Rotator Cuff Pathology

Front 1

Location of pathology: older vs younger atheletes

Back 1

older athlete: primary tendinopathy within the substance of the cuff. acromial changes may be secondary
younger: outlet impingement 2/2 GH laxity/dyskinesia & subacromial impingement
alternatively younger overhead atheletes may experience internal impingement: physiologic contact of articular surface of rotator cuff with posterosuperior glenoid rim becomes pathologic due to repeitivie supraphysiologic activity

Front 2

What is internal impingement

Back 2

esp in overhead athletes physiologic contact of articular surface of rotator cuff with posterosuperior glenoid rim becomes pathologic due to repeitivie supraphysiologic activity
1cm posterior rto biceps tendon

Front 3

Average prevalence of rotator cuff tearing in asymptomatic individuals:

Back 3

34% total, >50% if over 60yo.
per Sher et al.

Front 4

Pain associated with a rotator cuff tear best correlates to

Back 4

a progression of that tear per Yamaguchi

Front 5

Re-tearing after rotator cuff tendon repair

Back 5

extremely frequent (17/18 per Galatz et al)
but despite structural failure, mostpatients continue to have improvements & satisfaction (Jost et al)

Front 6

What makes repairing chronic cuff tears hard?

Back 6

with long-standing, chronic, massive rotator cuff tearing, fatty infiltration occurs
irreversible & predictive of failure (Goutalier et al)

Front 7

What is the "fifth" tendon of the rotator cuff

Back 7

the long head of the biceps tendon

Front 8

Describe the biceps tendon in the rotator cuff

Back 8

originate at the supraglenoid tubercle
transverses as intraarticular but extrasynovial (itself covered with synovial sheath) Passes deep to rotator interval between supraspinatus and subscapularis and exits in intertubercular sulucus bound by coracohumeral ligament superiorly and superior GH lig inferiorly (which form a pully for tendon); thereafter held by transverse humeral ligament
NB: variable anatomy of groove can be etiology of pathology

Front 9

what part ofthe GH joint does the cuff cover

Back 9

cuff envelops and bledns with GH capsule on all sides except the redundant inferior pouch

Front 10

Whence cometh the vascular supply of the rotator cuff?

Back 10

six branche of the axillary artery with the largest contributions from suprascapular and anterior and posterior humeral circumflex arteries
results in "critcal zone" of poor vascularity within supraspinatous tendon immediatly proximal to its insertion onto greater tubersoisyt;

Front 11

Matsen's humeroscapular articulation

Back 11

shoulder as two concentric spheres
inner is humeral head on glenoid
outer proximal humerus and coracoacromial arch
structures within normally have no problems with volume/impingement
loss of concentricity or alteration of morphology of arch results in impingement

Front 12

Describe the subacromial bursa

Back 12

attached at greater tubersotiy and undersufrace of acromion/coracoacromial arch. superior aspect on deltoid, inferior on rotator cuff
potential space which allows frictionless motion through synovial fluid interface

Front 13

describe rotator interval

Back 13

inferior edge of supraspinatous tendon, and superior edge of subscapularis tendon
superficial roof is coracohumeral ligmanet and floor is superior GH lig. Interval holds biceps tendon with ligs forming pully for tendon

Front 14

Orientation of supraspinatus attachment

Back 14

70 degrees from plane of glenoid

Front 15

Most important function of rotator cuff muscles

Back 15

maintaining articular congruity to create a stable fulcurm for more powerful muscle which would otherwise cause translation at the GH joint

Front 16

Depressors of humeral head:

Back 16

infraspinatus is primary, teres minor and subscapularis important as well

Front 17

Function of Biceps in GH stability

Back 17

No actual function during purely shoulder related activity (Yamaguchi)
passively contributes to to anterior stability in Abducted & externally rotated position by resisting torsional forces

Front 18

lax anterior structures and tight posterior structures

Back 18

allow greater anterior translation of humeral head resulting in impingmeent

Front 19

Muscle actions during wind-up (cocking) phase

Back 19

deltoid isprimary force levering humerus; nautrally wants to translated humeral head superiorly
supraspinatus compresses head into glendoid, infraspoinatus and teres minor oppose deltoid

Front 20

Muscle actions during Acceleration phase:

Back 20

Pectoralis major and subscapularis provide internal rotation force
Posterior cuff muscles stabalize with eccentric contraction (nosynergistic relaxn)
Supraspinatus continues providing compression
Additional eccentric contraction of lats, serratus anterior, and triceps

Front 21

Muscle actions during Deceleration phase

Back 21

entire rotator cuff is active
posterior cuff working to decelerate arm and maintain GH position
infraspinatus is still firing to internally rotate
suprasinatus actively compressing (as always)
long head of biceps eccentrically decelerates terminal elbow extension

Front 22

Humeral head motion during throwing

Back 22

hyperangulates with late cocking
posterior motion with extension and internal rotation
anterior movement with flexion or cross-body motion

Front 23

Scapular Lag

Back 23

Fatigue of scapular rotators on chest wall leads to inability of scapula to rotate properly, prevents acromion from clearing out of way when arm elevated & results in secondary impingement

Front 24

Asymptomatic labral abnormalities on MRI

Back 24

79% of completely asymptomatic baseball pitchers (Miniaci et al)

Front 25

Range of motion testing & rotator cuff tear

Back 25

Look for a true descrpenecy between active and passive ROMs,most suggestinve

Front 26

Looking for biceps tendon pathology

Back 26

tenderness at bicipital groove think tendonitis
rolling/subluxing from groove during passive external rotation

Front 27

Codman's point

Back 27

supraspinatus insertion
palpated through the deltoid, just distal to anterolateral acromino with shoulder extended and internally rotated.

Front 28

First consideration of shoulder pain in throwing atheletes

Back 28

anterior subluxation with secondary impingement until proven otherwise

Front 29

testing shoulder stability

Back 29

load-and-shift and sulcus tests

Front 30

apprehension sign

Back 30

passively abducting and ERing the shoulder until patient is aprehensionj. follow with Foler's aka Jobes' relocation test: same test with posteriorly directed force from examiner releives apprehension

Front 31

passively abducting and ERing the shoulder until patient is aprehension.

Back 31

apprehension sign

Front 32

Folwer's sign

Back 32

apprehension test (ER + Abduction = Apprehension) releived with posteriorly directed force from doc
aka Job's relocation test

Front 33

Jobe's relocation test

Back 33

aka Folwer's sign
apprehension test (ER + Abduction = Apprehension) releived with posteriorly directed force from doc

Front 34

apprehension test (ER + Abduction = Apprehension) releived with posteriorly directed force from doc

Back 34

Jobe's relocation test
aka Folwer's sign

Front 35

Painful arce of abduction between 60 and 120 degrees

Back 35

a sign of impingmenet

Front 36

Neer's sign

Back 36

pain on forced (passive) forward flexion
in which the greater tuberosity is forced against anterior acromion

Front 37

pain on forced (passive) forward flexion

Back 37

Neer's sign in which the greater tuberosity is forced against anterior acromion

Front 38

what tests the greater tuberosity is forced against anterior acromion

Back 38

Neer's sign

pain on forced (passive) forward flexion

Front 39

Position of arm when working in subacromial space

Back 39

apply traction to arm while in adducted position

Front 40

Position of arm when working arthroscopically in GH joint

Back 40

slight abduction,sligh tflexion about 30 degrees of ER

Front 41

Post-op management of rotator cuff repairs

Back 41

passive assisted motion and stretchign startedimmediately. afteer 6 weeks, progression to active then at 10 weeks begin resisted motion as tolerated. follow with non-op type management,.

Front 42

Treatment of rotator cuff pathology 2/2 overuse proglems

Back 42

extensive non-op (6-12 months of obsessive exercise); surgery only in chronic refractory or progression ot tear

Front 43

Treatment of rotator cuff pathology 2/2 internal impingement

Back 43

non-op with limitation of the extremes of abduction and ER until symptoms resolved;
very difficult to treat
surgery only for refractory symptoms (6-12 months of obsessive exercise)

Front 44

Treatment of rotator cuff pathology 2/2 instability and secondary impingement

Back 44

prolonged non-op management (6-12 months of obsessive exercise)

Front 45

Treatment of rotator cuff pathology 2/2 primary impingement

Back 45

surgical decompression early for failed non-op management

Front 46

Treatment of rotator cuff pathology 2/2 acute trauma

Back 46

rest until symptoms have subsided
rehab of gradually increasing stretching and strenghting
avoidimmobilization
prognosisis good.
surgical repair for persistent pain within 2 months to minimze effectsof chronic injury

Front 47

debridement vs repair for rotator cuff repairs

Back 47

<50% tear ok to debride c subacromion decompression
>50% should be repaired c subacromion decompression

Front 48

natural course of symptomatic full-thickness tear

Back 48

predictably poor results without surgery
lagre tear >3cm has poor recovery even with surgery

Front 49

Three main operative procedures for rotator cuff pathology

Back 49

subacromial decompression
rotator cuff repair
biceps tenodesis

Front 50

closed chain scapula stabalizer strengthening exercises

Back 50

Ball rolling
protraction & retraction

Front 51

how can you determine if scapular dysfunction is causing the shoudler pain

Back 51

manually stabalize the scapula and see if that relieves pain of shoulder motions

Front 52

Use of NSAIDs and Steroids in Rotator Cuff Injuries

Back 52

2 weeks of NSAIDs to reduce inflamation, prn thereafter
inflammation is importnat to healing, utility of NSAIDs is in allowing rehabilitative exercises
steroids can be used to break vicious cycle if NSAID's aren't cutting it, rarely more than once

Front 53

define active rest

Back 53

staying active but avoiding the specific motions which induce rotator cuff pathology
this is important for compliance and also maintenance of conditioning

Front 54

Describe a good preventative strengthening program

Back 54

with thermaband
1. resisted ER with arm at side and also 90 degrees abducted
2. Resisted IR
3. Pushups with arm adducted for scapular ortator contorl
4. sitting rows for serratus and rhomboid scapular control
5. shurgs for trapezius strenghtening
6. lat pull downs for deceleration of overhead motion
7. suprapsinatus: resisted abduction in scapular plane with internalr otation

Front 55

how should little league pitchers develop their throwing

Back 55

start with fastball
improve velocity and maintian consistent mechanics
then develop repertoire

Front 56

Three stages of rotator cuff-coracoacromial impingement

Back 56

1.Edemma and hemorrhage
2 fibrosis and tendonitis
3 degeneration (boney changes & tendon rupture)

Front 57

Reliability of US in rotator cuff pathology

Back 57

91% sensitivy and specificity with 100% positive predictive value of non-visualization of forcal thinning

Front 58

Acromial Humeral Joint Distance Indicative of Massive Rotator Cuff Tear

Back 58

<6mm

Front 59

acetabularization of acromion & femoralization of proximalhumerus

Back 59

advanced rotator cuff disease
sclerosis and cystic changes in geater tuberosity and osteophyte formation on the acromion

Front 60

Obtaining plain radiographs for rotator cuff pathology

Back 60

AP & Lateral at right angles to scapular plane
lateral film with 10 degree tilt to evaluate acromial shape & slope
an axillary view

Front 61

Injection tests

Back 61

Subacromial region after a positive Neer's sign with relief of sx
AC joint or bicipital groove

Front 62

biceps tendon instability (ie subluxation)

Back 62

passive abductionof shoulder to 90 degrees and eliciting palpable snap
indicative of lesion of superior fibers of subcapularis or SGHL

Front 63

passive abductionof shoulder to 90 degrees and eliciting palpable snap

Back 63

biceps tendon instability (ie subluxation)

indicative of lesion of superior fibers of subcapularis or SGHL

Front 64

indicative of long head of biceps even without a SLAP lesion

Back 64

Active compression test
O'brien's test
resisted elevation with the arm at 90 degrees of forward flexion and 10-15 degrees of adduction

Front 65

resisted elevation with the arm at 90 degrees of forward flexion and 10-15 degrees of adduction

Back 65

Active compression test
O'brien's test

indicative of long head of biceps even without a SLAP lesion

Front 66

O'brien's test

Back 66

Active compression test
O'brien's test
resisted elevation with the arm at 90 degrees of forward flexion and 10-15 degrees of adduction
indicative of long head of biceps even without a SLAP lesion

Front 67

Active compression test

Back 67

Active compression test
O'brien's test
resisted elevation with the arm at 90 degrees of forward flexion and 10-15 degrees of adduction
indicative of long head of biceps even without a SLAP lesion

Front 68

Yergason's test

Back 68

Yergason's test
elbow flexed to 90 degrees and supination is resisted (forarm starts pronated),
positive if produces pain in bicipital groove
indicative of pathology of long head of biceps

Front 69

elbow flexed to 90 degrees and supination is resisted (forarm starts pronated),

Back 69

Yergason's test
elbow flexed to 90 degrees and supination is resisted (forarm starts pronated),
positive if produces pain in bicipital groove
indicative of pathology of long head of biceps

Front 70

indicative of pathology of long head of biceps

Back 70

Yergason's test
elbow flexed to 90 degrees and supination is resisted (forarm starts pronated),
positive if produces pain in bicipital groove
indicative of pathology of long head of biceps

Front 71

test indiccative of biceps tendong involvement

Back 71

test indiccative of biceps tendong involvement
Speed's test
pain reproduced on resisted forward elevation of humerus against an extended elbow

Front 72

Speed's test

Back 72

test indiccative of biceps tendong involvement
Speed's test
pain reproduced on resisted forward elevation of humerus against an extended elbow

Front 73

pain reproduced on resisted forward elevation of humerus against an extended elbow

Back 73

test indiccative of biceps tendong involvement
Speed's test
pain reproduced on resisted forward elevation of humerus against an extended elbow

Front 74

Hawkin's sign

Back 74

Hawkin's sign
aka Impingement Reinforcement Test
pain on forced (passive) IR of the 90degree forwardflexed arm
causes impingement against coracoacrominal ligament

Front 75

Impingement Reinforcement Test

Back 75

Hawkin's sign
aka Impingement Reinforcement Test
pain on forced (passive) IR of the 90degree forwardflexed arm
causes impingement against coracoacrominal ligament

Front 76

pain on forced (passive) IR of the 90degree forwardflexed arm

Back 76

Hawkin's sign
aka Impingement Reinforcement Test
pain on forced (passive) IR of the 90degree forwardflexed arm
causes impingement against coracoacrominal ligament

Front 77

test which causes impingement against coracoacrominal ligament

Back 77

Hawkin's sign
aka Impingement Reinforcement Test
pain on forced (passive) IR of the 90degree forwardflexed arm
causes impingement against coracoacrominal ligament