Miscellaneous Shoulder Conditions

INTRODUCTION

We consider the arthroscopic treatment of several categories of miscellaneous shoulder problems in this chapter: conditions of shoulder stiffness, calcific tendinitis, fractures, the suprascapular nerve, and other interesting problems that defy categorization. These problems are united by their overall lower volumes of surgical treatment in our practices compared with other disorders discussed in this book. Perhaps especially for this reason, numerous conundra await the surgeon who undertakes treatment of these conditions.

SHOULDER STIFFNESS

The surgeon encounters shoulder stiffness most commonly either as idiopathic adhesive capsulitis (frozen shoulder) or as a postoperative complication. These entities have both common and distinct treatment principles. Arthroscopy has revolutionized our ability to treat all varieties of stiffness by giving the surgeon minimally invasive access to the sites of pathology in the shoulder, particularly intra-articular access to the thickened and contracted glenohumeral joint capsule and ligaments. Because postoperative pain and wound complications are lessened with arthroscopy, rehabilitation after stiffness surgery can progress much more effectively.

Idiopathic adhesive capsulitis is common and is likely underrecognized, especially when mild. We make a point to carefully screen patients presenting with undiagnosed shoulder pain for subtle passive stiffness, as these patients should have stretching as a part of their initial treatment.

The pathophysiology of adhesive capsulitis is poorly understood. Fortunately, the majority of patients recover with nonoperative treatment. One conundrum that immediately arises is who should be offered surgery for adhesive capsulitis. Once the diagnosis is made, patients are offered up to 3 monthly injections of corticosteroid (placed both intra-articular and subacromial) and given a home stretching program. After failure of 3 months of active, nonoperative treatment, patients are offered surgery versus continuing home stretching. Like others,¹,² we have found that certain patients are at higher risk of failing nonoperative treatment, and we may offer earlier surgery for patients with risk factors such as severe initial stiffness or type 2 diabetes mellitus. Even so, our success rate for the nonoperative management of adhesive capsulitis is ˜95%.

Postoperative stiffness may occur after almost any operation on the shoulder. Often, patients present after having failed months of nonoperative treatment with little hope of regaining motion in lieu of revision surgery. In this situation, a detailed preoperative workup is indicated including a thorough history (prior operative reports), physical, x-rays, advanced imaging (usually MRI), and preoperative screening labs for infection. The timing of surgery for postoperative stiffness may be a conundrum, especially for a frustrated patient with stiffness after rotator cuff repair. Our practice has been to wait 6 months after rotator cuff repair before offering surgery for postoperative stiffness in order to give the repair sufficient time for healing. However, for selected cases with extreme stiffness, we have offered surgery as early as 4 months after rotator cuff repair.

Arthroscopic capsular release followed by manipulation under anesthesia has proven to be an excellent treatment for shoulder stiffness.³ Like all arthroscopic shoulder surgeries, we perform this in the lateral decubitus position. Prior to prep and drape, we examine the shoulder under
anesthesia to record the amount of stiffness in forward elevation, axial rotation with the arm at the side and elevated, and horizontal abduction. In the typical case, the shoulder has global tightness, and we will plan to perform a 270° release, sparing only the superior joint capsule.

A second surgical technician standing across from the surgeon manipulates the arm (often adduction over a large bump which wedges the joint open) and is crucial for improving visualization while the joint space is very tight. After establishing a posterior portal and performing diagnostic glenohumeral arthroscopy, establish an anterior portal and electrothermically incise (OPES, Arthrex, Naples, FL) the rotator interval from the upper border of subscapularis to the anterior border of supraspinatus, making sure to spare the medial sling of the biceps if the tendon is to be preserved. Releasing all the way to the anterior border of supraspinatus ensures that the superior glenohumeral ligament (SGHL) is divided. Failure to release the SGHL will result in failure to restore horizontal abduction. It is often possible to begin working inferiorly at this point and to release a substantial part of the middle glenohumeral ligament while working from the anterior portal. We feel that it is important to preserve the labrum in shoulder stiffness surgery, and our rule of thumb is to stay about 1 cm away from the labrum, which also lowers the risk of damaging the axillary nerve during the inferior release.

The posterior and inferior capsular work can be done viewing from either an anterior or an anterosuperolateral portal. At this point, we switch to a hooked pencil tip cautery probe (OPES, Arthrex, Naples, FL) and release the posterior capsule, starting at the posterior portal and extending proximally to about the 11 o’clock position (right shoulder). Following the posterior release, we turn our attention inferiorly and sequentially release the axillary pouch, the inferior glenohumeral ligament (IGHL), and the middle glenohumeral ligament (MGHL) through the posterior working portal. We prefer a monopolar cautery probe over a bipolar probe because muscle contraction caused by the monopolar current can alert the surgeon that the axillary nerve is close to the instrument. If we feel that the nerve is in danger from this portion of the release, we make small perforations in the inferior capsule so that the capsule will tear in the desired location during the manipulation. It is critical when releasing the MGHL to maintain orientation to the tendinous upper subscapularis so that this vital structure is not inadvertently incised. If the upper border of subscapularis is not clearly seen, then we switch our viewing portal to posterior and divide the remaining portion of the MGHL with the cautery electrode or with arthroscopic scissors.

Following capsular release, we perform manipulation of the shoulder. Manipulation is important to break up remaining adhesions and to stretch out the muscle fibers, which may have developed thixotropy (shortening and stiffness of the muscle fibers). Shoulder swelling will limit the surgeon’s ability to manipulate the shoulder, so it is important to perform the capsular release steps in an efficient manner.

After arthroscopic capsular release and manipulation of the shoulder, we then do a subacromial debridement and subacromial lysis of adhesions. Even though most of the shoulder’s motion is restored by the capsular release and manipulation, we believe that it is important to restore an adhesion-free plane in the subacromial space for unimpeded gliding of the rotator cuff beneath the acromion. We have found it useful, in cases with dense subacromial scarring, to begin by creating a “virtual space” beneath the anterolateral acromion with a shaver and then carefully dissecting down to the intact cuff tendon to define the correct plane of dissection. This is much safer than beginning the subacromial dissection medially, over the muscles, where inadvertent muscle damage is likely.

TABLE 8-1 SELECTED RELEASES OF CONTRACTED GLENOHUMERAL LIGAMENTS AND CAPSULE MAY BE INDICATED WHEN SPECIFIC LOSSES OF SHOULDER RANGE OF MOTION ARE PRESENT

Direction of Stiffness	Tight Structure
Internal rotation (arm at the side)	Posterior capsule
Internal rotation (arm elevated)	Posterior capsule and posterior band of IGHL
External rotation (arm at the side)	SGHL, CHL, and rotator interval capsule
External rotation (arm elevated)	MGHL and IGHL (anterior band)
Horizontal abduction	SGHL, CHL, and rotator interval capsule
Forward elevation	IGHL
SGHL, superior glenohumeral ligament; CHL, coracohumeral ligament; MGHL, middle glenohumeral ligament; IGHL, inferior glenohumeral ligament.

When arthroscopic surgery is indicated for conditions of stiffness, many treatment and technical conundra may be encountered. These include the role of concomitant procedures in stiffness surgery, management of the long head of biceps tendon, and specific technical aspects of capsular release (Table 8-1) and manipulation under anesthesia, which are all highlighted in the following case examples.

History:

A 47-year-old right hand-dominant woman injured her left shoulder lifting a box overhead at work at a warehouse. She heard a pop and has had lateral shoulder pain with progressive stiffness over the last 9 months.
Nonoperative treatment failed to give her relief. Her SST score was 2, and she stated that her shoulder was 20% normal. Recently, her right shoulder has also been hurting because of overuse and has begun to be stiff.
She has been on light duty since the injury for her warehouse job, but she has been able to continue working at her second job as an office assistant without limitations. She smokes one-half pack per day of cigarettes.

FIGURE 8-1 Preoperative active forward elevation (A), external rotation (B), and internal rotation (C), with the left shoulder being affected with adhesive capsulitis.

FIGURE 8-2 Exam under anesthesia in forward elevation (A), internal rotation (B), and external rotation (C) confirms that significant glenohumeral joint stiffness is present.

Physical Exam:

Active and passive ROM were equal with forward elevation to 130°, external rotation to 20° with the arm at the side, external rotation to 40° with the arm abducted, internal rotation to L5 and internal rotation to 0° with the arm abducted (Figs. 8-1 and 8-2).
5/5 strength in abduction, internal, and external rotation.
Negative bear hug and belly press tests. No AC joint tenderness.

FIGURE 8-3 Axial (A) and coronal (B) T2 MRI showed subacromial bursitis only.

Imaging:

X-rays were unremarkable with a type 1 acromion.
MRI showed only subacromial bursitis without biceps, labral, or rotator cuff pathology (Fig. 8-3).

Arthroscopy Findings:

The glenohumeral joint space was very tight on diagnostic arthroscopy, but no chondromalacia, biceps, labral, or cuff pathology could be found. Synovitis was minimal. The subacromial space showed minimal bursitis without abrasive wear of the bursal cuff or the CA arch (Fig. 8-4).

FIGURE 8-4 The long head of biceps and sheath (A) and subscapularis insertion and associated structures were normal as viewed with a 70° scope from posterior. Additionally, the superior labrum and biceps insertion were normal (C). The subacromial space was relatively benign in appearance (D). BT, biceps tendon; MS, medial sling; SSc, subscapularis; H, humeral head; G, glenoid; CAL, coracoacromial ligament; SS, supraspinatus.

Pearls, Pitfalls, and Decision-Making:

In certain patients with idiopathic adhesive capsulitis, it is tempting to avoid surgery and perform isolated manipulation under anesthesia without capsular
release. Our philosophy is that arthroscopy with capsular release should always be done for the surgical treatment of the stiff shoulder, as this has several benefits. First, arthroscopy allows identification and treatment of additional sources of pathology that might have been missed on preoperative workup. Second, we have been referred patients who had iatrogenic injuries during isolated shoulder manipulation under anesthesia. Arthroscopic release allows for a controlled disruption of the offending capsuloligamentous structures (Fig. 8-5). Third, postmanipulation arthroscopy allows the surgeon to reexamine the shoulder and document that no iatrogenic injury has occurred (Fig. 8-5).
Fourth, incision of the capsule likely provides some pain relief via capsular denervation.
A controlled manipulation of the shoulder under anesthesia should always follow the arthroscopic capsular release, as this breaks up any remaining adhesions that might restrict postoperative motion (Fig. 8-6). Additionally, manipulation addresses thixotropy of muscle fibers that might be chronically shortened and fibrotic after disuse.
This patient had no pain or imaging findings to suggest symptomatic AC joint arthritis. Since the anatomy of the subacromial space, biceps, and labrum appeared to be nearly normal, no other concomitant procedures were performed (e.g., distal clavicle excision, biceps tenotomy, or subacromial decompression).
Postoperatively, the patient had a dramatic improvement in pain and active range of motion, even as early as postop day 3 (Fig. 8-7).
Many surgeons have a tendency to “write off” frozen shoulder patients, the idea being that they don’t improve with any treatment, surgical or nonsurgical. Our experience is the opposite, namely, that with a technically well-done arthroscopic capsular release and manipulation, these patients tend to improve dramatically quite quickly after surgery and that they tend to be very grateful.

FIGURE 8-5 Arthroscopic views of the anteroinferior joint capsule pre- (A) and postrelease (B) and the posterior joint capsule pre- (C) and postrelease (D). A 30° view from a posterior viewing portal of the subscapularis tendon shows the characteristic rolled upper border and the muscular fibers below (E). The capsule has been released in a 270° arc sparing only the superior capsule. A, anterior capsule; L, anterior labrum; P, posterior capsule; H, humeral head; SSc, subscapularis tendon.

History:

A 27-year-old RHD laborer who injured his left shoulder falling directly onto the shoulder at work. He had no instability event or symptoms.
He was treated with benign neglect initially, but after he had continued pain, he went to physical therapy for range of motion and strengthening. After 6 months of failed nonoperative treatment, he was referred for a surgical opinion.
He had been unable to return to full work duties or sports.

Physical Exam:

Marked AC joint tenderness without deformity or instability. Active and passive forward elevation 150°, external rotation to 45°, internal rotation to the greater

trochanter. With the arm at 90° abduction, internal rotation was to 0°.
No strength deficits.
Negative belly press and bear hug tests. Positive dynamic labral shear test. Positive Speed test. Negative anterior apprehension.

FIGURE 8-6 After capsular release, a gentle manipulation under anesthesia in forward elevation (A), internal rotation (B), and external rotation (C) completes the procedure by stretching the muscle fibers and any remaining adhesions. Subsequently, the arthroscope is placed back into the shoulder to confirm that no iatrogenic injury has occurred.

FIGURE 8-7 Active forward elevation (A), internal rotation (B), and external rotation (C) on postoperative day 3 is much improved and essentially pain-free. The patient was very thankful for such a dramatic improvement in her symptoms.

Imaging:

X-rays showed no significant AC joint injury or arthrosis.
MRI showed no Bankart lesion, only slight AC joint degenerative changes and distal clavicle increased T2 signal (Fig. 8-8).

Arthroscopy Findings:

An unexpected Bankart tear (Fig. 8-9A, B) was seen from 9:00 to 6:30 (left shoulder) with a small Hill-Sachs lesion (Fig. 8-9C).

FIGURE 8-8 Axial (A) and sagittal (B) MRI images demonstrate distal clavicle edema, but no labral tear was seen (C).

Pearls, Pitfalls, and Decision-Making:

Unexpected labral pathology is commonly encountered during shoulder arthroscopy. It can be difficult to decide which labral lesions require repair. In this case, because of the age of the patient, concomitant Hill-Sachs lesion, no degenerative changes of the joint or labrum, we decided that the labral lesion was most likely a traumatic tear and might be one source of the patient’s persistent pain.
Unexpected labral lesions represent a potential pitfall in shoulder arthroscopy. If a degenerative labrum is repaired as if were a traumatic lesion, especially with a capsulolabral shift, postoperative stiffness may result. The location of an abnormal-appearing labrum can also be a key to management. Except in the case of anterior instability, we routinely ignore anatomical variant or degenerative-appearing labra from 12 to 3 o’clock (right shoulder). In this example, even
though the tear was presumed to be a pain generator, we did not advance the capsulolabral complex onto the face of the glenoid or superiorly (Fig. 8-10). We ignored the labral detachment superior to the 9 o’clock position.
An advantage of shoulder arthroscopy is the ability to address pathology in any part of the shoulder. Selective capsular releases, as in this case, are occasionally required to address a specific range of motion deficit (e.g., posterior capsular release for loss of internal rotation, Fig. 8-11).
The correct course of postoperative activity restrictions and rehabilitation after a unique case such as this one may be difficult to discern. For this patient, we chose sling immobilization for 6 weeks with only a forward bend for passive shoulder range of motion (pendulum exercises). Our philosophy over the years has been to prioritize the protection of surgical repairs, and that with arthroscopic repair, postoperative stiffness unresponsive to physical therapy is unusual.
We make the decision to perform arthroscopic distal clavicle excision (Fig. 8-12) based primarily on patient history and clinical examination. When a patient reports superior shoulder pain and has consistent tenderness over the AC joint, we consider the decision to perform distal clavicle excision fairly straightforward. When done technically well, the procedure carries little risk and has been very successful in our hands for treating AC joint pain.

FIGURE 8-9 Posterior view with a 30° scope shows an unexpected low anterior labral tear of the shoulder (A). An anterosuperolateral view (30° scope) shows probing of the labral tear with an arthroscopic elevator from a posterior portal (B). Even though the patient reported no instability event or symptoms, this labral lesion likely was traumatic based on its location and the associated Hill-Sachs lesion (C). G, glenoid; H, humeral head; L, labrum; HSC, Hill-Sachs lesion.

FIGURE 8-10 Three-anchor knotless labral repair with LabralTape and 2.9-mm BioComposite PushLock anchors (Arthrex, Naples, FL) as seen from posterior (A) and anterosuperolateral (B) viewing portals. G, glenoid; H, humeral head.

History:

An active and independent 70-year-old right hand-dominant woman fell from a standing height and struck her right shoulder sustaining a minimally displaced fracture of the greater tuberosity.
After a 1-week period of sling wear for pain control, she started a program of supervised physical therapy with gentle, patient-directed passive range of motion.
At 2 months, her fracture was well healed but she had significant stiffness and continued pain with attempted use of the arm.
At 4 months, she had experienced no improvement after continued physical therapy for stiffness and a corticosteroid injection.

FIGURE 8-11 A selective posterior capsular release was performed to treat internal rotation preoperative stiffness in this patient. H, humeral head; G, glenoid; L, posterior labrum; P, posterior capsule.

FIGURE 8-12 Final view of arthroscopic distal clavicle excision using a 70° scope from a posterior portal. Orient the scope to look superiorly for an excellent view of the entire AC joint, especially the posterosuperior aspect that can be difficult to visualize well without the 70° scope. A burr introduced from an anterior portal demonstrates a 10-mm distal clavicle excision that has preserved the superior AC joint ligaments. DC, distal clavicle.

FIGURE 8-13 Grashey injury (A) and preoperative (B) x-rays show a minimally displaced greater tuberosity fracture that healed uneventfully.

Physical Exam:

Active and passive ROM were equal with right shoulder forward elevation to 100°, external rotation to 45° with the arm at the side and elevated, and internal rotation to -10° with the arm elevated. Horizontal abduction was to 0°.
4+/5 strength in abduction and external rotation
Negative bear hug and belly press tests. She had no AC joint tenderness.

Imaging:

Injury (A) and preoperative Grashey (B) x-rays showed no displacement of the fracture from the injury with solid healing (Fig. 8-13).
MRI showed healed fracture with supraspinatus tendinosis and degenerative labrum.

Arthroscopy Findings:

Exam under anesthesia confirmed preoperative stiffness (Fig. 8-14).
A type 2 SLAP lesion was found with a displaceable biceps root (Fig. 8-15). The rotator cuff was found to be intact.

Pearls, Pitfalls, and Decision-Making:

This case illustrates several advantages of an arthroscopic approach to shoulder stiffness over performing only a manipulation under anesthesia:
- First, this patient had a tremendous amount of thickening of the shoulder capsule and ligaments (Fig. 8-16), a common finding.
- Especially in a 70-year-old woman with posttraumatic stiffness, it is likely that this tissue would not have been the weakest link preventing motion. If only a manipulation had been performed, some other tissue would likely have been damaged first (i.e., rotator cuff, bone, or labrum).
- Performing an arthroscopic capsular release prior to manipulation gives the surgeon confidence that increased motion will occur through the capsular split, not elsewhere (Figs. 8-17 and 8-18).
Manipulation after release (Fig. 8-19) ensures that muscle fiber fibrosis and shortening (thixotropy) has been addressed and that any remaining capsular adhesions are disrupted.
- Postmanipulation arthroscopy allows the surgeon to verify and document that there has been no inadvertent iatrogenic damage to other shoulder structures (Figs. 8-17, 8-18, and 8-20).
- An arthroscopic approach allows the surgeon to address other pathology. In this patient, a Type 2 SLAP tear was treated with biceps tenotomy. We perform few tenotomies, but an elderly patient with stiffness is a good indication. Postoperatively, she
  
  was able to aggressively rehab the shoulder without having to protect a tenodesis repair.
A skilled second assistant performing manipulations on the arm greatly facilitates arthroscopy for shoulder stiffness. Often, adducting the arm over an axillary bump will increase the working space in the critical inferior joint space (Fig. 8-21).

FIGURE 8-14 Exam under anesthesia demonstrates stiffness in forward elevation (A), internal rotation (B), and external rotation with the arm abducted (C) and at the side (D).

FIGURE 8-15 A type 2 SLAP tear (A) with a displaceable biceps root (B) without any continuity of the tendon to the supraglenoid tubercle.

FIGURE 8-16 Extremely thick scarring of the rotator interval (A) is released with electrocautery though an anterior portal (B) after biceps tenotomy.

FIGURE 8-17 Anterosuperior 30° arthroscopic view of the inferior capsule (A) during and (B) after capsular release and manipulation.

FIGURE 8-18 Anterosuperior 30° arthroscopic view of the MGHL and subscap (A) before and (B) after capsular release.

FIGURE 8-19 Intraoperative motion after release and manipulation shows large increases in forward elevation (A), internal rotation (B), and external rotation with the arm abducted (C) and at the side (D).

FIGURE 8-20 Lateral portal, 30° arthroscopic view of the bursal supraspinatus tendon, which was intact after capsular release and manipulation.

FIGURE 8-21 Our standard OR setup includes a first assistant that stands next to the surgeon, a primary tech that stands behind the surgeon, and a second tech or assistant that stands opposite the surgeon and manipulates the arm. The second assistant ideally has their own monitor (not shown) for feedback on their movements of the arm. In this case, adducting the arm over a bump (white arrow) greatly increased the working space in the axillary recess (blue arrow).

History:

A 58-year-old right-handed woman presented with 9 months of progressive left shoulder pain and stiffness. Pain at night was predominant.
She had the most difficulty reaching behind her, with relatively preserved ability to reach overhead.
Oral analgesics and NSAIDs had given her no relief, and she had not tried physical therapy.

Physical Exam:

Active and passive range of motion were equal for the left shoulder: FE = 150°, ER = 40°, IR = L5.
Strength was 5/5 in abduction, ER, IR.
Negative bear hug and belly press tests. Positive AC joint tenderness.

Imaging:

X-rays showed only minimal AC joint degenerative changes.
The patient was unable to undergo MRI because of severe claustrophobia, but CT arthrogram confirmed severely diminished space in the axillary recess and no full-thickness rotator cuff tear (Fig. 8-22).

FIGURE 8-22 CT arthrogram showed an intact rotator cuff with a restricted axillary pouch.

FIGURE 8-23 The posterior capsule (A) and the rotator interval (B) had synovitis, which likely explains ongoing pain in this patient.

Arthroscopy Findings:

Diffuse synovitis was present intra-articularly, worst at the posterior joint capsule (Fig. 8-23).
The rotator cuff was intact, and there was no glenohumeral chondromalacia.

Pearls, Pitfalls, and Decision-Making:

Many health care providers (primary care physicians, physical therapists, surgeons) do not recommend patients for a surgical opinion or for surgery while pain is the predominant symptom in adhesive capsulitis (“pain-predominant” disease).
Unfortunately, many patients continue to have significant pain despite lengthy periods of nonoperative treatment. Our experience is that a well-done arthroscopic capsular release (Fig. 8-24) followed by manipulation provides excellent relief of pain and restoration of shoulder motion for these patients.

FIGURE 8-24 Anterosuperior viewing portal (30° scope). A technically well-done capsular release should have, as the endpoint, a 270° arc (sparing only the superior capsule) with complete division of the capsule such that the underlying muscle (A, posterior capsule release) is exposed. The upper border of the subscapularis tendon (B, anterior capsule and MGHL release) and the labrum (C, inferior glenohumeral ligament release) should be spared.

CALCIFIC TENDINITIS

Patients with symptomatic calcification of the rotator cuff typically present in one of two ways depending on the phase of the disease. Patients in a resorptive phase have acute, severe pain, presumably from a crystalline subacromial bursitis. Most patients with this clinical picture have a relatively short duration of symptoms that can be adequately treated with nonoperative measures such as corticosteroid injection, activity modification, stretching, and oral analgesics.

The second group, patients in a prolonged “formative” or “resting” phase,⁴ often reports milder, more chronic symptoms with characteristics like those of an impingement syndrome. Compared with patients in the acutely painful resorptive phase, patients in this latter group are much more likely to fail nonoperative treatment.

One principle that we have found to be universally valid in the arthroscopic surgical treatment of calcific tendinitis is that patients have much better symptom resolution with complete removal of the calcification. As such, if nonoperative treatment fails, we take an “aggressive” approach to surgical debridement of the calcific lesion, and we employ motorized shavers, burrs, and curettes to ensure that the lesion has been completely removed. Almost always, this results in a defect in the rotator cuff that necessitates surgical repair.

Some authors argue for a minimal approach to the surgical treatment of calcific tendinitis, with surgery primarily used as a way to perform guided needling or to make small longitudinal incisions in the cuff without much mechanical removal of calcium. Currently, we make this type of treatment available to our patients without surgery by performing ultrasound-guided barbotage of the lesion. In our experience, this has been a successful way to help some patients avoid surgery for calcific tendinitis.

Lastly, it is important to recognize that patients undergoing rotator cuff repair with calcium debridement are at higher risk of postoperative stiffness.⁵ Postoperative rehabilitation, specifically the addition of early passive range of motion exercises, should be modified to avoid this potential complication.⁶

Calcific Tendinitis

History:

A 53-year-old right-handed chef presented with 2 years of left shoulder pain, unresponsive to subacromial corticosteroid injection and physical therapy.
She took an oral NSAID daily for her pain, but this helped minimally. She stated that she could not take any time off of work.

Physical Exam:

Full range of motion of the left shoulder: FE = 170°, ER = 45°, IR = T7
5/5 strength in abduction, IR, and ER
Positive Neer and Hawkins tests

Imaging:

Shoulder radiographs showed a mature-appearing calcific deposit at the posterosuperior rotator cuff (Fig. 8-25).
Diagnostic ultrasound demonstrated an intact rotator cuff with a calcific deposit in the supraspinatus tendon.

Arthroscopy Findings:

Pearls, Pitfalls, and Decision-Making:

Since the patient stated that she could not have any time off work or comply with any restrictions of her arm, ultrasound-guided barbotage of the lesion was offered. This scenario has become more common in our practices, and we now typically reserve surgery for
chronic calcific tendinitis for patients who fail ultrasound-guided barbotage.
The procedure was performed in the office with local anesthetic using live ultrasound with an in-plane approach to the lesion (Fig. 8-26).

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