Updated: 7/8/2022

Rotator Cuff Tears

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  • summary
    • Rotator cuff tears are a very common source of shoulder pain and decreased motion that can occur due to both traumatic injuries in young patients as well as degenerative disease in the elderly patient.
    • Diagnosis can be suspected clinically with provocative tests of the supraspinatous, infraspinatous, teres minor and subscapularis, but confirmation requires an MRI of the shoulder. 
    • Treatment can be nonoperative or operative depending on the chronicity of symptoms, severity of the tear, degree of muscle fatty atrophy, patient age and patient activity demands. 
  • Epidemiology
    • Prevalence
      • age >60: 28% have full-thickness tear
      • age >70: 65% have full-thickness tear
    • Risk factors
      • age
      • smoking
      • hypercholesterolemia
      • family history
  • Etiology
    • Pathophysiology
      • mechanisms of tear includes
        • chronic degenerative tear ( intrinsic degeneration is the primary etiology)
          • usually seen in older patients
          • usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may extend anteriorly to involve the superior margin of subscapularis tendon in larger tears
        • chronic impingement
          • typically starts on the bursal surface or within the tendon
        • acute avulsion injuries
          • acute subscapularis tears seen in younger patients following a fall
          • acute SIT (supraspinatus, infraspinatus, teres minor) tears seen in patients > 40 yrs with a shoulder dislocation
          • full thickness rotator cuff tears need to be repaired in throwing athletes
        • iatrogenic injuries
          • due to failure of surgical repair
            • often seen in repair failure of the subscapularis tendon following open anterior shoulder surgery.
    • Impingement and rotator cuff disease are a continuum of disease including
      • subacromial impingement
      • subcoracoid impingement
      • calcific tendonitis
      • rotator cuff tears (this topic)
      • rotator cuff arthropathy
    • Associated conditions
      • AC joint pathology
      • proximal biceps subluxation
      • proximal biceps tendonitis
      • internal impingement
        • seen in overhead throwing athletes
        • associated with partial thickness rotator cuff tears
        • deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears
  • Anatomy
    • Rotator cuff function
      • the primary function of the rotator cuff is to provide dynamic stability by balancing the force couples about the glenohumeral joint in both the coronal and transverse plane.
        • coronal plane
          • the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions to balance the superior moment created by the deltoid
        • transverse plane
          • the anterior cuff (subscapularis) functions to balance the posterior moment created by the posterior cuff (infraspinatus and teres minor)
        • this maintains a stable fulcrum for glenohumeral motion.
        • the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes.
    • Rotator cuff footprint
      • supraspinatus inserts on anterosuperior aspect of greater tuberosity
      • medial-lateral width at insertion
        • supraspinatus is 12.7mm (covers superior facet of greater tuberosity)
          • 6-7 mm tear corresponds to 50% partial thickness tear
        • infraspinatus is 13.4mm
        • subscapularis is 17.9mm
        • teres minor is 13.9mm
      • distance between articular cartilage to medial footprint of rotator cuff is 1.6-1.9 mm
      • AP dimension of footprint is 20mm
        • corresponds to insertion of supraspinatus and anterior infraspinatus
    • Rotator cuff histologic areas (5 layers)
      • important because articular side has only half the strength of bursal side
        • explains why most tears are articular sided
      • Layer I
        • most superficial layer (1 mm thick) and composed of fibers from the coracohumeral ligament which extend posteriorly and obliquely
      • Layer II
        • composed of densely packed fibers that parallel the long axis of the tendon (3-5 mm thickness)
      • Layer III
        • smaller loosely organized bundles of collagen at 45° angle to the long axis of the tendon (3 mm thick)
      • Layer IV
        • loose connective tissue and thick collagen bands and merges with fibers from coracohumeral ligament
      • Layer V
        • shoulder capsule (2 mm thick)
    • Rotator cuff blood supply
      • from subscapular, suprascapular and humeral circumflex arteries
        • branching within layer II and layer III (see above for layers)
      • bursal side is more vascular than the articular side (which is hypovascular)
        • zone of critical hypovascularity adjacent to most lateral portion of supraspinatus insertion
    • Anatomic features associated with rotator cuff
      • rotator interval
        • includes the capsule, long head of the biceps tendon, SGHL, and the coracohumeral ligament that bridge the gap between the supraspinatus and the subscapularis.
      • rotator crescent
        • thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions.
      • rotator cable
        • thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons.
    • Complete glenohumeral anatomy
  • Classification
      • Anatomic Classification
      • Supraspinatus, infraspinatus, teres minor (SIT) tears
      • Make up the majority of tears
      • Associated with subacromial impingement
      • Mechanism is often a degenerative tear in older patients or a shoulder dislocation in patients > 40 yrs.
      • Subscapularis tears
      • New evidence suggests higher prevalence than previously thought
      • Associated with subcoracoid impingement
      • Mechanism is often an acute avulsion in younger patients with a hyperabduction/external rotation injury or an iatrogenic injury due to failure of repair
      • Cuff Tear Size
      • Small
      • 0-1 cm
      • Medium
      • 1-3 cm
      • Large
      • 3-5 cm
      • Massive
      • > 5 cm (involves 2 or more tendons)
      • Ellman Classification of Partial-Thickness Rotator Cuff Tears
      • Grade
      • Description
      • I
      • < 3mm (< 25% thickness)
      • II
      • 3-6 mm (25-50%)
      • III
      • > 6 mm (>50%)
      • Location
      • A
      • Articular sided
      • B
      • Bursal sided
      • C
      • Intratendinous
      • Goutallier Classification of Rotator Cuff Atrophy 
      • 0
      • Normal
      • 1
      • Some fatty streaks
      • 2
      • More muscle than fat
      • 3
      • Equal amounts fat and muscle
      • 4
      • More fat than muscle
      • Cuff Tear Shape
      • Crescent
      • Usually do not retract medially, are quite mobile in the medial to lateral direction, and can be repaired directly to bone with minimal tension.
      • U-shape
      • Similar shape to crescent but extend further medially with apex adjacent or medial to the rim of the glenoid.
      • Must be repaired side-to-side using margin convergence first to avoid overwhelming tensile stress in the middle of the rotator cuff repair margin.
      • L-shape
      • Similar to U shape except one of the leaves is more mobile than the other. Use margin convergence in repair.
      • Massive & immobile
      • May be u-shaped or longitudinal. Difficult to repair and often requires and interval slide.
  • Presentation
    • Symptoms
      • pain
        • typically insidious onset of pain exacerbated by overhead activities
        • pain located in deltoid region
        • night pain, which is a poor indicator for nonoperative management
        • can have acute pain and weakness with an traumatic tear
      • weakness
        • loss of active ROM with greater or intact passive ROM
      • Overview of Physical Exam of Rotator Cuff
      • Cuff Muscle
      • Strength Testing
      • Special Tests
      • Supraspinatus
      • Weakness to resisted elevation in Jobe position
      • Drop arm test
      • Pain with Jobe test
      • Infraspinatus
      • ER weakness at 0° abduction
      • ER lag sign
      • Teres minor
      • ER weakness at 90° abduction and 90° ER
      • Hornblowers
      • IR weakness at 0° abduction
      • Excessive passive ER
      • Belly Press
      • Lift off
      • IR lag sign
  • Imaging
    • Radiographs
      • views
        • true AP, AP in internal/external rotation, axillary
        • outlet view to assess acromion
      • findings
        • calcific tendonitis
        • calcification in the coracohumeral ligament
        • cystic changes in greater tuberosity
        • proximal migration of humerus seen with chronic RCT (acromiohumeral interval <7 mm)
        • Type III (hooked) acromion
    • Arthrogram
      • indications
        • not commonly used in isolation; used when MRI contraindicated
      • findings
        • rotator cuff tear present if dye leaks from glenohumeral joint into subacromial joint
      • MR arthrogram may improve sensitivity and specificity
    • MRI
      • indications
        • diagnostic standard for rotator cuff pathology
        • obtain when suspicion for pain or weakness attributable to a rotator cuff tear
      • findings
        • important to evaluate muscle quality
          • size, shape, and degree of retraction of tear
          • degree of muscle fatty atrophy (best seen on sagittal image)
        • medial biceps tendon subluxation
          • indicative of a subscapularis tear
        • cyst in humeral head on MRI seen in almost all patients with chronic RCT
        • tangent sign
          • failure of the supraspinatus to cross a line drawn between the superior borders of the scapular spine and coracoid process on a sagittal MRI slice
      • sensitivity and specificity
        • in asymptomatic patients 60 yrs and older, 55% will have a RCT
    • Ultrasound
      • indications
        • suspicion of rotator cuff pathology
        • need for dynamic examination
      • advantages include
        • allows for dynamic testing
        • inexpensive
        • readily available at most centers
        • helpful to confirm intraarticular injections
      • disadvantages include
        • highly user dependent
        • limited ability to evaluate other intraarticular pathology
      • sensitivity/specificity
        • similar sensitivity, specificity, and overall accuracy for diagnosis of rotator cuff disease as compared to MRI
        • 23% of asymptomatic patients had a rotator cuff tear on ultrasound in one series
  • Treatment
    • Treatment considerations
      • activity and age of patient
      • mechanism of tear (degenerative or traumatic avulsion)
      • characteristics of tear (size, depth, retraction, muscle atrophy)
        • partial thickness tears vs. complete tear
        • articular sided (PASTA lesion) vs. bursal sided
          • bursal sided tears treated more aggressively
    • Nonoperative
      • physical therapy, NSAIDS, subacromial corticosteroid injections
          • first line of treatment for most tears
          • partial tears often can be managed with therapy
        • technique
          • avoidance of overhead activities
          • physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening over a 3-6 month treatment course
          • subacromial injections if impingement thought to be major cause of symptoms
    • Operative
      • subacromial decompression and rotator cuff debridement alone
        • indications
          • select patients with a low-grade partial articular sided rotator cuff tear
      • rotator cuff repair (arthroscopic or mini-open)
        • indications
          • acute full-thickness tears
          • bursal-sided tears >3 mm (>25%) in depth
            • release remaining tendon and debride degenerative tissue
          • partial articular-side tears>50% can be treated with tear completion and repair
            • Partial articular-side tears <50% treated with debridement alone
          • PASTA with >7mm of exposed bony footprint between the articular surface and intact tendon represents significant (>50%) cuff tear (must have at least 25% healthy bursal sided tissue)
            • younger patients with acute, traumatic tears
              • in situ repair leave bursal sided tissue intact
            • older patients with degenerative tears
              • tendon release, debridement of degenerative tissue and repair
        • postoperative
          • rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity, which is believed to take 8-12 weeks
            • peribursal tissue and holes drilled in greater tuberosity are major source of vascularity to repaired rotator cuff
            • vascularity can increase with exercise
          • postop with limited passive ROM (no active ROM)
        • outcomes
          • Worker's Compensation patients report worse outcomes
            • higher postop disability and lower patient satisfaction
      • tendon transfer
        • indications
          • massive cuff tears
        • techniques (see details below)
          • pectoralis major transfer
          • latissimus dorsi transfer
            • best for irreparable posterosuperior tears with intact subscapularis
      • superior capsular reconstruction
        • indications
          • massive irreparable rotator cuff tear with intact subscapularis
      • reverse total shoulder arthroplasty
        • indications
          • massive cuff tears with glenohumeral arthritis with intact deltoid
  • Technique
    • Mini-open rotator cuff repair
      • once was gold standard but has been largely been replaced by arthroscopic techniques
      • approach
        • small horizontal variant of shoulder lateral (deltoid splitting) approach
      • advantages over open approach
        • decreased risk of deltoid avulsion
        • faster rehabilitation (do not need to protect deltoid repair)
          • may begin passive ROM immediately to prevent adhesive capsulitis
          • most surgeons wait ~6 weeks before initiating active ROM
    • Arthroscopic rotator cuff repair
      • advantages
        • studies now show equivalent results to open or mini-open repair
      • important concepts
        • margin convergence
          • shown to decrease strain on lateral margin in U shaped tears
        • anterior interval slide
          • release supraspinatus from the rotator interval (effectively incising coracohumeral ligament). This increases the mobility of supraspinatus and allows it to be fixed to the lateral footprint.
        • posterior interval slide
          • release supraspinatus from infraspinatus. This further increases the mobility of supraspinatus and allows it to be fixed to the lateral footprint. Then repair supraspinatus to infraspinatus with margin convergence.
        • subscapularis repair
          • although arthroscopic repair is technically challenging, new studies show superior outcomes (motion and pain) compared to open repair
          • stabilize biceps tendon with tenodesis
          • posterior lever push maneuver useful to identify insertional humeral footprint tears
          • superolateral margin of subscapularis identified by the "comma sign"
            • superior glenohumeral and coracohumeral ligaments attach to the subscapularis tendon
        • long head biceps tendon repair
          • most studies show negligible difference between tenotomy vs. tenodesis after concurrent rotator cuff repair
        • footprint restoration
          • it is hypothesized that a larger footprint will improve healing and the mechanical strength of the rotator cuff repair
          • double row suture techniques (mattress sutures in medial row and simple sutures in lateral row) have been shown to create a more anatomic repair of the footprint
            • lower retear rate compared with single row
            • no difference in functional score, pain score, time to healing (compared to single row)
          • addition of a trough in the greater tuberosity to allow tendon-to-cancellous bone interface as opposed to tendon-to-cortical bone has NOT show increased repair strength in animal models
        • coracoacromial ligament release
          • release leads to an increased anterior/inferior translation of the glenohumeral joint
    • Tendon transfer
      • indicated for massive and irreparable rotator cuff tears
      • pectoralis major transfer
        • indicated in chronic subscapularis tears
        • transferring pectoralis major under the conjoined tendon more closely replicates the vector forces of the native subscapularis
        • requires 4-6 weeks of rigid immobilization
      • latissimus dorsi transfer
        • indicated in large supraspinatus and infraspinatus tears
        • best candidate is young laborer
        • attach to cuff muscles, subscapularis, and GT
        • brace immobilize for 6 wks. in 45° abduction and 30° ER.
        • nerves at risk
          • radial nerve
            • runs along anterior surface of latissimus dorsi, ~3cm medial to humeral insertion
            • at risk during tenotomy
          • posterior branch of the axillary nerve
            • runs in deep fascia of posterior deltoid
            • at risk during passage of tendon deep to deltoid to subacromial space
    • Superior capsular reconstruction with biologic or synthetic grafts
      • some recent evidence of improved outcomes with the use of xenograft, allograft, or synthetic patches for massive cuff tears
      • limited human and long-term studies
      • xenograft
        • from bovine dermis or intestine
        • mixed functional outcomes and graft incorporation
      • allograft
        • from human skin or muscular fascia
        • some evidence of good function and survival at short-term
      • synthetics
        • concern for foreign body reaction
        • mixed functional results
    • Lateral acromionectomy
      • historic significance only
      • contraindicated due to high complication rate
  • Complications
    • Recurrence / repair failure
      • most common cause of failed RCR is failure of cuff tissue to heal, resulting in suture pull out from repaired tissue
      • patient risk factors for repair failure
        • patient age >65 years is a risk factor for non-healing of rotator cuff repair and subsequent failure
        • large tear size (>5 cm)
        • muscle atrophy
        • diabetes
        • smokers
        • tear retraction medial to glenoid
        • poor compliance with post-op protocol
          • no difference in clinical outcomes or healing with early vs. delayed motion protocols
        • multiple tendons involved
        • concomitant AC and/or biceps procedures performed at time of repair
      • treatment
        • revision rotator cuff repair vs RTSA
          • variables to consider when choosing revision RCR vs RTSA
            • patient age (older age favors RTSA)
            • etiology of re-tear
            • quality of tissue / MRI findings
            • static proximal humeral migration (favors RTSA)
    • Deltoid detachment
      • complication seen with open approach
    • AC pain
    • Axillary nerve injury
    • Suprascapular nerve injury
      • may occur with aggressive mobilization of supraspinatus during repair
    • Lateral femoral cutaneous nerve injury
      • Secondary to beach chair positioning without appropriate padding
    • Infection
      • less than 1% incidence
        • Usually common skin flora: staph aureus, strep, p.acnes
          • Propionoibacterium acnes is the most commonly implicated organism in delayed or indolent cases
      • risk factors
        • patients who underwent an injection within 3 months of surgery
    • Stiffness
      • Physical therapy and guided early range of motion exercises are not shown to reduce stiffness one-year post-operatively
    • Pneumothorax
      • Can be a complication of regional anesthesia (interscalene or supraclavicular block) or the arthroscopy itself
  • Prognosis
    • 50% of asymptomatic tears become symptomatic in 2-3 years
    • 50% of symptomatic full-thickness tears progress at 2 years and bigger tears progress faster
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(OBQ20.35) During shoulder arthroscopy, the posterior lever push maneuver is performed in order to improve visualization of which structure seen in Figure A?

QID: 215446
FIGURES:

Structure #1

6%

(68/1063)

Structure #2

13%

(133/1063)

Structure #3

4%

(45/1063)

Structure #4

19%

(207/1063)

Structure #5

56%

(600/1063)

L 1 E

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(OBQ19.70) A 32-year-old carpenter with chronic right shoulder pain is seen by a shoulder surgeon for the pathology depicted in Figure A. The shoulder surgeon recommends a muscle/tendon transfer for his pathology. This muscle/tendon is innervated by the thoracodorsal nerve. Which of the following physical examination findings would most likely decrease the ability of this proposed procedure to improve his pain, range of motion, and strength?

QID: 213972
FIGURES:

When he attempts to press his abdomen with his right palm, his right elbow drops back

55%

(695/1257)

There is increased passive internal rotation of the right shoulder compared to the left

6%

(74/1257)

There is pain/weakness when the right arm is elevator to 90 degrees in the scapular plane

10%

(129/1257)

When asked to hold his right arm in 90 degrees of abduction and external rotation, the arm falls into internal rotation

15%

(184/1257)

There is obvious deformity and ecchymosis in the area of the right axillary fold

13%

(162/1257)

L 4 E

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(OBQ19.59) A 40-year-old male presents to your clinic for evaluation of 8 months of left shoulder pain and weakness after a fall while skiing. MRI studies are shown in Figures A and B. Which of the following physical exam findings would be highly probable in this patient?

QID: 213961
FIGURES:

Increased passive flexion of the left shoulder compared to the right shoulder

1%

(14/1319)

Increased active internal rotation of the left shoulder compared to the right shoulder

3%

(46/1319)

Increased passive extension of the left shoulder compared to the right shoulder

3%

(45/1319)

Increased passive external rotation of the left shoulder compared to the right shoulder

90%

(1191/1319)

Increased passive abduction of the left shoulder compared to the right shoulder

1%

(14/1319)

L 1 A

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(OBQ19.204) Which of the following patients is the best candidate for a superior capsular reconstruction (SCR)?

QID: 214106
FIGURES:

59-year-old female with pseudoparalysis due to massive, irreparable supra- and infraspinatus tears and radiographic findings shown in Figure A

50%

(760/1506)

75-year-old male with pseudoparalysis due to massive, irreparable supraspinatus tear and radiographic findings showing Figure B

5%

(76/1506)

65-year-old mechanic with pseudoparalysis due to massive, irreparable supra- and infraspinatus tears with radiographic findings showing Figure B

10%

(151/1506)

59-year-old mechanic with pseudoparalysis due to massive, irreparable supraspinatus and subscapularis tears and radiographic findings shown in Figure A

11%

(163/1506)

45-year-old female with pseudoparalysis due to massive, irreparable supraspinatus and subscapularis tears with radiographic appearance showing in Figure A

23%

(351/1506)

L 4 A

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(OBQ18.166) A 52-year-old patient sustained a right anterior shoulder dislocation after falling down a flight of stairs several months ago and remains symptomatic. Which of the following figures demonstrates the expected injury associated with this?

QID: 213062
FIGURES:

A

7%

(179/2402)

B

64%

(1528/2402)

C

13%

(308/2402)

D

3%

(76/2402)

E

12%

(280/2402)

L 2 A

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(OBQ18.139) A latissimus dorsi tendon transfer is indicated for which of the following clinical scenarios?

QID: 213035
FIGURES:

A 30-year-old carpenter with MRI findings depicted in Figure A

79%

(1695/2136)

A 70-year old carpenter with MRI findings depicted in Figure A

6%

(121/2136)

A 30-year old carpenter with MRI findings depicted in Figure B

9%

(191/2136)

A 70-year old carpenter with MRI findings depicted in Figure B

1%

(21/2136)

A 30-year old on disability following a prior injury with MRI findings in Figure A

4%

(80/2136)

N/A A

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(OBQ18.138) A 70-year-old right-hand dominant female presents to your office complaining of continued right shoulder pain 12 weeks after falling from a ladder, despite participating in a rigorous physical therapy program. She was initially reduced in the emergency department and her injury films are shown in Figures 1 and 2. On exam, she has weakness on active elevation and external rotation, but full passive range of motion and intact sensation. New radiographs reveal no acute osseous abnormalities and a concentric reduction. What is best next step and which diagnosis will most likely be revealed?

QID: 213034
FIGURES:

No additional testing, observation; residual chronic pain from shoulder dislocation

2%

(46/2343)

MRI brachial plexus; axillary nerve palsy

1%

(29/2343)

MRI cervical spine; C5 and C6 nerve root radiculopathy

1%

(15/2343)

MRI right shoulder; rotator cuff tear

92%

(2148/2343)

Right upper extremity electromyography; axillary nerve palsy

3%

(82/2343)

L 1 A

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(OBQ18.167) A 27-year-old male reports right shoulder pain after sustaining a fall at work 3 weeks ago. He is found to have a rotator cuff injury with medial subluxation of the long head of the biceps tendon. Which of the nerves labeled in Figure A innervates the rotator cuff muscle that is likely injured in this patient?

QID: 213063
FIGURES:

A

16%

(368/2323)

B

66%

(1542/2323)

C

12%

(274/2323)

D

3%

(59/2323)

E

3%

(60/2323)

L 1 A

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(OBQ13.243) A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option?

QID: 4878
FIGURES:

Continue physical therapy

2%

(79/4027)

Latissimus dorsi transfer

72%

(2893/4027)

Arthroscopic rotator cuff repair

15%

(596/4027)

Pectoralis major transfer

2%

(93/4027)

Reverse total shoulder arthroplasty

6%

(232/4027)

L 3 A

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(OBQ13.125) Figure A shows an arthroscopic picture of a 62-year-old male undergoing repair of a torn subscapularis tendon. In the image shown, G represents the glenoid, H represents the humeral head, and the dotted line represents the superolateral border of the subscapularis tendon. Which two ligaments form the structure marked with the asterisk?

QID: 4760
FIGURES:

Inferior and middle glenohumeral ligaments

8%

(337/4448)

Middle and superior glenohumeral ligaments

29%

(1289/4448)

Coracohumeral and coracoacromial ligaments

5%

(244/4448)

Coracohumeral and superior glenohumeral ligaments

56%

(2487/4448)

Superior and inferior glenohumeral ligaments

1%

(57/4448)

L 4 B

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(OBQ12.132) A 45-year-old patient presents with pain and swelling after undergoing an arthroscopic rotator cuff repair 10 weeks ago. On physical exam the portal sites are healed and there is no drainage. Testing of the integrity of the rotator cuff is limited secondary to pain. He has a WBC of 11.0 (reference range, 3-11 cells/mL), ESR of 40 mm/hr (reference range, 0-22 mm/hr), and CRP of 1.5 mg/dL (reference range, 0-1 mg/dL). An aspiration is completed and no organisms are seen on the gram stain. Twelve days after the aspiration, positive cultures are reported. Which organism is most likely to have grown in culture medium?

QID: 4492

Staphylococcus aureus

3%

(198/6108)

Cutibacterium acnes

91%

(5555/6108)

Corynebacterium sp.

1%

(86/6108)

Staphylococcus epidermidis

3%

(191/6108)

Pseudomonas aeruginosa

1%

(45/6108)

L 1 B

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(OBQ12.141) A 47-year-old, healthy, active patient presents with a sub-acute, full-thickness supraspinatus tear. His physical examination reveals significant weakness and pain with abduction. There was no glenohumeral instability. Radiographs demonstrate a type 1 acromion. An MRI scan shows a crescent shaped tear with 2-cm of tendinous retraction and no tendinous fatty changes. A subacromial corticosteroid injection 6 weeks ago provided him with 24 hours of pain relief but no improvement in strength. What would be the most appropriate treatment option?

QID: 4501

Repeat subacromial corticosteriod injection

0%

(20/4285)

Biological augmentation of rotator cuff with porcine small intestine xenograft

1%

(44/4285)

Rotator cuff repair

77%

(3304/4285)

Rotator cuff repair plus acromioplasty

15%

(636/4285)

Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision

1%

(40/4285)

L 2 B

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(OBQ12.84) Which of the following statements regarding rotator cuff repair is true?

QID: 4444

Bone anchor drilling enhances vascularity following rotator cuff repair

51%

(2679/5216)

Shoulder motion following rotator cuff repair should be restricted to enhance blood flow to repair site

3%

(152/5216)

Double row rotator cuff repairs have better clinical results when compared to single row repairs

11%

(598/5216)

Subacromial decompression increases rates of successful rotator cuff repair

13%

(669/5216)

Failure to heal the rotator cuff tendon to bone consistently results in poor patient outcomes

20%

(1060/5216)

L 4 B

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(OBQ12.52) A 73-year-old right-hand dominant female presents with the right shoulder injury shown in Figure A. She denies having any shoulder pain prior to a fall at work after slipping on some water 4 weeks ago. She smokes a pack of cigarettes per week. Which of the following characteristics of this patient confer the highest risk of not healing the injury following surgical repair?

QID: 4412
FIGURES:

Pack of cigarette smoking per week

38%

(2115/5497)

Surgical repair 4 weeks after injury

2%

(131/5497)

Worker's compensation case

16%

(891/5497)

73 years of age

42%

(2297/5497)

Right-handed dominance

0%

(19/5497)

L 4 B

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(OBQ11.275) A 55-year-old carpenter presents with 6 weeks of right shoulder pain after installing ceiling drywall. He has no symptoms of night pain. His examination reveals 30 degrees lack of full flexion and abduction. He has full strength of the right shoulder. Radiographs are shown in Figures A and B. Coronal and Abduction-external rotation (ABER) MR images are shown in Figures C-E. What is the next most appropriate step in management?

QID: 3698
FIGURES:

Physical therapy

75%

(2755/3653)

Platelet rich plasma (PRP) injection

0%

(13/3653)

Arthroscopic rotator cuff repair

16%

(586/3653)

Arthroscopic SLAP repair

6%

(222/3653)

Arthroscopic subacromial decompression

2%

(60/3653)

L 2 B

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(OBQ11.120) A worker's compensation patient is scheduled for rotator cuff repair. His case manager asks you to comment on the expected outcomes of worker's compensation patients. In general, when compared to those of non-worker's compensation patients, the worker's compensation group shows which of the following?

QID: 3543

Better functional outcomes and equivalent patient satisfaction

1%

(39/3440)

Less functional improvement and lower patient satisfaction

82%

(2815/3440)

Equivalent functional outcomes and patient satisfaction

1%

(32/3440)

Equivalent functional outcomes and lower patient satisfaction

14%

(483/3440)

Less functional improvement and equivalent patient satisfaction

2%

(60/3440)

L 2 C

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(OBQ11.94) The rotator cuff in an overhead throwing athlete is most susceptible to tensile failure due to eccentric loading during which of the phases of throwing shown in Figure A?

QID: 3517
FIGURES:

A

0%

(12/4911)

B

4%

(180/4911)

C

25%

(1251/4911)

D

22%

(1087/4911)

E

48%

(2350/4911)

L 1 B

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(OBQ11.200) Which patient has the best indication for latissimus dorsi transfer?

QID: 3623

55-year-old man with cuff tear arthropathy and proximal humeral migration

2%

(86/3742)

85-year-old man with irreparable posterosuperior rotator cuff tear and 60 degrees of forward elevation and 0 degrees of active external rotation at his side

4%

(153/3742)

45-year–old man with complete irreparable supraspinatus and subscapularis tears with 90 degrees of active forward elevation

20%

(736/3742)

50-year-old man with large irreparable posterosuperior rotator cuff tear with 100 degrees of forward elevation and -10 degrees of external rotation

63%

(2350/3742)

35-year-old with an acute traumatic complete posterosuperior cuff tear with 0 degrees of active external rotation

10%

(391/3742)

L 3 B

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(OBQ10.152) During shoulder arthroscopy of a 58-year-old female recreational golfer, the rotator cuff is examined and is seen to be intact on the articular side. After a bursectomy is performed in the subacromial space, a bursal sided tear is found measuring 1.5 cm from anterior to posterior and 4 mm in depth from the surface of the tendon with surrounding cuff softening. What is the appropriate management?

QID: 3240

Debride the tear and perform an acromioplasty

28%

(449/1626)

Abort surgery and start a physical therapy program

1%

(14/1626)

Convert it to a full-thickness tear and repair it with suture anchors

61%

(994/1626)

Consider it incidental, as this is a common finding in this age group

7%

(114/1626)

Perform acromioplasty only

3%

(51/1626)

L 3 B

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(OBQ10.30) Rotator cuff tears (full thickness and partial thickness) in asymptomatic individuals are seen on MRI or ultrasound in what percentage of patients over the age of 60?

QID: 3118

0-5%

0%

(4/2594)

5-30%

11%

(298/2594)

30-55%

56%

(1450/2594)

55-80%

31%

(801/2594)

80-100%

1%

(31/2594)

L 4 C

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(OBQ10.197) What is the average medial-to-lateral distance of the supraspinatus tendon insertion at its footprint on the greater tuberosity?

QID: 3290

6-8mm

6%

(174/2820)

14-16mm

72%

(2017/2820)

20-22mm

16%

(456/2820)

24-26mm

5%

(135/2820)

30-32mm

1%

(25/2820)

L 3 C

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(OBQ10.92) A 64-year-old male suffers a fall while working on his farm and presents to the ER with the shoulder injury noted in Figure A. He undergoes reduction without complications, and post-reduction radiographs are shown in Figures B and C. At his 10 day clinic follow-up is noted to have an inability to abduct his arm. Which of the following studies will best confirm the most likely diagnosis in this patient?

QID: 3180
FIGURES:

MRI of the shoulder

69%

(1695/2445)

EMG

23%

(566/2445)

CT-angiogram of the affected extremity

0%

(8/2445)

Repeat shoulder x-rays

5%

(118/2445)

MRI of the brachial plexus

2%

(51/2445)

L 2 B

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(OBQ09.212) A 50-year-old man sustains a left shoulder injury after falling from a motorcycle. A physical examination test to examine for this shoulder injury is found in Figure A. What is the most likely diagnosis?

QID: 3025
FIGURES: