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On the innovative genius of Andreas Vesalius

Brinkman, R.J.C.

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Citation for published version (APA):Brinkman, R. J. C. (2017). On the innovative genius of Andreas Vesalius.

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Download date: 15 Oct 2020

Chapter 5

Vesalius and the rotator cuffconcept

Chapter based on article

Andreas Vesalius’ five hundreth anniversary: Initiation of the ro-tator cuff concept

Brinkman R.J., Hage J.J.

Int Orthop. 2015;39(12):2511-3

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Chapter 5. Vesalius and the rotator cuff concept

IntroductionThe shoulder rotator cuff is defined as a group of four scapulohumeral muscles andtheir tendons that act to stabilize the glenohumeral joint. The tendons of these supra-spinatus, subscapularis, infraspinatus, and teres minor muscles blend with the gleno-humeral joint capsule as they insert on the greater and lesser humeral tubercle [1, 2].Besides stabilizing the shoulder by compressing the humeral head into the glenoidfossa, the four muscles endo- and exo-rotate the humerus relative to the scapula andprovide muscular balance that allows precise coordination of movement [2].

The earliest published description of a rotator cuff tear was by Alexander Monroin 1788, when he described a “hole with ragged edges in the capsular ligament of thehumerus” [2, 3], but so far, the first description of the rotator cuff per se remainedunidentified [4, 5]. We came across an unmistakable record of this functional entityin the second of seven books compounding Vesalius’ De Humani Corporis Fabrica LibriSeptum (De Fabrica). In this chapter, we present his record of this entity and discussthe shortcomings of his observations.

Materials and MethodsThe text of Vesalius’ Book II - The Ligaments and Muscles of De Fabrica and the entiretext of Heseler’s eyewitness report of the public dissection of three corpses by Vesal-ius in Bologna, Italy, in 1540, were searched for references to the four rotator cuffmuscles and their function. In contemporary Galenic fashion, Vesalius categorizedmuscles according to their function and numbered them, rather than named them.Therefore, we identified the muscles by their current name on the base of their de-scription provided by Vesalius. For this inventory we used the digital copy of thefirst print of De Fabrica (1543) [6] and its English translation provided by Richardsonand Carman [7], while we used Heseler’s original text and its English translation aspresented by Eriksson [8].

Vesalius’ description of the rotator cuffVesalius acknowledged that “the head of the humerus was made large and round and thesocket of the scapula neither very broad or very deep” and that, therefore, “Nature producedcertain processes of the scapula and various ligaments binding the bones together so that thisloose joint should not be left without adequate protection nor the humerus be dislocated bysome particular movement” [7]. Before describing the ligaments of the joint, however,he presented “most of the muscles that keep it together.” Among these muscles, Vesalius“showed the muscles which move the arm in a circle: they are placed round the head of the boneof the arm opposite to each other and they move the arm round in both directions” during theseventh of twenty-six demonstrations in Bologna [8]. In De Fabrica, Vesalius notedto “recognize three muscles that rotate the arm; they all take origin from the scapula andare implanted by means of broad tendons into the membranes containing the joint” [7]. Hedescribed these muscles as the fifth, sixth, and seventh “muscles moving the arm” (Fig-ures 5.1 and 5.2). His descriptions fit the currently recognized supraspinatus muscle,

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Chapter 5. Vesalius and the rotator cuff concept

subscapularis muscle, and conjoined infraspinatus and teres minor muscles, respec-tively.

Vesalius furthermore observed that “the tendons of the three muscles that rotate the armembrace the ligaments of the joint virtually in a complete circle” and that they all insert“into the ligament of the joint” [7]. This ligament, “the one that all joints have,” “sur-rounds the whole joint, being inserted into the root of the inner head of the humerus and alsoimplanted into the mass of the whole outer head and the neck of each head.” [7] This descrip-tion corresponds with the greater and lesser humeral tubercle as the area of insertionof the rotator cuff muscles.

Vesalius went on to describe the ligaments we now distinguish as the coracohumeralligament and two of the three parts of the glenohumeral ligaments. He observed thattheir “function is to keep the humerus from slipping downward or outward from the socketin the scapula” and that these “three strong ligaments .[..]. bind the humerus into the socketof the scapula, in addition to the common bond that surrounds all joints like a membraneand is sometimes thin and sometimes thick” [7]. By his acceptance of the insertion oftheir tendons into that common bond of the joint Vesalius implicitly appreciated thebinding structure of the rotator cuff tendons with its binding and stabilizing function.This way, he defined the rotator cuff concept avant la lettre.

FIGURE 5.1: Detail of Tabula XI of the famous muscle men in Vesalius’ Hu-mani Corporis Fabrica Libri Septem showing the supraspinatus muscle (G) andthe infraspinatus and teres minor muscles (I) with their insertion on the gleno-

humeral capsule (K)

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Chapter 5. Vesalius and the rotator cuff concept

DiscussionIn 1543, Andreas Vesalius (1515-1564) described the anatomical parts and biomechan-ical functions of what is currently known as the shoulder rotator cuff. His descriptionfully agreed with Antony F. DePalma’s remark that the glenohumeral “capsule (thesuperior, anterior and posterior portions of which blend with the tendinous insertion of therotator muscles), together with the coracohumeral ligament, provides much stability to thejoint” [9].

Vesalius’ failure to discriminate between the infraspinatus and teres minor musclesmay easily be explained by their often being inseparable from each other [2]. The teresminor muscle was not recognized separately until after the publication of Fallopius[10]. Likewise, Vesalius discriminated only “three strong ligaments that bind the humerusin its socket.” We agree with Richardson and Carman that Vesalius probably failed torecognize the middle part of the glenohumeral ligament as it may be absent in up to30 per cent of human shoulders [11].

FIGURE 5.2: Detail of Tabula VII in Vesalius’ Humani Corporis Fabrica LibriSeptem showing the subscapularis muscle (Γ) and its insertion on the gleno-

humeral capsule (K)

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Chapter 5. Vesalius and the rotator cuff concept

Vesalius’ failure to record that the rotator cuff muscles help provide the muscularbalance that allows precise coordination of movement may be explained by his lackof muscle function examination in vivo. In general, Vesalius’ descriptions of mus-cle functions were mechanically basic and lacking the concept of movements result-ing from simultaneous action of multiple muscles. As such, he ascribed the rotatingfunction of the arm exclusively to the rotator cuff muscles whereas the biceps brachii,pectoralis major, deltoid, lattisimus dorsi, and teres major muscles are currently con-sidered to help rotate the arm.

ConclusionWe conclude that Vesalius recognized the need of a structure, or structures, that pre-vent dislocation of the shoulder inherent to the morphology of the humeral caputand scapular socket. He recorded “three strong ligaments” and the “three muscles thatrotate the arm” of which the tendons completely “embrace the ligaments of the joint” assuch structures. In doing so, Vesalius was the first to record the rotator cuff concept.

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Chapter 5. Vesalius and the rotator cuff concept

References1. DePalma, A., Rotator cuff, in Surgery of the shoulder, A. DePalma, Editor. 1983, Lippin-

cott: Philadelph2. Barr, K., Rotator cuff disease. Phys Med Rehabil Clin N Am, 2004. 15: p. 475-91.3. Clement, N.D., et al., Management of degenerative rotator cuff tears: a review and treat-

ment strategy. Sports Med Arthrosc Rehabil Ther Technol, 2012. 4(1): p. 48.4. Williams, G., et al., Why does it fail? The pathophysiology of rotator cuff disease., in

Rotator cuff disorders: Basic science and clinical medicine., N. Maffulli and J. Furia,Editors. 2012, JP Medical: London, UK. p. 15-24.

5. Matsen, F., et al., Rotator cuff, in The shoulder, C. Rockwood and F. Matsen, Editors.2009, Saunders: Philadelphia. p. 771-890.

6. Vesalius, A., De Humani Corporis Fabrica Libri Septem, Basel, 1543. 1998, Palo Alto,CA: Octavo Corporation.

7. Richardson, W.F., et al., Andreas Vesalius On the fabric of the human body, Book II: Theligaments and muscles. 1999, San Francisco, CA: Norman Publishing.

8. Eriksson, R., Andreas Vesalius’ first public anatomy at Bologna 1540 - An eyewitness re-port by Baldasar Heseler, medicinae scolaris. 1959, Uppsala, Sweden: Almqvist WiksellsBoktryckeri. 345.

9. DePalma, A., Biomechanics of the shoulder, in Surgery of the shoulder, A. DePalma,Editor. 1983, Lippincott: Philadelphia. p. 65-85.

10. Saunders, J.B.d.M., et al., The anatomical drawings of Andreas Vesalius. 1982, New York,NY: Bonanza Books. 252.

11. De Maeseneer, M., et al., Normal MR imaging anatomy of the rotator cuff tendons,glenoid fossa, labrum, and ligaments of the shoulder. Radiol Clin N Am, 2006. 44(4):p. 479-487.

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