IMPINGEMENT SYNDROMEROTATOR CUFF LESIONS

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IMPINGEMENT SYNDROME/ROTATOR CUFF LESIONS
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Gross Anatomy

• Bones
• humerus (greater tuberosity)
• scapula (acromion, coracoid)
• clavicle (distal end) to ligaments
• Bursa subdeltoid (subacromial) bursa
• Ligaments coracoacromial
• Tendons

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Rotator Cuff Footprint
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Gross Anatomy

• Tendons
• Supraspinatus (1 tear)
• Infraspinatus (2 tear)
• teres minor
• Subscapularis
• Strongest and Largest
• long head of biceps
• Envelopes 75 of GH articulation
• Multiple layers of collagen (type I)

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Muscle Functions

• Supraspinatus
• Initiates abduction
• Subscapularis
• Primary IR
• Infraspinatus/Teres minor
• Primary ER

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Rotator Cuff Function

• Minimize vertical displacement of humeral head
• Provide adequate horizontal compression to
  counter shear forces to provide dynamic
  stabilization of humeral head
• Initiate abduction

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Primary Impingement (not enough space)

• Definition The abutment of suprahumeral soft
  tissues (tendons and bursa) against overlying
  structures including the anterior acromion,
  acromioclavicular joint, coracoid process, and
  coracoacromial ligament with glenohumeral
  elevation (flexion/abduction) in 80 - 120o range.

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Types of Impingement

• Primary mechanical rub
• Secondary internal looseness
• Internal loose anterior ligaments, RC rubbing
  on the posterior superior labrum
• Associated with posterior glenoid cysts!!
• Tight posterior ligament get internal
  impingement
• Other
• Postural
• Scapular Dysfunction

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Predisposing Factors to Primary Impingement

• Acromion
• Morphology - Type I, II, III (Aoki, Bigliani)
• X-ray diagnosis

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Spur formation

• undersurface
• CA ligament attachment
• calcified

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Other Primary Impingements

• Coracoacromial ligament
• Hypertrophic bursa
• Acromioclavicular joint spurring (DJD)
• Rotator cuff tendon thickening due to
  inflammation, scarring, calcium deposits, partial
  tearing (top or bottom)

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ANDHumerus

• greater tuberosity prominence (after fracture)
• 5mm

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Secondary ImpingementLigament Problems

• Anterior laxity
• Posterior tightness

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Secondary Impingement

• Loss of adequate dynamic humeral head
  depression/stabilization
• rotator cuff/biceps tendon failure

• Posture
• protracted scapular
• forward head
• Position - loss of adequate glenohumeral external
  rotation and scapular retraction

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Instability

• glenohumeral or scapular
• repeated overhead use of shoulder

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Rotator cuff normal arthroscopic anatomy

• Vascularity
• Critical zone decreased vascularity 1 cm.
  proximal to insertion of supraspinatus tendon
  (Codman, Rothman, and Parke)
• Position dependent - less circulation to critical
  zone with shoulder adduction than with abduction
  (MacNab and Rathbun)

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Tendon aging (Brewer)

• Decreased tendon cellularity
• Disorganization of tendon collagen network
• Decreased vascularity
• Increased type III collagen GAG

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Rotator Cuff Natural History

• Asymptomatic
• 23 in 50-59 y.o.
• 51 in gt80 y.o.
• Supraspinatus
• Greater than 60 of all tears
• Articular surface tears 2-3x greater than bursal
  surface

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Classification of pathology

• Compressive failure - impingement, extrinsic,
  bursal side
• Tensile failure
• Traction (throwers)
• Incomplete articular
• Tendinosis (tendinitis)

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Acute - overuse
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Calcific tendonitis (1o Impingement)

• Degenerative process prior to calcification
• More often in females, dominant shoulder,
  supraspinatus

Calcific Tendinitis
Normal
Kidney Stone Ultrasound Protocol
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Diagnosis (1o Impingement)

• History - repetitive overhead use
• pain with or following activity
• night pain (cannot go to sleep and cannot roll
  over)- DONT forget tumors in smokers
• Decreased velocity in throwers

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Physical Exam

• Painful arc of motion (80o - 120o elevation),
  decreased range of motion
• Greater tuberosity tenderness
• Decreased strength in abduction, external
  rotation, internal rotation
• Secondary to pain
• Secondary to tendon failure

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Posterior/inferior capsular tightness

• loss of internal rotation
• Check mobility
• AC and SC joints

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Positive impingement tests

• Hawkins - flexion at 90o, internal rotation,
  horizontal ADD 20o
• Active - hand to opposite shoulder, elevate elbow
  with shoulder flexion
• Passive (Neer) - fix scapula, force shoulder into
  full flexion
• Biceps tendon Yergasons
• Glenohumeral stability - provocative tests
• elective muscle/tendon recruitment and stretching

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Diagnostic TestingOutlet view

• X-rays - look for superior migration of humeral
  head, greater tuberosity cysts, sclerosis of
  underside of acromion, acromial morphology with
  outlet view
• Arthrogram
• Ultrasound

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MRI scanning for RC injury
Healthy Supraspinatus With MRI scan notice Dark
color
Tear of supraspinatus Notice white spot
where Dark should be
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Non-operative Management

• Rest, educate patient on biomechanics
• Treat pain/inflammation
• Injections
• NSAID
• rehab

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Surgical Considerations

• Age
• Young, active - early repair
• 40 and UP - repair
• Demand related

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Size of tear

• 1 Outcome determinant
• Partial - acromioplasty
• Small to large - repair most, dominant arm
• Massive(gt 4cm 50 failure)
• Acromioplasty
• Marginal convergence
• Stabilize the remaining tissue
• Possible allograft
• Possible Restore (pig mucosa)

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Surgical Goals

• Remove impinging tissue
• Remove impaired cuff
• Address Rotator Cuff pathology
• Recreate footprint of supraspinatus

25 mm long
12 mm wide
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Surgical Procedures
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Arthroscopy - role

• Diagnostic
• Rotator cuff tears - partial - undersurface,
  complete - size
• Glenohumeral clean out
• Bursal hypertrophy
• PASTA

• Acromioclavicular osteophytes
• Hooked acromion or traction spur
• DJD AC joint
• Associated instability

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Arthroscopic assisted rotator cuff repair

• Arthroscopic acromioplasty and mini open repair
• Small, complete, limited retraction, minimal
  atrophy
• Physically active patient with pain and
  symptomatic weakness

Deltoid splitting acromial attachment preserved
but weakened
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All arthroscopic repair is being done

• fixation concerns
• Double row
• Special Suture Techniques

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Open rotator cuff repair

• Indications
• Acute traumatic tears - in large people with BP
  problems
• Degenerative tears - with marked atrophy and
  retraction
• Failed arthroscopic debridement
• Suture anchors

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Procedure for very large tears

• Perform acromioplasty (Neer)
• Mobilize soft tissue to get adequate coverage or
  closure
• Secure into trough near greater tuberosity
• Tendon transfers - latissimus and subscapularis
• Rehabilitate anterior deltoid and teres minor
• Reverse total shoulder arthroplasty
• Elderly (gt70) not young

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Acromioplasty (Open or Arthroscopic)

• 6 weeks of active rest
• OR

RUPTURED DELTOID!!
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Shoulder Dislocation

• Pt gt 40 y.o. PT
• Rule out RTC tear

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THE FROZEN SHOULDERAdhesive Capsulitis

• Clinical Entity - not diagnosis
• Essential lesion
• Coracohumeral ligament contracture
• Is it shoulder or is it NECK!

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Adhesive Capsulitis Stages

• I. Initiation/Inflammation
• Hot/painful
• Rx NSAIDs/Injection
• II. Frozen
• Less pain
• Lose more motion
• III. Slow improvement
• Each stage lasts 3-6 months

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Etiology/Associated Pathology

• Cervical
• Periarthritis
• Bicipital tendonitis
• Pericapsulitis
• Bursitis
• Rotator cuff tendonitis

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Associated Pathology

• Calcific tendonitis
• Traumatic osteoarthritis
• Impingement syndrome

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Predisposing Factors

• Immobilization
• 40 - 70 years old
• Diabetes
• Trauma
• Cervical disc
• Thyroid disorders
• Intrathoracic dysfunction
• Post MI

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Symptoms

• Diffuse ache about front and lateral aspect of
  shoulder
• Lack of arm mobility with increased symptoms when
  elevating arm
• Symptoms often worse at night
• 1 THEY LOST MOTION!

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Clinical Examination

• restriction in both active and passive ROM
• most often elevation, ER and IR, often with
  capsular type end-feel
• examine humeral head translation in all planes
  with patient supine.
• No pain abduction or extension

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Diagnosis

• Rule out myriad of possibilities
• X-rays before
• MRI and/or arthrogram - after

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Treatment

• Pre Dexa Scan
• Office
• ABD 90 Arc ER/IR gt60
• Injections (30-60 cc)
• 20 cc .25 lidocaine
• 2 cc depomedrol
• Remainder is saline
• Oral medications (NSAIDs and Analgesics) post
  manipulation
• Brisement

Delaware Touch Technique 90 accurate
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Treatment

• OR with regional block plus sedation
• Or general anesthesia
• Posterior glides
• Horizontal Adduction
• Forward flexion
• Inferior glides
• ABD
• Rotations in ABD 90 degrees
• ER
• IR
• IR in horz. Adduction
• Rotations in ABD 0
• ER
• Injection 10 cc lidocaine and 2 cc depomedrol

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Following manipulationOR or in-office

• Same day PT within 4 hours!!
• 4 PT visits the first week, 3 visits the second,
  PRN
• Average 10 PT visits
• MUST HAVE HEP

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Arthroscopic Release

• Failure with gt 4m PT
• Release CH ligament and Open RC Interval
• Avoid 600/Axillary nerve
• 12.5 mm
• Bad but only chance for IDDM