R. Frank Henn III, MD. Associate Professor Chief of Sports Medicine Residency Program Director

Transcription

1 R. Frank Henn III, MD Associate Professor Chief of Sports Medicine Residency Program Director

2 Disclosures No financial relationships to disclose

3 1. Labral anatomy 2. Adaptations of the throwing shoulder 3. GIRD 4. SLAP lesions 5. PASTA lesions 6. Spinoglenoid notch cysts

4 Fibrocartilage tissue along rim of glenoid Deepens socket and stabilizes the humeral head Anatomic variability anterosuperiorly Cooper JBJS 1992 Galinat CORR 1989

5 More complex and variable anatomy meniscoid, edge vs recessed origin Origin of long head of biceps variations Supraglenoid tubercle superior labrum

6 Sublabral foramen Bufford Complex NO labrum Cord-liked MGHL

7 Adaptation that predates humans Survival benefit Deadly with minimal risk to the thrower Refined in humans

8 Selection pressure continues Majority of us do not depend on throwing

9 Throwers have distinct demands on the upper extremity Pitchers are the most well studied Principals apply to any throwing Most principals apply to any overhead athlete

10 Linear velocity Running start Rotational Convert torque to linear velocity (Legs/hips/trunk) Height Throw downhill

11 Power/Velocity comes from the kinetic chain Upper extremity musculature least important primarily accuracy and control Disruption to the kinetic chain (e.g. hip injury) can put increased stress on the upper extremity pushing

12 Anatomic adaptations Increased humeral retroversion (~15 deg) Increased abducted external rotation Decreased abducted internal rotation Unchanged total arc of motion

13 Crockett et al. AJSM 2002

14 Shoulder and elbow injuries are associated with high pitch counts, curve balls, and poor mechanics Little League Shoulder Physeal stress fracture (widening) Kids do NOT get SLAP tears Treatment = rest

15 Prevention Limit pitch counts with appropriate rest Age 7-8: 50 pitches per game Age 9-10: 75 pitches per game Age 11-12: 85 pitches per game Age 13-16: 95 pitches per game

16 Mean 10 deg loss of abducted internal rotation for 24 hours after pitching (Reinold AJSM 2010) Probable teres minor tightness from deceleration stress Progress to contracture of posterior inferior capsule

17 GIRD (Glenohumeral internal rotation deficit) > 20 degree difference in abducted internal rotation Loss of over 5 degrees of total arc of motion Increased risk of injury (Wilk AJSM 2011)

18 GIRD accentuates stress on the superior labrum at risk shoulder Altered glenohumeral mechanics Treatment: Capsular stretching

19 Andrews AJSM 1985 Superior labral lesions in throwing athletes Synder Arthroscopy / 700 arthroscopies retrospectively evaluated Injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the "anchor" of the biceps tendon to the labrum SLAP Superior Labrum Anterior Posterior

20 Synder Arthroscopy 1990 Type I: Frayed or degenerated labrum Type II: Detachment of superior labrum & biceps from glenoid rim Type III: bucket-handle labral tear with intact biceps anchor Type IV: bucket-handle labral tear that extends into biceps tendon

21 Degenerative Altered glenohumeral mechanics rotator cuff tears, arthritis, throwing Traumatic Compression Fall on outstretched hand Tension Traction on the arm Recurrent anterior dislocations

22 Peel-back of the labrum medially and posteriorly Internal impingement of the greater tuberosity against the posterosuperior glenoid

23 Normal impingement that predisposes to pathology with repetitive insult Articular sided rotator cuff tears Glenoid retroversion may protect Sweitzer et al. Arthroscopy 2012

24 Multiple in-vitro studies demonstrate increased humeral head translations with unstable SLAP tears microinstability Radosky MW AJSM 1994 Panossian VR. JSES 2005 Uggen C Arthrscopy 2009 Chhadia AM. Arthroscopy 2010 Abnormal EMG during tackling Horsley IG. J Orthop Surg Res

25 Variable history Variable history of trauma Throwers: pain with throwing Pain is typically posterior Mechanical symptoms are unusual but suggestive of unstable flap Night pain and resting pain is atypical

26 No examination findings are reliably diagnostic >10 special physical examination tests described O Brien Active Compression Test Best sensitivity (67%) Yergason s Test Best specificity (95%) Hegedus Br J Sports Med 2012

27 Comprehensive shoulder examination Scapular thoracic mechanics SICK scapula Shoulder ptosis, inferior medial border prominence, coracoid pain, dyskinesia Bicipital groove tenderness Rotator cuff strength Spinoglenoid notch cyst infraspinatus weakness Weakness in external rotation with the arm adducted

28 Xays MRI Intra-articular contrast controversial Increased sensitivity, decreased specificity Paralabral cyst is pathognomonic of labral tear ABER: Abduction and External Rotation

29 Non-operative treatment 3 months of directed rehabilitation program Scapular strengthing Capsular stretching Dynamic stabilizations Throwing mechanics intra-articular corticosteroid injection Operative Compressive paralabral cyst, mechanical symptoms

30 Predictors of Failure of Nonoperative Treatment Jang et al. JSES % successful with nonoperative treatment (45 of 63) Multivariable analysis of treatment failure Overhead activity (OR 19.1) History of Trauma (OR 9.8)

31 Determined by stability of the biceps origin If biceps is stable, then debride (types 1 & 3) If biceps unstable, stabilize (types 2 & 4) Poor results with debridement of unstable lesions Good intra and inter-observer reliability of the Synder classification with respect to treatment decisions Gobezie AJSM 2008

32 SLAP repair Prepare glenoid (shaver) Accessory portal Rotator interval Portal of Wilmington Place anchors 1 anchor double loaded 2 anchors single loaded Suture-passer to shuttle sutures Posterior to biceps origin Simple or mattress

33 Biceps Tenodesis/Tenotomy Biceps tendinopathy, poor tissue quality Concomitant Rotator Cuff Repair Caution in throwers (no pitchers) Boileau et al. AJSM 2009 Cohort study SLAP repair: Constant score 83, 2 of 10 returned to sport. Tenodesis: Constant score 89, 14 of 15 returned to sport

34 83% good-to-excellent results 73% return to play Only 63% of overhead athletes returned to previous level of play Postoperative stiffness after SLAP repair is a concern

35 Partial articular supraspinatus tendon avulsion Capsular injury Can occur in isolation or with concomitant SLAP

36 Nonoperative Operative Debridement if <50% of the thickness Repair Take down to full thickness and repair Trans-tendon repair Good long term results (Synder et al. Arthroscopy 2013)

37 Paralabral cyst from a SLAP tear can compress the suprascapular nerve in the spinoglenoid notch Can denervate the infraspinatus (neurogenic edema) External rotation weakness and pain

38 SLAP Repair with or without decompression Good results with both Kim et al. JSES 2012