Impingement & rotator cuff Flashcards
Subacromial impingement oulet subacromial impingement calficic tendonitis rotator cuff disease rotator cuff arhtropathy proximal biceps tendonitis biceps subluxation
What is subcoracoid impingement?
- Subscapularis impingement is impingement between the coracoid and lesser tuberosity
- position of mx impingement is
- adduction, flexion, internal rotation
- risk factors
- pt w long excessively lateral coracoid process
- prior surgery -> posterior capsular tightening & loss of internal rotation
- assoc conditions
- combined subscapularis, supraspinatus, infraspinatus tears
What inserts onto coracoid?
- Muscle
- coracobrachialis
- pectoralis minor
- short head of biceps
- Ligaments
- coracohumeral
- coracoacromial
What are the presentatoion of subcoracoid impingement?
- pain in ant shoulder worsened by various degrees of flexion, adduction, rotation
- tenderness over anterior coracoid
- position of max pain is 120-130o arm flexion/internal rotation
What is seen on imaging of subcoracoid impingement?
- xrays
- decreased coracohumeral distance
- CT
- arms crossed on chest
- a coracohumeral distance of <6mm = abnormal
- MRI
- decreased coracohumeral distance and RC pathology

What is the tx of subcoracoid impingement?
Non operative
-
Rest, ice, activity modification, nsaids, corticosteriod injection
- 1st line of tx
- local steriod injection can be diagnostic
- physio focis on strething
Operative
-
Arthroscopic coracoplasty + subscapularis repair
- resect posterolat coracoid to create 7mm clearance betwen coracoid and subscapularis
- is significant subscapularis tendon tear then repair
-
Open coracoplasty
- resect lateral aspect of coracoid process and reattach the conjoint tendon to the remaining coracoid

What is oulet (subacromial ) impingement?
- 1st stage of rotator cuff disease which is a continuum progressing in partial to full-thickness to massive rotatot cuff tears & finally rotator cuff arthropathy
- effects millions of individuals
- associated conditions
- hook shaped acromium
- os acromiale
- posterior capsular contracture
- scapular dyskinesia
Describe the classification of oulet (subacromial ) impingement?
- Bigliani classification of acromion morphology ( based on supraspinatus outlet view)
- Type 1= Flat
- Type 2= Curved
- Type 3= Hooked

what is the presentation of oulet (subacromial ) impingement?
- Insidious onset of pain exacerabated by overhead activities
-
Night pain
- poor indication of successful non op mx
O/E
- Impingement tests
-
neer positive
- positive if passive forward flexion >90o= pain
-
hawkins test
- positive if int rotation and passive forward flexion to 90o = pain
-
neer positive
What is seen in imaging of oulet (subacromial ) impingement?
- Xray
-
true ap shoulder
- acromiohumeral interval n= 7-14 mm
-
30o caudal tilt
- identify subacromial spurring
-
supraspinatus outlet view
- identify acromial morphology
- Os acromiale
- prox migration of humeral head as seen in RC tear arthropathy
- traction osteophytes
- type 3 hook acromium
-
true ap shoulder
- MRI
- to identify degree of rotator cuff pathology

Describe the tx of oulet (subacromial ) impingement?
Non operative
- Physio, oral anti-inflammatory, subacromial injections
- agressive cuff strengthening & periscapular stabilizing exercises
Operative
-
Acrominoplasty/ subacromial decompression
- failed consx tx for 4-6months
Describe the technique for acromoplasty?sunacromial decompression?
-
Modified Neer acromioplasty
- open or arthroscopic
-
anterior acromionectomy preformed 1st
- anterior deltoid origin determines extent of acrominectomy when preformed arthroscopically and remain intact
-
anterioinferior acromioplasty to smooth of the undersurface of the acromion follow as the 2nd step
- deltoid is repaired if open proceedure
What are the complications of oulet (subacromial ) impingement surgery?
-
Deltoid dysfunction
- failed deltoid repair after open subacromial decompression or ecessive acromioplasty
- secondary to direct excision of os acromiale
-
Anteriosuperior escape
- avoid acromioplasty & CA ligament release to preserve the coracoacromial arch in pts with massive , irreparable RC tears
What is calcific tendonitis?
-
calcification and tendon degeneration at or near the rotator cuff interval
- assoc with subacromial impingement
- most pt 4th decade
- diabetes
- unknown aetiology
Describe the pathophysiology of calcific tendonitis?
-
Cell mediated calcification followed by phagoctyic resorption
- pain free during calcification
- painful during resorption
- Phases
- formative phase
- resorptive phase
What is the classifcation of calcific tendonitis?
- radiographic
- type 1= fluffy, fleecy appearance w poorly defined periphery. acute typically during resorptive phase
- type 2= discrete homogenous deposits, well defined periphery. subacute and chronic typically during formative phase

What is the presentation of calcific tendonitis?
- Catching
- crepitus
- intermittent pain similar to impingement
- mechanical block
- acute episodes of pain
o/E
- decreased rom
- painful rom from 70-110o
- subacromial impingement signs
What is seen in imaging of calcific tendonitis?
- Xray
- often calcium deposits in supraspinatus ( most common), infraspinatus, teres minor, suscapularis
- neutral view shows supraspinatus calcifications
- internal rotation shows infraspinatus, teres minor
- external rotation shows subscapularis
- Uss
- useful to determine extent of calcification
- utilise for needle decompression/injection
- MRI/CT
- limited

What is the tx fof calcific tendonitis?
Non operative
- NSAIDS
-
Physio & strengthening
- goal to maintain joint mobility & shoulder rom
-
Corticosteriod injection
- indicated for acute flare up
- combined with needle aspiration
-
Needle aspiration
- during resorptive phase
- USS for guidance + subaromial injection
-
Extracorporeal shock wave therapy
- mixed result- use formative phase
Operative
-
Arthroscopic vs mini open decompression of calcium deposit
- refractory of adls
What are rotator cuff tears?
- Are tears that may involve tendon or more than one tendon, assoc with AC joint pathology
- continum of disease
- subacromial impingement
- subcoracoid impingment
- calcific tendonitis
- Mechanism
-
chronic degenerative tears
- older pts
- suprapsinatus, teres minor, infraspinatus,
-
Acute avulsion tears
- acute subscapularis tear post fall
- young pts with shoulder dislocation
-
Iatrogenic injuries
- due to failure of surgical repair
-
chronic degenerative tears
Describe the rotator interval?
- Invovles the **capsule, SHGL, and coracohumeral ligament **that bridge the gap between supraspinatus and subscapularis
What is the rotator crescent?
- Thin crescent shaped sheet of rotatot cuff comprising distal portions of suprspinatus and infraspinatus
What is the rotator cable?
- Thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons
What is the primary function of the rotator cuff?
- Dynamic stabiliser of the shoulder by balancing foce couples
- coronal plane
- infraspinatus, teres minor, subscapularis( inferior cuff) balance forces by deltoid
- transverse plane
- Ant cuff (superspinatus) balances forced form post cuff ( teres minor, infraspinatus)
Describe the classification of cuff tears?
- Anatomical
- Supraspinatus, infrapsinatus & teres minor= make up majority of tears. assoc with subacromial impingement
- pt >40ys
- Subscapularis- young pt, subcoracoid impingement, acute avulsion
- Supraspinatus, infrapsinatus & teres minor= make up majority of tears. assoc with subacromial impingement
-
By size
- Small 0- 1cm
- medium 1-3cm
- Large 3-5cm
- Massive >5cm and involves more than 2 tendons
-
Cuff atrophy ( goutallier)
- 0 Normal
- 1 Some fatty streaks
- 2 More muscle than fat
- 3 equal fat & muscle
- 4 more fat than muscle
- Cuff tear shape
- Crescent- mobile , fix withouf tension
- U shaped- repaired side:side
- L shaped-margin convergence repair
- massive and immobile- difficult ro repair may need interval slide
what is the presentation of rotator cuff tears?
- Pain in overhead activity use
- night pain
O/E
- Jobe test- arms in sacpular plane, resisted elevation= weakness supraspinatus
- weakness external rotation, flexion 90o horn blower test= teres minor
- weakness external rotation= infrapsinatus
- belly press= subscapularis
What is seen on imaging of a rotator cuff tear?
xray
ap may show
- calcific tendonitis
- calcification in coracohumeral ligament
- proximal migration of humeral
outlet view
- hooked acromium
MRI arthrogram
- leakage of dye from gh joint to subacromial joint = rc tears
MRI
- in asymptomatic pt >60 yrs 55% will have RCT
- size, shape and present of fatty atrophy ( on sagittal)
- medial biceps subluxation= subscapularis tears
USS
- adv non invasive, low cost, allows dynamic testing, readilt available most centres
- dis: user dependent, limited to view other intra-articular pathology
- similar sensivity, specificity and overall accuracy dx rc tears cf mri
What is the tx of RC tears?
need to consider age of pt, type/ size of tear, mechanism of tear
-
Non operative
- Physio, nsaids, & subacromial injections
- first line, partial tearas often response to physio- aggressive Rc and scapular stabiliser strengthening
Operative
-
Arthroscopic or open RC repair +/- subacromial decompression (if impingement)
- bursal sided tears >3mm in depth
- articular sided superspinatus tears w 7mm of exposed bone between articular surface & intact tendon
- post op - key is the healing of supraspinatus to GTuberosity 8-12 wks
- limited passive rom- no active
-
tendon transfers
- massive cuff tears
- latissmus dorsi transfer- best for irrepairable postsuperior tears with intactsubscapularis
Describe the types of repair for different RC tears?
-
Margin convergence
- shown to decrease strain on lateral margin in U shpaed tears
-
Anterior interval slide
- release _supraspinatus from the RC interva_l ( incising coracohumeral ligament) this increase mobility of supraspinatus and allows it ot be fixed to lateral footprint
-
Posterior interval slide
- release supraspinatus from infraspinatus. further increases mobility of supraspinatus and allows it to be fixed to lateral footprint. Then repair suprapinatus to infraspinatus w margin convergence
-
Subscapularis repair
- technically challenging, outcomes better if repaired
-
Biceps tendon repair
- tenodesis to lateral humerus provides greater return of function than tenotomy
-
Foot print restoration
- hyposthesized a larger footprint will improve healing & mechanical strength of RC
- double row suture technique ( mattress medial row, simple lateral ) shown to create more anatomical repair of footprint
- addition of a trough in GTuberosity to allow tendon to cancellous bone interface as opposed to tendon - cortical bone has NOT shown increased repair strength in animals

what are tendon transfers indicated in RC repair?
- Massive or irreparable rc tears
-
Pectoralis Major transfer
- Chronic Subscapularis tears
- transfer under conjoint tendon leads to more closely resembles the vector forces of the native subscapularis
-
Latissmus Dorsi transfer
- indicated in large supraspinatus tears
- best candiate is young labourer
- attach to cuff muscles, subscapularis & GT
- brace immobilisation for 6 weeks, in 45o abduction and 30o ER
What are the complications of RC tear surgery?
-
Recurrence
- pt ages >65 years risk factor for non healing RC repair
-
Deltoid dettachent
- w open approach
- AC pain
- axillary neve injury
-
suprascapular nerve injury
- agressive mobilisation of supraspinatus during repair
-
infection
- <1%
- usually common skin flora- staph aureus
- propionoibacterium acnes most commonly implicated organism in delayed/indolent cases
What is rotator cuff arthropathy?
- shoulder arthritis in setting of rotator cuff dysfunction is defined as a combination of
- massive chronic rotator cuff tear
- glenohumeral cartilage destruction
- subchondral osteoporosis
- humeral head collapse
what is the epidemiology of rotator cuff arthropathy?
- F>M
- 7th decade common
- more common dominant shoulder
- risk factors
- RA
- Cuff tear arthropathy
- Cystalline- induced arthropathy
- Haemorrhagic shoulder - hameophiliacs & elderly on anticoagulants
Describe the pathophysiology of rotator cuff arthropathy?
-
mechanical factors
- loss of concavity due to compression effects
- decreased rom and shoulder function
- humeral head migration
- instability w possible recurrent dislocations
-
Nutritional factors
- loss of water tight joint space
- decreased joint fluid
- cartilage atrophy ( decreases in water and glycoaminoglycan content) & subchondral collapse ( disuse osteoporosis)
-
Crystalline induced atrthopathy
- degradation proteins in the synovium destroy the rotator cuff and cartilage
- end stage disease leads to calcium phosphate crystal deposits
Describe the classification of rotator cuff arthropathy?
- Seebauer
- type 1a- centred and stable- see pic
- minimal superior migration
- femoralisation of femoral head and acetabularisation of coracoacromial arch
- Type 1B- Centred and medialised
- minimal superior migration
- medial erosion of glenoid
- Type 2A- Decentered, limited stability
- sup translation
- Tyoe 2B- decentred, unstable
- anteriosuperior escape, non existent dynamic stabilisation

What is the presentation of rotator cuff arthropathy?
- Pain
- subjective weakness
O/E
- Supinatus/infraspinatus atrophy
- promience of humeral head anteriorly- anteriosup escape
- subcutaneous effusion
- ROM
- crepitus
- pseudoparalysis- inability to abduct shoulder
- external rotation lag- inability to maintain passively ext rotation w elbow at 90o= massive infraspinatus tear
- Hornblower sign- inability to externally rotate a shoulder placed in 90 flexionat elbow and 90 degrees of abduction= teres minor dysfucntio
how is rotator cuff arthropathy seen on imaging?
- LAck of osteophytes
- osteopenia
- snowcap sign due to subchondral sclerosis
- anterosuperior escape
- femoralisarion of humeral head- ap
- acromial acetabulisation - ap
Mri
- show irreparable RC w massive fatty infiltration and severe retraction

What is the tx of rotator cuff arthropathy?
Non operatively
- activity modification, subacromial injections physio
- 1st line
- scapular and RC strengthening programme
Operative
-
arthroscopic debridement
- contraversial
- unpredicted outcomes
-
Hemiarthroplasty
- if deltoid preserved
- coracoacromial arch intact- if not intact -> subcutanoeus humeral escape
- will relieve pain but not improve rom
-
Reverse shoulder prothesis
- contraversial
- pseudoparalytic cuff tear arthropathy
- elderly >70 with low activity
- anterosuperior escape
- requires functioning deltoid and good bone stock
- outcomes
- potential to improve function & pain
- risk of inferior scapular notching w poor technique
-
Resection arthroplasty
- salvage only- chronic osteomyleitis
- Total shoulder arhroplasty- contraindicted
- Glenoid resurfacing- CI- shear stress leads to failure
-
Pectoralis major transfer
- for internal rotation/ subscapularis def
- rotate portion or whole pectoralis transferred nr subscapularis tendon insertion on lesser tuberosity
-
Latissmus dorsi transfer
- pseudoparalysis with external rotation
- combine with reverse shoudler
What is proximal biceps tendonitis associated with?
- Subscapularis pathology
- more consitent with ‘tendinosis’ than true inflammation
describe the anatomy of biceps tendon?
- Orginates
- short head- tip of coracoid process of scapula
- long head- off supraglenoid tubercle of scapula & labrum
- Insertion-
- tuberosity of radius and fascia of forearm via bicipital aponeurosis
- action- supinates forearm and when supine flexes forearm
- stabilises within bicipital groove by transverse humeral ligament
- innervation- musculocutaneous nerve C5/6
- arterial supply- mucular branch of brachial artery

What is the presentation of biceps tendonitis?
- Anterior shoulder pain
- Tenderness w palapation over biceps groove
- worse with internal rotation 10 degrees
- speed test- apin in bicipital groove when ot attempts to forward elevate shoulder
- Yergason test- pain in biceps groove when pt atempts to actively supinate against resistance w elbow flexed to 90o and forearm pronated
-
Popeye deformity
- rutpture
what is the tx of biceps tendonitis?
Non ops
- nsaids, physio, steriod injections
- first line
Operative
-
Arthroscopic tenodesis vs tenotomy
- surgical release reserved for refractory cases
- tenodesis may decrease subjective arm cramping and improve cosmesis
What is biceps subluxation commonly associated with?
- Subscapularis tear
- coracohumeral tear
- transverse humeral ligament tear
What is the presentation of biceps subluxation?
- Anterior shoulder pain and clicking
- palpable click with arm abduction and external rotation as tendon subluxes out of groove
What is seen on imaging of biceps subluxation?
- USS
- dynamic test of biceps instability
- MRI
- show increased T2 signal adn displacment out of bicipital groove
- coincides with subscapularis tear
What is the tx of biceps subluxation?
Non operative
-
NSAIDS, Physio, Steriod injection
- steriod into proximity not tendon
Operative
-
Arthroscopic vs open surgical tendon repair , groove deepening +/- release/tenodesis
- for refractory cases
- can test instability intraoperatively
- reapir vs tenodesis/release