We'll call Tom Gill back up to the podium. I've known Tom for a long time. He's a smart guy and he's a very confident guy. He hedged his bet a bit about this spinal accessory nerve. If he was truly confident, he would have not wagered course tuition. He would have wagered one of his too-many-to-count Super Bowl rings from the New England Patriots. Tom Gill. Thanks, Bruce. Remember, I know stories about you from when you were young. I'll tell you one funny story about a Super Bowl ring. It comes home and if you've ever seen a Super Bowl ring, it's not really something that would look right on my hand, to leave it at that. My wife looks at it and it's like ... This is honest to God, true story. That is the ugliest piece of jewelry I've ever seen. Can't we, quote, can't we just take the diamonds out and make me a nice piece of jewelry with it? If you ever think you're going to get an ego in this world, it's never going to happen. This is a ... It's a lot in this talk, but I think a lot of it's going to be stuff that most of you are pretty comfortable with, depending on how we're doing on time. We'll do as many questions up front as we can. There's a lot of questions towards the end, which if we get a little bit tight, I'll just refer you to them. I have the explanations, not only the answers, but the explanations to the answers and some of the questions towards the end of the talk. If you look at that stuff we're going to talk about, it's all listed here. We'll start with adhesive capsulitis. One of the biggest thing with adhesive capsulitis or a stiff shoulder is to figure out, is this truly adhesive capsulitis, which is a pathophysiologic problem in the shoulder, or is this post-surgical stiffness from a too tight labor repair, too tight capsuloraphy, or whatever, because there's different types of ways to think about them that'll affect the answers that we're going to be asked. If you think about ... We're going to start first with adhesive capsulitis itself. As we all have seen, it's a thickened, contracted capsule. My patients always say it's like shrink wrapping a product. From a loose kind of shirt, something thinner, thicker. Loss of motion. It does not have to be global loss. You can have preferential loss of external rotation over internal rotation, or elevation over internal rotation. The biggest things that are going to be in a vignette, to keep in mind the buzzwords for adhesive capsulitis, is a 52-year-old woman with diabetes, a 61-year-old man with hypothyroidism. Typically it's going to be a woman, it's going to be diabetes, or it's going to be hypothyroidism. When you see those things, think adhesive capsulitis. The main lesion, at least on the test that comes up, is a contracted coracohumeral ligament, which basically means they ought to give you some description of an exam with a loss of external rotation. Historically, although we think maybe a little bit less about it in this way clinically now, it's still a good way from a testing standpoint to think about it. You've got the painful freezing phase, which is up to about six months. This is the most symptomatic. This is as most of it starts to get lost, and the pain goes up. You've got the frozen stage, which is much less painful, but people are stiff, and they can continue to lose a little bit of motion. And then there's the thawing stage, where it gradually gets better. And classically, if you talk about if and when you're going to operate on patients with adhesive capsulitis, it's typically during this frozen stage or after. You try not to operate when they're really super painful and symptomatic, because oftentimes they just get stiff again afterwards. And you've got to figure out on an exam which part of the capsule is affected. If they've lost external rotation, that coracohumeral ligament or the rotator interval is involved. External rotation and abduction is going to be more the anterior capsule. And then internal rotation and abduction is the posterior part of the capsule. On the test, look at the x-rays. If they give you an x-ray, the loss of motion, what's the differential diagnosis of loss of motion? If someone says, patient comes in pain, loss of motion, you've got to think of three things. Adhesive capsulitis, big rotator cuff tears, or locked dislocations. They're going to try to get you on a locked dislocation versus a capsulitis, and then we have a question about that that I'll show you. So just if they do give an x-ray, hopefully it'll be an axillary view. Keep that in mind. Typically, non-op, non-op, non-op for adhesive capsulitis. If they say, already had two injections, it's been six months, something else, then you can start thinking about a capsular release. But in general, treatment is PT. They prefer a glenohumeral injection over a subacromial injection, anti-inflammatories. And again, depending on what phase, that freezing or thawing phase, typically PT is more effective in the frozen phase than the freezing phase. Management, if it did fail, oftentimes they'll give you a list of manipulation, capsular release, or capular release with manipulation. And hydrodilation, if you really want your patient to hate you, do a hydrodilation therapy for adhesive capsulitis. Very painful. So it's going to be capsular release with manipulation in 2018. If you just do a manipulation, higher incidence of fracture, dislocation, axillary nerve injuries, et cetera. And then you want to try to coordinate your PT before surgery, not afterwards. If they give you the option of a glenohumeral catheter, they do not want you to use catheters because of the risk of chondrolysis. And remember that diabetics have a worse outcome than other people. So 47-year-old woman, painful stiff shoulder for three months. I'm thinking capsulitis. Doesn't say anything about a trauma, so let's think about dislocation. Could it be a cuff tear? Had a subacromial injection, anti-inflammation has not been helpful. Range of motion is limited. It's only 30 degrees of external rotation and locked internal rotation. So plane radiographs of the C-spine and shoulder are normal. So they're telling you it's not a high-riding head from a cuff tear arthropathy. It's not a dislocated shoulder. So 47-year-old woman, three months, PT. They want you to, we're all surgeons, they're going to give us arthroscopic capsulitis, try to make you jump to that. But if it's an adhesive capsulitis question, anything certainly less than six months, non-operative. Recalcitrant idiopathic capsulitis has been associated with males, no. Diabetes, yes. Renal, no. No. No. 50-year-old male, difficulty with overhead work following a slap repair. So got stiff, like Julie was talking about in her talk, stiff after a slap repair a year ago in PT for nine months. Limited motion. What's the best treatment option? It's never going to be a revision slap. At that point, it's going to be a capsule release. Now why? If something is different about this, then why not just say continue therapy? First of all, it's a year. For the purpose of the test, any time they tell you they've had PT for one year, that's like the golden marker. More PT is not the answer. So from a cost-effective standpoint, whatever. But this is a post-surgical stiffness question, not just adhesive. So even if it was six months, for instance, it's probably going to be reasonable to do a capsule release at this point. 50-year-old tennis player, PT on and off for three months without help. Globally limited motion, positive impingement signs. Strength is normal. So what would you do next? Here's a picture of it. So it's not a cuff tear. They want you at this point to do, if PT on and off alone didn't help, now they want you to do an injection. There's no repair that needs to be done. You're certainly not going to immobilize them because they're stiff, et cetera. Forty-seven-year-old man, outstretched arm and fell. So now I got limited motion and I have a trauma. And radiograph is shown. So this is where you want to start. First of all, it's a male. If they really wanted to try to trip us up, they would have said like a 52-year-old female with loss of motion, because then we'd be thinking capsulitis, capsulitis. Here's the x-ray. And even though it's, they really, if they were any kind of good people, they would give an axillary view. It's not. All right. So, but you can kind of see there was no space there and they want to get us that, but typically if it's a dislocated shoulder, oh, then they gave it to you afterwards, but they didn't give it to you. That wasn't part of the question. That was part of the explanation for the question. So AVN, the biggest questions for AVN are going to be the associations. What are the etiologies? What caused it? And the ones that are most commonly brought up, sickle cell has become the most common recently. In addition to chronic steroid use and alcoholism, right? Those are the three biggest affiliations with AVN. There is a classification, probably the most important part of this classification to understand is the crescent sign. So a stage three. So on a stage one and two, there is still a round head. Maybe there's a little sclerosis on a two, but most of the questions come when you start getting that crescent, a collapse of the humeral head, not unlike a crescent sign in the hip. Remember the upper extremity is not the lower extremity. We don't walk on our arms, therefore AVN arthritis, things like that in the shoulder are better tolerated than they are in the hip. So unless they give you severe pain, failed PT, etc., they want you to treat AVN, at least early AVN, nonoperatively. Maybe an injection, but therapy is going to be the mainstay. Now this, I was kind of all set to tell you don't worry about core decompressions because out of curiosity, how many people in the room have done a core decompression for AVN? One in the back, I'm impressed. Actually it's zero. Does that mean they're not going to ask you about it? Of course not. So core decompression for decreased pressure, increased vascularization, so some studies have said it's reasonable. Here's one of the things though that has been asked. Core decompression less helpful for sickle cell AVN, more helpful for steroids. If you have stage 3, 4, or 5, so this is post crescent sign, this is now collapse, one of the few times that hemiarthroplasty is going to be an answer on this exam is going to be for potentially, and I'll tell you why as we get on, potentially for AVN. But they have to say there's no glenoid involvement, it's like a 28-year-old patient, something else because I'm going to say it probably too many times to hammer it home later on, but almost never, if there's an oxymoron there, do they want you to say hemiarthroplasty. Total shoulder is pretty much the answer for most arthroplasty questions around the shoulder these days. So 35-year-old man, alcoholism, stop there with shoulder pain, probably going to be some kind of AVN question because they said alcoholism. Motion, not terrible, not perfect, but not terrible. Had an injection, no relief. X-ray show collapse. MRI shows AVN. So they're saying non-operative didn't work. So we don't want to do intra-articular hyaluronate, not PT. It's a symptomatic person that's changed. And I told you, this is from the OITE in 2013, but they're looking for a core decompression. Why? 35 years old. So if that's 55 years old, probably not a core decompression, but they should give you a pretty much of an extreme of age if they want to lead you down the core decompression range. And there's a little explanation about that in your handout as well. 39-year-old laborer, increasing pain, two months despite non-operative treatment. Has had intermittent stiffness in the past, but something has changed. Now he's got night pain and weakness. He's got a history of hepatitis and tobacco. And he's intact, and his MRI is here. So he's got collapse. So a hep C, these other disclaimers, they want you to see, this is from the self-assessment in 2015, that there is collapse. So what are we going to do? And this is the age was at, was 39. In this situation, they want you to do, because of the collapse, this is not just an early crescent sign or stage two, there's already collapse. You're not going to do a core decompression for collapse, OK? In this situation, it's going to be the hemiarthroplasty, again, because it's 35. That's why you're not doing a total shoulder. So DJD, and this is where I'm going to become a broken record a little bit. Most of your DJD questions, the answer is total shoulder, not hemiarthroplasty, even for some of the younger patients. And you have to have an intact subscap, otherwise you get a loss of external rotation and you get more glenoid wear. If you have arthritis from a proximal, from a nonunion or a malunion in general, arthroplasty results are worse. And certainly, as we'll talk about, one of the predisposing factors for dislocation after a reverse total shoulder is going to be previous proximal humerus fracture or previous shoulder surgery to that shoulder. If you have a vignette that talks about a previous capsuloraphy, now they've lost motion, typically they're looking for DJD. It's going to be posterior glenoid wear, because it's going to be tight in the front. It's going to be pushing the head posteriorly. And if they talk about a loss of external rotation, of active external rotation, think about could the subscap be off as well, because if it's an old type of surgery, or if it's like this where you have evidence of it open, was the subscap taken off? Usually they'll show you an MRI that might show an evolved subscap, or I'm sure Bill Palmer will show us how to find a subscap on the MRI. But classically, it's an internal rotation contraction, posterior glenoid wear, and again, total shoulder favored over humeral head. Contraindications to a total shoulder. The biggest one is certainly any kind of active infection, but absence of a rotator cuff is going to, or Charcot, et cetera, version, we'll talk a little bit about version. But the biggest thing is lack of a rotator cuff, how you get the rocking horse deformity, which I'll show you in a minute. Now, historically, just in case, when you try to look at the different answers, some of the potential advantages of just a HEMI, less lateralization, less blood loss, less time, but the key to remember is most of the randomized control trials are all demonstrating that total shoulders do better than HEMIs, and you say, we're not dumb, you've told me that five times, but you'll think about me on the test when you get three of these questions, and you'll know right away, total shoulder. There it is again. So complications listed here, but the biggest complication that they'll ask about, and why you may or may not do a total shoulder, is glenoid loosening. So what's the most common complication of a total shoulder? Glenoid loosening. Most common cause for revision? Glenoid loosening. They're not going to ask you about peg versus keel prostheses, nothing like that. As far as what's the role of arthroscopy, for the purposes of the test, a young patient with relatively early, early arthritis, so there's still some motion, but the key is a concentric humeral head. If the head is still round, capsular release is a reasonable option. Unless they kind of tee it up for you with a young patient with a round head, and they show you an X-ray, and there's not a big fight, typically arthroscopy is not going to be an answer to most of the arthritis questions, unless, again, concentric humeral head in a relatively young patient. So a 65-year-old woman had a total shoulder on the left a year ago. Now she can't tuck in her shirt, so she's lost external rotation. What's the problem? As soon as you see can't tuck in a shirt, can't have a total shoulder, again, the subscap was taken off for the procedure. It's subscap insufficiency. They love questions about the subscap, and it's actually a good lesson for all of us in our practice to spend more attention looking at the subscap than we probably do. So 65-year-old man with OA, and this is one of the few that I saw, but it was the same question was on two different, an OITE and a self-assessment test, but it's one of the few that's actually talking about a technical aspect of an arthroplasty procedure. Typically they're not asking a lot of these technical arthroplasty questions, but this was on there. So a pre-op CT scan is shown. Cuff is intact, so that means he can have a total shoulder and doesn't need a reverse. What's the most appropriate technique? So it's not going to be reverse. Why? Cuff is intact. Bone grafting of the posterior glenoid face, well, I can't find anything to bone graft back there, so that's not going to be it. An opening wedge osteotomy, if they ever ask you a question, again, you can have one of the rings, Bruce. The opening wedge osteotomy has an answer, but it's eccentric reaming will come up. Eccentric reaming of the glenoid, buzzword, if you have, if you see here and the version is off. 50-year-old athlete, history shows surgery for recurrent dislocation, so some old kind of putty plaque, magnesium stack, something like that, but it's going to be a post-capsulorophy OA, not much joint left. Debridement should consist of, well, he's 50, so we're not going to fuse him. It's not a concentric head, so we're not going to do a debridement. We're not going to resect it. It's a total shoulder. Fifty-five-year-old, worsening pain, has done lots of non-op treatment, not better. Concentric wear on the glenoid, what are we going to tell her about total versus hemi? That we're going to tell her that pain relief after hemi is less predictable. It's going to come up time and again. So osacromiali, the dreaded osacromiali, love to ask questions about this. Most commonly, it's between the meso and the meta-acromion. That has been a question on a lot of different tests. And the key x-ray, the way you diagnose it, is on the axillary x-ray. Non-op, non-op, non-op for the treatment. So this doesn't project super well, but 56-year-old male with a cuff tear undergoing a decompression and a rotator cuff tear. Here's the arthroscopic picture. They're trying to get us to see that there's an osacromiality right there. Fortunately, when you start thinking, I hope they're not going to ask me what to do about it. Do I resect it? Do I not resect it? Again, too controversial. Instead, they're going to say, what radiographic view of the shoulder is best to evaluate that os? And the answer is going to be an axillary x-ray. So 22-year-old male. So here's an axillary x-ray. You can see that there's an os right there. Presents with this. What's the most likely cause? Well, it's not a fracture. It's not a type IV AC, because in the AC talk, you see how the distal clavicle there is pointing right at the tip of the acromion. But it's a failure of fusion between. And then you've got to pick. Is it the mesacromion and preacromion, or meso and meta? Unfortunately, that's just a memorization tool. Pec major and the triceps. Two parts of the pec major, one from the clavicle, one from the sternum. They rotate about 90 degrees. Innervation, the medial pectoral nerve goes to the clavicular and the sternal head, both. And the lateral pectoral nerve to the sternal head. Internal rotator and adductor. And the thing to remember, the buzz words for pec injuries. All muscle injuries, eccentric, eccentric, eccentric mechanism. In pec, it's always going to be a bench press. So it's a bench press, an injury, painful in the chest or the shoulder, think pec. And oftentimes, history of steroid use. And it's actually interesting, because steroid, the use of antibiotic steroids actually is a better, it causes the tear. But also, patients do better after repair if they've been on steroids. It's an interesting clinical phenomenon. It's usually the final 30 degrees, either when they're locking out, or more when they're trying to re-rack it, and they're bringing the bar back down to go up again. So that's the eccentric load when the pec goes. On exam, they lose that inferior axillary fold. And on the MRI, I thank God I worked with Bill Palmer for 16 years, because I find it very difficult to read a lot of pec MRIs. Something like this is obvious when you have this kind of retraction. But the tendon is so small, it can be very, very hard to get a good read. Is this a muscle tendon tear? Is this a tendon avulsion? Is it surgical, non-surgical? That type of thing. As far as the non-op treatment goes, usually they should say it's a partial tear if they want you to say non-op. Usually, they want you to fix pec problems. And if you fix them, they want you to fix them quickly, typically within six weeks or so. So again, from OITE, during a bench press, when is the pec at greatest risk of rupture? It's either going to be locking out, or when you're trying to decelerate the bar on the way down. That's the eccentric phase. So I'm looking here. That's not the point of maximum elevation, because your triceps are already locked out there. The pec's no longer really firing all that much. So it's going to be during downward deceleration. That's the eccentric phase of a bench press. 23-year-old injures his shoulder during a bench press. Shoulder pain, echemosis medial arm, chest asymmetric, MRI. So you already see that when you hear the bench press, everything else, it's a pec injury. We're going to fix the pec. 43-year-old firefighter, it's going to be another fix the pec. 25-year-old baseball pitcher now. This is actually, I've seen this twice now, it comes up. 25-year-old baseball pitcher diagnosed with an acute rupture of the lat tendon, and of the latissimus dorsi muscle. What is the appropriate management? The only way to remember it is, if it's really rare, and you don't see it that much, whether it's a major tear or a lat tear, and they're asking you about it, don't fix it. When in doubt, they're looking for relatively conservative things. I have a simple mind. That's how I remember it. So in this case, non-operative, and it tells you that if you want to go back and read Marx-Chicken Dance Studies and stuff like that. But lat transfers, no. Primary repair, no. 30-year-old baseball player felt a pop in the back of his shoulder. Now he has asymmetry. So pain, but in the back of the shoulder. Pain in the back of the shoulder. So what lives in the back of the shoulder? Physical exam, he's got full but painful forward elevation. External rotation is limited a bit, secondary to pain. Internal rotation is normal. So it's got to be some kind of posterior muscle around the shoulder. Muscle tensing is good, but there is pain with belly press. So is that subscap involved? And internal rotation of the shoulder. So what's in that area that causes some internal rotation, et cetera, et cetera? So here's the MRI, and you just have to listen to Bill Palmer talk after me, and he'll show you that that's going to be Terry's major. And what do you do with it? Again, because we don't see it a lot, we're going to treat it non-operatively. That's not the clinical reason, but that's my reason. Triceps tear. Often, so pecs are associated with steroids, triceps associated with steroids, steroid use. Exam, palpable defect, can't extend against resistance. X-rays, you get this flex sign sometimes that you see. MRI, treatment of choice. You can see the degree of retraction. Partial tears, treat them non-operatively. PRP and things like that, as a general rule, I don't think we're there yet on these tests. I've not seen the biologic stem cells, PRPs for proximal tears, unless that's like the only non-operative option they give you is PT plus PRP. But in general, it's just going to be non-operative treatment for partial triceps tears. If it's a completely torn, then surgery is going to be the answer. And there's a couple of different ways to do that. The test loves Little League shoulder. So spent a couple of minutes on this now. If you look at these two X-rays here, radiographically, it's widening of the proximal physis. It's an osteochondrosis. And the injury, this has been a question several times as well, is to the hypertrophic zone of the physis. As a general rule, that's where most fissile injuries are going to occur. It's the hypertrophic zone of the physis. The treatment is cessation of pitching. So don't throw. It's not bed rest. It's not you can't run. It's not you can't do anything else. They just want you to say, refrain from throwing. And it's probably for three months. So they can still run. They can still be active. You don't have to tell a kid they can't do stuff. But it's just don't throw. A 12-year-old pitcher comes in with his dad, mild pain for a month. He's playing on two teams. So right away, overuse. Right away, some kind of little league shoulder problem. Traveling, an all-star team. The father was how to minimize his son's risk of injury. Well, I'm not really sure. You have to be in medicine to figure this out. But probably limit the number of his D number one risk factor. 16-year-old pitcher, posterior shoulder pain, decreased velocity and accuracy. The exam shows way too much, a lot of external rotation. But it is a pitcher, so maybe that's part of it. Decreased internal rotation. So lots of external rotation, less internal rotation, even 100 degrees at the side of external rotation. The rest of the exam is normal. MRI shows a small, partial, articular-sided infraspinatus tear. Initial treatment should consist of, well, first of all, if it is a 16-year-old, they don't want you to operate on a shoulder. Secondly, the vast majority of pitcher baseball questions, it's non-op, non-op, non-op, unless they say they've rehabbed for six months and they can't return. What's your next step? So don't operate on throwers on this test, as a general rule, unless they give you reasons why you should. So this is basically a GERD-type question, limited internal rotation. And the buzzword for pitchers with loss of motion, they love posterior capsular stretching. That's going to be the answer. Proximal biceps, things to keep in mind that are going to go together. Partial subscap tears, coracohumeral ligament type questions, proximal biceps. If you see one, especially a partial subscap tear, always think biceps as well. That kind of biceps interval always is going to come together. And remember, it's also very unusual for true pathology of the long head of biceps to happen in isolation. Like, truly isolated biceps tendonitis in a 50-year-old probably doesn't happen that much. Usually, there's going to be some associated cuff problem with it. If you see an MRI, if they give you an MRI like this, where you have a dislocated biceps tendon, they want you to recognize that, by definition, there's going to be some kind of subscap tear, usually an upper border subscap tear, that goes with it. And this is on almost every self-assessment test, OITE, any kind of standardized test that's been out there. Some form of this question comes up. Now, what do you do for biceps? So if it's inflamed, classically, we talk about if it's more than 50% torn, you're going to operate on it. But really, how do you know if it's 50%, not 50%? The question is going to come up a lot. Do you do a tenotomy or a tenodesis? And then, what do you do about the subscap? Diagnostically, so anterior shoulder pain, point tenderness is the big one, positive speeds in Jurgensen's test. The thing to remember is there's no difference in strength between a tenotomy and a tenodesis for the purpose of this exam. You can argue in your own clinical practice what's better for you. For the purpose of this test, they don't want to make that distinction. Maybe in a young patient, they'll bring up something about a patient had a previous tenotomy, 35-year-old laborer, now has spasm. What do you want to do? They'll tell you it's basically a revision type of tenodesis. But as a general rule, the difference between the two they want you to understand is you have to counsel your patient about a cosmetic deformity, a Popeye deformity with a tenotomy. But yet, it's very, very well tolerated in older patients. With a tenodesis, it's the fact that you need an extra incision and have more surgery. So again, no difference in anything except the cosmetic deformity. So denervation most typically associated with the finding in this MRI is most closely associated with what? So it's a cuff type of question. They talk about supraspinous weakness, external rotations. But we talked about this a little bit more previously on my last talk. This is a paralabral cyst sitting in the suprascapular notch, which is going to cause rotator cuff weakness. It's going to cause supra and infra weakness. So I go through these options here. I don't see anything about just the cuff is going to initiate forward flexion. And down here, they said more than that, which is going to be more of your deltoid type stuff. So it's external rotation weakness in adduction. It's going to be the infraspinatus weakness is what they're trying to get at there. In addition to arthroscopic debridement of the joint for an irreparable cuff tear, what will a simple bicep stenotomy most likely produce? This is pain relief. So tenotomy, pain relief, possible biceps are kind of all the things. The reason Popeye is not an answer here is because it says significant strength defect. So significant. So it wants you to say there is not a significant difference between the two operations. Rotator cuff tear arthropathy. So a couple of things. One is they don't want you to take down the CA ligament if you're working on an irreparable cuff tear because of superior escape. Pseudoparalysis, when someone has no cuff, a lot of times they're going to give you some information on the amount of motion someone has because in their mind, that's going to dictate what type of surgery, if any, you need. Is this some kind of primary repair? Is this a hemi? Is this a reverse? And we're going to spend a little time going over that. So in cuff tear arthropathy, symptoms being pain, decreased motion, a lot of times you get this bicep stenotomy. Decreased motion, a lot of times you get this bursal type of swelling, atrophy of the supraninfraspinatus fossa. Typically, for cuff tear arthropathy, we're going to start with non-operative treatment. So PT, injections, et cetera, especially in older patients. Here's the way we talked a little bit earlier, this rocking horse, these old kind of kid's horses that kind of go back and forth. If you don't have an intact cuff, the humeral prosthesis is going to sit on the rim of the glenoid implant and cause loosening. So anytime it's an arthritis question about an arthroplasty, you've got to have an intact cuff to do a total shoulder. Treatment, if you do have cuff tear arthropathy, yes, historically, hemiarthroplasty used to be the preferred answer of choice. But for your purposes, 2018, moving forward, reverse total shoulder is now well enough accepted that, unless they give you some disclaimers in the question, a reverse should be your answer when it comes to cuff tear arthropathy. What are kind of the buzzwords about rotator cuff arthropathy and et cetera? Well, historically, it was going to be for a hemi. If you have a young patient, at this point, it can't be 70. It's got to be like 30, 35. And maintained elevation, you can think about doing a hemi. But again, we talked about the fact that they really want total shoulder. But if you don't have a cuff, you can't do a total. So that's why hemi has a potential role here. Concerns over reverse are going to be mostly dislocation and notching are the two things they're going to ask you about. Scapular notching is common if you have a 155 degree inclination angle. Asymptomatic, but you see radiographic notching, you're just going to observe it. And the risk is necromial fracture. So here's a question. What factor is associated with this increased risk for this complication? So the biggest complication you're going to be asked about with a reverse is a dislocation. The things that predispose you to a dislocation are going to be failed previous arthroplasty, proximal humeral trauma, previous proximal humerus surgery. 71-year-old, insidious onset of night pain, can't raise her arm above shoulder level. PT hasn't helped. Injection, temporary. So they want you to operate on her. So if you operate on her, what are you going to do? She can't raise her arm, so they're telling you that her cuff's not working. They show you an X-ray that shows high-riding humeral head. So again, 2018, the answer is going to be reverse total shoulder, not hemiarthroplasty. 82-year-old woman, one month of shoulder pain. Pretty bad, right? Look at that terrible joint, high-riding head, active elevation. She can actually raise her arm, but she does have discomfort. Now, discomfort, not terrible pain. One month of shoulder pain, 82. They give you a total shoulder right away. You're not going to operate on this patient. Why? Because the symptoms aren't bad enough, and they're only for a short period of time, and it's an older patient. So start with non-op. 76-year-old, left shoulder pain. Two injections without relief. Exam shows minimal active forward elevation, but you have increased posterior. A 30-degree lag, external rotation lag, and a positive hornblower sign. So kind of massive posterior cuff tear. No infra, probably no teres because of the hornblower sign. And you see this. So you say, oh, I know the answer to this. It's going to be an arthroplasty. It's not much of a cuff, high-riding head, so it's going to be a reverse. But, and they were actually nice to you here for a change, because they probably, if they wanted to be really tough, would have had started with reverse, and then down here put reverse with lat-dorsi transfer. It's a little bit of an esoteric question, but it does come up. When they tell you about this external rotation lag, the hornblower sign, all of this, know that there's enough data out there now that they want you to add a latissimus transfer for the increased external rotation when you do your arthroplasty. Now, cuff tears and impingement. A little bit of this is going to be repetitive. Why we started with cuff tear arthropathy, but we know the footprint, where the cuff is, how it's congruent or confluent with the articular margin. The cuff, the role of the supra, and that's on that question I talked about before, when you had the notch cyst taking out the supra and the infra. The supra initiates abduction. It doesn't finish it. So it initiates abduction, and then the deltoid takes over from a biomechanical standpoint, and it's going to be the most common tear. The infra, typically we're going to test that with the arm at the side for external rotation. And then the subscap, things to remember about the subscap, it blends with the coracohumeral ligament. It's the strongest internal rotator. and we test it with either a lift-off test, a belly press test, or a bear hug. Now if we look at the basic science of a cuff, it's type 2 collagen. The tendon itself is type 1. At the insertion site though, near bone, it becomes type 2. Functionally, the most important thing for the test purpose is that the cuff functions as a mid-range stabilizer of the glenohumeral joint. Right, so not the extremes of motion, but as a mid-range stabilizer. Functionally, supra initiates the abduction and a little bit of flexion. Primary internal rotator, external rotator, and both again, same thing with the teres minor. When you get past 30 degrees of abduction, there's obligate superior head translation, which is why the cuff is important, which is why you go on to get cuff tear arthropathy. Natural history, and this is why if you get a vignette about a small cuff tear in a 75 year old that's not symptomatic, they don't want you to fix it. Many can be asymptomatic, but usually they're going to give you a framework of the exam, how much weakness they have, and how much pain they're having. As far as a question that will come up a lot is, 45 year old skiing, falls, dislocates their shoulder for the first time. Your next step in treatment should be, your next diagnostic test should be, you know, how should this patient be handled? They want you to differentiate in instability. Any patient they say dislocates over the age of 40, think of cuff first, so it should be examine the rotator cuff, MRI of the rotator cuff, something about the cup workup for a cuff. If it's under 20, that's an instability path type of question, but assume when you do get that history that it's a rotator cuff question for our dislocation over 40 until proven otherwise. And by cuff, that can not only be a supra, but also a subscap tear as well. Outlet impingement, you can see here, so a little ossification of the CA ligament, decreases the amount of subacromial space associated. It is associated with partial cuff tears, classic near type of impingement sign, examination or the treatment being injections, physical therapy. The most common, the most sensitive sign for impingement, for outlet impingement, is the Hawkins exam maneuver. So Hawkins test, remember near, straight forward elevation, Hawkins, forward elevation, 10 degrees adduction, internal rotation. Hawkins test, most sensitive for impingement. Painful arc between 60 and 120 degrees, different types of acromial morphologies, that's falling less and less out of favor now, but they will sometimes show you a calcified CA ligament. Now with imaging, about partial cuff tears versus full cuff tears, and Bill's going to go over this in more detail, so I won't, but just know that it's going to come up, you seldom, if ever, is operating on a partial cuff tear going to be the answer. Unless they said they've already done all the PT and everything else, do not operate primarily on partial cuff tears. Non-operatively, it's going to be PT, it's going to be injections. If you do have a cuff tear, obviously here's your options. For patients with severe external rotation loss, whether you do an arthroplasty or not, latissimus transfer still kind of comes up from time to time. And to do a lat transfer, you do need to have a functioning subscapularis. All right, so surgically, if it does come up that there's a partial tear that has failed non-operative treatment, typically, unfortunately, 50% is still the rule. They don't give you any kind of anything else to go by. So you debride it if it's less than 50, you fix it if it's greater than 50%. For full thickness cuff tears, you want to repair them. The non-operative treatment, again that vignette that we talked about, is if it's an old patient, chronic problem, minimally symptomatic, maybe just a loss of 10 or 20 degrees of motion, you can start with non-operative treatment for that patient. The biggest complication of rotator cuff repairs are recurrent tearing. Okay, stiffness can be a problem. If an infection comes up, any infection around the shoulder, whether it's for, usually it's going to be more of an arthroplasty question, but any infection about a cuff or a arthroplasty, think P. acnes. All right, that's probably the most common isolated organism around the shoulder. There's definitely been more than a few questions that have come up about that. What is the role of a decompression, or probably more accurately, what is the role of an acromioplasty? It's going to be a type 3 hooked acromion like this, distal clavicle excision. Probably the biggest type of thing you'll be asked is indications, when to go from non-operative to operative. So again, they should say it's usually going to be a weightlifter. They had, you know, distal clavicular osteolysis has failed, has had two injections without benefit, what's your next step, etc. That's when you're going to do your excision, but it's going to be cross-body adduction, point tenderness, but do not recommend surgery just because someone's got some AC joint OA on an x-ray. So if they show you an x-ray or an MRI like this, all right, and they just show, you know, what's the next step in here, there has to be something about the amount of symptoms that they have, because there's been more than a few times that's come up with a, they're trying to get you to not operate on, it's not a radiographic diagnosis, all right, it's a clinical diagnosis. The only thing that's radiographically potentially symptomatic with it is bone marrow edema, and so if they show you an MRI like this and say, you know, what's the most likely cause of the patient's pain or whatever, that's AC joint arthritis, because you see the associated bone marrow edema here. But again, it should be some kind of clinical vignette about it. Single row, double row, things to know there. Double row, they'll say, what's the advantage of one over the other? Single row is better this, double row is better that, one's less expensive. Double row has been shown to have higher healing rates, but for the purpose of the test, there is no clinical evidence of better functional outcomes with double row versus single row, okay. Post-op, they want you to be conservative. Whether you do this in your own practice typically or not, they don't want you to do a lot of PT or a lot of motion for the first six weeks after you fix a big tear, and certainly no strengthening for at least 12 weeks. Do they heal? It's going to be a lot of pointing towards the fact that there is a high radiographic incidence of rotator cuffs not fixing or not healing. That being said, just because they show you this MRI, previous surgery, didn't heal, what should we do? And by the way, they're a smoker, a diabetic, these are all, all of these things have negative influences. They only want you to operate again if the patient is symptomatic, because the studies will show that even if you have a failed cuff repair, pain relief can still be good, function can still be improved. So correlate what the patient's exams are with whether the cuff tore or not. And then remember that a massive tear, if they show you one, it's not the same as irreparable. Typically an irreparable, if they show you a humeral head that's engaging the acromion, that is not something they want you to fix, right. That's something that's going to get replaced. Now just a minute or two on calcific tendonitis, because there's generally a couple of questions on this. Calcific tendonitis is self-limited. It can actually take years to resolve. The symptoms tend to come and go. It's almost always embedded in the supraspinatus tendon near the greater tuberosity. And the bigger the deposit, the more symptomatic. Pearls from the standpoint of the self-assessment exams. First of all, it's the difference between the formation phase versus the resorptive phase. While it's being formed, they tend to be a little bit more symptomatic. What you want to do is you want to treat them non-operatively as much as possible. And there's really, for the purpose of the test, there's not a role for shockwave therapy. So whether you do it in your practice or not, it's not the issue. We're not saying anyone's doing something right or wrong. For the purpose of the test, it's going to be PT, but it's going to be injections. And they don't want you to operate on them unless everything else has failed, because they'll think that's going to cause the cuff tear, because you have to take the calcium out of the tendon. So relatively any, even for something this big, short duration of symptoms, limited size of deposits, cuffs intact, injections and anti-inflammatories. Ultrasound, shockwave, don't answer that one. Who do you operate on? So people who have failed the non-operative treatment, big deposits, continued pain, in which case you can do a decompression and likely some kind of cuff repair. So six-week visit after an arthroscopic repair of a cuff tear, patient's not yet attended formal PT. What is the outcome at one year? So they love this about the fact that they don't think PT makes a difference for if you start early versus start late. Again, whether we believe that, whether that's your protocol, for the purpose of this test, things that's like CPM after ACL questions, theoretically no benefit. Doesn't matter whether we use them or not. CPM is not supposed to be a big difference. Formal PT is not supposed to be a big difference for long-term results. 24-year-old right-hand dominant javelin thrower, comes late, can't work up. At the end of his follow-through has a sharp pain. He's unable to continue throwing on exam. He's tender over the biceps. Full passive range of motion, positive O'Brien's, so telling he's got a slap. Weakness of internal rotation and a positive liftoff test. All right, so liftoff test is going to be a subscap though. So we have something about a slap, something about a subscap, and then the hornblower's test, so the teres is intact. Here's the MRI, so labral tear, cyst, but the bigger issue is, here's the subscap to here, and the biceps is dislocated. You see that there? So they want you to see that it's perched there, and they want you to fix the subscap. 30-year-old pitcher, recent onset of weakness and inaccuracy, velocities down, tender lateral and anterior to the acromion, so over his cuff. Mark weakness of external rotation. Here's an MRI. Here's another cyst, so the infra is going to be involved. Why? Because it's going to be below in the spinal glenoid notch. 55 year old woman, pain in her right shoulder for five days, keeps her awake. She states the pain is in her shoulder and grabs the area of her humeral head. So very symptomatic, keeping her awake. Calcific deposit, positive impingement, you would suggest PT and injection for calcific tendonitis. 52-year-old, look at the sag, you can see all this fatty atrophy. This is really not something that's going to get fixed. So right away, you can't fix it if you're trying to restore your motion, external rotation, so significant weakness of external rotation, lat-dorsi transfer. I've shown you a lot more questions on lat-dorsi transfers than you would think. It's not something we do talk a lot about now or we do so much clinically, but it still hasn't kind of fallen off favor on some of the exams. So 80-year-old tennis player falls, first time dislocation, which is reduced. Two weeks later, complains of difficulty raising the arm. What's the most likely diagnosis? So this is kind of a gift at 80. They probably could have said 60 or 50 and made it a little bit tougher, but rotator cuff tear, and look how many times this has come up just in the not too distant past. So older patient, dislocation, cuff tear. 56-year-old laborer, subcoracoid dislocation. Three weeks ago, can't actively raise his arm. What's the most likely diagnosis? If you look at it, cuff tear. I was trying to find something to trick us, but it's just cuff tear. Unable to actively externally rotate the shoulder when the arm is in 90 degrees of abduction and neutral rotation. So that's hornblowers, right? So hornblowers test the posterior or the very, very posterior cuff. Tears minor. If they said external rotation lying at the side, that's more infra, but up at 90 degrees, that's a hornblower sign. Tears minor. Risk factor with non-healing, smoking, yes. Age, definitely not smaller. Age has not been shown definitively to make a big difference, although probably a lot of us think maybe the vascularity is worse. Maybe it is. Early repair of an acute tear, no. As much as we like to think that workers' comp, or know that workers' comp patients may have worse subjective events or subjective results, the objective results are not different. So, oops, sorry. So that's actually should be smoking. 48-year-old arthroscopic cuff repair. Infra is mobilized to the footprint, but the super cannot reach. What's the appropriate treatment? So in this case, the partial cuff repair is fine. They don't want you to switch midstream and go to something you didn't talk to the patient about, which is a tendon transfer, which is a reverse, etc. 68-year-old man, shorter weakness, but no pain. Exam shows atrophy and weakness. What's the most appropriate treatment? Non-surgical. Okay, so no pain. Here's the tear, about two centimeter tear, but again, telling you that there's some weakness, but everything is actually okay from a symptomatic standpoint. They have to talk about more pain and weakness. So almost done now. Subcoracoid impingement. I'm not going to talk much about. It's very, very rare to get a question. It's a lateral, it's impingement of the lesser tuberosity against the coracoid. The distances, you won't be asked the exact distances. They just want you to know that this does exist. Seldom, if ever, do they want you to operate on subcoracoid impingement and do a coracoplasty or anything like that. At most, it would be an injection. Okay, and then last, just on the subscap. Subscap is great fodder. You're going to be asked something about the subscap. So clues, if you have a very anterior supraspinatus tear, a biceps subluxation or dislocation, falling, and they talk about increased passive external rotation, positive belly press test, positive liftoff test that goes with a subscap, but especially the biceps, those are the keys. And a subscap tear is literally something about almost every OIT or self-assessment that I looked at, there was a question that had a dislocated shoulder with something about a subscap on it. On exam, increased passive external rotation. We talked about the other ones. The MRI, right here, on the axials, you want to start at the level of the coracoid. Look for your biceps here being subluxed or dislocated. Look for an anterior supraspinatus tear. Treatment is going to be some kind of repair. They probably should not be asking, I have not seen them ask you to truly differentiate between open versus arthroscopic. It's just repair or no repair at this point. Most of the time, if you are doing especially an open subscap, it'll be a biceps tenodesis would be the answer, and there's no evidence to do a coracoplasty or anything else like that. So 23 year old football player, contact injury to the shoulder, an external rotation, immediate pain and swelling. Exam shows internal rotation weakness, increased external rotation. So right away, might there have been a dislocation or a subscap rupture. Positive lift-off test subscap. What's the most appropriate treatment? It is going to be an open subscap repair. 35 year old labor, here's that MRI again with a perched biceps and a torn subscap. What serves as a landmark for appropriate placement of the anchor for the upper border of a subscap repair? And that's just a memorization thing. It's going to be the superior glenohumeral ligament and the coracohumeral ligament. 20 year old college football player, hyperextension injury to the shoulder four months after undergoing an anterior capsular shift. So notice it doesn't say an arthroscopic anterior capsular shift. So they want you to assume it's an open one, four months later. So could the subscap was probably taken down? Could it be pulled off? Two weeks later, anterior tenderness, unable to lift the dorsum of his hand away from his back. So positive lift-off test, most likely subscap rupture. So here's an empty groove, biceps in the joint, 25 year old carpenter falls on his outstretched arm. Positive lift-off test, because why the subscap storm? All right, so I'm gonna let you go through the rest of those questions. Just remember, subscap, biceps always go together. Non-operative for most of the things that we don't do that much, lats, teres, minors, etc. And with the biggest thing on the arthroplasty, total shoulder over hemi. And if you do a reverse, dislocation is the biggest complication and prerequisite or the predisposing factors are previous shoulder surgery, previous arthroplasty or fracture. All right, so good luck. Take care.

shoulder injuries

muscles in shoulder movement

rotator cuff tears

impingement syndromes

calcific tendonitis

subscapularis tears

surgical procedures

arthroplasty

tendon transfers