Impingement & rotator cuff

Question 1

What is subcoracoid impingement?

Answer 1

• 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

Question 2

What inserts onto coracoid?

Answer 2

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

Question 3

What are the presentatoion of subcoracoid impingement?

Answer 3

• pain in ant shoulder worsened by various degrees of flexion, adduction, rotation
• tenderness over anterior coracoid
• position of max pain is 120-130^o arm flexion/internal rotation

Question 4

What is seen on imaging of subcoracoid impingement?

Answer 4

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

Question 5

What is the tx of subcoracoid impingement?

Answer 5

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

Question 6

What is oulet (subacromial ) impingement?

Answer 6

• 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

Question 7

Describe the classification of oulet (subacromial ) impingement?

Answer 7

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

Question 8

what is the presentation of oulet (subacromial ) impingement?

Answer 8

• 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 >90^o= pain
  • hawkins test
    
    • positive if int rotation and passive forward flexion to 90^o = pain

Question 9

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

Answer 9

• Xray
  
  • true ap shoulder
    
    • acromiohumeral interval n= 7-14 mm
  • 30^o 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

Question 10

Describe the tx of oulet (subacromial ) impingement?

Answer 10

Non operative

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

Operative

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

Question 11

Describe the technique for acromoplasty?sunacromial decompression?

Answer 11

• 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

Question 12

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

Answer 12

• 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

Question 13

What is calcific tendonitis?

Answer 13

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

Question 14

Describe the pathophysiology of calcific tendonitis?

Answer 14

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

Question 15

What is the classifcation of calcific tendonitis?

Answer 15

• 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

Question 16

What is the presentation of calcific tendonitis?

Answer 16

• Catching
• crepitus
• intermittent pain similar to impingement
• mechanical block
• acute episodes of pain

o/E

• decreased rom
• painful rom from 70-110^o
• subacromial impingement signs

Question 17

What is seen in imaging of calcific tendonitis?

Answer 17

• 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

Question 18

What is the tx fof calcific tendonitis?

Answer 18

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

Question 19

What are rotator cuff tears?

Answer 19

• 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

Question 20

Describe the rotator interval?

Answer 20

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

Question 21

What is the rotator crescent?

Answer 21

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

Question 22

What is the rotator cable?

Answer 22

• 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

Question 23

What is the primary function of the rotator cuff?

Answer 23

• 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)

Question 24

Describe the classification of cuff tears?

Answer 24

• 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

Question 25

what is the presentation of rotator cuff tears?

Answer 25

• Pain in overhead activity use
• night pain

O/E

• Jobe test- arms in sacpular plane, resisted elevation= weakness supraspinatus
• weakness external rotation, flexion 90^o horn blower test= teres minor
• weakness external rotation= infrapsinatus
• belly press= subscapularis

Question 26

What is seen on imaging of a rotator cuff tear?

Answer 26

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

Question 27

What is the tx of RC tears?

Answer 27

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

Question 28

Describe the types of repair for different RC tears?

Answer 28

• 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

Question 29

what are tendon transfers indicated in RC repair?

Answer 29

• 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 45^o abduction and 30^o ER

Question 30

What are the complications of RC tear surgery?

Answer 30

• 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

Question 31

What is rotator cuff arthropathy?

Answer 31

• 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

Question 32

what is the epidemiology of rotator cuff arthropathy?

Answer 32

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

Question 33

Describe the pathophysiology of rotator cuff arthropathy?

Answer 33

• 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

Question 34

Describe the classification of rotator cuff arthropathy?

Answer 34

• 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

Question 35

What is the presentation of rotator cuff arthropathy?

Answer 35

• 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

Question 36

how is rotator cuff arthropathy seen on imaging?

Answer 36

• 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

Question 37

What is the tx of rotator cuff arthropathy?

Answer 37

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

Question 38

What is proximal biceps tendonitis associated with?

Answer 38

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

Question 39

describe the anatomy of biceps tendon?

Answer 39

• 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

Question 40

What is the presentation of biceps tendonitis?

Answer 40

• 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

Question 41

what is the tx of biceps tendonitis?

Answer 41

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

Question 42

What is biceps subluxation commonly associated with?

Answer 42

• Subscapularis tear
• coracohumeral tear
• transverse humeral ligament tear

Question 43

What is the presentation of biceps subluxation?

Answer 43

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

Question 44

What is seen on imaging of biceps subluxation?

Answer 44

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

Question 45

What is the tx of biceps subluxation?

Answer 45

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