Annals of Anatomy 233 (2021) 151615

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Annals of Anatomy
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RESEARCH ARTICLE

The subscapularis tendon: A proposed classification system

Nicol Zielinska a , R. Shane Tubbs d,e,f,g,h , Michał Podgórski c , Piotr Karauda a ,
Michał Polguj b , Łukasz Olewnik a,∗
a
Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
b
Department of Normal and Clinical Anatomy, Chair of Anatomy and Histology, Medical University of Lodz, Poland
c
Polish Mothers’ Memorial Hospital Research Institute, Lodz, Poland
d
Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA
e
Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
f
Department of Anatomical Sciences, St. George’s University, Grenada
g
Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
h
Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: The subscapularis muscle originates from the medial two-thirds and from the lower two-
Received 22 August 2020 thirds of the groove on the subscapular fossa of the scapula and inserts into the lesser tubercle of the
Received in revised form humerus. Our initial hypothesis is that it shows little morphological variation. The aim of this study is to
19 September 2020
demonstrate and classify the morphological variability of the subscapularis muscle.
Accepted 22 September 2020
Methods: Classical anatomical dissection was performed on 64 upper limbs (44 females, 20 males, 30 left
and 34 right, fixed in 10% formalin). The mean age “at death” of the cadavers was 75.6 years (range 48–95),
Keywords:
and the group comprised equal numbers of female and male adults (Central European population). Upon
Anatomical study
Cadaveric study
dissection, the following morphological features were assessed: the number of tendons of the SM, the
New classification type of insertion of each tendon of the SM, morphometric measurements of the SM.
Subscapularis muscle Results: Four types of morphology (based on number of tendons) were observed in the cadavers. Type I
Accessory subscapularis muscle was characterized by a single band. This was the most common type, occurring in 43.7% of all cases. Type
Phylogenesis II was characterized by a double tendon (superior and inferior); it occurred in 9.4%. Type III had three
Ontogenesis tendons (superior, middle, and inferior). It was the rarest type (7.8% of cases). Type IV, called “multiband”,
was the second most common (39.1%) and was divided into five subtypes.
Conclusions: The subscapularis muscle is highly morphologically variable. Knowledge of particular types
of insertion is essential for both clinicians (for example orthopedists, physiotherapists) and anatomists.
© 2020 Elsevier GmbH. All rights reserved.

1. Introduction
The rotator cuff consists of the supraspinatus, infraspinatus,
teres minor, and subscapularis (SM) muscles, the SM being the
strongest and largest. The SM originates on the subscapularis fossa,
which is part of the anterior surface of the scapula. Its distal attach-
ment is located on the humerus, usually on a lesser tuberosity
(Moore and Dalley, 1999; Bergman et al., 2017). We can distinguish
the tendinous and muscular parts of the SM, and both of them are
generally divided into smaller structures. The SM is supplied by
∗ Corresponding author.
E-mail addresses: nicol.zielinska@stud.umed.lodz.pl (N. Zielinska),
shane.tubbs@icloud.com (R.S. Tubbs), chilam@o2.pl (M. Podgórski),
piotr.karauda@umed.lodz.pl (P. Karauda), michal.polguj@umed.lodz.pl (M. Polguj),
lukasz.olewnik@umed.lodz.pl (Ł. Olewnik).
the subscapular artery, which is the largest branch of the axillary
artery; it divides into the circumflex scapular artery and the thora-
codorsal artery (Maruvada et al., 2020; Zielinska et al., 2020). The
upper subscapularis (USN) and lower subscapularis (LSN) nerves
innervate this muscle. Both the USN and LSN arise mainly from
the posterior cord (part of the brachial plexus) (Kasper et al., 2008;
Zielinska et al., 2020).
The SM is responsible for shoulder movements and stabiliza-
tion of the glenohumeral joint. Its contraction causes internal or
medial rotation of the humerus. Internal rotation is a feature that
distinguishes the SM from the other muscles of the rotator cuff.
Moreover, in certain positions, the SM can work as an adductor and
extensor (Miniato and Caire, 2018; Zielinska et al., 2020).
The SM varies morphologically in both origin and insertion. For
example, as mentioned above, the distal attachment is located on
the humerus, but a tendon or tendons can insert on to the lesser

https://doi.org/10.1016/j.aanat.2020.151615
0940-9602/© 2020 Elsevier GmbH. All rights reserved.
2 N. Zielinska, R.S. Tubbs, M. Podgórski et al. / Annals of Anatomy 233 (2021) 151615
tubercle, greater tubercle, bicipital groove or another part of that
bone (Miniato and Caire, 2018). As for its proximal attachment, this
muscle always originates on the anterior surface of the scapula, but
sometimes it fuses with another such as the latissimus dorsi or teres
major (Zielinska et al., 2020). We can also distinguish accessory sub-
scapularis muscles (ASM) (Gruber, 1859; Kameda, 1976; Zielinska
et al., 2020).
Rotator cuff syndrome (involving acute rotator cuff tendinitis or
advanced/chronic rotator cuff tendinopathy and degenerative con-
ditions) is a clinical pathology connected with the SM. The main
symptom is severe shoulder pain. This syndrome usually occurs
among athletes because of improper athletic technique, position
or condition. The histological architecture of the rotator cuff ten-
don fibers protects against such situations. Tendinous fibers are
composed of multiple crossed-over and interlocked fibrous lay-
ers. Moreover, these fibers blend with the glenohumeral capsule
and reinforce it (Arias-Martorell, 2019; Maruvada et al., 2020). If
an accessory SM (ASM) is present, this additional structure can
compress a neurovascular structure such as the posterior cord or
posterior humeral circumflex artery, and cause for example quadri-
lateral space syndrome, muscular weakness and atrophy, or wrist
drop (Zielinska et al., 2020).
A few studies have described morphological variations or
anomalies of the shoulder musculature related to the SM. Gener-
ally, they are connected with various types of ACM. The aim of our
present work is to classify the types of SM according to number of
tendons and their insertion on to the various parts of humerus. This
classification may be helpful during arthroscopy of the shoulder
joint, treating the subscapularis tendons tears, or nerves decom-
pression. Another goal is to compare the study results to determine
relationships with sex or body side. Prior to our study, we hypoth-
esized that the number of tendons of the SM is morphologically
constant.
2. Materials and methods
Sixty-four upper limbs (44 females, 20 males, 30 left and 34
right, fixed in 10% formalin) were examined. The mean age “at
death” of the cadavers was 75.6 years (range 48–95), and the
group comprised equal numbers of female and male adults (Cen-
tral European population). The cadavers were the property of
the Department of Anatomical Dissection and Donation, Medical
University of Lodz, Poland, following donation to the university
anatomy program. Any upper limbs with evidence of surgical inter-
vention in the dissected area were excluded and were not counted
among the limbs examined. All dissections of the shoulder and arm
areas were performed in accordance with a pre-established pro-
tocol (Olewnik et al., 2018a, 2018b, 2020; Podgórski et al., 2019;
Czerwonatis et al., 2020; Zielinska et al., 2020).
Dissection began with removal of the skin and superficial fas-
cia from the area of the shoulder and the medial side of the arm.
The next step included visualizing the lateral, medial and posterior
cords of the brachial plexus, and accurate visualization of both the
biceps brachii and coracobrachialis muscles. Next, the nerves, arter-
ies and veins running anteriorly from the SM were gently cleansed.
Then the fascia in which the SM was located was removed. The
muscle belly was thoroughly cleaned and the tendons or tendon
were cleaned and checked in the medial direction. The number
of tendons and their insertion(s) were checked. Following this, all
structures were thoroughly cleaned.
Upon dissection, the following morphological features were
assessed:
• The number of tendons of the SM.
• The type of insertion of each tendon of the SM.
• Morphometric measurements of the SM.
Potential problem:
• Due to the fact that the mean age of the cadavers was 75.6 years
old, aging degeneration of the subscapularis tendons may have
occurred.
When dissecting the SM:
• Special attention should be paid when removing the fascia,
because there could be an ASM (Zielinska et al., 2020).
• Particular attention should be paid to cleansing the head of the
long biceps brachii, as one can cut the SM tendons.
An electronic digital caliper was used for all measurements
(Mitutoyo Corporation, Kawasaki-shi, Kanagawa, Japan), and each
measurement was performed twice with an accuracy of up to
0.1 mm. The Bioethics Committee of the Medical University of Lodz
(resolution RNN/1337/20/KE) approved the study protocol. The
cadavers belonged to the Department of Anatomical Dissection and
Donation of the Medical University of Lodz, Poland.
2.1. Statistical analysis
Statistica 13 software (StatSoft Polska, Cracow, Poland) was used
and the following tests were applied:
• The chi2 test to compare nominal data: association between
types of muscle belly and tendon, and differences in tendon type
between sexes and body sides.
• The Shapiro–Wilk test to assess the normality of continuous data.
As the data were not normally distributed, nonparametric tests
were used:
◦ The Mann–Whitney test to compare morphological measure-
ments between genders and body sides;
◦ The Kruskal–Wallis test by ranks with a dedicated post hoc test
to compare measurements between subscapularis tendon types.
A p-value lower than 0.05 was considered significant, with Bon-
ferroni correction for multiple testing. The results are presented as
mean and standard deviation unless otherwise stated.
3. Results
The SM was found in all 64 specimens (44 females, 20 males, 30
left and 34 right). After meticulous dissection, the following types
were differentiated on the basis of numbers of tendons:
• Type I: a single band that inserts on to the crest of lesser tubercle
and goes down to the inferomedial part of the lesser tubercle.
This type was found in 28 upper limbs (43.7%) – Fig. 1.
• Type II: characterized by a double tendon (superior and inferior);
the superior band inserts on to the intertubercular groove and
the crest of the lesser tubercle, while the inferior band is and
inserts on to the medial border of the surgical neck just below
the lesser tubercle of the humerus. This type was observed in six
cases (9.4%) – Fig. 2.
• Type III: characterized by three tendons (superior, middle and
inferior). The superior band inserts on to the intertubercular
groove while the middle and inferior bands insert on to the crest
 N. Zielinska, R.S. Tubbs, M. Podgórski et al. / Annals of Anatomy 233 (2021) 151615
Fig. 1. Type I insertion of the subscapularis muscle. ST subscapularis tendon, SM
subscapularis muscle, lhBB long head of the biceps brachii, H humerus. The white
circle indicates the tendon of the subscapularis muscle.
Fig. 2. Type II insertion of the subscapularis muscle. ST subscapularis tendon, SM
subscapularis muscle, lhBB long head of the biceps brachii. The white circle indicates
the tendon of the subscapularis muscle. 1 first tendon, 2 second tendon.
of the lesser tubercle. This type was found in five upper limbs
(7.8%) – Fig. 3.
• Type IV: a multiband. This type was observed in 25 cases (39.1%)
and can be divided into five subtypes:
◦ Four tendons; the first tendon inserts on to the intertubercular
groove and anatomical neck, the second and third on to the lesser
tubercle, and the fourth on to the medial part of lesser tubercle.
This subtype was found in five cases – Fig. 4
a.
◦ Five tendons; the first, second, third, and fourth insert on to the
lesser tubercle, while the fifth inserts on to the medial border of
the surgical neck just below the lesser tubercle of the humerus.
This subtype was observed in 11 upper limbs – Fig. 4b.
◦ Six tendons; the first inserts on to the intertubercular groove and
the crest of the lesser tubercle, the second inserts on to the crest of
the lesser tubercle, the third, fourth, fifth insert on to the medial
part of the lesser tubercle, and the sixth inserts on to the medial
border of the surgical neck just below the lesser tubercle of the
humerus. It was observed in five cases – Fig. 4c.
◦ Seven tendons; the first and second tendons insert on to the
greater tubercle, the third and fourth on to the crest of the lesser
tubercle, and the fifth, sixth, and seventh on to the medial part of
the lesser tubercle. This subtype was found in two cases – Fig. 4d.
◦ Eight tendons; the first and second tendons insert on to the
greater tubercle, the third and fourth on to the crest of the lesser
tubercle, and the fifth, sixth, seventh and eighth on to the medial
3
Fig. 3. Type III insertion of the subscapularis muscle. ST subscapularis tendon, SM
subscapularis muscle, H humerus. The white circle indicates the tendon of the sub-
scapularis muscle.1 first tendon, 2 second tendon, 3 third tendon.
part of the lesser tubercle This subtype was observed in two cases
– Fig. 4e.
All of possible places of the insertions are presented on the prox-
imal part of the humerus – Fig. 5.
Comparisons of morphometric parameters according to sexes
and body side are presented in Table 1, and according to subscapu-
laris tendon type in Table 2. Only significantly different parameters
are presented; insignificant data are given in Supplementary Tables
1 and 2.
4. Discussion
This study is important in that it is the first to demonstrate such
high morphological variability in the number of tendons, so our ini-
tial hypothesis that the number of tendons is constant is disproved.
We distinguished four types (I-IV), the last of which, called multi-
band, was divided into five subtypes (a–e). These results prompted
us to look for a correlation with the phylogenesis of the SM.
Arias-Martorell et al. (2015, 2019); Arias-Martorell et al., 2015
considered that stabilization of the shoulder region was one of the
main factors to have changed during evolution. Ligaments, carti-
lage and muscles provide proper stabilization of the glenohumeral
joint. Glenohumeral joints are more stable among primates with
quadrupedal locomotion, while among more acrobatic primates,
for example hominoids, they show less stabilization (Rose, 1989;
Larson, 2013; Arias-Martorell et al., 2015). Increased mobility is
connected with less stabilization, and also with the evolution of
the upright body posture that led to bipedalism, a characteristic fea-
ture of humans (Keith, 1902; Gebo, 1996; Arias-Martorell, 2019).
The more mobile glenohumeral joint allows for combinations of
movements such as flexion, extension, abduction, adduction and
axial rotation (Arias-Martorell, 2019).
4 N. Zielinska, R.S. Tubbs, M. Podgórski et al. / Annals of Anatomy 233 (2021) 151615

Table 1
Comparison of morphometric measurements between the sexes and body sides.

Parameter Sex P value Body side P value

Females Males Right Left

Humerus LENGTH 244.90 (16.86) 284.87 (24.40) 0.0000 254.84 (23.69) 258.39 (26.02) 0.5698
Inferior angle – Lesser tubercle LENGTH 162.30 (12.93) 178.64 (16.42) 0.0024 164.32 (17.54) 167.19 (17.07) 0.5103
Superior angle – Lesser tubercle LENGTH 109.59 (11.24) 127.07 (12.70) 0.0002 114.20 (11.89) 116.58 (14.29) 0.4714
Superior angle – Greater tubercle LENGTH 122.92 (10.27) 137.49 (12.68) 0.0007 124.36 (23.19) 130.01 (14.02) 0.2505
Fifth tendon THICKNESS PA 1.18 (0.10) 2.50 (1.29) 0.0321 2.35 (1.60) 2.27 (1.74) 0.9137
Seventh tendon WIDTH PA 1.96 (0.05) 3.98 (0.00) 0.0191 3.07 (1.62) 2.99 (1.41) 0.9627

Table 2
Comparison of morphometric measurements between accessory bands.

Variable Mean number SD Mean SD Mean SD Mean SD P value

1* 1 2 2 3 3 >2 >3

Superior angle – Inferior 140.89* 18.26 144.22* 20.03 152.79 8.05 162.42* 11.68 0.0001
angle LENGTH
First tendon WIDTH PA 28.92* 5.05 9.89* 5.57 6.43* 1.23 5.54* 1.87 0.0000
First tendon THICKNESS PA 4.76* 0.96 2.40* 1.01 2.08* 1.08 2.32* 0.94 0.0000
First tendon WIDTH DA 26.45* 5.72 8.76* 4.94 7.69* 1.20 6.51* 2.52 0.0000
First tendon THICKNESS DA 4.92* 1.58 1.89* 0.99 1.76* 0.65 1.69* 0.79 0.0000
Second tendon WIDTH PA 16.89* 0.00 16.01† 4.21 7.52*, † 2.03 4.69*, † 1.33 0.0000
Third tendon WIDTH PA 10.71 1.84 3.94 1.27 0.0000
Third tendon THICKNESS PA 3.24 0.41 1.66 0.58 0.0000
Third tendon WIDTH DA 7.02 0.52 3.67 1.60 0.0001

According to Bonferroni correction p < 0.0016 is significant.

*
Significant differences between subgroups according to post-hoc analysis.
†
Significant differences between subgroups according to post-hoc analysis.

The important finding is the variable number of tendons
inserted on to the humerus in different places. When the tendon
or tendons are located on the proximal (medial) part of the lesser
tubercle, they take part in abduction and medial rotation. Those
inserted on to the distal part are involved in adduction and medial
rotation. These tendons, the lowest in location, take part in pulling
the humeral head downwards toward the axilla (Arias-Martorell
et al., 2015). These contrasts influence the versatility of the SM and
help in climbing and stabilization. Our research showed that there
are various points of insertion among humans, which could be an
adaptation for preforming different types of movements. In every
type (I–IV) we can divide the distal attachment into medial, distal
and inferior parts, but we wanted to create a general classification
for comparison. We deem the intertubercular groove and crest of
the lesser tubercle to be the “distal part” of insertion. When the
distal attachment is located on the surface of the lesser tubercle
it is the “proximal (medial) part”. When there is a distinct tendon
located inferiorly to another, we can say that there is also an infe-
rior point of insertion. We also noticed that this division is more
clearly visible among muscles with more tendons.
In type I, one tendon is responsible for performing every func-
tion of the SM, so we can only suppose that the movements are not
very precise.
It is important that in types II, III and subtype b of type IV there
was one tendon that we assigned to the medial and inferior parts of
distal attachment, so it performs the functions of medial rotation,
abduction and pulling the humeral head downwards. For example,
type II is characterized by a double tendon superior band inserting
on to the intertubercular groove and crest of the lesser tubercle,
which we called the “distal part”, while the inferior band inserted
on to the medial border of the surgical neck just below the lesser
tubercle of the humerus, so this tendon attached to the “proximal
(medial) and inferior” part.
Every subtype of type IV (excluding subtype b) has distinct ten-
dons responsible for different functions. For example, we found five
cases of SMs in which the distal attachment was divided into six
tendons. These inserted on to the intertubercular groove (a distal
part), the medial part of the lesser tubercle, and below the lesser
tubercle. This range of insertions allows for abduction, adduction,
medial rotation, and pulling the humeral head downwards toward
the axilla.
An important finding of our study is that there were cases (sub-
types d and e of Type IV) in which some tendons were inserted on
to the greater tubercle. Distal attachment positioned on the greater
tubercle structure is responsible for major compressive, shearing
or tensile stresses that connect with the glenohumeral joint (Arias-
Martorell et al., 2015). This could be an adaptive change.
During our research we observed that the tendons numbered
one to eight. We suppose that the number of tendons has increased
during evolution. The single, wide, undivided tendon (stronger
than a set of narrower tendons) occurred among animals with
quadrupedal locomotion. During evolution leading to the two-
legged gait, the number of tendons increased. This could have
influenced the possibility of performing more complicated move-
ments and protecting against tears of all tendinous parts during
repetitive movements.
Moreover, we observed that tendons were inserted on to the
greater tubercle only in cases with division of the tendons into
seven or eight parts. This confirms the view that the number of ten-
dons and their variable placement on the humerus are connected
with adaption and evolution.
We suppose that the increased number of tendons and mor-
phological variations of insertion are directly proportional to the
increased share of bipedal gait and precision of movements. How-
ever, there is one puzzle. If our society becomes more robotic and
the need for precise movements is reduced, will this result in mus-
cle regression? Maybe distinct tendons will fuse again and the SM
will present with a single, wide, undivided tendon.
Pathologies causing shoulder pain could result from subscapu-
laris tendinopathy, tendinitis or tears. We can divide tears of the SM
into partial-thickness and full-thickness, but most of them involve
only the upper third of the tendon. One result of the research by
Malavolta et al. (Malavolta et al., 2019) was that a full-thickness tear
of the SM was more strongly connected with a higher incidence of
injured and unstable biceps tendons than a partial-thickness tear
(Malavolta et al., 2019).
 N. Zielinska, R.S. Tubbs, M. Podgórski et al. / Annals of Anatomy 233 (2021) 151615
Fig. 4. Type IV insertion of the subscapularis muscle. (a) Type IVa insertion of the
subscapularis tendon. SM subscapularis muscle, D deltoid muscle. The white circle
indicates the tendon of the subscapularis muscle. 1 first tendon, 2 second tendon, 3
third tendon, 4 fourth tendon. (b) Type IVb insertion of the subscapularis tendon.
SM subscapularis muscle. The white circle indicates the tendon of the subscapularis
muscle. 1 first tendon, 2 second tendon, 3 third tendon, 4 fourth tendon, 5 fifth
tendon. (c) Type IVc insertion of the subscapularis tendon. SM subscapularis muscle.
The white circle indicates the tendon of the subscapularis muscle. 1 first tendon, 2
second tendon, 3 third tendon, 4 fourth tendon, 5 fifth tendon, 6 sixth tendon. (d)
Type IVd insertion of the subscapularis tendon. SM subscapularis muscle. GR greater
tubercle of the humerus. The white circle indicates the tendon of the subscapularis
muscle. 1 first tendon, 2 second tendon, 3 third tendon, 4 fourth tendon, 5 fifth
5
In turn, Lafosse et al. (2007) divided subscapularis tears into five
types, defined on the basis of the structures destroyed (tendons,
humeral head, coracoid process, and muscle fibers). Of course, as in
the foregoing, it is important whether the rupture covers the entire
tendinous mass or only part on it (Oliva et al., 2015). The similarity
between the classifications is that the tears can be partial or full-
thickness, and the part (upper, middle, inferior) is also significant
(Lafosse et al., 2007; Osti et al., 2013; Oliva et al., 2015; Miniato and
Caire, 2018).
A partial tear can be treated non-operatively with NSAIDs and
physical therapy for six to twelve weeks. Patients suitable for sur-
gical treatment are mainly athletes, young individuals, and those
with full-thickness tears (Miniato and Caire, 2018).
We looked for correlations associated with our research. As
mentioned above, we suppose that the presence of several distinct
tendons can preclude tearing of the entire tendinous part, mak-
ing non-operative treatment possible. Tears of all tendinous parts
of the SM cause the loss of functions performed by this muscle.
Among the muscles of rotator cuff, the SM is only one responsible
for internal rotation, so after such a rupture, this type of movement
is taken over by other muscles such as the teres major pectoralis
major (Decker et al., 2003; Lee et al., 2018). If there is more than one
wide undivided tendon, it is possible that only some of the tendons
will be torn and the others will work properly; so the movement
will not be lost, but it will be limited or painful.
We conclude that a single wide undivided tendon is stronger,
but more tendons provide a kind of protection, and generally the
effects are milder and the treatment is less invasive in the event of
tearing.
The statement that the SM shows wide morphological vari-
ability was confirmed by our research. But it is worth saying that
another anomaly can be also classified as volatility. The ASM is a
rare structure that can cause nerve compression. Zielinska et al.
(2020), Kameda (1976), Takafuji et al. (1991), Krause and Youdas
(2017) and Yoshinaga et al. (2008) described cases of ASM.
We did not find the ACM among our sixty-four cases, so the
prevalence was 0%. However, Kameda (Kameda, 1976) studied 190
human cadavers (380 upper limbs) and found 10 structures that
he called accessory subscapularis-teres-latissimus muscles, which
he divided into three types. The prevalence of that structure in his
study was 2.6% (Maruvada et al., 2020; Zielinska et al., 2020). The
other authors we mentioned Zielinska et al. (2020), Takafuji et al.
(1991), Krause and Youdas (2017) and Yoshinaga et al. (2008) found
only isolated cases of ASMs. However, there were significant differ-
ences among them, so the effects of such a structure are difficult to
establish. For example, it could compress the axillary nerve, lead-
ing to quadrilateral space syndrome manifested by weakness and
atrophy of the teres major and deltoid muscles.
In the case described by Zielinska et al. (2020), the location of
the ACM predisposed to compression of the posterior cord. Such
a pathology usually causes symptoms characteristic of compres-
sion of every nerve arising from the posterior cord below the point
of compression (axillary, lower subscapularis, and thoracodorsal
nerves). In such cases, we can also observe wrist drop syndrome,
which is a sign of pressure on the radial nerve (also a branch of
posterior cord).
The foregoing examples show that the ASM, which is really a
morphological variable, is clinically significant and can cause seri-
ous dysfunction of the upper limb.
tendon, 6 sixth tendon, 7 seventh tendon. (e) Type IVe insertion of the subscapularis
tendon. SM subscapularis muscle. The white circle indicates the tendon of the sub-
scapularis muscle. 1 first tendon, 2 second tendon, 3 third tendon, 4 fourth tendon,
5 fifth tendon, 6 sixth tendon, 7 seventh tendon, 8 eighth tendon.
6 N. Zielinska, R.S. Tubbs, M. Podgórski et al. / Annals of Anatomy 233 (2021) 151615
Fig. 5. All of possible places of the insertions are presented on the proximal part of
the humerus.
Summarizing this discussion, we can reject our initial hypoth-
esis. There are many variations in the number of tendons and the
placement of insertions. Moreover, there can be an ASM, which is
an additional structure. However, some questions arise. We know
about some effects caused by the ASM, but could this muscle have
some special function? Maybe it is a result of evolution (like the
increased number of tendons) that allows for adaptation to more
complicated movements. On the other hand, this muscle could be
a residue of one that occurred among non-human hominoids and
helped them to climb, and is now degenerating.
5. Conclusions
The SM presents high morphological variability. Our initial
hypothesis that the number of tendons is constant was disproved.
Also, there is some association between number of tendons and the
location of the distal attachment(s) and adaptive changes.
Ethical approval and consent to participate
The cadavers belonged to the Department of Anatomical Dissec-
tion and Donation, Medical University of Lodz.
Consent to publish
Not applicable.
Availability of data and materials
Please contact authors for data requests (Łukasz Olewnik PhD –
email address: lukasz.olewnik@umed.lodz.pl).
Competing interests
The authors declare that they have no competing interests.
Financial Disclosure: Friedrich Paulsen receives royalties from Else-
vier for the 24th Ed. of the anatomy atlas “Sobotta” and the ‘Sobotta
Textbook of Anatomy’ 2nd Ed.
Funding
The authors have no financial or personal relationship with any
third party whose interests could be positively or negatively influ-
enced by the article’s content. This research did not receive any
specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.
Authors’ contribution
Nicol Zielinska – Assistant – project development, data collection
and management, data analysis and manuscript writing; Michał
Podgórski (MD., PhD) – Associate Professor – statistical analysis,
data analysis and manuscript editing; R. Shane Tubbs (MD, PhD)
– Professor – data analysis and manuscript editing; Piotr Karauda
– Assistant – data analysis and manuscript editing; Michał Pol-
guj (MD., PhD) – Professor – data analysis, manuscript editing;
Łukasz Olewnik (D.P.T., PhD) – Associate Professor – data collec-
tion, data analysis and manuscript editing. All authors have read
and approved the manuscript.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgements
The authors wish to express their gratitude to all those who
donated their bodies to medical science.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in
the online version, at https://doi.org/10.1016/j.aanat.2020.151615.
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