0:01

Okay, in the last five minutes, maybe about eight minutes,

0:05

we're gonna discuss a few other things

0:07

because I told you at the very beginning

0:10

that unfortunately the anatomy of the muscles

0:13

and tendons of the rotator cuff

0:15

and elsewhere is far more complex than

0:18

that simple drawing that I showed you.

0:21

You can have situations shown here

0:23

with single muscle bellies, double muscle bellies,

0:26

multiple exiting tendons.

0:28

So what you need to have is a vocabulary

0:31

that is large enough to describe such a situation

0:35

where you have one muscle belly, one good tendon,

0:38

one full thickness shown here.

0:40

And here's two muscle bellies with the same situation.

0:44

One muscle belly, full thickness tears

0:46

of both exiting tendons,

0:48

and the same thing with two muscle bellies.

0:51

Now whether you use our terminology

0:53

or your own, it has to be detailed enough

0:57

to describe this situation.

0:59

Now you who are listening might argue, I just don't see this

1:02

so I don't need this.

1:04

But indeed you see it even in the rotator cuff, uh, muscles.

1:08

Classically, as you look down on the supraspinatus,

1:11

there are two muscle bellies, a larger anor muscle belly,

1:16

a smaller strap posterior muscle with a long,

1:20

somewhat slim anterior tendon and a broader

1:24

but terminal posterior tendon that merged.

1:27

Here's what they look like, the anterior muscle

1:29

with the long tendon.

1:30

Here's the posterior muscle with a more terminal tendon.

1:34

And so what can occur with this particular muscle

1:37

and tendon unit, you can get a full thickness tear of one

1:42

of those exiting tendons here shown anteriorly,

1:45

and yet the posterior tendon is intact.

1:49

I would ask you, do you have the terminology for

1:52

that particular uh, situation?

1:57

Here's another example.

1:59

The yellow all pointing to failure of the tendon

2:02

of the anterior muscle belly, the white all pointing

2:06

to the intact posterior tendon.

2:09

The situation is even more complex

2:12

with the in infraspinatus tendon

2:14

and there are a variety of, uh, descriptions of the anatomy

2:18

of the muscles of the in infraspinatus.

2:21

I'm just gonna show you one in this sort of arrangement.

2:24

There are two muscle bellies.

2:28

The larger one is the oblique muscle here

2:31

with an oblique tendon that extends up

2:34

and it goes all the way to the greater tuberosity

2:37

with a second smaller muscle belly located superiorly

2:41

with a transverse tendon that connects to the myo tendons

2:45

or proximal tendonous region of the tendon

2:48

of the oblique part.

2:50

And one of the failure patterns that we see is a

2:54

full thickness tear of the tendon of the transverse part

2:59

Shown here with the lower tendon

3:02

of the oblique part intact.

3:04

This was called the novel lesion

3:07

of the infraspinatus tendon novel.

3:10

It is not, it's seen in a variety of places, uh,

3:13

not just in the rotator cuff tendons,

3:15

but it is a classic pattern that you will see.

3:18

And here's another example of it is a full thickness tear,

3:23

but involving only one of the terminal tendons

3:28

of the in infraspinatus muscle.

3:31

That is why when I describe tendon tears, I don't use

3:35

for the rotator cuff tendon complete

3:38

or incomplete in my vocabulary.

3:41

I talk about full, uh, width, uh, thickness in width.

3:45

Is it full thickness? Is it full width?

3:47

Uh, that's the description I use.

3:49

And I use the sagittal plane

3:51

because it lays out all of the tend tendons shown here,

3:55

even the cortical humeral ligament.

3:57

So here are some examples

3:59

where you can see in fact a variety of patterns

4:03

full thickness, but some are full width,

4:05

some are partial width depending upon the measurement in

4:09

the sagittal plane.

4:11

So let's just summarize what I have said here.

4:16

I'm showing you cross sections of the collagen bundles.

4:20

This would be a full thickness for width tear.

4:23

Here's a full thickness partial width tear.

4:27

Here is a partial thickness for width tear.

4:32

Here is a partial thickness, partial width there

4:36

and here is a delaminated collagen sparing there.

4:40

And in the last three

4:41

or four minutes, just a few words about pairs

4:44

of the footprint, particularly of the SSM

4:48

and infraspinatus, you see the list on your left.

4:51

If you go into the literature,

4:53

particularly the arthroscopy literature, these are the terms

4:56

that you'll see and there are about two

4:58

or three others I didn't put on the list.

5:00

Now if you just use these terms

5:03

other than maybe the REM rant, I can tell you for most, most

5:08

of the time you'll be talking to yourself

5:11

because most orthopedic surgeons do not know these terms.

5:15

Alright? They may know rim rent,

5:18

but I can tell you even the Italian ones don't tend

5:21

to know pasta lesions.

5:23

All right? So I tend not to use these terms.

5:27

I talk about whether or not they will be concealed

5:31

or possibly concealed at the time of arthroscopy

5:35

and bursoscopy or whether because they violate the articular

5:39

or bursal sided surfaces, they should be non-con concealed.

5:44

That's the term that I use.

5:46

So here I show you non-con concealed articular sided

5:50

and bursal sided tears

5:52

and a concealed interstitial delamination

5:55

within the substance.

5:57

A good orthopedic surgeon will probe that tendon

6:00

and even detect the concealed tears

6:03

to show you what they look like.

6:05

Here's what they might look like.

6:07

This is an old case,

6:08

but it shows you a concealed lesion, certainly

6:13

disrupting some of the collagen bundles.

6:16

Whether or not it is symptomatic, I,

6:18

I can't remember in this particular case whether it was the

6:21

cause of the symptoms.

6:23

And what's interesting to me, it is when I section cadavers,

6:28

it is these sorts of tears that lead to the cysts

6:32

that we see in the greater tuberosity.

6:35

So I'm gonna say a word about cyst. I know Dr.

6:38

Pomerance also will be talking briefly about them.

6:41

Because of that anatomy of the greater tuberosity and

6:45

because of the bare area that is located in the region

6:50

of the infraspinatus tendon with exposed bone,

6:54

that seeing cyst in the posterior aspect

6:57

of the greater tuberosity is less significant

7:01

than seeing cyst in the anterior aspect

7:03

of the greater tuberosity, at least in young people.

7:07

Because in young people, the footprint in fact

7:10

of the supraspinatus tendon is right at the edge

7:14

of cartilage and there is no bear or exposed areas.

7:18

Now, in an older person where you get that peeling away

7:22

that I described, that can be asymptomatic,

7:25

you may find cysts in the anterior aspect of

7:28

that greater tuberosity that can be, uh, asymptomatic.

7:33

But many of these small pairs that I saw

7:38

of the tendons were associated

7:40

with cyst in the greater tuberosity in cadavers

7:43

derived from elderly persons.

7:45

So what I have done here in my period of time is to cover

7:50

exactly these objectives.