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Impingement & rotator cuff Flashcards

Subacromial impingement oulet subacromial impingement calficic tendonitis rotator cuff disease rotator cuff arhtropathy proximal biceps tendonitis biceps subluxation

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1
Q

What is subcoracoid impingement?

A
  • 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
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2
Q

What inserts onto coracoid?

A
  • Muscle
    • coracobrachialis
    • pectoralis minor
    • short head of biceps
  • Ligaments
    • coracohumeral
    • coracoacromial
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3
Q

What are the presentatoion of subcoracoid impingement?

A
  • 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
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4
Q

What is seen on imaging of subcoracoid impingement?

A
  • xrays
    • decreased coracohumeral distance
  • CT
    • arms crossed on chest
    • a coracohumeral distance of <6mm = abnormal
  • MRI
    • decreased coracohumeral distance and RC pathology
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5
Q

What is the tx of subcoracoid impingement?

A

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
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6
Q

What is oulet (subacromial ) impingement?

A
  • 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
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7
Q

Describe the classification of oulet (subacromial ) impingement?

A
  • Bigliani classification of acromion morphology ( based on supraspinatus outlet view)
  • Type 1= Flat
  • Type 2= Curved
  • Type 3= Hooked
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8
Q

what is the presentation of oulet (subacromial ) impingement?

A
  • 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
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9
Q

What is seen in imaging of oulet (subacromial ) impingement?

A
  • 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
  • MRI
    • to identify degree of rotator cuff pathology
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10
Q

Describe the tx of oulet (subacromial ) impingement?

A

Non operative

  • Physio, oral anti-inflammatory, subacromial injections
    • agressive cuff strengthening & periscapular stabilizing exercises

Operative

  • Acrominoplasty/ subacromial decompression
    • failed consx tx for 4-6months
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11
Q

Describe the technique for acromoplasty?sunacromial decompression?

A
  • 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
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12
Q

What are the complications of oulet (subacromial ) impingement surgery?

A
  • 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
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13
Q

What is calcific tendonitis?

A
  • calcification and tendon degeneration at or near the rotator cuff interval
    • assoc with subacromial impingement
    • most pt 4th decade
    • diabetes
    • unknown aetiology
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14
Q

Describe the pathophysiology of calcific tendonitis?

A
  • Cell mediated calcification followed by phagoctyic resorption
    • pain free during calcification
    • painful during resorption
  • ​Phases
    • formative phase
    • resorptive phase
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15
Q

What is the classifcation of calcific tendonitis?

A
  • 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
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16
Q

What is the presentation of calcific tendonitis?

A
  • 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
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17
Q

What is seen in imaging of calcific tendonitis?

A
  • 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
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18
Q

What is the tx fof calcific tendonitis?

A

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
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19
Q

What are rotator cuff tears?

A
  • 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
20
Q

Describe the rotator interval?

A
  • Invovles the **capsule, SHGL, and coracohumeral ligament **that bridge the gap between supraspinatus and subscapularis
21
Q

What is the rotator crescent?

A
  • Thin crescent shaped sheet of rotatot cuff comprising distal portions of suprspinatus and infraspinatus
22
Q

What is the rotator cable?

A
  • 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
23
Q

What is the primary function of the rotator cuff?

A
  • 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)
24
Q

Describe the classification of cuff tears?

A
  • Anatomical
    • Supraspinatus, infrapsinatus & teres minor= make up majority of tears. assoc with subacromial impingement
      • pt >40ys
    • Subscapularis- young pt, subcoracoid impingement, acute avulsion
  • 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
25
Q

what is the presentation of rotator cuff tears?

A
  • 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
26
Q

What is seen on imaging of a rotator cuff tear?

A

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
27
Q

What is the tx of RC tears?

A

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
28
Q

Describe the types of repair for different RC tears?

A
  • 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
29
Q

what are tendon transfers indicated in RC repair?

A
  • 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
30
Q

What are the complications of RC tear surgery?

A
  • 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
31
Q

What is rotator cuff arthropathy?

A
  • 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
32
Q

what is the epidemiology of rotator cuff arthropathy?

A
  • F>M
  • 7th decade common
  • more common dominant shoulder
  • risk factors
    • RA
    • Cuff tear arthropathy
    • Cystalline- induced arthropathy
    • Haemorrhagic shoulder - hameophiliacs & elderly on anticoagulants
33
Q

Describe the pathophysiology of rotator cuff arthropathy?

A
  • 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
34
Q

Describe the classification of rotator cuff arthropathy?

A
  • 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
35
Q

What is the presentation of rotator cuff arthropathy?

A
  • 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
36
Q

how is rotator cuff arthropathy seen on imaging?

A
  • 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
37
Q

What is the tx of rotator cuff arthropathy?

A

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
38
Q

What is proximal biceps tendonitis associated with?

A
  • Subscapularis pathology
  • more consitent with ‘tendinosis’ than true inflammation
39
Q

describe the anatomy of biceps tendon?

A
  • 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
40
Q

What is the presentation of biceps tendonitis?

A
  • 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
41
Q

what is the tx of biceps tendonitis?

A

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
42
Q

What is biceps subluxation commonly associated with?

A
  • Subscapularis tear
  • coracohumeral tear
  • transverse humeral ligament tear
43
Q

What is the presentation of biceps subluxation?

A
  • Anterior shoulder pain and clicking
    • palpable click with arm abduction and external rotation as tendon subluxes out of groove
44
Q

What is seen on imaging of biceps subluxation?

A
  • USS
    • dynamic test of biceps instability
  • MRI
    • show increased T2 signal adn displacment out of bicipital groove
    • coincides with subscapularis tear
45
Q

What is the tx of biceps subluxation?

A

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

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