Shoulder impingement

Question 1

What is Bigliani classification of acromion morphology (based on a supraspinatus outlet view)?

Answer 1

◦ classification types

Type I - flat

Type II - curved

Type III - hooked

Question 2

What are the associated conditions with sub-acromial impingement?

Answer 2

• hook-shaped acromion
• os acromiale
• posterior capsular contracture
• scapular dyskinesia
• tuberosity fracture malunion
• instability

Question 3

Physical exam of patient with sub-acromial impingement

Answer 3

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

Question 4

What view is useful for acromial morphology?

Answer 4

Supra-spinatus outlet view: useful in defining acromial morphology

Question 5

What are the common radiographic findings associated with impingement

Answer 5

• 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

Question 6

poor subjective outcomes have been observed after acromioplasty in patients with

Answer 6

• workers’ compensation claims
• anxiety and depression

Question 7

What are the complications of acromioplasty?

Answer 7

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

Question 8

What is calcific tendonitis?

Answer 8

Calcification and tendon degeneration near the rotator cuff insertion

associated with subacromial impingement

Calcium hydroxyapatite in the tendon

Question 9

Epidemiology of calcific tendonitis?

Answer 9

▪ typically affects patients aged 30 to 60

more common in women

Question 10

What tendon is most frequently involved in calcific tendonitis?

Answer 10

Supra-spinatus tendon is most often involved

Question 11

What are the risk factors of calcific tendonitis?

Answer 11

▪ diabetes

hypothyroidism

Question 12

What are the three stages of calcification in calcific tendonitis?

Answer 12

▪ 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

Question 13

Gartner and Heyer Classification of Calcific Tendinitis

Answer 13

Question 14

Treatment of Calcific tendonitis algorithm

Answer 14

1. Conservative: 60-70% resolution at 6 months
2. Adjuvent: ECSWT in formative and resting phase
3. US needle lavage vs barbotage if persistent symptoms in resorptive
4. Arthroscopic debridement of RC with repair if needed + removal of calcium deposits

Question 15

What structures constitute the biceps sling?

Answer 15

• fibers of the subscapularis
• supraspinatus
• coracohumeral
• superior glenohumeral ligaments

Question 16

variables to consider when choosing revision RCR vs RTSA

Answer 16

▪ patient age (older age favors RTSA)

etiology of re-tear

quality of tissue / MRI findings

static proximal humeral migration (favors RTSA)

Question 17

patient risk factors for RC repair failure

Answer 17

• 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

Question 18

Risk Factor for developing pneumothorax after scalene block?

Answer 18

Smokers with pulmonary disease have hyperinflated lungs and an elevated pleural dome, which increases the risk of injury.

Question 19

Indications for rotator Cuff repair?

Answer 19

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

Question 20

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

Answer 20

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.

Question 21

What is the most likely mechanism of failure of rotator cuff repair?

Answer 21

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.

Question 22

What is the highest risk factor for nonhealing of a surgically repaired rotator cuff?

Answer 22

Patient age older than 65 is the highest risk factor for nonhealing of the surgically repaired rotator cuff.