Welcome, everybody. I've been lucky enough to be a part of this course for a while now and it really is probably of all the courses I've been to either as a participant or as a faculty, I think it really is the best from a sheer knowledge standpoint. You're going to be overwhelmed with knowledge. The good part about the knowledge you're going to be overwhelmed with is it's 90% of it's going to be on the test. This is unlike a lot of residency programs where we try to say, oh, you know, we don't train residents for tests. We train them to be great surgeons. We want to train you for the test. Okay? Period. So I think that's what all these talks are geared towards. And along those lines, first of all, I've got nothing specific to this talk to disclose, but if you see this laundry list, we're going to move a little bit quickly because we have an awful lot to go over. So I apologize for that. I know we don't like to overload talks as much, but pretty much everything we go over has been on a test, OITE self-assessment board. As you can see in the highlighting, I know it's going to be a long day, but I've highlighted the stuff that comes up over and over. It's going to be in yellow. So if you say, well, he says I got to know this, but do I really have to know this? If it's bold in your handout or it's in yellow, it's been used a lot. Okay? So moving forward, we're going to kind of go through all this whole laundry list here. First, stiffness. Stiffness in the shoulder. The key thing when we start trying to sort through questions about stiffness is, is this an adhesive capsulitis intra-articular problem or is this a post-surgical onset of a stiffness from either a capsuloraphy type of procedure? Is it from a subacromial procedure that may have caused some adhesions? That's the first thing to sort through. If it's a capsulitis, there's a couple of key points about it. First of all, adhesive capsulitis, you have a thickened and contracted capsule and you have a significant loss of motion. Now it doesn't have to be a global motion. It doesn't have to be elevation external and internal. It can be one more than the other, but typically it's going to be more loss of external rotation than some of the others. The key associations to remember are diabetes, diabetes, diabetes, as well as hypothyroidism and female. Okay? Those are the main associations. They talk about the essential lesion being a contracture of the coracohumeral ligament. I like to, rather than think of the coracohumeral ligament, just think of it as when you're looking at a patient that has adhesive capsulitis, think of that rotator being the capsular interval. So just above the subscap, behind the biceps, beefy red inflamed superior glenohumeral ligament, coracohumeral ligament. That's the key area. And then what does that area prevent? External rotation and adduction. Kind of the simplest way to think about this is the painful freezing phase, frozen phase, thawing phase. The punch line is you just don't want to operate early during the freezing phase. If you're going to operate, it's going to be at least six months. Never operate on adhesive capsulitis for the purpose of the test before six months. And do it once. It's less painful but more stiff. And then they try to pick out which part of the capsule or what part of the motion is lost the most. Remember that external rotation and adduction is kind of contracture of that rotator interval. External rotation and abduction, anterior inferior capsule, the anterior band of the inferior glenohumeral ligament. And then internal rotation, posterior capsule. Now this comes up quite a bit. They want to lead you down, you know, a 40-year-old diabetic woman presents with stiff shoulder, but by the way, she fell off her mountain bike, et cetera, et cetera. Just rule out, make sure that you don't get, and they show you an AP only. If you look at that, you can kind of get a feel that there's something wrong there. You want to make sure there's no dislocation involved. And so you're always going to want to make sure you have at least an axillary view as well as an AP. That's the one thing to try to get you tripped up on. But other causes of stiff shoulder, obviously, high-riding humeral head and arthritis. I can't remember the last of all the tests and prep tests I've taken. I can't remember someone, an answer that said operate on adhesive capsulitis unless they said it's been a year, they've had three injections, they've had PT, not getting better, what do you want to do? Okay? The vast majority of questions about how do you treat this, non-operative, non-operative, non-operative of injections, they like you to do glenohumeral injections as opposed to subacromial, but usually they don't get that specific. And, but it's really stretch, stretch, stretch. Remember, the long-term results of adhesive capsulitis is even if you treat it non-operatively, you can often still get a little bit of soreness, but the number one complication of non-operative treatment is persistent lack of motion compared to the contralateral shoulder. Hydrodilation, never going to be an answer. Straight manipulation. Okay? A lot of people, they really don't want you to do a straight manipulation on a test because of the risk of fracture, dislocation, axillary nerve injury. So if they lead you down the path, and I'll give you an example of that, but of wanting you to operate, it's going to be a capsular release with a manipulation. All right? So the release first, and then you manipulate. And then for the post-op rehab, it's as you might expect, the key is no glenohumeral pain catheters. Glenohumeral pain catheters equals chondrolysis for this examination. And if you look at the results, obviously what's the risk, biggest risk factor for poor results after a capsular release? It's going to be diabetes. So question, 47-year-old woman, painful stiff shoulder, and treatment spend, all right, so here's an example where they said, I've done an injection, anti-inflammatory is ineffective. Mark limitation, but what does it say? You want to, if you just read the second sentence, you're going to say, I'm going to operate on that. Everything else is normal, but here's the key, three months. All right? If that had said nine months, after that you're going to operate on it, but three months, look at timeframes, and look at what previous treatment are. Anything under six months, you're not going to operate on for adhesive capsulitis. Idiopathic adhesive capsulitis, no, it's females. No, no, no, diabetes, diabetes, 50-year-old man, stiff after slap repair. By the way, this test hates slap repairs. I don't care if we like them, or you like them, or I like them, the test hates them. The only time they want you to do a slap repair is a general rule, sorry Julie, I don't want to take away the thunder from the test here, Dr. Bishop's going to talk to you about this shortly, but is if they give you a spinal glenoid notch cyst. Is that basically right, Julie? That's pretty much when they want you to do it. So, but short of that, they're going to say, you had a slap repair, now you're stiff, what do you do? So this is one of those post-surgical stiffnesses, not a primary capsulitis. They're saying that you got a lack of motion, so in that situation, you're going to have to do a capsular release. 50-year-old tennis player, right shoulder pain, again, on and off for three months. Positive impingement signs, it's mostly loss of external rotation and abduction. What are you going to do next? Look at the MRI. So not a great MRI, I agree, but it's going to be basically 50-year-old tennis player's primary adhesive capsulitis. So injection PT, glenoid humeral injection PT. 47-year-old man falls on an outstretched arm six weeks earlier, immediate pain, limited motion, here's the x-ray. All right, so what do we talk about? What do you got to rule out? If there's a history of loss of motion with a trauma, chronic dislocation, so be careful of that. So you need an axillary radiograph. They're going to say, you know, what's the diagnosis or what do you need to make the diagnosis, what's that next step? Always need two orthogonal views. All right, AVN. Remember, AVN of the shoulder is not AVN of the hip. Very, very different, different prognoses, different outcomes, different vascular considerations. If you look at the most common etiologies that they're going to ask about, it's going to be chronic prednisone steroid use, sickle cell, especially in some of the athletic questions that you're going to be asked, and then alcoholism. Typically, they're not going to talk about barometric pressures and scuba divers and all this other stuff. It's going to be steroids, sickle cell, alcohol for this exam. Just like in the hip, the break point for your treatment is going to be that, remember in the hip, FECOD classification, type 3, crescent signs, et cetera. It's the crescent signs. So when you're looking at AVN questions, just like DJD questions, it's going to be the sphericity or the concentricity, good words, sphericity and concentricity, but it's going to be a round humeral head. If it's still round, it's going to be non-operative, PT, et cetera. If it's starting to collapse, that's when they want you to operate and think about operating. All right, so that really, that crescent sign, the stage 3 here where it starts to collapse, again, that's in yellow, that's the part of AVN to remember. Non-op, definitely the mainstay when you still have a round head. It's interesting, you know, we as sports medicine physicians don't think a lot about core decompressions of the proximal humerus. I can't imagine, I can't remember ever seeing one in practice or hearing about one being done, but they do ask about it on a couple of the tests. Rarely are you going to do surgery for stage 1 and 2. It's really this stage 3 that the first time you're going to think about maybe a core decompression, that stage 3 is the crescent sign. Now, this is where it starts to get a little bit more controversial. For the purposes of the test, for young, active patients who might still have, who might get a collapsed head, hemiarthroplasty still is getting answered up until about a year or two ago as the treatment of choice. You can argue, we can argue, is a total shoulder better for pain relief, et cetera, et cetera, but they're going to, as long as there's no glenoid involvement, hemiarthroplasty is still kind of the key here. So, 35-year-old with alcoholism. So, alcoholism and shoulder pain, we're already thinking about AVN. Exam, some limited motion, already had a steroid injection, no relief, and again, pain for several years. Time frame is critical in all these questions. X-rays, no collapse, but MRI shows AVN. What's the best treatment option? So, young person, long, they want you to operate. You're not going to do a hemi if someone's got no collapse, core decompression. So, they're leading you to how to preserve a young patient with a round head. First non-op, when that doesn't work, preserve the joint, core decompression. 39-year-old laborer. So, that's the key. They're going to tell you, when they tell you it's a laborer, they're telling you, this patient is going to load that shoulder. It's going to be, needs to be something, it's not going to be probably a prosthetic. What do you need to do? So, intermittent shoulder stiffness would work in the past, but state that something has changed, right? When something changes, your treatment has to change. Hep C, tobacco use, images shown. Here's a collapsed head, starting to collapse from AVN. What do you want to do? Well, when you have a collapsed head, you're not going to do a core decompression, you're not going to do an arthroscopic debridement for a collapsed head in a laborer. Here's that question again, total versus hemi. You're not going to do a total shoulder on a 35-year-old with, who's a laborer. Whether you wouldn't practice doesn't matter for this test. You're not going to do it. It's a hemi. Arthritis. Different types of arthritis you want to go through. Primary osteoarthritis versus RA. Most of your questions for sports tests are going to be along the post-capsuloraphy arthritis and primary osteoarthritis. The key, and I'm going to be a little bit repetitive here as we go through, because it always comes back to the same type of thing for this test. Total shoulder is, in 2019, is the answer over hemi for better pain relief, lower complications, and I'll go over that in a minute. But that's the primary thing. The second thing is, other big thing for this is, for arthritis, the questions are going to be a lot about post-stabilization arthritis, post-capsuloraphy arthritis, loss of external rotation, previous surgery. Those are the general categories that we're going to talk about. The reason that's important is a lot of the patients we're going to be seeing now that have arthritis that have capsuloraphies in the past or something, that also allows them to ask about subscap insufficiency on the one hand, or over-tightening of the subscap, which led to loss of external rotation. And that's going to influence not only how you treat it, but the pathology. Increased posterior glenoid wear, contractures. If there's more posterior glenoid wear, you can ask questions about when you treat, if you do a total shoulder, you've got to eccentrically ream, so preferentially ream the anterior side because you have posterior wear, and I'll go over a little bit about that here. So with the arthritis, the primary thing with arthritis is that stiffness, when you have arthritis due to AVN, and you then operate on it, the shoulder tends to be more stiff when you do an arthroplasty or surgery for AVN than if it's for primary osteoarthritis. And also, if they talk about, if you have a shoulder like this and they want you to do, so what is the risk factor for a poor outcome from an arthroplasty, etc. If you do a previous osteotomy, you have worse outcomes after you do a total shoulder than if you don't. So again, post-capsuloraphy arthritis, younger patients, usually severe loss of motion, particularly external rotation, and beware that subscap insufficiency. Posterior glenoid wear, internal rotation contractures, and I'm going to say this about five more times before the end of this section, total shoulders favored over hemis. Indications, when is it time to answer for surgery on this examination? Pain unresponsive to non-operative treatment, and a minimum of six months of non-operative treatment. Six months seems to be the magic time when we're allowed to operate. Contraindications for total shoulders is really, the biggest one is going to be lack of a cuff. And more and more with each year, there's more and more questions about reverses to the point where it almost seems like they want you to do reverses more than standard, but we'll get into that in a sec. Now, potential advantages of a humeral head replacement or a hemiarthroplasty. Theoretically less lateralization of the joint. The biggest though is going to be no glenoid loosening because you're not putting a glenoid in. The problem is that you end up wearing out your glenoid. But advantages of the total shoulder is going to be randomized controlled trials demonstrate improved pain relief with total shoulders over hemiarthroplasty. There's been a couple of questions about peg versus keel glenoids for loosening. It doesn't matter. And they shouldn't be getting into that much detail now, but there are a couple of questions about that. Complications of total shoulders. The biggest one is subscap failure. So patient has a total shoulder. They come back to you. You know, they fail. They have some pain. You notice they have increased external rotation. Subscap failure after a total shoulder gets brought up a fair amount. But the biggest, the number one complication they'll ask about or look for after a total shoulder is glenoid loosening. Now, what about arthroscopic? Indications for arthroscopic should be we like to do arthroscopy. That's our field. They know that. So they're going to ask you when should we be doing arthroscopy for patients with arthritis? Just like with the AVN, you have to have a concentric head, a round head. Anything that doesn't say concentric or a round head, you are not going to do an arthroscopy for arthritis. They want no severe contracture, but that's normally because severe contractures are not only soft tissue, but these are the osteophytes as well. But again, key, concentric humeral head. So a 65-year-old woman had a total shoulder a year ago. Now she can't tuck her shirt in. What is this motion? That's liftoff test, right? Total shoulder, something changed, I can't do a motion, subscap, subscap, subscap. All right, that should be the first thing you start thinking about. 65-year-old man with arthritis. Here's the CT scan. All right, so what do we talk about? Primary osteoarthritis tends to have posterior glenoid wear. You look at this like I got to do a total shoulder. But it's not just, they're not just going to let you do a total shoulder. How are you going to address this posterior wear? It's going to be eccentric reaming to bring down the anterior part of the glenoid to match the posterior. You're not going to do, I can't remember the last time someone wanted you to do a glenoid osteotomy on a sports test. Okay, glenoid osteoarthritis and posterior bone grafts, they're going to get thrown in as options, but it's really, really rare unless they really lead you down that path. Don't jump to those answers. 50-year-old athlete with severe loss of motion, they show you this. Okay, so staple capsular or if he's putty plat type thing, mag stack, one of those procedures. Severe pain, so when they say severe, they don't want you to do non-op treatment anymore. 12 months, again, not going to be non-operative. Underwent surgery 22 years ago, so what are we going to do for this patient? He's 50, so we're not going to do a shoulder fusion. We're not going to do an arthroscopic debridement. We're not going to do a resection arthroplasty and we're not going to manipulate him. So, total shoulder pain relief in this post-capsular orthoarthritis. 55-year-old woman, worsening pain, failed numerous trials, numerous of anti-inflammatories, so you're done with that type of approach. MRI shows severe joint space narrowing, concentric wear, intact cuff. So, you start thinking about what the guys, but, oh, why don't they just ask me this? When counseling patients, total shoulder versus humeral head, what's the most appropriate? Gil was a broken record during my sports review course. The answer is going to be pain relief, right? This is almost on every test. Okay, osacromiales. How many people decide to carry osteoarthritis every year? How many people have treated an osacromiales surgically? Really? That's amazing. I think they probably have seen me a lot more than I've seen them then, but the key is junction of mesacromiales, mesacromian, and metacromian. How many people remember that? Yeah, me neither, but it's going to be on, it is on a test, and the key, the way you diagnose it is the axillary x-ray is the most important x-ray. So, when you're looking at it, primarily they want you to treat osacromiales non-operatively. The only time they want you to operate on them is if they show you they're a displaced os, or they say give you a sign of severe impingement syndromes or blocking motion, but otherwise it's non-operative almost all the time. You don't want to excise the os. That's never going to be an answer because of deltoid dysfunction. If they do lead you down a surgical path, it's going to be an ORIF of some sort. So, a 56-year-old man, rotator cuff tear, having a repair and doesn't show very well, but here's an osacromiale right there. What radiographic view is best? Axillary view. 22-year-old, right here, another os. What's the most likely cause? They want you to jump to, and of course they give you acromial fracture first, but it's not. Now you just have to remember, oh my God, so I know it's an os, but is it the preacromial? It's meso and meta. So, it's more posteriorly. The preacromial is just going to be the tip. Just think of it as the fact that the more posterior in the acromion, the bigger the part of the acromion that's involved, the more that's involved, the more potential symptoms, so that's got to be where the problem is. Meso and meta, more posterior in the acromion. Pec major and triceps. So, pec major, got the clavicular head, sternal head, rotate about 90 degrees to insert on the humerus. Medial pectoral nerve for the clavicular head, lateral pectoral nerve for the sternal head. The pec, powerful internal rotator and adductor, and like any muscle, whether it's a hamstring or a quad, eccentric, this is the buzzword on this test for any muscle injury, is eccentric loading. Eccentric loading causes muscle tendon injuries. That's when you rupture. Also, always think of bench press. Just like water skiing for proximal hamstring injuries, if they ask you a question about a pec, it's usually going to be, it's either a linebacker in football, but more commonly it's bench pressing, and it's going to be on the eccentric phase of a bench press. On physical exam, in addition to ecchymosis, it's loss of the inferior axillary fold. When you get your MRI, you have to ask more, it's not a shoulder MRI, it's really a chest wall view MRI, but if you look, these can be hard to read. Okay, so here's the kind of tip of the tendon retracted medially. Treatment, there's really very little role for non-operative treatment of a complete pec rupture. It's going to, if they say partial tear, yes, but otherwise, they're going to want you to fix it, they want you to fix it soon. They really don't care as much about whether it's a tendon avulsion, which is usually what they really want you to fix, but even for the purposes of this, if they say acute muscle tendon injury, it's still going to, in an athlete, it's still going to be surgical, what they're looking for. And even if it's a chronic tear, you can fix it either with primary or with an allograft. So, question, during a bench press, when is the pec major insertion at greatest risk of rupture? So we, you know, if you just think quickly, you've got to think, if you take it off the rack and you're starting to go up, but it's not, that's a concentric contraction, is as you're starting to lower the bar down, so it's going to be during downward deceleration, eccentric contraction of a bench press. Twenty-three-year-old athlete bench pressing, what's the best treatment? Bench press, twenty-three-year-old athlete, you already know he's going to fix his pec. Forty-three-year-old firefighter opening a fire hydrant, same type of thing, acute severe onset of anterior shoulder pain, ecchymosis, loss of normal axillary fold, here's the tendon, fix the pec. Now, along the lines of, because we are sports docs, they're going to ask pitching questions. When you hear pitching questions, there's labral tears, but also think about lat and think about, as we talk about in my next talk, vascular issues, axillary artery, thromboses, things like that. But so a pitcher is diagnosed with an acute rupture of the lat. How many people have fixed a lat? Really? It's two more than most, three, that's a lot. So that just tells you, if none of you have done it, you're not going to do it for the test either. Okay? So the treatment is, for the purpose of just this, for the exam, Mark Schickendance is the guy that wrote the article on this. Pitching, lat, you actually do see this a fair amount in throwers, lat injuries, but you're going to treat them non-operatively. Thirty-year-old baseball player, prints to the office after injuring his shoulder, felt a pop. When you feel a pop, it's bad, whether it's your knee, your shoulder, back of the shoulder, asymmetry when he looks at his posterior shoulder in the mirror. That's a typical baseball player for you, checking himself out posteriorly in the mirror. Physical exam, full but painful forward elevation, external rotation is limited, internal rotation is normal, but there's pain, mild pain with belly press, and internal rotation. So no asymmetry of the pec, and a little bulge at the inferior border of the scapula. So basically, what lives at the inferior border of the scapula? It's a pitcher, a bulge, it's going to be, it's not going to be the infraspinatus, right? That doesn't cause it to get balled up. This is going to end up being, right down here, teres. And they want you to, sorry, they want you to have limit weight lifting, but it's a teres injury, right? It's a partial tear of the teres. And again, just like for the purpose of the lat, you're not going to fix it. Triceps, people that get a lot of triceps injuries, offensive lineman in football, and you think offensive lineman in football has historically been some kind of association with anabolic steroids, so that's just how you kind of remember what the different associations are. If they're partial, you can treat them non-operatively, but if you see this flex sign, you see this kind of piece of bone that's avulsed, they're going to want you to fix it. MRI test of choice, again, partial teres you can treat non-operatively, but for complete teres, we're going to operate on them. You guys hanging in there? All right. Little League shoulder. Little League shoulder, I guarantee you you're going to have questions about Little League shoulder. Important topic, but it's always the same questions. So, widening, first of all, you want comparison x-rays. You're going to have widening of the physis. It's an injury to the hypertrophic zone of the cartilage. The treatment is at least three months of no throw. Okay? Anti-inflammatories rest, but it's limiting throwing, limiting innings pitched. So, a 12-year-old pitcher comes in with his dad. He's had mild pain for a month. He's playing on two teams, so as soon as someone says this kid's playing on multiple teams, you know this is going to be an overuse, too many pitches, probably Little League shoulder, traveling all-stars, et cetera, et cetera. How do you minimize his risk of injury? Limit the number of pitches. They don't want you injecting kids. They don't want you operating. Limit the number of pitches. 16-year-old collegiate baseball player. That's a young collegiate baseball player. Posterior shoulder pain, decreased velocity and accuracy. When you examine him, he's got basically, look at total arc of motion. So, on his throwing shoulder, about 160 degrees, and then on his non-opposite side, 170 degrees. So, with throwers, it's not just the absolute number. All throwers have increased external rotation, some decreased internal rotation. It's just, it's an altered arc of motion. So, what's really important is what's the total arc? So, they're telling you, in this case, that the total arc of motion in this thrower is decreased. Decreased arc of motion, pitching question, they want you to stretch the posterior capsule, okay? Proximal biceps. Proximal biceps, any pathology of the biceps, also think subscap, coracohumeral ligament, any kind of biceps subluxation, they want you to make the association with a subscap problem. And it's very, very rare to have any question or any pathology of a long-headed biceps in isolation. Normally, it's going to be an association with a rotator cuff tear. It's particularly a subscap. And as you can see here, this has been for multiple self-assessment tests, OITs, asked about this problem. So, instability of the biceps, always associated with upper border subscap and rotator interval type tears. Diagnosis, anterior shoulder pain, sometimes you can get some clicking or pain. But things like speeds tests and Yergeson's tests are, you can pick them up, but it's very nonspecific. Usually, it's going to be more of an MRI that's going to make the diagnosis. So next is the question of tenotomy versus tenodesis. and I'm sure we all have thoughts about this in our own practice. Try to focus less on maybe our own personal bias and just kind of for the purpose of this exam, what do they look for? First of all, there's two things that happen with a tenotomy that they come down with. The only real complication of a tenotomy, the biggest one, is a cosmetic deformity or a Popeye deformity. That'll be when they ask what's the biggest risk of a tenotomy, it's cosmetic. Now, if they say 30-year-old laborer, et cetera, that they might want you to think about spasm being a problem if you don't do a tinnadusis, but the main thing is gonna be cosmetic, not necessarily a big loss of strength, okay? And it can be a good adjuvant to an irreparable cuff tear. If you're not gonna do a reverse or something else, you can do a biceps tenotomy. Tinnaduses, younger patients, prevents the Popeye deformity, prevents spasm. And in the comparisons of the two, remember there's no real difference overall except for the cosmetic deformity. So if you look at this, next question now. Denervation, most typically associated with the fighting scene and what classic fighting. So denervation here is gonna be, you're thinking biceps. Remember what happens with the biceps pathology, but here is a spinal glenoid notched cyst. When spinal glenoid notched cyst, when you have optimal biceps, think of slap tears. Slap tears lead to cysts for this exam, okay? So you're not gonna be weak internally rotated. What you're gonna look for is external rotation weakness in adduction. Why? Spinal glenoid notched cyst caused by a biceps, proximal biceps slap, is gonna pick off the infraspinatus, right? Superspinatus is gonna be intact. The infraspinatus is gonna get picked off. Now, in addition to arthroscopic debridement for an irreparable cuff tear, what will a simple biceps anatomy most likely do? It's gonna be pain relief. That's it. All right, cuff tear arthropathy. Now, this is a moving field right now, so it's a little tough to be as definitive about a lot of the answers now. I would just say that now in 2019, we're moving more towards reverse being the answers. And if they're gonna try to lead you down a HEMI or some other type of path, I'll try to show you kind of the way they'll phrase that. But as a general rule, cuff tear arthropathy right now, they like you to think of reverses, in which case you also have to know the complications of reverse, which we'll talk about. So what causes cuff tear arthropathy? Massive cuff tears. Normally, don't forget, they ask a lot about iatrogenic injuries to the coracoacromial arch. So if someone had a decompression, an acromioplasty, they took down the CA ligament, they come back, superior scape, cuff tear, cuff tear arthropathy. The exam for cuff tear arthropathy, a lot of times you get this soft tissue swelling or this bursal fluid that you see in the front of the shoulder. Decreased motion and then severe atrophy posteriorly. The treatment for cuff tear arthropathy. All right, so let's take a second to go through this. Depending on how it's phrased, if they try to talk about a lot of comorbidities, medical complications, the non-operative treatment for cuff tear arthropathy is gonna be injections and then physical therapy for the anterior deltoid and the tears, although to be honest with you, that's not gonna do a ton. The key thing to remember is, if you have a chronic cuff tear, they don't want you to do a regular total shoulder because of the rocking horse effect, glenoid loosening. They want you to think more about either HEMI or really now reverse. So up until about five years ago, four years ago, HEMI was still the key, but again, as we'll talk about, I'll try to tell you when they want you to do a HEMI versus a reverse. So HEMI, if you have forward elevation, good forward elevation above 90 degrees and it's no more or less than 70, now it's gonna be probably more like less than 50 or 40, but say less than 50. Those are the patients you're gonna do a HEMI on. For reverse, the classic indications for this is gonna be either some pseudoparalysis or older types of patients, you're gonna go right to a reverse. Now, what are the problems with a reverse? These you have to know. So for the semi-constrained prostheses, you worry about dislocations and poly wear, but the number one thing you're gonna be asked about is scapular notching. When is that gonna be the most common? Scapular notching is most common with a 155 degree inclination angle and the key to think or the treatment for that is gonna be to observe it as long as they're asymptomatic. Now, here's a dislocated prosthesis. So what factor is associated with increased risk for a dislocated reverse? So, failed previous arthroplasty, that sounds like reasonable. Anterior superior approach, no. Complete rupture of the subscap, no. Inferior inclination of the glenosphere, humeral stem, no. It's gonna be failed previous arthroplasty, right? That's gonna be one of the big potential, the results of reverses after previous arthroplasty are worse than primary reverse, which is why we're starting to go now primarily straight to a reverse. 71 year old woman, insidious onset of night pain. Can't raise her arms. So if you look here, she's got a cuff tear arthropathy. She's already had an injection which only gave her temporary relief, but no functional improvement. So, even if she's 71, they're telling you the non-op hasn't worked. So what's the best chance of restoring function above the shoulder and doing pain relief? That's a reverse. And why? 71, best chance of pain relief is reverse, not a HEMI. You're not gonna do a HEMI in a 71 year old woman. 82 year old woman with one month of shoulder pain, active elevation to 150, but painful. She can't sleep. What are you gonna do? So, if you go read right away, you're quick. We're trying to get through the test quickly. You're gonna go, oh, you kind of glaze through that first sentence. She's 82. She's got limited motion. She can't sleep. She has pain. I'm a surgeon. I gotta fix her. Am I gonna do a total or HEMI or reverse? Oh, I remember it's gonna be reverse. But what's the key here? One month. And they kind of went high on the age, 82. So, they don't want you to operate on her with one month of pain, all right? Anti-inflammatories are cortisone and deltoid. You gotta read it carefully. Always look for a time of symptoms, the degree of symptoms, and then the exam. 76 year old woman. She's had two steroid injections and anti-inflammatories without relief. She's only got 60 degrees of active forward elevation versus 120 passively. She has a 30 degrees of an external rotation lag and a positive hornblowers. Remember, positive hornblowers is for a teres minor. So, this is gonna be a massive tear, right? Cuff tear arthropathy. Look at the degree of fatty atrophy. So, you say, well, that's simple, right? I'm gonna do a reverse. So, this is actually a very kind question. Usually, it'll be reverse or number three. When they say there's a giant extensive external rotation lag, they want you to think about doing a lat transfer as well for external rotation. So, in this case, it's gonna be reverse with a lat transfer. Cuff tears. You know the anatomy of the cuff tears here. The footprint, confluent with the articular margin. The key is, remember that the rotator cuff, and some questions will be along this way, it's not just an abductor, it's a humeral head depressor, especially after 30 degrees. After 30 degrees of abduction, your humeral head has to rise up to the acromion if you don't have a cuff to keep it down, all right? So, for the infra, the infra is gonna be framing the bare area, so when you're doing your scope and you see the bare area, that's how you know where your infra starts. It's the primary external rotator. You're gonna check the function of the infra spin. It's not an abduction, that's more gonna be tears, but it's gonna be down here in adduction. Super's the most common tear, followed by infra. The subscap, we've talked a little bit about. Primary internal rotator tested by lift-off test, belly press test, or you can also do it with a bare hug. But remember, we talked about this with the biceps. Anytime you think subscap, coracohumeral ligament, long head of biceps is the biceps in the groove that just should always go together in your thinking. Basic science, the insertion, believe it or not, there's been questions about what type of collagen is. Just the tendon itself is type one. The insertion, sharpie fibers, type two collagen. The function of the rotator cuff is to be a dynamic stabilizer of the glenohumeral joint in the mid-ranges of motion. So, severe abduction external rotation is gonna be glenohumeral ligament, but 45 degrees abduction, 45 degrees external rotation, that's where your cuff's gonna come into play. The supra initiates abduction, can cause a little bit of flexion, but you really need your deltoid plus the depressive effect of the supra to abduct your arm. And again, as I mentioned before, you have obligate superior translation after 30 if you don't have a cuff. Different types of tear patterns. The answer for treating a partial thickness tear is usually gonna be non-operative, but for this test, I've never seen selective, or selective partial repair be an answer. Usually for a partial tear, especially a bursal partial tear that's failed non-operative treatment, it's take it down and then fix it, right? Don't do partial repairs on the test. Natural history tears. Remember, especially in older patients, more than half of these can be asymptomatic, so if they give you a big tear, we almost always say, oh yeah, let's fix that, but if they say this patient is asymptomatic, even if they have a tear, they want you to talk about non-operative treatment. What causes cuff tears? Traumatic overload, vascular etiologies. External compressions, impingements. But the big one is, again, sports test. Someone who dislocates their shoulder over the age of 40, they want you to think about a cuff tear first and recurrent instability second. So just assume on a test, patient over 40, they want you to go down the road of rotator cuff tear until proven otherwise. If you see here, you can get true outlet impingement. This is an outlet view. Decreased subacromial space. Other ways treatments, subacromial injections, PT, and then MRI is gonna be your mainstay. Now remember, 55% of patients who are asymptomatic over the age of 60 have a cuff tear or some type of cuff tear on MRI. So any description of a patient has to include pain, weakness, and symptomatic problems that are not responsive. And then the most sensitive physical exam sign for impingement type symptoms is the Hawkins, the Hawkins impingement test. On exam also, painful arc of motion, positive Hawkins test. Always look at the AC joint, tenderness, biceps, tenderness, and looking for lag signs. Type I acromion flap, type II acromion curved, type III is gonna have this osteophyte, it's gonna be hooked. Partial cuff tears, again, typically are gonna be nonoperatively treated. Full thickness cuff tears, gonna be more operatively. So how do we treat them nonoperatively? Subacromial injections, physical therapy to decrease pain, increase flexibility. If we do have to go to surgery, all right, depending on how it's described, anything from cuff repairs, very rarely now are you gonna answer a humeral head replacement. We talked a little bit about the indications for that. Totals and reverses. The most important thing is to have a functioning subscapularis. If you don't, that's when you're gonna think about doing tendon transfers. If you have a functioning subscap and you have a massive tear and someone says they have some preservation of motion, it's a young patient, there's still occasionally questions about that being the indication for a LAT transfer. Approaches, every once in a while you'll see something about marrow stimulation to help healing. Complications, the biggest complication of a cuff repair is recurrent tearing or non-healing, whether you look at it as a recurrent tear or non-healing, but either way, it's not healing. The number one infection, proprionibacterium acnes. There's usually some question about P-acnes and you have to keep the cultures around for 21 days in order to make sure that you don't grow out P-acnes. Indications for a decompression, almost never, if that's not an oxymoron, but almost never answer for this test, I want to do an isolated subacromial decompression. The fact is that you can't even get paid for that anymore. You can't just do a 29826 and submit that. That's not reimbursed. Tells you that they don't want you that to be the only thing you're doing when you take someone to surgery, okay? You can do it in association with a cuff repair if you have a type three acromion or something like that, but they never want you to say acromioplasty alone. What about the role of a distal clavicle excision? So on exam, tentative palpation at the AC joint, positive cross-body adduction test, good response to an injection. Do not recommend distal clavicle excisions alone just because someone's got a little arthritis on an x-ray or an MRI. It's more bone marrow edema of the distal clavicle, like you see here, is much better correlation to having a symptomatic AC joint, but it's really physical exam that's gonna lead you towards AC joint surgery. Now what about single versus double rows? What are the theoretic benefits of both? The theoretic benefit or the theoretic issue with a single row is increased gapping at the repair site and theoretically decreased strength at the repair site. The theoretic benefit of double row suture bridge versus single row is decreased gapping and increased strength. However, there has been no difference in functional studies, in studies between the two, right? So I promise you, they're not gonna tell you, they do not want you to say double row is better for this test, whether you think so or not. Okay, it's gonna be there's no functional difference in any study between the two. So they're gonna say fix it, but they're not gonna ask you how to fix it. Maybe they might say which has a higher healing rate, but again, that does not correlate and it's double row, but that does not correlate to functional outcome. Post-op, they just don't want you to move too early, right? They don't want you to do too much too early. So it's typically six weeks passive, six weeks active, resistive at not until 12 weeks. Do cuff tailors heal? Again, whether they heal or they weren't fixed right or they're just gapping, it's anywhere between 10 and 90%. All right, that's a real helpful range, I know. But usually the bigger the tear in most series, like the results of, it's because for massive tears, there's gonna be up to that ultrasound study from St. Louis talked about to a 90% tear rate. But the things to look at, look at the Goutelier classification or the amount of fatty atrophy on your sagittals. Look at the degree of retraction, smoking, osteoporosis, diabetes. These are all negative. These are all things that negatively affect tendon healing after cuff repair. Now, massive tear, just because something's massive doesn't mean it's irreparable. What makes something irreparable is a chronic retracted tear with at least grade three or four fatty atrophy. So that means more than 50% fatty atrophy of the supraspinatus fossa, infraspinatus fossa on the sagittal obliques. Four massive tears. We talked a little bit about this already. Tendon transfers on a very young patients, a younger patients. Now, calcific tendonitis definitely gets asked a fair amount. They seldom if ever want you to jump to surgery for this. Calcific tendonitis tends to burn out with time. It can take three or four years, but basically the mainstay is gonna be cortisone injections and time. Remember, the calcium is not at the insertion site. It's embedded in the tendon. So when you start taking the calcium out, you're gonna put a hole in the tendon as far as the thinking for the exam here. So from some of the self-assessment exam pearls to think about for calcific tendonitis, think about the formative phase versus the resorptive. So the formation phase is the symptomatic. It's painful. Resorption is when it tends to be x-ray signs, just but less painful. Kind of like with adhesive capsulitis. Treat them non-operatively initially, and there's no role in the present answering for shockwave therapy for this, for the test. Non-operatively, short duration of symptoms. These big deposits, because it seems counterintuitive, but the bigger the deposit, the bigger the hole you're gonna put in the tendon if you try to fix it. So that's why they want you to start non-operatively. When should you operate on them? Failed non-operative, multiloculated, continued pain, and typically you end up doing a repair too. So at a six-week follow-up after arthroscopic repair of a full thickness cuff tear, the patient has not come to PT. What's the outcome at one year? Well, remember I said the test hates slap repairs? The test also hates CPM machines and formal PT versus home exercises. So the issue is there's no difference in motion compared for early versus late therapy. Whether we, that may or may not be our own experience, that's the test experience, all right? 24-year-old right-handed javelin thrower arrives late for competition and is unable to warm up. On the first throw, at the end of the follow-through, he has a sharp pain in the right shoulder, and he can't continue throwing. So 24-year-old, so it's a little bit young for a cuff tear, but so it's gonna be something a little different. Is it a slap? Is it a labrum? You know, what's going on? On exam, acutely tender over the biceps. Okay, so now that's starting to make more sense. Abduction, external rotation with the javelin. Biceps, is this gonna be a subscap question? Is this gonna be a slap question? Is this gonna be a dislocated biceps question is kind of what I'm thinking about. Full passive motion, okay, and so not increased passive motion externally, which would have been a subscap rupture, just full passive motion. Positive O'Brien's, so there's slap. Weakness of internal rotation, uh-oh, but wait a minute. That is a subscap, and a positive lift-off, that's also a subscap. Hornblower's test is negative for Terry's. So here's the MRI. So now on the MRI, the two things I wanna look at are subscap, and I wanna look at where the biceps is. So what's the best recommendation? It's gonna be, in this case, it is the subscap, because they told you a Gerber's lift-off test. So they weren't giving you the piece of the passive external rotation, but they did say lift-off and weak internal rotation. 30-year-old pitcher, recent onset weakness, velocity's dropped, he's tender lateral and anterior to the acromion of the shoulder. With weakness of the external rotation when he's abducted, externally rotated. Here's the MRI. So what do you see back here? It's not a great unit, but it's a cyst. Okay, so that's a spinal glenoid notch cyst. Velocity's dropped, and he's got some tenderness, and he's got marked weakness of external rotation. So that's gonna be a posterior cuff, infra, teres, that area, okay? But because the spinal glenoid notch cyst only gets the suprascapular nerve, remember, teres is axillary nerve, in that case, teres is almost never involved in a pitching type of thing. It's always gonna be a suprascapular nerve, infraspinatus problem, okay? Spinal glenoid notch cyst, infra. How do you get the notch cyst? You're a pitcher, you get a labral tear, you get the cyst. 55-year-old woman, pain in the right shoulder for five days, keeps her up at night. Her pain is in her shoulder, and she grabs her humeral head. So remember, when people have calcific tendinitis, they're upset, it hurts, okay? It's the same thing like with pes bursitis in the knee. DJD doesn't cause people to be upset. Calcific tendinitis makes people upset and miserable. So on exam, positive impingement signs, decreased motion, and weakness of the cuff. So what are you gonna do? Steroid PT, capsule-released MRI, steroid and PT for calcific tendinitis. 52-year-old man. Prior cuff repair, persistent pain and limited motion. Okay, so here's this, you look at this, look at all this fatty atrophy that we talked about here. Here's a cuff tear. He says significant atrophy of the infraspinatus, active overhead elevation of 140 with a painful arc and weakness of shoulder external rotation. So what are you gonna do here? So he's 52, he's already had a cuff repair once, so you're not gonna do another primary cuff repair for this. Plus, he's got all that atrophy. You're certainly not gonna do it, remember? Test, hate, slaps, not gonna do a slap. Lat transfer, well, that's a potential, right? Because he's got good maintenance of function and he's only 52. So I'm gonna keep that as one of my choices. I'm not gonna do a reverse on a 52-year-old and then a revision cuff. We already said we're not gonna do that. So if there is an indication for a lat transfer, it's gonna be a young patient with preservation of motion and weakness of external rotation. Those are the key buzzwords for doing a lat transfer. 80-year-old tennis player falls. First time dislocation reduced. Two weeks later, complains of difficulty elevating the arm. What's the most likely diagnosis? Well, we talked about this already. They kind of gave that away with the 80. They could have said 50, which would have been a lot better. But older patient, it's not gonna be recurring instability. Something else, it's gonna be a cuff tear. And that's been, you saw the multiple places that's been asked. 56-year-old laborer, subcoracoid dislocation as a result of falling off a scaffold three weeks ago. Can't raise his arm and has constant pain. What's the most likely diagnosis? Well, subcoracoid dislocation, 56. Tear of the rotator cuff. That's the question, better question to get. Patient's unable to actively externally rotate the shoulder. That's gonna be a tear of the infra and the teres. Now, this is one I always wanna go back and review. The risk factor most commonly associated with non-healing, I always jump to smoking. But in fact, the answer is age. It's not small tears, it's not early repair, it's not work comp. They don't want you to discriminate against work comp. It's gonna be one of the first two. And although they are both associated, age is a bigger indicator. You just have to remember that for non-healing. 48-year-old has an arthroscopic cuff repair. The infra is mobilized to the footprint, but the supra can't make it. What's the appropriate treatment? So what they're telling you is, you can get the infraspinatus back, which means you can get above the equator of the humeral head, so you're still gonna have some head depressive function. What should you do? Should you convert to a transfer? Should you do reverse? No, partial cuff repair is still a good option for a young patient, as long as you can get at least the infra fixed. 68-year-old man, shoulder weakness, but no pain. He's got some atrophy, he's got some weakness. What's the best treatment? So I initially, oh, here's this cuff tear here. I'm gonna fix it, right? But wait a minute, this is too easy. This is a self-assessment, this is a board review test. 68-year-old, why did they tell me he had no pain? Because we have to be egalitarian for our cuff treatments, and we have to have no pain. You can start to have non-surgical treatment. Okay, if he's had pain, that's a different story. All right, almost done. Subcoracoid impingement. Subcoracoid impingement is impingement of the lesser tuberosity against the coracoid process with flexion, internal rotation of the arm. If you look at the normal distances as listed there, in an exam, cross-body bothers them. You can do a subcoracoid or pericoracoid injection to help determine it. And then treatment is supposed to be a coracoplasty. I gotta be like, Bruce, you've been doing this a long time, have you seen any subcoracoid plasty questions? No, right? Chris, I don't think so either. So I mentioned it to be complete. It's one of the topics we're supposed to review, but I can't imagine they're gonna ask you to give an answer of a coracoplasty for the purpose of this test. And then subscap, we've beaten to death a little bit, but just remember, subscap tears often missed, usually seen in conjunction with anterior supraspinatus tears. When you have a subscap tear, think of a biceps dislocation. And oftentimes there's a history of a previous dislocation and it's literally, there's some kind of this question on almost every OITE self-assessment test that's out there. So be aware of it. Lag signs, increased external rotation, MRI, you have to be at least as medial as the coracoid to do it. Treatment is gonna be to fix them. So a 23-year-old football player, contact injury to the shoulder, with his arm already in external rotation, immediate pain and swelling, exam shows internal rotation weakness, positive liftoff, most appropriate treatment is gonna be a subscap repair. 35-year-old, and by the way, they're not gonna differentiate between arthroscopic versus open. If they're not gonna give you both of those, they're just gonna give a subscap repair. So however they say to do it, fix it. 35-year-old laborer, anterior shoulder pain after a fall, ecchymosis in the anterior aspect of the shoulder. Strength testing is limited by pain. Here's the MRI, here's the subscap, here's the subluxed biceps. What are you gonna do? Fix the subscap tear. This, I just didn't know, this was just on one of the exams, but landmark for the appropriate placement of an anchor for the upper border of the subscap, it's gonna be the superior glenohumeral ligament and coracohumeral ligament. I just threw that in for completeness. I didn't know that. I hope they don't ask that again because I wouldn't remember it. 20-year-old college football player, forceful hyperextension injury to the shoulder four months after going in anterior capsular shift. All right, anterior capsular shift means they did it open. So forceful, had a previous open repair of the subscap. Two weeks later, anterior tendinous, can't lift his hand away from his back, so positive lift-off test, subscap rupture. 25-year-old carpenter, falls on outstretched arm, biceps in here, what physical exam test correlates with that? It's gonna be positive lift-off. Okay, and then 39-year-old laborer, had a traction injury six months ago, four months of PT, two steroid injections, minimal relief, all kinds of bicep signs, mild weakness, what's the next step in management? 39-year-old manual laborer is gonna be a subscap repair and a tenodesis. You're not gonna do a tenotomy for a laborer, and then the fact is that he has subscap tear as well. Okay, so I think we're right on there. I'm around at the break if you have any questions, but I think we'll go over, I'd be happy to talk in the back later on, thanks very much.

shoulder pathology

treatment options

cuff tear arthropathy

calcific tendinitis

subcoracoid impingement

subscapularis tears

diagnosis

conservative management

surgical options

rotator cuff repair