Shoulder & Hip Sports MCQs

The normal rotator cuff insertion consists of four zones: tendon (Type I), uncalcified fibrocartilage (Type II and aggrecan), calcified fibrocartilage (Type II and Type X), and bone (Type I).

Overhead throwing athletes frequently develop posteroinferior capsular contracture, clinically presenting as GIRD. This contracture shifts the glenohumeral contact point posterosuperiorly in maximum external rotation, leading to internal impingement and subsequent SLAP tears.

The bear hug test is considered the most sensitive examination maneuver for detecting upper subscapularis tears. The lift-off test is better suited for assessing the lower portion of the subscapularis muscle belly.

Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation.

At one year, quality of life, pain, disability and shoulder range of motion are the same for patients treated with therapy and placebo versus patients treated with therapy andPRP injection.Platelet rich plasma has been used for the treatment of chronic tendinopathy in different areas with mixed results. No benefit to patients with symptoms of subacromial impingement has been demonstrated for subacromial injection of PRP, when added to a standard therapy program.Kesikburun et al. conducted a randomized controlled trial in which patients with rotator cuff tendinopathy or partial rotator cuff tears were randomized to receive ultrasound-guided subacromial injection of either PRP or lidocaine, followed by a standard six-week therapy program. The authors found no difference in pain, range of motion or validated outcome scores at one year follow up.Hall et al. reviewed sports medicine applications for PRP. At that time (2009), with regard to PRP, they concluded that there was "little clinical evidence for its use."Ketola et al. sought to determine the effectiveness of subacromial decompression for the treatment of subacromial impingement syndrome. They randomized 140 patients to a supervised exercise program or arthroscopic subacromial decompression followed by a supervised exercise program. They found no clinically important differences between the two groups at 24 months follow up.Figure A shows a right shoulder radiograph without osseous pathology. Incorrect answers:

DISCUSSION: The MRI scan reveals a full-thickness rotator cuff tear with retraction and increased signal in the subacromial space indicating joint fluid. REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20. Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.

According to Morgan and associates, a type II SLAP lesion can create or is associated with a superior instability pattern. They suggest that this can exist without a co-existing anteroinferior instability pattern. They reported that repair of the SLAP lesion alone resulted in satisfactory outcomes in 90% of patients and a return to throwing in more than 90% of pitchers. The arthroscopic findings in this patient do not support a diagnosis of anteroinferior laxity or instability; therefore, thermal capsular shift or capsular placation is not necessary.

Femoroacetabular impingement is a mechanism for the development of early osteoarthritis for most nondysplastic hips. Early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients. There are two general types of femoroacetabular impingement. In cam impingement, the femoral deformity is usually a bump on the head-and-neck junction that impinges on the acetabular rim. The pincer type of impingement is caused by deformity on the acetabular side such as a deep socket or acetabular overcoverage due to retroversion. Both mechanisms create an obstacle for flexion and internal rotation.

DISCUSSION: The sagittal image reveals increased signal and decreased size of the supraspinatus and infraspinatus muscles, indicating muscle atrophy. The rotator cuff tendon signal is normal. The subscapularis and teres minor muscles are unaffected. Muscular dystrophy and thoracic outlet syndrome would be expected to have a more global effect. Although muscular atrophy can occur in the setting of a rotator cuff tear, the coronal image shows an intact supraspinatus. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles. Therefore, suprascapular nerve entrapment would result in atrophy of these muscles with sparing of the surrounding musculature. Any lesion within the suprascapular notch, including neoplastic disease, a venous varix, or neuroma, can place pressure on the suprascapular nerve. Suprascapular nerve entrapment most commonly results from extension of a paralabral cyst or ganglion, often with associated labral pathology. Spinal accessory nerve disruption would show trapezius muscle atrophy.

During an anteroinferior dislocation, the posterosuperior portion of the humeral head impacts the inferior rim of the glenoid, resulting in an impaction injury. This lesion is classically referred to as a Hill-Sachs lesion.

The arthroscopic view shows a HAGL lesion. With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site. In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability. Failure to recognize and treat this lesion leads to persistent anterior instability. An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation. A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim. The subscapularis tendon and the rotator interval are not shown in the figure.

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minormay experience a better functional result with latissimus dorsi transfer.

Little Leaguer's shoulder is a chronic stress injury to the proximal humerus growth plate. Imaging findings demonstrate widening of the proximal humeral growth plate. Treatment consists of rest and avoidance of pitching for the remainder of the season. Surgery is not indicated.

The clinical presentation is consistent with a tear of the subscapularis, which is a well-described complication after total shoulder arthroplasty. The most likely additional complaint this patient will have is anterior shoulder instability, noticeable with external rotation of the shoulder.Total shoulder arthroplasty is the preferred treatment for glenohumeral arthritis in patients with intact rotator cuff and good glenoid bone stock. The surgical approach involves detaching the subscapularis and capsule from the anterior humerus and dislocating the humeral head anteriorly. Post operatively, external rotation is limited to protect the subscapularis repair. If there is suspicion of a postoperative subscapularis tear, and ultrasound can be performed to confirm the diagnosis.Miller et al. reported 7 cases of subscapularis tendon rupture after total shoulder arthroplasty, all of which were subsequently repaired. Decreased functional outcomes were observed in these patients, with lengthening techniques to address internal rotation contractures and prior surgery involving the subscapularis tendon as risk factors for ruptureWestoff et al. performed static and dynamic ultrasounds on 22 patients after total shoulder arthroplasty evaluating for numerous periarticular pathologies. The authors concluded that sonography is a useful tool for evaluation of peri-implant tissues after TSA.Figure A shows an intact left total shoulder arthroplasty without evidence of fracture, dislocation, or hardware loosening. Illustration A shows the incision for the subscapularis tendon during TSA.Incorrect Answers:

Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. In their series, the incidence of injury to the axillary nerve was 7.8% as compared with 100% for rupture of the rotator cuff.

A total shoulder arthroplasty (TSA) is indicated in the 72 year old male with debilitating shoulder pain and an intact rotator cuff on MRI. The other patient scenarios are examples of contraindications for TSA.A TSA involves replacement of the humeral head with a metal head and resurfacing of the glenoid to a cemented all-polyethylene surface. In order to achieve optimal results, patients must be selected carefully. Patients with an irreparable rotator cuff tear, non-functioning deltoid, inadequate glenoid bone stock and brachial plexopathy are poor candidates for TSA.Edwards et al. conducted a multicenter randomized controlled trial to compare TSA versus hemiarthroplasty in patients with primary osteoarthritis of the shoulder. They found that TSA provided better scores for pain, mobility, and activity than hemiarthroplasty at 2 year follow-up. Boileau et al. followed 45 consecutive patients who underwent reverse TSA ( rTSA) for cuff tear arthropathy (CTA), post-traumatic arthritis, and failure of revision arthroplasty. After a mean follow-up of 40 months, they found that the reverse prosthesis improved function and was able to restore active elevation in patients with incongruent cuff-deficient shoulders. They also found thatthe results were less predictable and complication and revision rates were higher in patients undergoing revision surgery as compared to those patients undergoing rTSA for CTA.Illustrations A and B show the preoperative and postoperative x-rays of a patient with characteristic OA of the glenohumeral joint that was treated with TSA.Incorrect Answers:Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?Immobilization in external rotation for 6 weeks Arthroscopic bony Bankart repairArthroscopic Remplissage procedureGlenoid augmentation using coracoid transfer Glenoid augmentation using tricortical iliac crest graftThis patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.Older (>20 years old), recreational athletes with minor glenoid bone loss (<20 % of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid.Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss. Incorrect Answers:A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?Nonsynergistic action of the transferred muscle Fatty atrophy of the supraspinatus and infraspinatus Deficiency of the subscapularisAbsence of the coracoacromial ligament Deltoid weaknessA latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer.The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure?Anchor fatigue and breakage Anchor pull out from boneSuture rupture secondary to anchor eyelet abrasion Suture pull out from the repaired tissueInfectionRotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include highstrength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, singlerow configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 1215 mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing. Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.Incorrect ResponsesBiocomposite anchors exhibit high load-to-failure and result in fatigue failure less commonly than metal anchors.A 32-year-old cross-training athlete awakens with severe left neck and shoulder pain after a day of intense upper body training. Aside from a recent viral illness, he is otherwise healthy. His pain improves, but two weeks later he notes significant left shoulder weakness. Examination reveals weakness of shoulder abduction, forward elevation and external rotation with the arm at his side. Radiographs are normal. Electromyography demonstrates 2+ positive sharp waves and fibrillations. Sensory nerve conduction studies show reduced amplitudes. MRI of the brain, cervical spine and shoulder are shown in Figures A-D, respectively. Which of the following is true of his prognosis?Decompression will result in improved muscle strength and function.The patient can expect a gradual return of muscle strength without long term functional deficits. Immunomodulators may decrease the number and severity of his relapses. 4 . Arthroscopic repair will result in the best functional outcomes given the patient's high activity level.

Subscapularis rupture is most likely, given weakness with the lift-off test. The injury is usually caused by either forceful hyperextension or external rotation of the adducted arm. Patients will complain of anterior shoulder pain and weakness of the arm when used above and below shoulder level. SLAP lesions usually occur with a fall onto an outstretched arm in abduction and slight forward flexion. No mention was made of shoulder instability or deltoid weakness.

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures.

The patient has a partial articular supraspinatus tendon avulsion (PASTA) lesion. Outcome studies suggest that articular-sided tears of this magnitude do well with arthroscopic decompression and debridement alone. Determination of lesion thickness is important in recommending treatment, and may be done with a variety of methods. Tears that involve exposure of less than 5 mm of the rotator cuff footprint likely measure less than half of the tendon thickness. In the absence of other associated pathology, bicipital tenotomy or synovectomy would be unnecessary. Completion of the tear or transtendinous repair would be considered for lesions of greater than 50% thickness.

Medial dislocation of the biceps tendon in the shoulder is commonly associated with subscapularis tendon tears. Although type II SLAP tears can result in bicipital instability, type I SLAP lesions do not. Congenitally shallow grooves and tears of the transverse ligaments usually do not lead to dislocation of the biceps tendon. Supraspinatus tendon tears are associated with long head of the biceps tendon ruptures but do not cause biceps tendon dislocations.