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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?
Continue physical therapy
Latissimus dorsi transfer
Arthroscopic rotator cuff repair
Pectoralis major transfer
Reverse total shoulder arthroplasty
Select Answer to see Preferred Response
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?
Inferior and middle glenohumeral ligaments
Middle and superior glenohumeral ligaments
Coracohumeral and coracoacromial ligaments
Coracohumeral and superior glenohumeral ligaments
Superior and inferior glenohumeral ligaments
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?
Repeat subacromial corticosteriod injection
Biological augmentation of rotator cuff with porcine small intestine xenograft
Rotator cuff repair
Rotator cuff repair plus acromioplasty
Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision
Which of the following statements regarding rotator cuff repair is true?
Bone anchor drilling enhances vascularity following rotator cuff repair
Shoulder motion following rotator cuff repair should be restricted to enhance blood flow to repair site
Double row rotator cuff repairs have better clinical results when compared to single row repairs
Subacromial decompression increases rates of successful rotator cuff repair
Failure to heal the rotator cuff tendon to bone consistently results in poor patient outcomes
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?
Pack of cigarette smoking per week
Surgical repair 4 weeks after injury
Worker's compensation case
73 years of age
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?
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?
Platelet rich plasma (PRP) injection
Arthroscopic SLAP repair
Arthroscopic subacromial decompression
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?
Better functional outcomes and equivalent patient satisfaction
Less functional improvement and lower patient satisfaction
Equivalent functional outcomes and patient satisfaction
Equivalent functional outcomes and lower patient satisfaction
Less functional improvement and equivalent patient satisfaction
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?
Which patient has the best indication for latissimus dorsi transfer?
55-year-old man with cuff tear arthropathy and proximal humeral migration
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
45-year–old man with complete irreparable supraspinatus and subscapularis tears with 90 degrees of active forward elevation
50-year-old man with large irreparable posterosuperior rotator cuff tear with 100 degrees of forward elevation and -10 degrees of external rotation
35-year-old with an acute traumatic complete posterosuperior cuff tear with 0 degrees of active external rotation
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?
Debride the tear and perform an acromioplasty
Abort surgery and start a physical therapy program
Convert it to a full-thickness tear and repair it with suture anchors
Consider it incidental, as this is a common finding in this age group
Perform acromioplasty only
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?
What is the average medial-to-lateral distance of the supraspinatus tendon insertion at its footprint on the greater tuberosity?
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?
MRI of the shoulder
CT-angiogram of the affected extremity
Repeat shoulder x-rays
MRI of the brachial plexus
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?
Teres minor tear
During diagnostic arthroscopic evaluation of a patient's shoulder, you identify a thickened portion of the coracohumeral ligament, near its avascular zone, running perpendicular to the supraspinatous tendon. The structure is identified in Figure A with black arrows. What is the name for this structure?
Middle glenohumeral ligament
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 subscapularis
Absence of the coracoacromial ligament
Which of the following may be seen during arthroscopy in a patient with a subscapularis tear?
Uncovered lesser tuberosity
Retraction of the subscapularis tendon to the level of the glenoid
Avulsed superior glenohumeral ligament
Medial biceps subluxation
All of the above
Which of the following patients is the optimal candidate for a latissimus dorsi transfer?
36-year-old laborer with massive rotator cuff tear and associated supraspinatus atrophy
67-year-old non-laborer with rotator cuff tear arthropathy and pseudoparalysis
34-year-old laborer with massive rotator cuff tear and thoracodorsal nerve palsy
63-year-old with supraspinatus rotator cuff tear and subacromial impingement
37-year-old non-laborer with extensive chondrolysis following a rotator cuff repair and indwelling pain catheter placement for postoperative pain
A 50-year-old recreational league baseball pitcher reports that 3 months ago he started having right shoulder pain after every game he had pitched. One month ago he injured his shoulder further when he fell off of a ladder. He has attempted to participate in a shoulder rehabilitation program but could not return to pitching secondary to pain and weakness. Figure A demonstrates an arthroscopic image taken from a lateral portal in the subacromial space (HH= humeral head, LHB= long head of the biceps) while in the beach-chair position. What is the injury pattern sustained as highlighted by the injured structure labeled with the asterisk in Figure A?
Humeral avulsion of the glenohumeral ligament (HAGL lesion)
Superior labrum anterior-posterior (SLAP) tear
Rotator cuff tendon tear
Anterior-inferior capsulolabral lesion (Bankart lesion)
Anterior labral periosteal sleeve avulsion (ALPSA lesion)
A 65-year-old right-hand-dominant man reports acute right shoulder pain and inability to lift his arm overhead after a glenohumeral dislocation while skiing 2 weeks ago. Physical exam reveals active forward elevation to 30 degrees and 3/5 external rotation strength, pain with motion, and intact lateral arm sensation. An MRI is contraindicated due to a pacemaker, and therefore an arthrogram is performed and shown in Figure A. What is the most appropriate treatment option?
Rotator cuff repair
Proximal humerus ORIF
Total shoulder arthroplasty
A large rotator cuff tear is repaired through 3 trans-osseous tunnels by a mini-open approach. What is the most appropriate post-operative therapy protocol?
early passive range-of-motion and active range-of-motion at 6 weeks
early active range-of-motion with emphasis on eccentric exercises
early active range-of-motion with emphasis isometric exercises
early active range-of-motion with emphasis on plyometric execises
sling immobilization for 12 weeks, followed by delayed active-assisted range-of-motion
A 34-year-old carpenter has left shoulder pain for the past 3 months following a fall from a ladder. Figure A displays a coronal T2 MR image. Which of the following diagnoses most appropriately describes this patient's lesion?
Anterior labral periosteal sleeve avulsion (ALPSA)
Partial articular surface tendon avulsion (PASTA)
Humeral avulsion of the glenohumeral ligament (HAGL)
Superior labral anterior to posterior tear (SLAP)
Glenolabral articular disruption (GLAD) lesion
Resection of the coracoacromial ligament during shoulder arthroscopy results in which of the following?
Increased glenohumeral joint translation
Increased passive shoulder internal rotation
Increased axillary recess volume
Decreased acromioclavicular joint reactive forces
Decreased resting tension in the long head of the biceps