Sports - Upper Extremity (Complete) Flashcards
What is the rotator interval of the shoulder?
[DeLee & Drez’s, 2015]
- Triangular space formed by:
- Supraspinatus
- Subscapularis
- Glenoid
- Contents
- Coracohumeral ligament
- Superior glenohumeral ligament
- Joint capsule
What is the critical shoulder angle (CSA)?
[JBJS REVIEWS 2018;6(8):e1]
- CSA is the angle between the plane of the glenoid fossa (the line from the inferior edge of the glenoid to the superior edge of the glenoid) and a line drawn from the inferior edge of the glenoid to the lateral edge of the acromion on a true anteroposterior (Grashey) shoulder radiograph
* Accounts for contributions from both glenoid inclination and lateral acromial length - Normal = 30-35°
- <30 = increased risk for GH arthritis
- Decreased CSA (<30°) increases compressive forces across the glenohumeral joint
- >35 = increased risk for rotator cuff tear
- Increased CSA (>35°) is thought to alter deltoid vectors, which results in increased superior shear forces on the rotator cuff muscles
What is the epidemiology of rotator cuff tears?
[Clin Sports Med 31 (2012) 589–604]
- Full thickness tear is present in 25% of patients in their 60s and 50% of patients in their 80s
- 50% of patients >65 with a symptomatic full thickness tear will have an asymptomatic full thickness tear on the contralateral side
- 50% of asymptomatic tears develop symptoms in 2-3 years
- 50% of symptomatic tears increase in size
Where is the ‘bare area’ located in the proximal humerus?
[J Am Acad Orthop Surg 2014;22:521-534]
- It is the triangular area between the humeral head articular surface and the medial margin of the posterior cuff insertion
- The superior apex of the triangle is where the supraspinatus and infraspinatus fibres converge
Where does the rotator cuff re-tear or failure of healing occur?
[JAAOS 2017;25:e261-e271]
Tendon-bone interface
Although adequate pain relief and patient satisfaction can be achieved in the absence of tendon healing following RTC repair, what are the benefits of tendon healing?
[JAAOS 2017;25:e261-e271]
- Higher strength
- Increased function
- Higher outcome scores
What risk factors are associated with lower tendon-bone RTC healing following repair?
[JAAOS 2017;25:e261-e271]
- Increased age
- Osteoporosis (independent of age)
- Chronic rotator cuff tear
- Muscle atrophy
- Fatty degeneration
- Larger size
- Tobacco use
- Low initial fixation strength
- Larger gap
- High tension repair
What is the DeOrio and Cofield classification for RTC tear size?
[J Am Acad Orthop Surg 2014;22:521-534]
Measurement based on “length of the greatest diameter of the tear” (ie. AP or ML)
- Small = 0-1cm
- Medium = 1-3cm
- Large = 3-5cm
- Massive = >5cm
What are the classification systems used to describe RTC tears?
[J Am Acad Orthop Surg 2014;22:521-534]
- Patte classification – D**egree of retraction
- Stage 1 = lateral margin of cuff close to footprint area
- Stage 2 = lateral margin of cuff at level of humeral head
- Stage 3 = lateral margin of cuff at level of glenoid
2. Goutallier Staging System – Fatty infiltration - Stage 0 - normal muscle
- Stage 1 - some fatty streaks
- Stage 2 - amount of muscle is greater than fatty streaks (<50% fat)
- Stage 3 - amount of muscle is equal to fatty streaks (50% fat)
- Stage 4 - amount of muscle is less than fatty streaks (>50% fat)
3. Thomazeau classification – Muscle atrophy - Stage 1 - normal or slight atrophy
- Occupation ratio = 0.6-1
- Stage 2 - moderate atrophy
- Occupation ratio = 0.4-0.6
- Stage 3 - severe atrophy
- Occupation ratio = <0.4
- Ellman classification – Degree of partial thickness tear
- Grade 1 - tear <3mm in depth
- Grade 2 - tear 3-6mm in depth
- Does not exceed 50% of tendon thickness
- Grade 3 - tear >6mm in depth
- Involves > 50% of tendon thickness
- Snyder classification – Tear type
- Involves > 50% of tendon thickness
- Type A - Articular sided partial tear
- Type B - Bursal sided partial tear
- Type C - Complete tear
What is the classification of rotator cuff tear shape proposed by Davidson and Burkhart; Describe repair of each shape?
[J Am Acad Orthop Surg 2014;22:521-534]
- Crescent-shaped
- Most common
- Excellent medial-lateral mobility allowing tension-free repair back to GT
- U-shape and V-shape
- Apex of tear extends farther medial toward glenoid
- Medial-lateral mobility is limited, anterior-posterior mobility is adequate
- Repair by “margin convergence”
- Suture free margins together converting tear into a smaller crescent tear
- L-shape and reverse L-shape
- Have both a transverse and longitudinal component
- L-shape tears propagate along the interval between the supraspinatus and infraspinatus
- Reverse L-shape tears propagate through the rotator interval
- One edge is more mobile than the other
- Repair by technique similar to “margin convergence”
4. Massive, contracted, immobile - L-shaped or U-shaped
- Immobile in both AP and ML direction
- Interval slide technique to enhance mobility
- Anterior interval slide
- Incise the superior margin of the rotator interval and the CHL at the corocoid base
- Posterior interval slide
- Incise the interval between supraspinatus and infraspinatus towards the scapular spine
- ***Suprascapular nerve at risk
- Anterior interval slide
- Management options [JSES 2015; 24, 1493-1505]
- Nonoperative management
- Arthroscopic debridement with biceps tenotomy or tenodesis
- Complete repair
- Partial repair
- Patch augmentation
- Superior capsular reconstruction
- Tendon transfer
- Reverse total shoulder arthroplasty
What angle should a suture anchor be inserted to increase an anchors resistance to pullout?
45 degrees (the Deadman Angle)
What is the definition of a ‘massive’ RTC tear?
[International Orthopaedics (2015) 39:2403–2414]
Various definitions exist:
- >5cm tear in either the A-P or M-L direction (Cofield)
- Complete tears of at least 2 RTC tendons (Gerber)
- Coronal length and sagittal width ≥2cm on MRI (Donaldson)
What is the classification of massive rotator cuffs based on location?
[J Am Acad Orthop Surg 2013;21:492-501]
- Posterosuperior
* Involving the supraspinatus, infraspinatus, and possibly teres minor - Anterosuperior
* Involving the subscapularis and supraspinatus
What factors should be considered when determining if a RTC tear is repairable or irreparable?
[J Am Acad Orthop Surg 2013;21:492-501]
- Size
- Retraction
- Fatty infiltration and atrophy
* Goutallier stage 3-4 = generally considered irreparable - Acromiohumeral distance
* <7mm = generally considered irreparable - Static vs. dynamic superior migration
* Static migration = generally considered irreparable
What tendon transfers can be considered for irreparable RTC tears?
[J Am Acad Orthop Surg 2013;21:492-501]
- Latissimus dorsi for irreparable posterosuperior tears
- Pectoralis major for irreparable anterosuperior tears
What is the classification system for fatty infiltration on CT/MRI?
[J Am Acad Orthop Surg 2013;21:492-501]
Goutallier Staging System
- Stage 0 - normal muscle
- Stage 1 - some fatty streaks
- Stage 2 - amount of muscle is greater than fatty streaks (<50% fat)
- Stage 3 - amount of muscle is equal to fatty streaks (50% fat)
- Stage 4 - amount of muscle is less than fatty streaks (>50% fat)
***Note – fatty infiltration is not reversible
What factors contribute to retear rates after repair of massive RTC tears?
[J Shoulder Elbow Surg (2015) 24, 1493-1505]
- Increased fatty infiltration
- Decreased acromiohumeral space
- Smoking
- Size of the rotator cuff tear
- Increased tension on the repair
What are the indications for surgery for rotator cuff tears?
[Sports Med Arthrosc Rev 2018;26:129–133]
- Persistent pain despite nonoperative treatment (4-6 months)
- Options:
- Decompression with arthroscopic acromioplasty +/- debridement
- Indication
- Impingement
- Low grade partial articular sided tear
- Indication
- Rotator cuff repair
- Indication
- Symptomatic full-thickness tears
- Acute bursal-sided partial thickness tears that involve >25% of tendon thickness
- Partial articular-sided tears involving >50% of tendon thickness
- Indication
What patient factor predispose to developing calcific tendinitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
- Female
- Age (30-60)
- Right shoulder > left shoulder
- Endocrine disorders
- Hypothyroidism
- Diabetes
- ?estrogen/menstrual disorders
- Tendon overuse
Where are the calcific deposits most commonly found in calcific tendonitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
- 5-2 cm from the insertion in the hypovascular zone of the superior cuff
* Most common tendon involved is the supraspinatus
Describe the pathogenesis of calcific tendinitis of the RTC and the three main stages described by Uhthoff and Loehr
[J Am Acad Orthop Surg 2014;22:707-717]
- Calcific tendinitis of the RTC has a different pathogenesis than insertional RTC calcific tendinitis and calcific tendinitis at other sites (eg. Achilles, patellar tendon) which are degenerative
- Calcific tendinitis of the RTC is an active, cell-mediated process (rather than degenerative)
- Three main stages
- Precalcific stage
- Fibrocartilage metaplasia of the tendon in hypovascular zone
- Calcific stage
- Formative phase
- Calcific deposits form
- Resting phase
- Dormant
- Resorptive phase
- Calcific deposits replaced by fibroblasts and granulation tissue
- Most painful
- Postcalcific stage
- Formative phase
What are the two commonly used radiographic classification systems for calcific tendonitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
- Gartner and Heyer
- Type I
- Well circumscribed, dense
- Type II
- Soft contour/dense or sharp/transparent
- Type III
- Translucent and cloudy appearance without clear circumscription
- Mole et al (French Society of Arthroscopy)
- Type A
- Dense, homogenous, sharp contours
- Type B
- Dense, segmented, sharp contours
- Type C
- Heterogeneous, soft contours
- Type D
- Dystrophic calcifications at the insertion of the rotator cuff tendons
What are the radiographic features of cuff tear arthropathy?
[AAOS comprehensive review 2, 2014]
- Superior humeral head migration
* Decreased acromiohumeral space - Acetabularization of the acromion
- Femoralization of the humeral head
* Rounding of the GT - Eccentric superior glenoid wear
- Osteopenia
- Snowcap sign
* Subarticular sclerosis - Absence of the typical peripheral osteophytes
* Lack inferior and medial humeral head osteophytes
Describe ‘pseudoparalysis’ of the shoulder
[J Bone Joint Surg Am. 2012;94:e34(1-11)]
- Defined as inability to actively elevate the arm in the presence of free PROM and in the absence of a neurologic lesion
- Occurs as a result of superior migration of the humeral head due to unopposed deltoid contraction in the presence of a rotator cuff tear (loss of the inferior directed force)
What is the management of rotator cuff arthropathy?
[J Shoulder Elbow Surg (2009) 18, 484-494]
- First line = nonoperative
- Physical therapy
- Injections
- Activity modification
- Second line = surgery
- Shoulder arthrodesis
- Indication:
- Significant anterior deltoid deficiency
- Multiple previous surgeries
- Indication:
- Arthroscopic debridement
- Indication:
- Multiple medical co-morbidities
- High risk patient
- Indication:
- Hemiarthroplasty (typically CTA prosthesis)
- Indication:
- Intact deltoid
- Intact CA ligament
- FF >90
- ER >30
- Indication:
- rTSA
- Indication
- Intact deltoid
- Incompetent CA ligament
- Elderly, low demand
- Indication
What is the blood supply to the glenoid labrum?
- Suprascapular artery
- Circumflex scapular artery
- Posterior humeral circumflex artery
What are the 3 most common anatomic variants of the superior labrum?
[DeLee & Drez’s, 2015][AJSM 2012;41(2):444]
- Buford complex
* Combination of an absent anterosuperior labrum with an associated “cordlike” middle glenohumeral ligament that attaches to the superior labrum near the base of the biceps tendon - Sublabral recess
* Potential space located under the biceps anchor and the anterosuperior portion of the labrum - Sublabral foramen
* Groove between the normal anterosuperior labrum and the anterior cartilaginous border of the glenoid rim
What is the classification system for SLAP tears?
[AJSM 2013;41(2):444]
- Snyder classification – 4 types
- Type I
- Fraying and degeneration of the free edge of the superior labrum with an intact biceps anchor
- Type II
- Detachment of the superior labrum with detachment of the biceps anchor from the supraglenoid tubercle
- Morgan subclassification
- Anterior
- Predominant anterior detachment of the superior labrum–biceps tendon anchor
- Posterior
- Predominant posterior detachment of the superior labrum–biceps tendon anchor
- Anterior and posterior
- Combined anterior and posterior detachment of the superior labrum–biceps tendon anchor
- Anterior
- Morgan subclassification
- Detachment of the superior labrum with detachment of the biceps anchor from the supraglenoid tubercle
- Type III
- Bucket handle tear of the superior labrum with an intact biceps anchor
- Type IV
- Bucket handle tear of the superior labrum with extension into the biceps tendon root
- Maffet modification of Snyder classification
- Bucket handle tear of the superior labrum with extension into the biceps tendon root
- Type V
- Anteroinferior capsulolabral separation (Bankhart lesion) + Type II tear
- Type VI
- Unstable labral flap + Type II tear
- Type VII
- Type II tear with extension into the capsule inferior to the MGHL
- Moderresi modification
- Type II tear with extension into the capsule inferior to the MGHL
- Type VIII
- Type II tear with a posterior labral extension as far as the 6-o’clock position
- Type IX
- Type II tear with circumferential extension
- Type X
- Type II tear with a posteroinferior labral disruption (reverse Bankhart)
What is the most common type of labral tear based on Snyder’s original publication?
[J Am Acad Orthop Surg 2014;22:554-565]
Type II lesions were most common (55%)
- Followed by:
- Type I (21%)
- Type IV (10%)
- Type III (9%)
What is the general approach to treatment of each type of SLAP lesion?
[Knee Surg Sports Traumatol Arthrosc (2016) 24:447–455]
- Nonoperative management is first line for all
- Failure of nonoperative management can consider surgery
- Type I = debridement
- Type II = repair or biceps tenotomy/tenodesis
- Consider tenodesis for overhead athletes
- Consider tenotomy or tenodesis for age >40
- Type III = debridement of bucket handle
- Repair labrum if necessary
- Type IV = debridement if there is <50% of biceps tendon involved (repair labrum if necessary) OR tenotomy/tenodesis if there is >50% of biceps tendon involved (repair/debride labrum if necessary)
- Type V = Bankart repair and labral repair
- Type VI = debride unstable flap and repair labrum
- Type VII = repair
What is the definition of a failed SLAP repair?
[J Am Acad Orthop Surg 2014;22:554-565]
Postoperative pain and/or stiffness (not associated with concomitant pathology) that does not resolve with nonsurgical measures
- A failed repair is characterized by symptoms that either never resolve or resolve postoperatively and return at a later date
What is the treatment algorithm for surgical management of failed SLAP repair?
[J Am Acad Orthop Surg 2014;22:554-565]
- First line = nonoperative
- Second line = surgery
- Revision SLAP Repair if:
- Patient <30
- Overhead athlete
- No biceps pathology
- Diagnostic arthroscopy and biceps tenodesis if:
- Patient >30
- Female
- Biceps pathology
- Cosmesis
- Diagnostic arthroscopy and biceps tenotomy if:
- Patient >50
- Preoperative stiffness
- Poor tendon quality
Describe the impingement involved in subcoracoid impingement
[J Am Acad Orthop Surg 2011;19:191-197]
The subscapularis tendon or LHBT becomes impinged between the coracoid and lesser tuberosity of the humerus
What is the provocative shoulder position that causes subcoracoid impingement?
[J Am Acad Orthop Surg 2011;19:191-197]
Flexion, horizontal adduction, internal rotation
What factors/conditions can lead to primary or secondary subcoracoid impingement?
[J Am Acad Orthop Surg 2011;19:191-197]
- Idiopathic
- Congenitally elongated or curved coracoid
- Calcification of the subscapularis tendon
- Ganglion cyst
- Traumatic
- Fracture of humeral head and neck
- Malunion of coracoid or glenoid fracture
- Displaced scapular neck fracture
- Anterior glenohumeral instability
- Iatrogenic
What is internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
Condition characterized by repetitive or excessive contact between the greater tuberosity of the humerus and the posterosuperior glenoid when the arm is abducted and externally rotated leading to impingement of the adjacent rotator cuff (articular side of posterior supraspinatus and/or anterior infraspinatus) and labrum
What are the cardinal lesions of internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
- Articular-sided rotator cuff tears
- Posterosuperior labral lesions
What are the five structures at risk with internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
- Posterosuperior labrum
- Rotator cuff (articular surface)
- Greater tuberosity
- Posterosuperior glenoid
- IGHL complex
What factors/pathologies contribute to the development of internal impingement?
[AJSM 2009; 37(5): 1024]
- Anterior shoulder instability (attenuation of the AIGHL)
- GIRD (GH internal rotation deficit)
- SICK scapula
- Scapular malposition
- Inferior medial border prominence
- Coracoid pain and malposition
- dysKinesis of scapular movement
- High glenoid anteversion
- Low humeral head retroversion
What are four radiographic features associated with internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
- Exostosis of the posteroinferior glenoid rim
- AKA Bennett lesion
- Due to repetitive traction from the PIGHL and posterior capsule
- Sclerotic changes of the greater tuberosity
- Posterior humeral head osteochondral lesions or cystic “geodes”
- Rounding of the posterior glenoid rim
What are the phases of throwing?
- Wind up
- Early cocking
- Late cocking
- Acceleration
- Deceleration
- Follow through
What is the critical point in the throwing cycle that injuries occur?
Transition between late cocking and acceleration phase
What anatomical structures are at risk during the late cocking phase of throwing?
- Anterior capsule stretching
- Coracohumeral ligament stretching
- Internal impingement
* Posterosuperior rotator cuff
* Posterosuperior glenoid labrum - Biceps anchor
What is the muscle activity about the shoulder during late cocking and acceleration phases of throwing?
- Late cocking
- Concentric contraction = infraspinatus, teres minor
- Eccentric contraction = pec major, lat dorsi, subscapularis
- Minimal supraspinatus activity
- Acceleration
- Concentric contraction = pec major, lat dorsi, subscapularis
- Eccentric contraction = teres minor > infraspinatus
What anatomical structures are at risk during the deceleration phase of throwing?
- Posterior capsule stretch
- Posterior rotator cuff stretch
What are the most important dynamic stabilizers of the thrower’s shoulder?
- Rotator cuff
- Long head of biceps
What are the common adaptive changes to the thrower’s shoulder?
- Increased proximal humeral retroversion
- Normal = 33° dominant, 29°nondominant
- Throwers = 36.6°
- Thickening of the PIGHL and posterior capsule
- Attenuation of the AIGHL and anterior capsule
- Sclerosis of the posterosuperior glenoid rim
- Cystic changes in the posterolateral humeral head
- Altered scapular position and motion
- Alterations in total arc of motion
* At ≥25° loss of total arc GIRD is considered symptomatic - Alterations in kinematics
In the presence of a tight posterior inferior capsule which direction does the GH joint center of rotation shift (in thrower’s shoulder)?
GH center of rotation shifts posterior and superior
What are the 3 groups of injuries seen in the thrower’s shoulder?
Group 1
- Internal impingement
- Pinching of the posterolateral rotator cuff and the labrum between the posterolateral portion of the greater tuberosity and the posterosuperior glenoid
- Presentation:
- Pain with abduction and ER
- Pathology:
- Rotator cuff injury at junction of supraspinatus and infraspinatus
- Tendinitis, tendinosis or partial articular supraspinatus tendon avulsion (PASTA)
- Posterosuperior labral injury
- Cystic changes in posterolateral tuberosity
- SLAP lesion with peel back of labrum posteriorly (not anteriorly)
- Tight posteroinferior capsule
- Rotator cuff injury at junction of supraspinatus and infraspinatus
Group 2
- Internal impingement + acquired secondary anterior instability
- Repetitive microtrauma to anterior structures results in stretching of AIGHL and anterior capsule leading to symptomatic instability
- Presentation:
- Deep anterior pain with late cocking and acceleration, 2+ anterior translation
- Pathology
- Anterior labral tears
- PASTA
Group 3
- Primary anterior or multidirectional instability
- Presentation:
- Extremity fatigue (“dead arm”) – instability as the rotator cuff fatigues
- Positive anterior apprehension, relocation, sulcus sign
- Extremity fatigue (“dead arm”) – instability as the rotator cuff fatigues
What is the nonoperative management of thrower’s shoulder?
- All should trial nonop (90% respond)
- Posterior capsular stretching (GIRD)
- Scapular stabilization (address SICK scapula)
- Rotator cuff strengthening
- Address kinetic chain
What is the surgical management of thrower’s shoulder?
Group 1 (Internal Impingement)
- Type I SLAP = debride
- Type II SLAP = repair
- Limit anchors to posterior to avoid limiting ER
- Partial thickness RCT <50% = debride
Group 2 (Internal Impingement + 2o anterior instability)
- As group 1
- Drive through sign present = Plication of AIGHL
- Include ≥20% of anterior capsule in plication
Group 3 (1o Anterior instability or MDI)
- Instability = capsular shift
- So-called 270° repair involving the rotator interval and the anterior and posterior bands of the inferior glenohumeral ligament
What is the criteria for return to play following an in-season acute anterior shoulder instability event?
[J Am Acad Orthop Surg 2012;20:518-526]
- Symmetric pain-free shoulder ROM and strength
- Ability to perform sport specific skills
- Absence of subjective or objective instability