator cuff interval,
including the superior glenohumeral ligament and the cor-
acohumeral ligament, closes the junction between the supra-
spinatus and subscapularis tendon. Inside the glenohumeral
joint, the biceps leaves the glenoid and exits the room through
the rotator interval, like a chimney.
Remaining on the ground floor but anterior and medial to the
main room is the coracoid process. This is a key landmark and
serves as the attachment of two musculotendinous structures:
the pectoralis minor and the conjoint tendons. These structures
help define the sub-coracoid and supra-coracoid spaces. The sub-
coracoid space is the second room on the ground floor, located
between the subscapularis tendon (posteriorly) and the conjoint
tendon (anteriorly). Medial to the coracoid, the brachial plexus
including the axillary nerve and the subscapular nerves can be
found. The ceiling of the sub-coracoid space is the coracoid
process and the pectoralis minor tendon.
Posterior to the infraspinatus and teres minor tendons exists
the back room on the ground floor, lying between the rotator cuff
and the deltoid muscle. This posterior sub-deltoid space can
provide access like a staircase up to the subacromial space on the
first floor and also down to the basement where the axillary
nerve can be found.
The first floor
The subacromial space is on the first floor. The supraspinatus
tendon and the coracohumeral ligament now form the floor. The
acromion, the clavicle, and the deltoid muscle all represent roof.
The subacromial bursa is found here in the anterior part of the
sub-acromial space, like a room within a room. Moving medially
on the first floor is the supra-coracoid space beneath the clavicle.
Herein lie the coracoclavicular ligaments and the suprascapular
nerve. The coracoacromial ligament forms the division between
the supra-coracoid space and the subacromial space.
The basement
Finally, at the level of the basement, the quadrilateral space is
located beneath the gleno-humeral joint. The quadrilateral space
communicates anteriorly with the most inferior part of the sub-
coracoid space and posteriorly with the inferior part of the
posterior sub-deltoid space. Importantly, it contains the axillary
nerve, the teres major and the latissimus dorsi tendons.
Figure 3 The shoulder as a house.
ORTHOPAEDICS AND TRAUMA 23:4
Arthroscopic portals
Arthroscopic portal selection, and correct siting, are fundamental
steps essential for a good view of the joint and associated
pathology. The portals must be placed with the subsequent
procedure in mind, to permit unhindered instrument access to
relevant anatomical structures. The portals may just be required
for suture management but they must be placed to minimise risk
to local neurovascular structures.
General technique
Firstly the bony landmarks of the shoulder are palpated and
marked with a surgical site pen (see Figure 4). The clavicle,
acromioclavicular joint (ACJ), acromion, and scapula spine
should be clearly marked, followed by the coracoid. One may
choose to draw in the biceps tendon, in the bicipital groove, and
the conjoint tendon. A bursal orientation line can be made which
begins at the posterior edge of the ACJ to extend 4 cm laterally
down the arm. This indicates the start of the subacromial bursa
and demonstrates the anterior nature of its position. This is
particularly helpful for the placement of the lateral portal.
It is also helpful to recall that moving the scope through
a portal resembles moving it within an hourglass, with the
constriction or pivot at the level of the portal. We use a 30 scope
and regularly change the direction of the lens by rotating the light
cable to optimise our view. It is also important to review
a structure through different portals, to give a better 3 dimen-
sional perspective of the anatomy in question.
To confirm that instrument access to an anatomical structure
will be adequate, we introduce a needle at the potential portal
site and probe the anatomy prior to making that definitive portal.
We name our basic arthroscopic portals A to E, after which
the more advanced and procedure specific portals can be labelled
F to K (Figures 4 and 5).
Portal A e the posterior portal
This is often the first portal established, as it is the standard
viewing portal for the gleno-humeral joint. The entry point is
located in the ‘‘soft spot’’, a location found approximately 2 cm
Figure 4 Skin markings of shoulder anatomy with basic and advanced
portals.
294 Ó 2009 Published by Elsevier Ltd.
 SHOULDER
Figure 5 3D graphical representation of portal placement.
inferior and 1cm medial to the posterolateral corner of the
acromion. A needle is inserted and directed towards the coracoid,
into the inferior apex of a triangle formed by the acromion
(superiorly), humeral head (laterally) and the glenoid (medially)
(Figure 6). The needle serves as a guide to the correct direc-
tion of the joint and occasionally a hiss can be heard con-
firming its intra-articular location. A 5 mm skin incision is
then made and the arthroscope containing a blunt trocar is
introduced into the joint. To assist in the correct placement,
the scope can be directed towards the middle finger of the
opposite hand which is placed on the tip of the coracoid. In
more difficult cases, the apex of this triangle and therefore the
joint line, can also be identified by gently flicking the tip of
Figure 6 Triangle used for posterior portal placement.
ORTHOPAEDICS AND TRAUMA 23:4
the scope over the posterior edge of the glenoid just above its
equator, prior to advancing it into the joint.
There is a feeling of ‘‘give’’ once the scope successfully enters
the joint and this can be confirmed by attaching the camera.
Structures seen e anterior capsule, gleno-humeral ligaments,
rotator interval, subscapularis (superior 1/3), intra-articular
biceps tendon, labrum, inferior recess, glenoid and humeral
articular surfaces, supraspinatus and infraspinatus.
Internervous plane e between infraspinatus (suprascapular
nerve) and teres minor (axillary nerve)
Structures at risk e posterior deltoid and/or infraspinatus
fibres may be traversed with this portal
- axillary nerve
- posterior circumflex humeral vessels.
Posterior subacromial portal
This utilises the same skin incision as the posterior A portal and
is used to gain access to the subacromial space. This takes place
after completion of the gleno-humeral joint inspection and the
scope is withdrawn and the blunt trocar reinserted. The scope
and trocar are reintroduced but redirected towards the antero-
lateral corner of the acromion. A sweeping motion is also used to
clear any adhesions prior to recommencing fluid distension. The
trocar is then replaced by the camera and a bursoscopy is
performed.
Structures seenesubacromial space, bursal side of rotator cuff,
ACJ, extra-articular biceps, coracoid, coraco-acromial ligament.
Structures at riskeposterior deltoid fibres may be traversed.
Portal Bepostero-lateral subacromial
This portal is used to provide access to the posterior cuff and
posterior labrum (posterior Bankart repair). Its position is
generally located 1 cm antero-inferior to the postero-lateral edge
of the acromion.
Structures seeneposterior rotator cuff, often used for instru-
mented repair and suture management. Intra-articular advance-
ment reveals the posterior labrum and joint structures as seen
from a slightly different angle to the A portal.
Structures at riskeposterior fibres of deltoid and if used to
instrument articular structures, then infraspinatus is also
breached. The axillary nerve is 4e5 cm inferior to this portal.
Portal Celateral subacromial
We use this portal as our initial portal in cases of large cuff tears and
adhesive capsulitis. It is located at the level of the mid-acromion
and provides excellent access to the subacromial space, but also
allows visualisation, manipulation and repair of rotator cuff tears.
As with the initial A portal, a needle is used confirm correct
placement and to aid direction of the scope after the skin incision.
This is an excellent working portal for many procedures.
Structures seen - subacromial space, bursal side of rotator
cuff, ACJ, suprascapular nerve, coraco-clavicular ligaments,
extra-articular biceps, coracoid, coraco-acromial ligament,
coracohumeral ligament and rotator interval, extra-articular
subscapularis, conjoint tendon.
Structures at riskelateral fibres of deltoid traversed, axillary
nerve well inferior.
295 Ó 2009 Published by Elsevier Ltd.
 SHOULDER
Portal Desupero-lateral
This is known as the sub-bicipital portal and provides good
access to the biceps tendon and the subscapularis insertion. It is
positioned optimally using a spinal needle but is generally placed
1 cm lateral to the antero-lateral edge of the acromion. It can also
provide access for single or double row repairs of the anterior
labrum (Cassiopeia technique) as it gives excellent access to the
anterior glenoid rim and neck. When the cuff is intact, intra-
articular access is gained by traversing the CHL and rotator
interval, where the CHL can be safely identified at its origin on
the coracoid. This allows access not only to the joint but also to
the sub-coracoid space for subscapularis releases and plexus
exploration. It is also used for instrumenting the supra-coracoid
space for suprascapular nerve exposure.
Structures seen e supraspinatus, subscapularis, rotator
interval, coracoid, sub-coracoid space/bursa, intra-articular
access through the RI, suprascapular nerve,
Structures at risk e antero-lateral deltoid, rotator interval,
biceps tendon.
Portal Eeanterior
This portal provides a useful adjunct in diagnostic arthroscopy
by allowing instrument access and therefore a means of palpating
and dynamically stressing shoulder anatomy. The key to portal
placement here is visualisation of the biceps tendon and rotator
interval as seen through the posterior portal. A needle is first
placed using an outside in technique, to confirm the best position
of the portal and also to probe the relevant anatomy. The surface
landmark is found halfway on a line joining the coracoid and
acromion. It is important to remain lateral to the coracoid to
minimise risk to the neurovascular structures.
The intra-articular view confirms correct needle placement
and the skin is then incised. The blade is advanced following the
direction of the needle into the rotator interval, being cautious
not to injure the adjacent structures. Alternative methods include
the use of a blunt trocar to puncture the anterior capsule, use of
a cannulated portal or techniques employing a switching stick.
Structures seen e this portal is generally used for anterior
instrumentation but it does provide alternative views of the
biceps anchor, anterior labrum and glenoid neck, subscapularis
and good views of the glenoid, infraspinatus, teres minor,
posterior labrum and capsule.
Structures at risk - this portal transgresses the anterior deltoid,
and the rotator interval.
- medially lies the brachial plexus and axillary vessels
- infero-laterally lies the musculocutaneous nerve
- cephalic vein.
ORTHOPAEDICS AND TRAUMA 23:4
Summary
Shoulder arthroscopy still has a critical role in the diagnosis of
shoulder pathology and for a range of conditions it allows
better visualisation and interpretation of the pathoanatomy
than other imaging modalities. Experience with arthroscopy has
led to an explosion of interest and expertise in the technical
skills that have made arthroscopic surgery the mainstay of
surgical management for a wide range of shoulder conditions.
In part 2 of this article we will consider the wide range of
findings that can confuse the newcomer, as the spectrum of
normal findings is wide yet the pathological lesions can be
obscure. A
REFERENCES
1 Burman MS. Arthroscopy or the direct visualisation of joints: An
experimental cadaver study. J Bone Joint Surg 1931; 13: 669e95.
2 Kieser CW, Jackson RW. Severin Nordentoft: the first arthroscopist.
Arthroscopy 2001; 17-5: 532e5.
3 Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. Tokyo: Igakin-
Shoin; 1957.
4 Bircher E. Die Arthroendoskopie. Zentralbl Chir 1921; 40: 1460e81.
5 Kreuscher PH. Semi-lunar cartilage disease, a plea for early recog-
nition by means of the arthroscope and early treatment of this
condition. Illionois Med J 1925; 47: 290e2.
6 Andren L, Lundberg BJ. Treatment of rigid Shoulders by joint
distension during arthrography. Acta Orthop Scand 1965; 36: 45e53.
7 Watanabe M, Takeba S, Ikeuchi H. Atlas of arthroscopy. 3rd edn.
New York: Igaku-Shoin; 1978.
8 Watanabe M. Arthroscopy: the present state. Orthop Clin North Am
1979; 10e13: 505e22.
9 Conti V. Arthroscopy in rehabilitation. Orthop Clin North Am 1979;
10e13: 709e11.
10 Johnson LL. Arthroscopy of the shoulder. Orthop Clin North Am 1980;
11e12: 197e204.
11 Abrams JS, Bell RH. Arthroscopic rotator cuff surgery. New York:
Springer; 2008.
12 Peruto CM, Ciccotti MG, Cohen SB, (in press). Shoulder arthroscopy
positioning: lateral decubitus versus beach chair. Arthrocopy.
13 Silliman JF, Hawkins RJ. Classification and physical diagnosis
of instability of the shoulder. Clin Orthop Relat Res 1993; 291:
7e19.
14 Fitzpatrick MJ, Powell SE, Tibone JE, Warren RF. The anatomy,
pathology, and definitive treatment of rotator interval lesions:
current concepts. Arthroscopy 2003; 19(Suppl. 1): 70e9.
296 Ó 2009 Published by Elsevier Ltd.