Clinical Anatomy 27:702706 (2014)

ORIGINAL COMMUNICATION

Tensile Properties of a Morphologically

Split Supraspinatus Tendon
TOMOYA MATSUHASHI,1 ALEXANDER W. HOOKE,1 KRISTIN D. ZHAO,1 AKIRA GOTO,1
JOHN W. SPERLING,2 SCOTT P. STEINMANN,2 AND KAI-NAN AN1*
1

Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, Minnesota

2
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

The supraspinatus tendon consists morphologically of two sub-regions, anterior

and posterior. The anterior sub-region is thick and tubular while the posterior is
thin and strap-like. The purpose of this study was to compare the structural
and mechanical properties of the anterior and posterior sub-regions of the
supraspinatus tendon. The supraspinatus tendons from seven human cadaveric
shoulders were morphologically divided into the anterior and posterior subregions. Length, width, and thickness were measured. A servo-hydraulic testing machine (MTS Systems Corporation, Minneapolis, MN) was used for tensile
testing. The maximal load at failure, modulus of elasticity and ultimate tendon
stress were calculated. Repeated measures were used for statistical comparisons. The mean anterior tendon cross-sectional area was 47.3 mm2 and the
posterior was 32.1 mm2. Failure occurred most often at the insertion site:
anterior (5/7) and posterior (6/7). All parameters of the anterior sub-region
were signicantly greater than those of the posterior sub-region. The moduli of
elasticity at the insertion site were 592.4 MPa in the anterior sub-region
and 217.7 MPa in the posterior (P 5 0.01). The ultimate failure loads were
779.2 N in the anterior sub-region and 335.6 N in the posterior (P 5 0.003).
The ultimate stresses were 22.1 MPa in the anterior sub-region and 11.6 MPa
in the posterior (P 5 0.008). We recognized that the anterior and posterior
sub-regions of the SSP tendon have signicantly different mechanical properties. In a future study, we need to evaluate how best to repair an SSP
tendon considering these region-specic properties. Clin. Anat. 27:702706,
2014. VC 2013 Wiley Periodicals, Inc.
Key words: shoulder; supraspinatus tendon; morphological split; sub-region;
tendon property

INTRODUCTION
Rotator cuff tears cause signicant pain and disability to the shoulder. The rotator cuff is composed
of four tendons that are important for coordinating
shoulder motion. The supraspinatus (SSP) tendon
contributes specically to abduction and stability of
the humeral head and is the most common site of
rotator cuff tears. Morphologically, the SSP tendon is
not a single fusiform tendon but consists of two subregions, anterior and posterior (Vahlensieck et al.,

C
V

2013 Wiley Periodicals, Inc.

*Correspondence to: Kai-Nan An; Biomechanics Laboratory,

Division of Orthopedic Research, Mayo Clinic, 200 First Street
S.W., Rochester, Minnesota 55905. E-mail: an.kainan@
mayo.edu
Received 20 May 2013; Revised 22 August 2013; Accepted 28
August 2013
Published online 8 November 2013 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.22322

Properties of Morphologically Split SSP Tendon

1994; Volk and Vangsness, 2001; Roh et al., 2000;
Kim et al., 2007;Gates et al., 2010). The anterior
sub-region is thick and tubular with a brous frame
running within the supraspinatus muscle. In contrast,
the posterior sub-region is thin and strap-like and has
no brous frame running within the SSP muscle.
The muscular parts of the SSP also have different
physiological cross-sectional areas (Vahlensieck et al.,
1994; Roh et al., 2000;). Several studies have
addressed the mechanical properties of the SSP tendon (Itoi et al., 1995; Nightingale et al., 2003; Huang
et al., 2005; Lake et al., 2009). In a previous report,
one group studied the mechanical properties of the
SSP tendon divided equally into three strips (anterior,
middle, and posterior; Itoi et al., 1995). They demonstrated that the anterior-most strip was stronger than
the others. A second group studied the mechanical
properties of a small part of the anterior and posterior
regions of the SSP tendon (Lake et al., 2009). In both
studies, the moduli of elasticity did not differ signicantly between the joint and bursal sides of the tendon
within the studied regions. In view of the differences
in region-specic mechanical properties and morphology identied in these previous studies, we suspect
that the SSP tendon behaves as two functionally independent tendons. If each anatomical or morphological
sub-region is considered as a single tendon, little is
known regarding its mechanical properties. Understanding these properties will help in the development
of new repair strategies and suture procedures.
In this study, we divided the SSP tendon into two
parts, the anterior and posterior sub-regions, on the
basis of anatomical and morphological structure. The
purpose of the study was to evaluate the morphological and mechanical properties of the anterior and posterior sub-regions of the SSP tendon. We hypothesized
that the mechanical properties of the two sub-regions
would differ.

703

Fig. 1. Sub-regional anatomy of supraspinatus anterior (ant) and posterior (post). (A) Intact. (B) Divided.
The anterior sub-region of the SSP tendon is thick and
tubular. The posterior sub-region is thin and strap-like.
[Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

1. Specimens were visually inspected to identify

differences between sub-regions;
2. Specimens were palpated to identify the border
between sub-regions (anterior is thick and
tubular);
3. Sub-regions were manually separated longitudinally using a surgical knife.
All lengths, widths, and thicknesses were measured
at three sites (proximal, middle, and distal) using a
precision caliper (0.1 mm accuracy). Cross-sectional
area was computed by assuming an oval crosssection. The three measurements were averaged to
represent the dimensions of the tendon strip.

Tendon Load to Failure

MATERIALS AND METHODS

Specimen Preparation
SSP tendons were obtained from seven freshly
frozen human cadaveric shoulders (mean age 68.3 6
15.0 years, three male and four female). The shoulders were stored at 220 C and were thawed overnight
at room temperature before testing began. Exclusion
criteria included current, or evidence of past, rotator
cuff tears, fractures, contracture, osteoarthritis, or
other disease of the shoulder detectable by direct
inspection or radiograms. The humeral shaft was cut
distal to the deltoid attachment. All soft tissues except
for the SSP were removed from the humerus. Capsular tissue and the infraspinatus tendon were removed
carefully. The SSP muscle was preserved at half its
length to be rigidly xed in a cryogenic clamp. The
humeral shaft was secured in an acrylic cylinder using
polymethylmethacrylate cement. The SSP tendon was
divided into the anterior and posterior sub-regions
(Fig. 1) as in a previous study (Gates et al., 2010). To
determine the border between the two regions, three
modalities were used:

A servo-hydraulic testing machine (MTS Systems

Corporation, Minneapolis, MN) was used to test the tendons, which were kept moist with a physiological saline
spray during preparation. The humeral shaft of each
specimen was mounted in a custom grip such that the
tendon was loaded at 45 degrees relative to the humeral axis (Fig. 2). The muscle belly of each sub-region
was gripped using a cryogenic clamp. Each tendon was
extended to failure at a rate of 1 mm/s. Tendon elongation during testing was measured with a DVRT transducer and measurements were collected at 20 Hz. Each
DVRT was set at the insertion site. The load at failure
was recorded. The modulus of elasticity was calculated
using the DVRT elongation data. Tendon stress was also
calculated as ultimate failure load divided by distal
cross-sectional area. Mode of failure was recorded by
direct observation of the specimen during testing.

Data Analysis
All data are represented as mean 6 standard deviation. Repeated measures were used for statistical
comparisons. The level of signicance was set at P <
0.05. Post hoc power calculations demonstrated that a

704

Matsuhashi et al.

Fig. 2. Test setup for the anterior sub-region of the

supraspinatus tendon. The tendon section was held proximal to the musculotendinous junction with a cryo-jaw
and tested with a material-testing machine. A differential
variable reluctance transducer was attached to the tendon. [Color gure can be viewed in the online issue, which
is available at wileyonlinelibrary.com.]

sample size of seven had greater than 80% power to

detect an effect size of 2 SDs, where effect size is the
mean change divided by the standard deviation of the
change.

RESULTS
The overall anatomical dimensions of the anterior
and posterior sub-regions of the SSP tendon are
detailed in Figure 3. At all measurement sites (distal,
middle, and proximal), the posterior sub-region was
signicantly thinner than the anterior (P < 0.05). The
anterior sub-region had a signicantly greater crosssectional area than the posterior at the distal site (P <
0.05).
All parameters of the anterior sub-region (the modulus of elasticity, the ultimate failure load, and the
ultimate stress) were statistically signicantly greater
than those of the posterior sub-region (Fig. 4). The

Fig. 4. Results of mechanical properties. [Color gure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

moduli of elasticity at the insertion site were 592.4 6

237.4 MPa in the anterior sub-region and 217.7 6
102.1 MPa in the posterior (P 5 0.01). The ultimate
failure loads were 779.2 6 218.9 N in the anterior
sub-region and 335.6 6 164.0 N in the posterior (P 5
0.003). The ultimate stresses were 22.1 6 5.4 MPa in
the anterior sub-region and 11.6 6 5.3 MPa in the
posterior (P 5 0.008).
Both the anterior (5/7) and posterior (6/7) subregions failed most frequently at the insertion site.
Osseous failure occurred in two cases during testing
of the anterior (2/7) and one case during testing of
the posterior (1/7) sub-region.

DISCUSSION

Fig. 3. Cross-sectional image and morphological

data (width, thicknesses, and cross-sectional areas) of
the supraspinatus sub-regions at three locations (distal/
middle/proximal). *The morphological data differed signicantly between the anterior and posterior sub-regions.
[Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

The purpose of this study was to determine the

morphological and mechanical properties of two subregions of the SSP tendon divided on the basis of anatomical and morphological structure. There have been
several studies of the mechanical properties of the
SSP tendon (Itoi et al., 1995; Nightingale et al., 2003;
Huang et al., 2005). However, to the best of our
knowledge, there have been few attempts to compare
the mechanical properties of the anterior and posterior sub-regions. In this study, we divided the SSP
tendon into two sub-regions on the basis of tendon
morphology. In a previous report, Itoi et al. (1995)
studied the mechanical properties of the SSP divided

Properties of Morphologically Split SSP Tendon

into three strips (anterior, middle, and posterior).
They demonstrated that the anterior strip had a
higher tensile strength than the others despite its
equal cross-sectional area. Recently, several studies
have revealed that the SSP tendon is not a single fusiform tendon like the Achilles tendon, but consists of
anterior and posterior sub-regions (Roh et al., 2000;
Volk and Vangsness, 2001; Reinold et al., 2004; Kim
et al., 2007; Gates et al., 2010). The results of this
study support this notion by identifying signicant differences between the regions in mechanical and morphological properties.
Regarding tensile properties, we did not measure
the modulus of elasticity over the whole sub-region
but only at the insertion area, and there were signicant differences between the anterior and posterior
sub-regions. The modulus of elasticity was signicantly higher in the anterior than the posterior subregion. This higher modulus of elasticity helps tendon
shape to be retained during shoulder motion. We suspect that supraspinatus tendon tears could be initiated
because of the posterior regions lower modulus of
elasticity, allowing it to deform at a different rate from
the anterior region. In a previous study, Kim et al.
(2010) demonstrated 1317 mm posterior to the
biceps tendon to be the most common tear location in
posterior cuff tendons. In our study, the location of
the border between the anterior and posterior subregions in the tendon insertion area was 13.4 6 0.9
mm (1215 mm). Therefore, we suggest that the initial location of an SSP tear is at the border between
the anterior and posterior sub-regions.
In this study, we demonstrated signicant differences in the ultimate failure load and the ultimate
stress between these two sub-regions: the posterior
sub-region of the SSP was signicantly weaker than
the anterior. These results suggest that the SSP is
more easily torn in the posterior than the anterior
region if both sub-regions undergo the same stress.
Regarding the supraspinatus muscle, the anterior SSP
tendon receives the loading of approximately 70% of
the muscle bers (Roh et al., 2000). In vivo, the
stress applied to the anterior sub-region of the SSP
tendon is approximately 230% that to the posterior.
This ratio between muscular load distributions to the
anterior and posterior regions of the SSP tendon is
close to the ratio of the ultimate failure stresses
between the two sub-regions. This matching of ratios
suggests that the morphological and mechanical differences between the sub-regions serve a functional
purpose.
There are several classications of rotator cuff
tears (DeOrio and Coeld, 1984; Harryman et al.,
1991; McLaughlin, 1994; Gerber et al., 2000). However, these classications had not been addressed by
tissue geometry until recently (Davidson and Burkhart, 2010). In the classication by Davidson and
Burkhart, a type 2 tear is a longitudinal tear in a U- or
L-shape. According to Kim et al., the initiation of rotator cuff tears often occurs 15 mm posterior to the
biceps (Kim et al., 2010). Given these considerations
and our results, we consider that the SSP tendon
tears most commonly at the intersection of the anterior and posterior sub-regions owing to the differences

705

in mechanical properties between the sub-regions,

causing a U-shaped tear.
The results of this study suggest consideration of
the suture procedures for repairing SSP tears. There
are many reports regarding such procedures (Tocci
et al., 2008; Bisson and Manohar, 2009; Grimberg
et al., 2010; Lorbach et al., 2010; Kaplan et al., 2011;
Jost et al., 2012). In addition, several studies have
reported the effect of the materials used for rotator
cuff repair (Beck et al., 2012; Omae et al., 2012; Friel
et al., 2013). In this study, we demonstrated that the
anterior sub-region is stronger than the posterior and
that the elastic properties differ between regions. We
consider it preferable to repair the anterior rather
than the posterior sub-region. We did not evaluate the
effect of the repair procedure in this study. Therefore,
we need to evaluate the interaction between repair
technique and SSP failure in a future study.

CONCLUSIONS
In this study, we showed signicant differences in
mechanical properties between the anterior and posterior sub-regions of the supraspinatus tendon. We
recognized that the SSP tendon comprises two functionally different tendons with different tensile properties. In a future study, it is necessary to evaluate how
best to repair an SSP tendon considering its regionspecic mechanical properties.

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