Vascular Injuries in the Throwing Shoulder MLB Winter Meeting 2015

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Erick May
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Neurovascular Problems in the Throwing Athlete s Shoulder Professor, Department of Orthopedics Head, Section of Shoulder and Elbow Surgery

Consultant: Arthrex 3. Miscellaneous Support: Arthrex 4.

Editorial Board: Orthopedics Today (Chief Medical Editor), Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow, Techniques

1 Neurovascular Problems in the Throwing Athlete s Shoulder Professor, Department of Orthopedics Head, Section of Shoulder and Elbow Surgery Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics Today Disclosures: 1. Royalties: Arthrex, Elsevier 2. Consultant: Arthrex 3. Miscellaneous Support: Arthrex 4. Basic Science/Research Support: Arthrex, Smith and Nephew, Ossur, Miomed, DJOrtho, Conmed Linvatech, Athletico 5. Editorial Board: Orthopedics Today (Chief Medical Editor), Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow, Techniques in Sports Medicine, Sports Health, Orthopedics 6. Publisher Support: Elsevier (Textbook), Orthopedics Today Case Report: Steve Soderstrom Drafted #6 Overall in 1993 Amateur Entry Draft 3 years from Draft to MLB Lasted only 10 days in Majors 1

Case Report: Steve Soderstrom 22 year old right-handed starting pitcher presented with a

On physical examination, a shallow dry ulcer, 5 mm in diameter, was evident at the tip of the

Allen test showed delayed filling of the right second finger.

November-December 1995 Axillary Artery Branch / Subscapular Artery Aneurysm On the basis of

repeatedly perform strenuous shoulder rotations, and demonstrate symptoms of upper limb

2 Case Report: Steve Soderstrom 22 year old right-handed starting pitcher presented with a 4-month history of recurrent numbness in the second and third fingers of his throwing hand. On physical examination, a shallow dry ulcer, 5 mm in diameter, was evident at the tip of the right second finger. Upper extremity pulses were normal and symmetric. Allen test showed delayed filling of the right second finger. Case Report: Steve Soderstrom Journal of Vascular and Interventional Radiology November-December 1995 Axillary Artery Branch / Subscapular Artery Aneurysm On the basis of our experience and previous reports, it seems prudent to suggest that individuals who repeatedly perform strenuous shoulder rotations, and demonstrate symptoms of upper limb ischemia, undergo noninvasive testing and, if warranted, detailed arteriography to exclude abnormalities of the axillary Abnormal Doppler Study artery and its branches 2

Anatomy Elite Overhead Athletes Forceful and repetitive

providers must possess a thorough understanding of the

The usual problems Muscle/Tendon strain Biceps-Labral

3 Anatomy Elite Overhead Athletes Forceful and repetitive use Varying symptoms and clinical presentation Care providers must possess a thorough understanding of the neurologic and vascular abnormalities Uncommon Injuries The usual problems Muscle/Tendon strain Biceps-Labral Complex Impingement Rotator Cuff What else 3

Other Considerations Thoracic Outlet Syndrome

Effort Thrombosis Aneurysm Artery Occlusion Thoracic

(Arterial) High Performance Overhead Athletes Most

development of Subclavian Artery Aneurysm from

4 Other Considerations Thoracic Outlet Syndrome Quadrilateral Space Syndrome Suprascapular Neuropathy Effort Thrombosis Aneurysm Artery Occlusion Thoracic Outlet Syndrome (Arterial) Thoracic Outlet Syndrome (Arterial) High Performance Overhead Athletes Most commonly Volleyball and Baseball Can involve development of Subclavian Artery Aneurysm from Compression Occurs within scalene triangle at level of first rib 4

5 Allen Test Thoracic Outlet Syndrome (Arterial) Often with neurologic symptoms More pronounced with arm in elevation Can cause swelling/discoloration Perform Adson s test Thoracic Outlet Syndrome (Arterial) Nonsurgical Treatment is Mainstay! 5

6 Thoracic Outlet Syndrome (Arterial) Surgical Options Scalenectomy First rib resection Pec minor tenotomy Claviculectomy Compressive Axillary Artery Lesions Positional Compression 6

7 9 athletes with arterial insufficiency 7 elite baseball pitchers 2 professional baseball coaches Physical Examination Arm Fatigue Finger Numbness Cold hypersensitivity Rest Pain Cutaneous finger embolism 7

Treatment Segmental reconstruction of the diseased artery

2013 AJSM 1990 Level of Evidence: IV 13 Elite Pitchers: 9

fatigue, finger ischemia Testing: Arteriiography with

8 Treatment Segmental reconstruction of the diseased artery or ligation/excision of the branch aneurysms Sports Health 2013 AJSM 1990 Level of Evidence: IV 13 Elite Pitchers: 9 amateur or professional baseball pitchers Symptoms: Arm fatigue, finger ischemia Testing: Arteriiography with positional testing recreating overhead 8

AJSM 1990 2 Subclavian Aneurysms Remaining 11 with compression disease 5 subclavian compression beneath anterior scalene 2 axillary

humeral circumflex embolization Arteriography AJSM 1990 2 Subclavian Aneurysms- Saphenous vein bypass with cervical rib resection

9 AJSM Subclavian Aneurysms Remaining 11 with compression disease 5 subclavian compression beneath anterior scalene 2 axillary compression beneath the pec minor 2 compressed both arterial segments 1 arterial compromise at level of humeral head 1 posterior humeral circumflex embolization Arteriography AJSM Subclavian Aneurysms- Saphenous vein bypass with cervical rib resection All with resection of 2-3cm segment anterior scalene or pec minor All returned to previous level of activity 9

Effort Thrombosis Venous Thrombosis of the Upper Extremity Termed Effort Thrombosis or Paget-Schroetter Syndrome Requires Timely Diagnosis and Treatment RARE!

10 Effort Thrombosis Venous Thrombosis of the Upper Extremity Termed Effort Thrombosis or Paget-Schroetter Syndrome Requires Timely Diagnosis and Treatment RARE! 4 Cases in MLB players of effort or spontaneous thrombosis Compression of the subclavian vein due to extreme abduction/er Complaints of Heavy or dead arm and swelling All four players returned to play with no sequelae Diagnosis and Treatment Diagnosis: Contrast Venography Serologic Screening for hypercoagulable state Treatment: Transluminal catheter directed urokinase thrombolysis followed by systemic anticoagulation therapy Follow up venography in 1-3 weeks Persistent Stenosis: Balloon angioplasty 10

Follow up venography in 1-3 weeks Persistent Stenosis: Balloon angioplasty 32 Competitive Athletes Treated

11 Diagnosis and Treatment Diagnosis: Contrast Venography Serologic Screening for hypercoagulable state Treatment: Transluminal catheter directed urokinase thrombolysis followed by systemic anticoagulation therapy Follow up venography in 1-3 weeks Persistent Stenosis: Balloon angioplasty 32 Competitive Athletes Treated for Venous TOS Key to successful outcomes: Early Venography, Throbolysis, Tertiary Referral 11

Radiographic and Operative Findings Suprascapular neuropathy: described in

Spinoglenoid notch cysts in association with SLAP tears with posterior

(1990). Suprascapular neuropathy in pitchers.

Suprascapular Neuropathy Potential cause of shoulder pain and weakness

12 Radiographic and Operative Findings Suprascapular neuropathy: described in rare case reports Etiology unclear Stretch injury? Microvascular injury? Spinoglenoid notch cysts in association with SLAP tears with posterior extension Ringel, S. P., Treihaft, M., Carry, M., Fisher, R., & Jacobs, P. (1990). Suprascapular neuropathy in pitchers. American Journal of Sports Medicine, 18(1), Suprascapular Neuropathy Potential cause of shoulder pain and weakness Most frequently injuried peripheral branch of the brachial plexus in athletes Diagnosis often overlooked 12

Neuroanatomy: Upper Trunk of the Brachial Plexus (C5, C6) 50% have contributions from C4 Motor Nerve 2 motor branches to the Supraspinatus 3 motor branches to the

13 Neuroanatomy: Upper Trunk of the Brachial Plexus (C5, C6) 50% have contributions from C4 Motor Nerve 2 motor branches to the Supraspinatus 3 motor branches to the Infraspinatus Pathophysiology: How does the nerve get injured? Traction Microtrauma Trauma Iatrogenic Extrinsic Compression Rotator Cuff Retraction 13

14 Scapular Notch Pain, Weakness Referred to Lateral Shoulder Repetitive Trauma Sport Work MRI Decompression at Scapular Notch 14

Shaver Shaver Spinoglenoid notch cyst Spinoglenoid notch

Spinoglenoid notch cysts Bhatia, S., Chalmers, P. N.

Arthroscopic suprascapular nerve decompression:

15 Shaver Shaver Spinoglenoid notch cyst Spinoglenoid notch cyst wall remnants Suprascapular neuropathy from Spinoglenoid notch cysts Bhatia, S., Chalmers, P. N., Yanke, A. B., Romeo, A. A., & Verma, N. N. (2012). Arthroscopic suprascapular nerve decompression: transarticular and subacromial approach. Arthroscopy Techniques, 1(2), e cases Labral repair only 10.2 months f/u Successful 10 / 10 Post-op MRI: no cyst 15

Summary: Suprascapular Neuropathy Differential

months If + Cyst, decompress Arthroscopic

uncommon diagnoses Venous Effort as well as

them challenging Early diagnosis and treatment is

16 Summary: Suprascapular Neuropathy Differential Diagnosis MRI / EMG No lesion, can be patient 6 months If + Cyst, decompress Arthroscopic Techniques Summary Remember to think about uncommon diagnoses Venous Effort as well as Arterial Compression Rarity of conditions make them challenging Early diagnosis and treatment is the key Lifestyle modifications Thank you! Chicago 16

17 Section Head, Shoulder and Elbow Service Professor, Dept. of Orthopaedic Surgery 1611 W. Harrison St., Suite 300 Chicago, IL Chicago 17

Case 1: Primary Dislocation. How I Manage Failed Instability Surgery. Case Presentations: Shoulder Instability

Case 1: Primary Dislocation. How I Manage Failed Instability Surgery. Case Presentations: Shoulder Instability Case Presentations: Shoulder Instability Chicago Professor, Department of Orthopedics Head, Section of Shoulder and Elbow Surgery Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics