Progressive Understanding of Cord, Capsule, and Cable Functional Anatomy Can Optimize Rotator Cuff Outcomes: A 25-Year Perspective.

With open rotator cuff repair, the acknowledgement of capsular cable and tendinous cord structures was practically impossible. Open surgery ironically limited our perspective with a top-down bursal perspective of the tendons only, which appeared as a flat uniform strap of tissue. This perspective biased our understanding, terminology, and approach as arthroscopic rotator cuff repair became the norm. Arthroscopic single- to double-row concepts evolved, with a focus on footprint restoration and technical ease. Biomechanical testing further improved our understanding of anterior versus posterior anatomic differences, highlighting the obliquity of tendon fibers on the insertion, affecting our understanding of practical anatomy with each suture pass. Biomechanical studies of capsular reconstructions compelled the full acknowledgement of capsular cable functional anatomy. The cable has a shared anterior attachment on the footprint, interdigitating with the supraspinatus cord, posterior to the bicipital groove. The capsular cable occupies the articular margin; this margin defines cable (cord-like graft) and capsular (sheet-like graft) reconstructions. The partial articular-sided supraspinatus tendon avulsion lesion does not exist for "50%" tears (or less) and should be categorized as partial articular-sided supraspinatus capsular avulsions, or "PASCA" lesions. What perspectives are we missing now that we realize to fruition over the next 25 years, and beyond? LEVEL OF EVIDENCE: Level V, expert opinion.