Impingement Syndrome and Rotator Cuff Tears

Question 1

Impingement syndrome is seen typically in what age group?

Answer 1

30s-40s

Question 2

Rotator cuff tears are seen typically in what age group?

Answer 2

50s-60s

Question 3

What is impingement syndrome?

Answer 3

The tendons of the rotator cuff are compressed in the tight subacromial space during movement, producing pain

Question 4

What tendon is most likely to be affected in impingement syndrome?

Answer 4

Supraspinatus

Question 5

Patients with impingement syndrome will typically have pain when? What is this known as? What muscle is this related to?

Answer 5

Between 60-120 degrees abduction (variable)- painful arc, related to the deltoid muscle

Question 6

Why do patients with impingement syndrome get painful arc?

Answer 6

This occurs as an inflamed part of the tendon passes through the subacromial space

Question 7

What are the most likely causes of impingement syndrome in a younger patient?

Answer 7

Tendonitis/subacromial bursitis

Question 8

What is the most likely cause of impingement syndrome in a middle aged patient?

Answer 8

Hooked acromion rotator cuff tear

Question 9

What is the most likely cause of impingement syndrome in an older patient?

Answer 9

AC joint OA with inferior osteophyte

Question 10

Pain from impingement typically radiates where?

Answer 10

Deltoid and upper arm

Question 11

Where may tenderness be felt in impingement syndrome?

Answer 11

Below the lateral edge of the acromion

Question 12

What clinical test will recreate the pain of impingement syndrome? Briefly describe the test.

Answer 12

Hawkins-Kennedy test: internally rotate the flexed shoulder

Question 13

When considering a diagnosis of impingement syndrome, what is important to exclude?

Answer 13

Cervical radiculopathy

Question 14

Are investigations required in order to start treatment for impingement syndrome?

Answer 14

No

Question 15

What is the first line management for impingement syndrome?

Answer 15

Conservative: NSAIDs, analgesics, physiotherapy, subacromial injections

Question 16

How many subacromial injections may be required in impingement syndrome?

Answer 16

Up to 3

Question 17

Cases of impingement syndrome which do not benefit from conservative management could benefit from what?

Answer 17

Subacromial decompression surgery

Question 18

What is the point of subacromial decompression surgery in impingement syndrome?

Answer 18

To create more space for the tendon to pass through

Question 19

How can subacromial decompression surgery be performed?

Answer 19

Open, or with minimally invasive arthroscopic techniques

Question 20

What describes impingement?

Answer 20

The imbalance of forces in the coronal plane

Question 21

In order to abduct the limb, the deltoid needs power to be offset by force from where?

Answer 21

Inferior

Question 22

What happens if there is an imbalance between the deltoid and rotator cuff?

Answer 22

Elevation of the humerus and narrowing of the subacromial space

Question 23

The tendons of the rotator cuff usually tear when? Why is this?

Answer 23

With little or no trauma, as a consequence of degenerative change

Question 24

What is a classic history of a rotator cuff tear?

Answer 24

A sudden jerk in a patient > 40 with subsequent pain and weakness

Question 25

Rotator cuff tears are very uncommon in young people. What may they occur as a result of?

Answer 25

Significant injury, including shoulder dislocation

Question 26

Can you get different degrees of rotator cuff tears?

Answer 26

They can be partial or full thickness

Question 27

Rotator cuff tears usually involve which muscle?

Answer 27

Supraspinatus

Question 28

Large rotator cuff tears can extend into which muscles?

Answer 28

Subscapularis and infraspinatus

Question 29

In rotator cuff tears, weakness of initiation of abduction implies damage to which muscle?

Answer 29

Supraspinatus

Question 30

In rotator cuff tears, weakness of internal rotation implies damage to which muscle?

Answer 30

Subscapularis

Question 31

In rotator cuff tears, weakness of external rotation implies damage to which muscle?

Answer 31

Infraspinatus

Question 32

What clinical sign may be seen when looking at a patient with a rotator cuff tear?

Answer 32

Supraspinatus wasting

Question 33

Rotator cuff tears can be confirmed with which investigations?

Answer 33

Ultrasound or MRI

Question 34

What are the non-operative management options for a rotator cuff tear?

Answer 34

Physiotherapy and subacromial injections

Question 35

What is the role of physiotherapy in rotator cuff tears?

Answer 35

To strengthen the remaining cuff muscles, to compensate for the loss of supraspinatus

Question 36

Which patients with a rotator cuff tear require quick investigation and physiotherapy? Why?

Answer 36

Patients in their 50s/60 to prevent them from having a massive tear

Question 37

What surgical management can be used for rotator cuff tears?

Answer 37

Rotator cuff repair with subacromial decompression

Question 38

What is the role of surgery for rotator cuff tears?

Answer 38

To improve/maintain strength and prevent subsequent arthritis from chronic cuff deficiency

Question 39

What is the failure rate of rotator cuff repair surgery? Why?

Answer 39

1/3rd of cases fail to repair because the tendon is so diseased or the tear is too large and the tendon is retracted too far

Question 40

What are the long term results of rotator cuff repair surgery?

Answer 40

These are not well known

Question 41

In the short term following rotator cuff repair surgery, how long will patients need a sling for? For how long will they be unable to drive? For how long will they be unable to lift heavy objects?

Answer 41

Sling for 6 weeks, no driving for 8-10 weeks, no heavy lifting for 12 weeks

Question 42

What is the recovery from rotator cuff repair surgery like?

Answer 42

Prolonged physiotherapy and recovery time, with a 30-40% chance of re-tear at 1 year

Question 43

What are intrinsic causes of rotator cuff problems?

Answer 43

Degeneration and tendon vascularity

Question 44

What is the extrinsic cause of rotator cuff problems?

Answer 44

Compression