Objectives. Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue. Methods. A total of 20 fresh-frozen AT specimens were used. In ten specimens, ink was injected into the RB. The remaining ten specimens were split into two groups to be injected with radiological contrast medium into the RB either with or without ultrasonography guidance (USG). Results. In specimens injected with ink, diffusion outside the RB was observed with staining of the anterior portion of the AT. In eight contrast-injected specimens (five USG, three non-USG), a similar localised diffusion pattern was observed, with the contrast identified superiorly and anteriorly. In two contrast-injected specimens (non-USG), the diffusion pattern was more extensive. Conclusion. This study confirmed the existence of connections between the RB and the AT, especially rich in the anteroinferior portion of the tendon, which should be considered a weak zone for substances injected into the RB. We hypothesise that this part of the AT might be most vulnerable to rupture after corticosteroid injections. Cite this article: P. A. Pękala, B. M. Henry, J. R. Pękala, K. Piska, K. A. Tomaszewski. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone Joint Res 2017;6:446–451. DOI:10.1302/2046-3758.67.BJR-2016-0340.R1

We dissected 12 fresh-frozen leg specimens to identify the insertional footprint of each fascicle of the Achilles tendon on the calcaneum in relation to their corresponding muscles. A further ten embalmed specimens were examined to confirm an observation on the retrocalcaneal bursa. The superficial part of the insertion of the Achilles tendon is represented by fascicles from the medial head of the gastrocnemius muscle, which is inserted over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens this insertion was in continuity with the plantar fascia in the form of periosteum. The deep part of the insertion of the Achilles tendon is made of fascicles from the soleus tendon, which insert on the medial aspect of the middle facet of the calcaneal tuberosity, while the fascicles of the lateral head of the gastrocnemius tendon insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 15 of the 22 examined specimens. . This new observation and description of the insertional footprint of the Achilles tendon and the retrocalcaneal bursa may allow a better understanding of the function of each muscular part of the gastrosoleus complex. This may have clinical relevance in the treatment of Achilles tendinopathies. Cite this article: Bone Joint J 2014; 96-B:1344–8

Background. It was hypothesised that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression. Methods. Patients consented to randomisation to treatment with either preservation of the parietal layer of the ulnar bursa beneath the flexor retinaculum at the time of open carpal tunnel decompression (57 patients) or division of this gliding layer as part of a standard open carpal tunnel decompression (61 patients). Grip strength was measured, scar pain was rated and the validated Patient Evaluation Measure questionnaire was used to assess symptoms and disability pre-operatively and at eight to nine weeks following surgery in seventy-seven women and thirty-four men; the remaining seven patients were lost to follow-up. Results. There was no difference between the groups with respect to age, sex, hand dominance or side of surgery. Grip strength, scar pain and Patient Evaluation Measure score were not significantly different between the two groups, although there was a trend towards poorer subjective outcome as demonstrated by the questionnaire in the group in which the ulnar bursa within the carpal tunnel had been preserved. Preserving the ulnar bursa within the carpal tunnel did however result in a lower prevalence of suspected wound infection or inflammation (p=0.04). Conclusions. In this group of patients, preservation of the ulnar bursa around the median nerve during open carpal tunnel release produced no significant difference in grip strength or self-rated symptoms. We recommend incision of the ulnar bursa during open carpal tunnel decompression to allow complete visualisation of the median nerve and carpal tunnel contents

1. The previous literature in English on tuberculosis of the subdeltoid bursa is reviewed. 2. Two further cases are reported. 3. Emphasis is placed on the neglect of the condition in standard text-books and the need for bearing the diagnosis in mind. 4. Treatment by radical excision, a period of immobilisation and full supportive antibiotic therapy are recommended

Seven psoas bursae filled with purulent fluid and inspissated debris were revealed at revision operations for failed resurfacing hip arthroplasties, an incidence of 5.8% in such revisions. Histological and microbiological investigations demonstrated that the psoas bursa collections resulted from the tissue response to polyethylene wear debris. None was due to infection

Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is “too high” and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability. Cite this article: Bone Joint J 2023;105-B(8):839–842

Introduction. The results of repair and reconstruction of lesions found in the abductor muscles and tendons during posterior approach to primary total hip arthroplasty (THA) were reported in 2018. During the course of this series it became apparent that the extent of damage in the abductor tendons and muscles usually was obscured by the hypertrophic greater trochanteric bursa, especially the deep layer adherent to the greater trochanter and abductor muscles. The purpose of this study was to evaluate the surgeon's ability to see these lesions during standard posterior approach, and also to describe the dissection necessary to fully expose them. Patients and Methods. A total of 525 patients (525 hips) underwent primary THA through posterior approach between 2009 and 2013. Fifty-four patients had mild chronic damage to the tendon. Forty-one patients had severe damage with major avulsion of the gluteus medius and minimus muscles. Results. None of the hips with normal abductor muscle structure had a dense trochanteric bursa to obscure the abductor attachment to bone, but in 35 hips (85.3%) with significant abductor tendon avulsion, the lesions in the tendons were hidden from view until the greater trochanteric bursa was dissected. Splitting the deep layer of the trochanteric bursa in line with the fibers of the abductor muscles was necessary to reveal avulsion of the tendons from the edge of the greater trochanter. Only six hips (14.6%) had abductor tendon avulsion from the greater trochanter that could be seen without removing the trochanteric bursa tissue. Conclusion. The posterior approach offered excellent exposure of the abductor mechanism during primary THA, but the avulsion defects in the gluteus medius and minimus muscles remained obscured until the outer layer of the greater trochanteric bursa was completely removed and the deep fibrous layer was dissected adequately to expose the tendon attachment to bone. For any tables or figures, please contact the authors directly

Aims. The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG. Methods. In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)). Results. AG was best visualized with T1-weighted axial images providing sufficient cover in 25 cases confirmed by pathological findings.These results demonstrate AG as a discrete and substantial muscle of the anterior compartment of the thigh, deep to VI and useful in providing anterior soft tissue margin in distal femoral resection in bone tumours. Conclusion. Preoperative assessment of cover by AG may be useful in predicting cases where AG can be dissected, sparing the remaining quadriceps muscle, and therefore function. Cite this article: Bone Joint Open 2020;1-9:585–593

Gluteal Tendinopathy is a poorly understood condition that predominantly affects post-menopausal women. It causes lateral hip pain, worse when lying on the affected side or when walking up a hill or stairs. It has been labelled ˜Greater Trochanteric Pain Syndrome” a name that recognises the lack of understanding of the condition. Surgical reconstruction of the gluteal cuff is well established and has been undertaken numerous times over the last 16 years by the senior author (AJL). However, the quality of collagen in the tendons can be very poor and this leads to compromised results. We present the results of gluteal cuff reconstruction combined with augmentation using a bioinductive implant. 14 patients (11 female, 3 male; mean age 74.2 ± 6.3 years) with significant symptoms secondary to gluteal tendinopathy that had failed conservative treatment (ultrasound guided injection and structured physiotherapy) underwent surgical reconstruction by the senior author using an open approach. In all cases the iliotibial band was lengthened and the trochanteric bursa excised. The gluteal cuff was reattached using Healicoil anchors (3–5×4.75mm anchors; single anchors but double row repair) and then augmented using a Regeneten patch. Patients were mobilised fully weight bearing post-operatively but were asked to use crutches until they were no longer limping. All had structured post-surgery rehabilitation courtesy of trained physiotherapists. There were no post-operative complications and all patients reported an improvement in pain levels (Visual Analogue Scale 7.8 pre-op; 2.6 post-op) and functional levels (UCLA Activity Score 3.5 pre-op; 7.1 post-op) at 6 months post surgery. Surgery for gluteal tendinopathy produces good outcomes and the use of Regeneten as an augment for poor quality collagen is seemingly a safe, helpful addition. Further comparative studies would help clarify this

Complete or nearly complete disruption of the attachment of the gluteus is seen in 10–20% of cases at the time of THA. Special attention is needed to identify the lesion at the time of surgery because the avulsion often is visible only after a thickened hypertrophic trochanteric bursa is removed. From 1/1/09 to 12/31/13, 525 primary hip replacements were performed by a single surgeon. After all total hip components were implanted, the greater trochanteric bursa was removed, and the gluteus medius and minimus attachments to the greater trochanter were visualised and palpated. Ninety-five hips (95 patients) were found to have damage to the muscle attachments to bone. Fifty-four hips had mild damage consisting of splits in the tendon, but no frank avulsion of abductor tendon from their bone attachments. None of these cases had severe atrophy of the abductor muscles, but all had partial fatty infiltration. All hips with this mild lesion had repair of the tendons with #5 Ticron sutures to repair the tendon bundles together, and drill holes through bone to anchor the repair to the greater trochanter. Forty-one hips had severe damage with complete or nearly complete avulsion of the gluteus medius and minimus muscles from their attachments to the greater trochanter. Thirty-five of these hips had partial fatty infiltration of the abductor muscles, but all responded to electrical stimulation. The surface of the greater trochanter was denuded of soft tissue with a rongeur, the muscles were repaired with five-seven #5 Ticron mattress sutures passed through drill holes in the greater trochanter, and a gluteus maximus flap was transferred to the posterior third of the greater trochanter and sutured under the vastus lateralis. Six hips had complete detachment of the gluteus medius and minimus muscles, severe atrophy of the muscles, and poor response of the muscles to electrical stimulation. The gluteus medius and minimus muscles were sutured to the greater trochanter, and gluteus maximus flap was transferred as in the group with functioning gluteus medius and minimus muscles. Postoperatively, patients were instructed to protect the hip for 8 weeks, then abductor exercises were started. The normal hips all had negative Trendelenburg tests at 2 and 5 years postoperative with mild lateral hip pain reported by 11 patients at 2 years, and 12 patients at 5 years. In the group of 54 with mild abductor tendon damage that were treated with simple repair, positive Trendelenburg test was found in 5 hips at 2 years and in 8 hips at 5 years. Lateral hip pain was reported in 7 hips at 2 years, and in 22 at 5 years. In the group of 35 hips with severe avulsion but good muscle tissue, who underwent repair with gluteus maximus flap transfer, all had good abduction against gravity and negative Trendelenburg tests at 2 and 5 years postoperative, and none had lateral hip pain. Of the 6 hips with complete avulsion and poor muscle who underwent abductor muscle repair and gluteus maximus flap transfer, all had weak abduction against gravity, mildly positive Trendelenburg sign, and mild lateral hip pain at 2 and 5 years postoperative. Abductor avulsion is uncommon but not rare, and is detected during THA only by direct examination of the tendon and removal of the trochanteric bursa. Simple repair of mild abductor tendon damage did not prevent progressive abductor weakness in some hips; and the increase in number of patients with lateral hip pain from 2 to 5 years suggests progressive deterioration. Augmentation of the repair with a gluteus maximus flap appears to provide a stable reconstruction of the abductor muscles, and seemed to restore abductor function in the hips with functioning muscles

Introduction. Complete or nearly complete disruption of the gluteus attachment is seen in 10–20% of cases at the time of total hip arthroplasty (THA). Special attention is needed to identify the lesion at the time of surgery because the avulsion often is visible only after a thickened hypertrophic trochanteric bursa is removed. The purpose of this study was to evaluate a technique designed to restore abductor function by transferring the gluteus maximus to compensate for the deficient medius and minimus muscles. Methods. From Jan 1 2009 to Dec 31 2013, 525 primary THAs were performed by the author. After the components were implanted, the greater trochanteric bursa was removed, and the gluteus medius and minimus attachments to the greater trochanter were visualized and palpated. Ninety-five hips (95 patients) were found to have damaged muscle attachments to bone. Fifty-four hips had mild damage consisting of splits in the tendon, but no frank avulsion of abductor tendon from the bone attachment. None had severe atrophy of the abductor muscles, but all had partial fatty infiltration. All hips with this mild lesion had repair of the tendons with #5 Ticron sutures to repair the tendon bundles together, anchored to the greater trochanter. Forty-one hips had severe damage with complete or nearly complete avulsion of the gluteus medius and minimus muscles from their attachments to the greater trochanter. Thirty-five of these hips had partial fatty infiltration of the abductor muscles, but all responded to electrical stimulation. The surface of the greater trochanter was denuded of soft tissue with a rongeur, the muscles were repaired with five-seven #5 Ticron mattress sutures passed through drill holes in the greater trochanter, and a gluteus maximus flap was transferred to the posterior third of the greater trochanter and sutured under the vastus lateralis. Six hips had complete detachment of the gluteus medius and minimus muscles, severe atrophy of the muscles, and poor response of the muscles to electrical stimulation. The gluteus medius and minimus muscles were sutured to the greater trochanter, and the gluteus maximus flap was transferred. Postoperatively, patients were instructed to protect the hip for 8 weeks, then abductor exercises were started. Results. The normal hips all had negative Trendelenburg tests at 2 and 5 years postoperative with mild lateral hip pain reported by 11 patients at 2 years, and 12 patients at 5 years. In the 54 with mild abductor tendon damage treated with simple repair, positive Trendelenburg test was found in 5 hips at 2 years and in 8 hips at 5 years. Lateral hip pain was reported in 7 hips at 2 years, and in 22 at 5 years. In the 35 hips with severe avulsion but good muscle tissue, who had repair with gluteus maximus flap transfer, all had good abduction against gravity and negative Trendelenburg tests at 2 and 5 years postoperative, and none had lateral hip pain. Of the 6 hips with complete avulsion and poor muscle who underwent abductor muscle repair and gluteus maximus flap transfer, all had weak abduction against gravity, mildly positive Trendelenburg sign, and mild lateral hip pain at 2 and 5 years postoperative. Conclusions. Abductor avulsion is uncommon but not rare, and is detected during THA only by direct examination of the tendon and removal of the trochanteric bursa. Simple repair of mild abductor tendon damage did not prevent progressive abductor weakness in some hips; and the increase in number of patients with lateral hip pain from 2 to 5 years suggests progressive deterioration. Augmentation of the repair with a gluteus maximus flap appears to provide stable reconstruction of the abductor muscles, and seemed to restore function in the hips with functioning muscles

An operation for chronic prepatellar bursitis is described in which only the posterior wall of the bursa is excised, thus preserving, undamaged, healthy and normally sensitive skin. This procedure is easier and less traumatic than complete excision of the bursa and results in fewer complications. It is suggested that removal of tha anterior wall of the bursa results in unnecessary and harmful interference with the underlying skin. The operation described gives a good functional and structural result; leaving the anterior wall of the bursa does not predispose to recurrence

Introduction:. The insertion footprint of the different muscles tendon fascicles of the Achilles Tendon on the calcanium tuberosity has not been described before. Method:. Twelve fresh frozen leg specimens were dissected to identify the different Achilles Tendon fascicles insertion footprint on the calcaneum in relation to their corresponding muscles. Further ten embalmed cadaveric leg specimens were examined to confirm an observation on the retrocalcaneal bursa. Results:. The superficial part of the AT insertion is made by tendon fascicles from the medial head of the gastrocnemius muscle which insert over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens, this insertion had continuity with the plantar fascia in the form of periostium. The deep part of the TA insertion is made of fascicles from the soleus tendon which insert on the medial aspect of the middle facet of the calcaneal tuberosity while the lateral head of the gastrocnemius tendon fascicles insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 68% of examined legs. Conclusion:. This new observation and description of the Achilles insertion footprint and the retrocalcaneal bursa may allow a detailed understanding of the function of each muscular part of the gastrosoleous complex. This has potential significant clinical relevance in the treatment of Achilles pathologies around its insertion

The intermetatarsophalangeal bursa was investigated by dissection, radiography and injection. In the web spaces between the second and third and the third and fourth digits the bursa lies superior to the transverse metatarsal ligament but projects distally to it, closely applied to the neurovascular bundle. Tissue from the web spaces of patients with classical Morton's metatarsalgia often shows lymphocytic infiltration, with additional fibrinoid necrosis of the bursal wall. It is suggested that inflammatory changes in this bursa could account for the pathological and histological findings in this condition. The bursa in the most lateral web space does not extend beyond the ligament and is not in contact with the neurovascular bundle, which may explain the rarity of symptoms in this space

The aim of this study was to observe the macroscopic and microscopic appearance of the Coracoacromial ligament and Subacromial bursa during Subacromial decompression and correlate it with the outcome at 3 months. Twenty patients with Subacromial Impingement without Rotator Cuff tear and five patients with large/massive irreparable Rotator Cuff tears who underwent a Subacromial Decompression. Patients with other shoulder pathology were excluded. Patients completed an Oxford Shoulder Score pre-operatively and their injection history was noted. At operation the shape of the acromion was noted. The macroscopic appearance of the CA ligament and the Subacromial bursa was classified as normal, mild/moderate and severe. Biopsies of the Subacromial bursa and CA ligament were taken and were analysed using histological and contempory immunocytochemical techniques. A histological analysis was performed using Mayer’s Haemotoxylin and Eosin, Toluidine Blue and Congo Red. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), Mast Cell Tryptase, CD3 (T-cell), CD20 (B cell), CD 34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68 and D2–40 (Lymphatic Endothelial Marker). Post operatively the patients completed an Oxford Shoulder Score at 3 months. All the patients demonstrated an improvement in their Oxford Shoulder Score. The histological analysis demonstrated thickening of the synovial membrane and increased vascularity within the bursa and ligament. Increased numbers of inflammatory cells were present within the ligament and bursa of patients with impingement compared with massive rotator cuff tears. There was a relationship between outcome and the appearance of the bursa and ligament

Purpose of the study: The iliopsoas bursa lies immediately anteriorly to the hip joint capsule and in certain cases there exists a natural communication between a hip prosthesis and the iliopsoas bursa, enabling formation of an inguinal mass by distension of the bursa. Material and methods: We report six cases of a pseudo-tumoral mass which developed in the femoral scarpa triangle revealing a complication of total hip arthroplasty. These six patients, aged 66–79 years had their prosthesis for 11.5 years on average (range 4–20 years). Three had a history of acetabular dysplasia. All complained of pain. Five patients presented a palpable mass in the inguinal region. Two patients underwent emergency surgery, one for suspected strangulation of a crural herniation and the second for septic inguinal adenopathy. In two patients the clinical presentation was related to the local effect of the mass: lower limb edema with recurrent phlebitis due to venous and lymphatic compression, and femoralgia due to compression of the femoral nerve. The underlying prosthetic complications were: aseptic loosening (n=4), polyethylene wear (n=2), infection (n=1). All patients underwent revision surgery to change the prosthesis. The cystic formation was drained without resection. Symptoms resolved after replacement surgery in all patients. Discussion: Palpation of an inguinal mass with signs of local compression in a patient with a painful total hip arthroplasty is a sign of a prosthetic complication (infection, loosening, wear). The diagnostic work-up should include bacteriology and plain x-rays of the hip joint. Bone scintigraphy may be contributive. Arthrography can demonstrate presence of a communication. Computed tomography provides the best visualization of the mass and its relations with neighboring organs. A duplex-Doppler is needed in all cases to search for thromboembolic complications prior to surgery. We chose not to resect the cystic formation in our patients, preferring treatment of the intra-articular cause. The fact that the mass and local its effects resolved in all cases with no recurrence at last follow-up leads us to recommend this attitude for typical presentations

Insertional Achilles tendonitis is an inflammatory disorder affecting mainly active young patients. The etiology is multifactorial and include the combination of anatomical and biomechanical characteristics. One fifth of the tendon injuries in athletes are insertional complaints which includes bursitis and insertion tendinitis.The complex of the insertion of the Achilles tendon includes three main components of fibrocartilage sesamoid, periosteum and enthesis. A conservative regime is recommended as the first line of treatment. In case of failure a surgical decompression of the posterior margin of the calcaneum is indicated. Nine cadaveric legs were used for the experiment. The leg was mounted on an MTS machine and was axially loaded 360 N. The foot was attached to a plate which enabled dorsal and plantar flexion. The Achilles was sutured twice in an Ethibond No. 5 using the Krakow technique in order to anchor the tendon to an actuator. A thin pressure sensor plate (Teckscan) was inserted into the retrocalcaneal bursa to measure the force, pressure and contact area of the Achilles to the calcaneus in various positions of the foot. The conditions included 90 degrees of the foot, 15 and 30 degrees of dorsiflexion while the tension that was applied on the Achilles was 0, 200 N and 300 N. After resection of the posterior surface of the calcaneus in a 20 degrees inclination. The mean peak force, pressure and area did not change in Achilles tensioning while the foot was in 90 degrees and were close to zero. In 15 degrees of dorsiflexion there was increase in the mean peak force, pressure and area when the Achilles was tensed to 200 and 300 Newton. Larger increase in these parameters was achieved by further dorsiflexion of the foot to 30 degrees. After resection of the posterior margin of the calcaneus in an angle of 20 degrees the mean peak force, pressure and area dropped close to zero and remained almost unchanged during the various conditions of the experiment. Dorsiflexion and tension of the Achilles tendon increases the mean peak force, pressure and area in the Achilles retrocalcaneal bursa. These data may explain the mechanism for insertional Achilles tendinosis. Resection of the posterior surface of the calcaneus in 20 degrees efficiently decompresses the retrocalcaneal bursa in various angles of the foot and in various tensions of the Achilles

Purpose: Reports on the histological lesions observed in patients with degenerative disease of the shoulder have generally involved only a few cases. We conducted a prospective study in 662 shoulders operated on for impingement or rotator cuff tear. Material: The cases analysed included 402 subacromial impingements and 260 rotator cuff tears. Methods: Pathology specimens were obtained from the subacromiodeltoid bursa, the acromion, the acromio-coracoid ligament, the acromioclavicular joint, the borders of the rotator cuff tear, and the biceps tendon. There were 2573 pathology specimens. Results: The pathology examination revealed degenerative lesions (fibrosis, oedema, calcifications, fissuration, atrophy, delamination, fatty infiltration, necrosis, chondroid metaplasia, fragmentation), or inflammation. The subacromiodeltoid bursa presented fibrosis lesions in 3 out of 4 cases (74%). Signs of inflammation were found in 21% of the cases, oedema in 9%, and no lesion in 15%. The acromiocoracoid ligament showed oedema in 35%, fissuration in 35%, delamination in 25%, fragmentation in 11%, atrophy in 8%, fatty infiltration in 6%, necrosis in 4%, hypervascularisation in 2%, chondroid metaplasia in 1%, and no lesion in 27%. For the acromion, degenerative lesions were present in 88%, impingement in 83%, cuff tears in 92%. Lesions of the cuff in patients with tears showed degeneration in 86% (fissuration 46%, necrosis 35%, fragmentation 30%, vascular penetration with chondroid metaplasia 17%, delamination 10%, haemorrhagic remodelling 4%, adipose degeneration 3%, atrophy 2%, oedema 42%, calcifications 30%, fibrosis 26%, inflammation 7%, and no lesion 1 case). The biceps tendon showed degenerative lesions (90%), inflammation 2 cases, no lesion 3 cases. The acromioclavian joint (67 cases) showed degenerative lesions in all cases. Rotator cuff tears showed inflammatory lesions 30%, and subacromial impingement 16%. Discussion: The statistical analysis revealed a significant correlation between the presence of a normal subacromiodeltoid bursa and the type of pathology. There was a significant statistical relationship between the presence of inflammatory lesions and the type of pathology. There was no significant correlation with the pain score. There was a significant relationship between the presence of fibrosis of the acromiocoracoid ligament and the functional score at last follow-up. The presence of ligament fibrosis would be a sign of poor prognosis. This relationship was present irrespective of the pain, force and stability scores. Conclusion: The acromiocoracoid ligament was not found to be particularly involved suggesting that the idea of impingement should be revisited. For cases with a tear, the presence of a acromiocoracoid ligament with no histological lesion confirms that tears are not always associated with an impingement. Among cuff tear or impingement cases, there was a number of acromions with no bone lesion. Inflammatory lesions were not frequent. Unravelling the pathology of the degenerative shoulder is a complex process making interpretation and correlation with clinical signs and proposed therapeutic protocols difficult