Innervation of the subscapularis: an anatomic study

Background: Successful healing of the subscapularis during anatomic total shoulder arthroplasty surgery is critical to optimize functional outcomes and avoid complications. The purpose of this study was to examine the upper and lower subscapularis nerve insertion in relation to the musculotendinous junction to estimate the risk of nerve injury. Our hypothesis was that arm position changes the risks to these nerves when exposing the anterior glenoid. Methods: Twenty cadaveric shoulders were dissected, and the subscapular nerves were identified from the posterior cord of the brachial plexus to the muscle insertion. The nerve length from the origin to the muscle insertion and the distance to the myotendinous junction were measured in various shoulder positions including neutral, external, and internal rotation. Results: The mean length of the upper subscapular nerve was 51.4 ± 12.8 mm; that of the lower subscapular nerve was 50.5 ± 14 mm. The mean distance from the insertion of the upper subscapular nerve to the myotendinous junction 53.0 ± 14.7 mm with external rotation, 38.5 ± 9.7 mm with neutral rotation, and 30.0 ± 9.2 mm with internal rotation. The mean distance from the lower subscapular nerve to the myotendinous junction was 44.5 ± 13.8 mm with external rotation, 31.9 ± 9.3 mm with neutral rotation, and 25.4 ± 8.8 mm with internal rotation. The internally rotated position placed these nerves closest to the glenohumeral joint. Conclusion: The upper and lower subscapular nerves insert in the muscle belly close to the myotendinous junction, putting them at risk of iatrogenic injury. Care must be taken to avoid damage with retractor placement in the anterior glenoid neck as these nerves are at risk of compression or torsional injury.