Superior Labral Pathology in Throwers

Transcription

1 Superior Labral Pathology in Throwers Disclosures Available via AAOS website None relevant to this presentation L. Pearce McCarty, III M.D. Team Physician, Minnesota Twins Chairman, Orthopedic Surgery, Abbott Northwestern Hospital Allina Health 5 th Annual Sports Medicine Conference, July 7 th, 2017 Evolution of Thought Re: SLAP Anatomy of the Glenoid Labrum Credit to Dr. David Lintner, Head Team Physician, Houston Astros, Houston Texans 1990 s: What s a SLAP? 2000: There is a SLAP. I must fix it! 2005: Everybody has a SLAP. This is crazy! 2010: Those other surgeons SLAP repairs aren t doing so well 2017: I am not fixing your SLAP. It s normal. Supraglenoid tubercle Long head of the biceps tendon integration Interdependent ring concept Injury to one part of the labrum can generate laxity in another part Fibrocartilage with limited capacity to heal AllinaHealthSystem 1

2 Classification Extended Classification Snyder Classification I: Fraying II: Detachment from supraglenoid tubercle IIA: Anterior IIB: Posterior ( Thrower s ) IIIC: Ant - Post III: Bucket handle tear IV: Extension into long head of the biceps tendon Type V: SLAP II + anterior labrum Type VI: Detachment from supraglenoid tubercle + flap Type VIII: SLAP II + posterior labrum Type IX: SLAP II + anterior + posterior Diagnosis: Mechanism of Injury Diagnosis: Symptoms Repetitive mechanical stress Excessive ER + ABD during late cocking Repetitive BB loading during follow through Detachment of superior labrum from supraglenoid tubercle Mihata et al., AJSM, 2008 Anterior capsular laxity Anterior shoulder pain Dead arm Quick fatigue Unstable Deep, vague Mechanical popping, clicking, clunking AllinaHealthSystem 2

3 Diagnosis: Physical Exam Diagnosis: Physical Exam Special Tests Rotator cuff weakness in ER GIRD / Total arc difference Tenderness in bicipital groove Apprehension O Brien s active compression test Supination external rotation test Biceps load test I (90) Biceps load test II (120) Crank test (160) Compression rotation test (90) Diagnosis: Imaging Diagnosis: Arthroscopic Evaluation MRI or MRA? MRI: Relatively high sensitivity, low to moderate specificity in throwing population MRA: Better sensitivity, specificity, PPV and NPV Neither perfect Must combine with historical and physical exam data AllinaHealthSystem 3

4 Rest Address coexisting deficiencies Scapular mechanics Shoulder rotation Rotator cuff activation Progressive loading of superior labrum / biceps complex Jang et al., JSES, 2016 Factors independently associated with failure of non-operative treatment Participation in overhead sports (P = 0.002) History of trauma (P = 0.005) Positive compression rotation test (P = 0.015) Not associated Positive O Brien s or Kim biceps load test Cools et al., AJSM, 2014 Surface EMG 16 common shoulder rehab exercises Evaluation of biceps activation with concentric loads No eccentric or plyometric loading Coons et al. Lowest surface EMG activation IR based resistance exercises (2 8%) Highest surface EMG activation FF + ER + sup in sagittal plane* (up to 54%) FF + ER + sup in scapular plane Elbow flexion in 45 FF Intermed surface EMG activation for ER / RC based exercises AllinaHealthSystem 4

5 Treatment: Surgical Coons et al. Periscapular exercises LT / MT targeting exercises low BB surface EMG activation E.g. weighted side lying FF to 90 SA targeting exercises moderate to high BB surface EMG activation FF + ER + sup in sagittal plane* (up to 54%) FF + ER + sup in scapular plane Arthroscopic debridement Arthroscopic repair of superior labrum +/- anterior capsule +/- concomitant labral pathology Anterior Posterior Anterior + Posterior Biceps tenodesis Arthroscopic Anatomic Repair Arthroscopic Repair: Results Anatomic repair Address concomitant labral pathology Address concomitant rotator cuff pathology Transition to knotless fixation Avoidance of mechanical damage to articular surface of rotator cuff during late cocking Neri et al. 57% RTP at pre-injury level, mean 9 months post-operatively 17% failed RTP at any level Failure of RTP correlated (P = 0.0) with RC pathology Richetti et al. 73% RTP at pre-injury level, mean 13 months postoperatively AllinaHealthSystem 5

6 Biceps Tenodesis Biceps Tenodesis Arthroscopic, suprapectoral, subpectoral? Strauss et al., JSES, 2014 Tenodesis does not restore anterior or posterior glenohumeral stability* caution in overhead throwing population Cannot apply data from general population to elite overhead throwing population However Chalmers et al., unpublished data Biceps tenodesis more closely restored surface EMG activity for LHBT than SLAP repair No difference in restoration of pitching mechanics or other surface EMG Biceps Tenodesis Conclusion Current consensus Weighted towards anatomic SLAP repair in elite overhead throwing population Better restoration of glenohumeral stability Data on return to play SLAP lesions are challenging to: Diagnose Treat Rehab Rehab should avoid BB activation during early phases Repair should restore normal anatomy to degree possible Good luck! AllinaHealthSystem 6

7 Thank You! AllinaHealthSystem 7