0:01

So I'm gonna start out, um, with, you know, a basic case

0:05

and, um, it's hard to follow that fantastic,

0:09

elegant lecture.

0:11

Um, but I hope to, I heap some additional pearls on you.

0:14

And let's start out with this 53-year-old woman

0:17

who is a former NCAA division one college volleyball player

0:23

who now complains of weakness and pain in the shoulder.

0:27

And I'd like to start out

0:28

by saying a word about impingement.

0:30

Um, there's numerous,

0:33

numerous philosophies about impingement.

0:35

And about 22 years ago I described a grading system

0:40

that I have used, uh, for quite some time.

0:43

And it looks something like this.

0:45

Much, much the same as what, uh, Dr.

0:47

Resnick, what Don showed in his lecture.

0:49

And I broke it down into external, uh, uh, sorry, extrinsic

0:54

and intrinsic causes of impingement.

0:57

And then from there, the extrinsic causes, I broke down into

1:03

subcoracoid, sub acromial,

1:06

and then underneath the AC joint, the least common,

1:09

which in cases of extrinsic impingement,

1:12

which I see usually in people over age 60,

1:16

extrinsic impingers are older.

1:18

The AC joint accounts for less than 1% of all of these, most

1:22

of them are subacromial.

1:25

Then I read an article, uh, published by our colleagues,

1:29

the, the French, um, on biomechanical impingement,

1:34

and they broke it down into, um, internal

1:37

and external biomechanical impingement.

1:41

And this was described predominantly in people

1:43

that were very active young individuals.

1:46

So you have the external

1:48

and internal variety,

1:49

the external occurring in the deceleration movement

1:54

or the end stage movement of going from the abor position

1:58

to a follow through position.

2:00

And those people had disease in the anterior aspect

2:03

of the shoulder, including cysts,

2:06

rotator cuff pathology, et cetera.

2:08

The internal impingers a far more common

2:12

and well-known type of biomechanical impingement.

2:15

And these occur in active individuals who are young,

2:18

occur in the caulking phase of the overhead motion,

2:21

be it volleyball, be it tennis, be it American baseball.

2:25

And those individuals have a combination of lab pathology

2:31

cysts in the back of, of the shoulder

2:33

and disease of the posterior rotator cuff.

2:38

So with that in mind, our search pattern starts out

2:41

with an assessment of the conformity of the shoulder.

2:45

How does the humerus look relative to the, to the glenoid?

2:48

Is it centered up pretty well? It is.

2:51

How does it look in the axial projection?

2:53

Is it centered up pretty well?

2:54

I'll show you in a few moments that it is,

2:57

and I look at the shape of the, uh,

2:59

because if you have a shift in the relationship

3:02

between the glenoid and the humerus,

3:05

or you have a tight capsule, which is hard to detect,

3:08

you're predisposed to various types

3:11

of pathologies involving the rotator cuff.

3:14

I then look at those, those areas of interest, uh,

3:17

the subacromial space,

3:18

and we see a, an acromion that's down sloping,

3:21

but it looks a little bit like the end of a,

3:23

of a telephone receiver.

3:25

It's got this broad, uh, spur to it,

3:27

which is really an enthesophyte, uh, as Don described.

3:31

And attaching to this area is the CAL,

3:34

the caracal acromial ligament.

3:36

And frequently these travel together, they're like twins.

3:40

The acromion, uh, enlarges.

3:43

And in concert with that enlarged acromion,

3:45

you have this thickened CAL, which is

3:48

tugging on that acromion.

3:49

And I too feel that the, the anterior, uh, spur

3:53

of the acromion is really an zaphy

3:55

that's acquired almost never developmental.

3:59

So in this case, we have a very thick CAL,

4:02

we have a down sloping acromion.

4:04

We have a broad-based acromion,

4:06

and it has resulted in a bursal collection

4:10

and truncation of the rotator cuff in

4:12

the coronal projection.

4:13

So I would describe this tear

4:15

and give the retraction dimension,

4:17

and I'd measure it from say here to here,

4:20

but then I would go on

4:21

and tell the clinician

4:23

that you also have diseased tendon otic cuff,

4:26

where they have to repair this into a,

4:28

a locus on the humeral head

4:30

with bioresorbable suture anchors.

4:32

So we have an unhealthy piece of tendon

4:34

and look at the distortion of the architecture,

4:37

of the superficial aspect of the cuff

4:40

as the CAL passes right over it right there.

4:43

So we have diseased cuff that we're gonna try and pull over

4:46

and anchor into the humerus,

4:47

and that is, that is problematic.

4:49

Look at how diseased this cuff tissue is in the sagittal

4:53

projection, making it problematic.

4:55

Now, the in infraspinatus, uh, over, over top

4:59

of the middle facet is spared,

5:01

but we do have a large pseudocyst in the back.

5:04

So what that tells me, I, the other thing

5:06

that I do in cases like this, as I look at the pattern

5:09

of cysts and how misshapen the, the humeral head is,

5:14

and if I have cysts in the back, I know

5:16

that I've had a problem in the past in,

5:18

in the caulking position.

5:20

And at this patient has had at some point a, a form

5:23

of internal biomechanical impingement.

5:26

And most people between the ages of say, 40

5:28

and 60, we'll have a combination of both.

5:30

They've had biomechanical impingement

5:32

and now they have anatomic impingement,

5:34

and the two really collide.

5:36

And that's exactly what's happening here.

5:38

This gal was a, a volleyball player,

5:41

so she was constantly in the overhead position.

5:43

Now she's got subacromial impingement.

5:46

I'll then look at the remainder of the cyst.

5:48

So we've got some in the back, but we also have some in the

5:51

front as well, some large ones.

5:53

So she's had multi-directional, uh,

5:56

biomechanical micro instability in the past that is combined

6:00

with her subacromial impingement

6:02

and eventually led to this rotator cuff rupture.

6:05

You can see in the sagittal projection,

6:07

the infraspinatus is spared.

6:09

And the oblique segment of the in infraspinatus that Dr.

6:12

Resnick talked about earlier often comes in at a curve.

6:16

It makes these little hairs in the back that looks like

6:19

Bart Simpson's hairdo right here.

6:22

And then the, the front fibers are, are more linear,

6:25

linearly oriented.

6:26

Then as we go off to the side, we get the

6:29

ant posterior dimension of the cuff tear.

6:32

So I'm gonna give a retraction dimension.

6:34

I'm gonna tell the clinician that the, the, the edge

6:37

of the tear is diseased.

6:39

I'm going to give an AP dimension.

6:41

Some people refer to this as full width.

6:43

I will just give the AP dimension and measure it.

6:46

The reason I don't use full width myself is

6:49

because it makes me think about retraction.

6:51

You know, width is usually a media lateral thing,

6:54

but that's a commonly used descriptor for this.

6:57

Or you can simply measure the AP dimension.

7:00

Now, as I said, I I, I look for anatomic impingement.

7:03

I've done that under the acromion.

7:05

I do that at the AC joint, which almost never cleaves

7:10

or impinges on the myotendinous junction,

7:13

but it can in rare instances.

7:15

And then I look at the corticoid.

7:17

Now in the sagittal projection, a little pearl here,

7:20

Don talked about, uh, let's see later.

7:23

Don talked about the, the, uh, subacromial arch.

7:27

It's kind of triangular in shape.

7:29

And I look at the position of the cricoid.

7:31

If the cricoid is drooping below 50%

7:36

of the cranial caut dimension of the, of the subscapularis,

7:41

those are patients who are more prone

7:43

to subcoracoid impingement or, or a button.

7:46

This patient doesn't have it.

7:48

The, the individual segments

7:50

of the subscapularis can be seen.

7:53

1, 2, 3, and then four, it's intact.

7:56

So we've got involvement of the supraspinatus.

7:59

We've got a width or a retraction dimension.

8:02

We've got an anter posterior dimension,

8:04

which I refer to as length.

8:06

Many people refer to it as full width.

8:08

So you might wanna use retraction here, either full width

8:11

or give the dimension here.

8:14

And then you would, in the body of the report,

8:17

talk about the, the pattern of

8:19

pseudocyst formation in the humeral head.

8:22

So this is an impinger with a full depth rotator cuff tear.

8:26

Don any comments on this case?

8:28

Uh, first one question.

8:30

Do you have a measurement that you use for thickness

8:33

of the corco acromial ligament?

8:36

I do. I, I, I use about three and a half millimeters.

8:39

But honestly, I, you know,

8:41

because I'm in a practice, very busy practice,

8:43

I eyeball it most of the time.

8:45

And I look for what you described in your

8:47

lecture indentation.

8:49

So if I see indentation

8:51

and I see swelling right underneath that CAL,

8:53

which I do here, and this patient's arm isn't even over the

8:56

head, so it's gonna get a lot worse when the arm is up

8:59

and maybe the humeral head decenters superiorly, then

9:02

that becomes problematic.

9:04

So I I, I do not measure it routinely.

9:06

I did in my, in my earlier career.

9:08

Okay. And the other thing I talking about that ligament,

9:11

one of the interesting aspects

9:12

and easily overlooked is in a significant number of cases,

9:17

it's not a single ligament, it is bifid or more,

9:20

and there have been some articles that have tried

9:23

to address is there a higher risk of impingement.

9:26

But most of the time the results have been negative,

9:28

that even though it is bifid, uh, or trife

9:31

or what have you, that it doesn't, uh, carry a risk of, uh,

9:36

of impingement apparently.

9:37

But, but it's amazing

9:39

how often you can find more than a single uh, ligament,

9:43

a single cortical acromial ligament.

9:44

That's very interesting.

9:46

And you know, I do like

9:47

to differentiate whether it's a bony stenosis

9:51

or a ligamentous stenosis or both.

9:53

Frequently in middle age it is both.

9:55

And, and then again, in this case, look at the opposition

9:59

of the diseased cuff to the CAL

10:01

and you see it in the sagittal projection as well.

10:03

And you see a little interstitial tear that is just starting

10:06

to develop just deep to it.

10:08

Shall we move on to the next case?

10:10

Yeah.