0:01

The next thing that I'm going to, uh, turn

0:02

to is the terminology.

0:04

And I realize that people who are listening

0:07

probably from various, uh, places in,

0:09

in the globe don't have the same terminology.

0:12

But this is the terminology that I use

0:15

to describe particularly the tendons of the rotator cuff.

0:19

I might change it a little bit when we talk about other

0:22

tendons as we will during this course.

0:25

But for the tendons of the rotator cuff,

0:28

a full thickness tear is a tear that extends entirely

0:33

from the superior to the inferior surface, the medial

0:36

to the lateral surface of the tendon, or in both directions.

0:41

I'm showing you only a single sagittal image

0:45

of the Achilles tendon,

0:46

but I would tell you every sagittal image

0:48

through the tendon looked like this.

0:50

So this is a full thickness,

0:53

full width tear involving the Achilles tendon.

0:56

We can see the degree of retraction

0:59

and tendonous gap

1:00

that it has produced a split tear.

1:05

If you are using that terminology.

1:09

A split tear is a full thickness tear.

1:14

It does go from one side of the tendon to the other side,

1:18

but it is a unique pattern.

1:21

The classic pattern as it goes through the tendon is between

1:27

collagen bundles.

1:28

So it is a full thickness collagen sparing tear

1:32

and of interest, even when you have these full thickness

1:36

tears like this, you test the muscle

1:38

and the muscle strength may seem to be normal.

1:41

Alright, the classic place we see it, of course, is here

1:47

behind the fibula.

1:48

This is a transverse section, anatomic section,

1:51

and a transverse MR image showing you the peroneous

1:56

brevis with a split tear.

1:58

Here's brevis. Here's brevis. It's the two dots in front.

2:03

The peroneous longest present right behind it,

2:07

which is often the cause of splitting of

2:10

that peroneous brevis full thickness,

2:13

but often collagen sparing.

2:16

Okay? And by the way, in this particular cadaver,

2:19

there's no significant perineal groove

2:22

on the posterior aspect of the fibula

2:24

and that there's a lot of variability in the depth

2:27

of the groove, probably explaining why it's these tendons

2:29

that subluxate and dislocate most commonly around the ankle.

2:34

But in any case, getting back to the point here,

2:37

this is a, a split tear.

2:40

Now, we do have certain names that are applied to the tears

2:44

of the rotator cuff.

2:45

One of the names that we uh, hear is a massive tear,

2:50

and there are several definitions to a massive tear.

2:54

A massive tear is said to be a full thickness tear

2:58

That involves the full width of two

3:01

or more contiguous tendons

3:04

or a full thickness tear whose width in the sagittal plane

3:09

is greater than five uh, centimeters.

3:13

Now, these tears may involve the more posterior structures

3:16

or the more anterior structures.

3:19

Here I'm showing you massive tear involving supraspinatus

3:23

and infraspinatus tendons with mark retraction

3:27

and mark nowing of the acromial humeral distance.

3:30

More about that in a few minutes.

3:32

These tears may also extend from the supraspinatus across

3:36

the rotator interval

3:38

to involve the subscapularis tendon as well.

3:41

So the, this is a massive tear.

3:44

Others define it slightly more differently based on the

3:47

degree of retraction.

3:49

Does it reach the joint line or beyond?

3:53

How much of the greater tuberosity is exposed?

3:57

Does it expose more than two thirds

3:59

of the greater tuberosity?

4:01

Those are other definitions for massive tears.

4:07

I wanted to show you this,

4:09

but I, okay, something called a fosbury flopped air.

4:14

Now, I know a lot of you listening are not old enough

4:17

to remember this particular thing

4:19

that occurred many years ago in the Olympics,

4:24

but Dick Fosbury was a high jump, a athlete,

4:28

and during the Olympics he introduced what was called

4:33

the fosbury flop.

4:35

And it's because of that and

4:37

because of the pattern of failure that we see in the tendons

4:41

of the rotator cuff

4:42

that we've identified a fosbury flopped air,

4:47

it is a full thickness tear that involves the posterior cuff

4:50

that inverse upside down like fosbury did right here

4:55

and leads to adhesions between the torn inverted tendon

4:59

and the wall of the subacromial bursa.

5:02

And so it is a difficult tear to treat

5:04

and I've actually, since I learned about it a couple years

5:07

ago, I've identified this quite often in most

5:10

of the cases proved at surgery.

5:12

Here's another one. You can see the inverted end.

5:15

It's a full thickness retracted tear,

5:18

but the important point,

5:20

the fibers are inverted upside down.

5:23

Just remember Dick Fosbury

5:25

and his gold medal cuff tear

5:30

arthropathy is a term introduced

5:33

by orthopedic surgeon years ago.

5:36

And what it refers to is a primary process leading

5:41

to tendon failure, which

5:43

because of tendon failure, leads to abnormal

5:48

mechanics at the Glen humeral joint

5:49

with secondary arthropathy of that joint leading

5:54

to osteoarthrosis, a elevation of the humeral head

5:58

and narrowing of the acromial humeral distance.

6:01

And there are measurements that have been introduced for

6:04

that particular distance.

6:06

I've listed them here on your left.

6:10

The orthopedic, uh, the orthopedic

6:11

surgeons will use this term.

6:13

But if you're a rheumatologist,

6:15

and I doubt there are many listening, you're gonna say,

6:17

wait a minute, that's not the proper term.

6:20

They used the term Milwaukee shoulder syndrome

6:24

because you see, there was a very famous rheumatologist,

6:28

Daniel McCarty, who lived in the city of Milwaukee,

6:32

Wisconsin, who said, no, this is not a primary tendon tear.

6:37

This is calcium hydroxyapatite crystal deposition

6:41

that occurs within

6:43

and around the joint that leads to the release

6:47

of collagenase

6:49

and other enzymes that lead to secondary failure

6:53

of the tendon and subsequent mal alignment.

6:57

So it's their belief and the belief of many rheumatologists.

7:01

This is a crystal deposition problem

7:04

and not a mechanical problem that begins within the tendons,

7:08

but this is what it looks like.

7:10

Cuff tear arthropathy or Milwaukee shoulder.

7:14

And if Milwaukee shoulder has been described

7:16

by the way in the hip, Milwaukee, hip Milwaukee knee,

7:20

and other joints as well,

7:23

the geyser sign was a term introduced years ago when we were

7:27

doing standard arthrography to evaluate the cuff,

7:32

the rotator cuff, and we would do the arthogram

7:36

and the contrast here, I'm showing you latex

7:39

contrast injected in the joint would extend

7:42

through the tendons of the rotator cuff

7:44

and reach the subacromial subdeltoid bursa.

7:47

And so it looked, in fact, if you saw that

7:51

and there was failure of the inferior capsule,

7:54

the contrast would extend up into the AC joint.

7:58

So the geyser sign was described for that

8:01

increased vertical elevation of

8:05

contrast within the AC joint.

8:07

And by the way, the failure of the capsule inferiorly

8:11

did not add significance to the findings.

8:13

The most important part of the AC capsule by far

8:17

is the anterosuperior capsule of the joint.

8:21

The supergas are shown here where there is a synovial cyst

8:25

as well that is communicating

8:27

with the acromial ca the joint as you can, uh,

8:32

see also clinic, uh, in the clinical picture.

8:36

Let's turn our attention to partial thickness hair.

8:39

The definition of a partial thickness tear, a tear

8:43

that extends partially from the superior

8:46

to the inferior surface, the medial to the lateral surface

8:50

of the tendon or in both directions. Okay?

8:55

So these tears can be totally

8:58

intrasubstance, okay?

9:01

But they do not communicate all the way from one side

9:04

of the tendon to the other.

9:06

Now, one of the patterns we see commonly involving the

9:09

tendons of the roter

9:10

or rotator cuff is a articular sided tear

9:16

with partial thickness

9:18

and then delamination extending medially toward

9:21

the myo tendonous junction.

9:23

And I show you an example of it here on your right.

9:27

Now, when you have those sort of tears, a

9:30

phenomenon may occur where there is a cyst like structure

9:36

that fills with fluid

9:37

or contrast agent known as a sentinel cyst.

9:40

I show you one here in, in the supraspinatus tendon.

9:45

And these sentinel cysts typically occur at the myotendinous

9:49

junction, and they are strong evidence of a delaminated tear

9:53

and also in most cases of articular sided violation.

9:59

Here's another one.

10:00

This was a partial thickness articular sided tear

10:04

near the footprint of the subscapularis, uh, tendon

10:08

with delamination

10:10

and a moderate size sentinel cyst at the Myo Tendonous

10:15

junction of Group One Fibers.