Shoulder impingement Flashcards
What is Bigliani classification of acromion morphology (based on a supraspinatus outlet view)?
◦ classification types
Type I - flat
Type II - curved
Type III - hooked
What are the associated conditions with sub-acromial impingement?
- hook-shaped acromion
- os acromiale
- posterior capsular contracture
- scapular dyskinesia
- tuberosity fracture malunion
- instability
Physical exam of patient with sub-acromial impingement
positive Neer impingement sign: positive if passive forward flexion >90° causes pain
positive Neer impingement test: if a sub-acromial injection relieves pain associated with passive forward flexion >90°
positive Hawkins test: positive if internal rotation and passive forward flexion to 90° causes pain
Jobe test: pain with resisted pronation and forward flexion to 90° indicates supraspinatus pathology
Painful Arc Test: pain with arm abducted in scapular plane from 60° to 120°
Yocum Test
positive if pain reproduced with elbow elevation while ipsilateral hand placed on contralateral shoulder
sensitive but nonspecific
Internal Impingement test: positive if pain is elicited with abduction and external rotation of the shoulder
What view is useful for acromial morphology?
Supra-spinatus outlet view: useful in defining acromial morphology
What are the common radiographic findings associated with impingement
- proximal migration of the humerus as seen in rotator cuff tear arthropathy
- traction osteophytes
- calcification of the coraco-acromial ligament
- cystic changes within the greater tuberosity
- Type III-hooked acromion: associated with impingment
- os acromiale : best seen on axillary lateral
poor subjective outcomes have been observed after acromioplasty in patients with
- workers’ compensation claims
- anxiety and depression
What are the complications of acromioplasty?
Deltoid dysfunction
resulting from a failed deltoid repair following an open acromioplasty or an excessive acromionectomy during an arthroscopic procedure
secondary to direct excision of an os acromiale
Antero-superior escape
avoid acromioplasty and CA ligament release to preserve the coraco-acromial arch in patients with massive, irreparable rotator cuff tears
What is calcific tendonitis?
Calcification and tendon degeneration near the rotator cuff insertion
associated with subacromial impingement
Calcium hydroxyapatite in the tendon
Epidemiology of calcific tendonitis?
▪ typically affects patients aged 30 to 60
more common in women
What tendon is most frequently involved in calcific tendonitis?
Supra-spinatus tendon is most often involved
What are the risk factors of calcific tendonitis?
▪ diabetes
hypothyroidism
What are the three stages of calcification in calcific tendonitis?
▪ Pre-calcific
Fibro-cartilaginous metaplasia of the tendon
clinically this stage is pain-free
Calcificsubdivided into 3 phasesformative phase
cell-mediated calcific deposits
+/- pain
resting phase
lacks inflammation or vascular infiltration
+/- pain
resorptive phase
phagocytic resorption and vascular infiltration
clinically this phase is most painful
Post-calcific
Gartner and Heyer Classification of Calcific Tendinitis
Treatment of Calcific tendonitis algorithm
- Conservative: 60-70% resolution at 6 months
- Adjuvent: ECSWT in formative and resting phase
- US needle lavage vs barbotage if persistent symptoms in resorptive
- Arthroscopic debridement of RC with repair if needed + removal of calcium deposits
What structures constitute the biceps sling?
- fibers of the subscapularis
- supraspinatus
- coracohumeral
- superior glenohumeral ligaments
variables to consider when choosing revision RCR vs RTSA
▪ patient age (older age favors RTSA)
etiology of re-tear
quality of tissue / MRI findings
static proximal humeral migration (favors RTSA)
patient risk factors for RC repair failure
- patient age >65 years is a risk factor for non-healing of rotator cuff repair and subsequent failure
- large tear size (>5 cm)
- muscle atrophy
- diabetes
- smokers
- tear retraction medial to glenoid
- poor compliance with post-op protocol
no difference in clinical outcomes or healing with early vs. delayed motion protocols
- multiple tendons involved
- concomitant AC and/or biceps procedures performed at time of repair
Risk Factor for developing pneumothorax after scalene block?
Smokers with pulmonary disease have hyperinflated lungs and an elevated pleural dome, which increases the risk of injury.
Indications for rotator Cuff repair?
Acute full-thickness tears
Bursal-sided tears >3 mm (>25%) in depth
release remaining tendon and debride degenerative tissue
Partial articular-side tears>50% can be treated with tear completion and repair
Partial articular-side tears <50% treated with debridement alone
PASTA with >7mm of exposed bony footprint between the articular surface and intact tendon represents significant (>50%) cuff tear (must have at least 25% healthy bursal sided tissue)
younger patients with acute, traumatic tears : in situ repair leave bursal sided tissue intact
older patients with degenerative tears: tendon release, debridement of degenerative tissue and repair
Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted
A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.
Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.
What is the most likely mechanism of failure of rotator cuff repair?
Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
What is the highest risk factor for nonhealing of a surgically repaired rotator cuff?
Patient age older than 65 is the highest risk factor for nonhealing of the surgically repaired rotator cuff.
