SLAP Lesions in High Demand Performers Randy Schwartxberg, MD

Transcription

1 SLAP Lesions in High Demand Performers Randy Schwartxberg, MD How does this impact Cirque? Our challenge Return to prior form Training sessions 10 shows per week Cirque Medical Set-up Team Physician Orthopaedic surgeon Sports medicine trained Regular training room visits Dedicated clinics Sports team approach Rehab Clinicians 3 full time therapists Highly skilled Sports experience ATCs, PTs & other credentials Rehab all in house Regular interaction with team physician Additional Resources Massage therapy Pilates Chiropractic Accupuncture Anatomy & Biomechanics SLAP Lesions Superior Glenoid Labrum Injury Extends Anterior to Posterior Involves the biceps tendon insertion. Biceps Superior Labral Complex Possible LH Biceps Functions Humeral head depressor Aids in anterior and posterior stability in certain positions Superior Labral Complex Itoi et al. (JBJS-B,1993) Cadaver study. Loaded biceps tendon and applied A/P forces to humeral head. Decreased A/P humeral head translation.

2 Superior Labral Complex Rodosky et al. (AJSM,1994) Cadaver study Evaluated position of glenohumeral abduction and ER Biceps tendon helps prevent ER With SLAP lesion, this ability decreases Superior Labral Complex Pagnani et al. (JBJS,1995) Cadaver study Superior labral injury without biceps injury -- No increase in A/P or S/I translation With biceps injury -- increase in both Mechanisms of Injury Which athletes get SLAP lesions? Traditional Thoughts Baseball Softball Volleyball Tennis Waterskiing Football Mechanisms of Injury Trauma Throwing Overhead Sports Traumatic Mechanisms Forceful traction Compression -- fall on outstretched arm. Throwing Mechanism Eccentric biceps contraction Andrews (AJSM,1985) Secondary to anterior instability Jobe (Arthroscopy,1998) Peel-back mechanism Morgan & Burkhart (Arthroscopy,1998) SLAP Lesion Diagnosis History Characteristic injury event Often no discreet event Symptoms Anterior &/or posterior joint level pain May only be activity related May have night time pain Clicking, etc. uncommon

3 Physical Exam Isolated SLAP Lesion FROM Normal strength No pain with palpation Specific SLAP Lesion Tests Plethora of Tests Compression-rotation Active compression Anterior slide Crank Biceps load (I&II) Pain provocation How accurate are these tests? Initial reports claimed high accuracy. Published Accuracy Levels Crank Test 91% sens, 93% spec Liu et al. (AJSM,1996) Active Compression Test 100% sens, 98% spec O Brien et al. (AJSM,1998) Published Accuracy Levels Anterior Slide Test 78% sens, 91% spec Kibler (Arthroscopy,1995) Pain Provocation Test 100% sens, 90% spec Mimori et al. (AJSM,1999) Published Accuracy Levels Biceps Load Test II 90% sens, 97% spec Kim et al. (Arthroscopy,2001) Not corroborated through multiple further studies Poor Accuracies Morgan (Arthroscopy,1998) Guanche (Arthroscopy,2000) Stetson (AJSM,2002) McFarland (AJSM,2002) Guanche (Arthroscopy,2003) Accuracy of Physical Exam Tests For Isolated Type II SLAP Lesions Randy Schwartzberg, M.D. Chris Lariviere, PA-ATC Methods SLAP Lesion Relevant Tests Active Compression Test Compression-Rotation Test Biceps Load Test II (2/01)

4 Internal Impingement Sign Jobe Relocation Test Only patients with confirmed arthroscopically isolated type II SLAP lesions were included. Positive Test Results Recommendations Anterior slide test discard Choose these tests in order 1) Active compression 2) Crank 3) Speed SLAP exam tests Best diagnostic test for SLAP lesions Noncontrast MRI Questionable accuracy One study reports high accuracy Potter et al. (AJSM,1999) MRI Arthrography Better than noncontrast MRI Gadolinium injection into joint Contrast pressure may enhance visualization MRI for SLAP Lesions High accuracy reported in literature Accurate in the community setting? Problems With Community MRI Low Quality MRI Scanners Variable Tech Quality Few Quality Musculoskeletal Radiologists Economy MRI Scans Community MRI Accuracy Study Summary Community Radiologists Very Inaccurate Lesser Training Poor Quality Scans Musculoskeletal Radiologists Lesser accuracy than literature 61% & 69% Some accuracy correlation with perceived MRI quality Best diagnostic test for SLAP lesions SLAP Lesion Classification Type 1 Superior Labral Fraying Type II Labrum & Biceps Anchor Detachment Type III Labral Bucket Handle Tear

5 Type IV Labral & Biceps Bucket Handle Tears Cases 24 y.o. trapeze artist with shoulder pain without one discreet event. Functional Rehab Objective Present innovative activities, exercises, and functional movements related to returning high level artistic and acrobatic performers to pre-surgical activities Post Surgical Goals Protect surgical repair Minimize pain and swelling Gradually normalize ROM Restore functional strength Restore skilled movement Phase I (weeks 0-3) Wrist and Elbow ROM Shoulder ROM o Pendulums o No restrictions in Ext, Add, IR o Flex through pain-free arc o ER to 20 degrees No isolated biceps contractions Sling for first 3 wks especially in public Phase II (weeks 4-6) Shoulder ROM o Progress gradually towards full ROM in all planes Initiate Rotator cuff and scapular strengthening Bicep isometrics Phase 3 (weeks 7-12) Initiate Functional strengthening Optimize rotator cuff and scapular stabilizers strength and function Incorporate proprioceptive and dynamic stabilization activities Phase IV (weeks 13-16) Regain large shoulder muscle strength and endurance Progress toward skilled and sports/activity specific exercises Phase V (weeks 17+) Normalize strength Build power and endurance with sport/activity specific exercises Begin training sport/skill specific activities such as trapeze Overall Recovery Time Average 5-6 months Due to the work schedule o Perform 5 days per week

6 o 2 shows per day o 10 shows per week o 476 shows per year Add 1-2 months to recovery time to return to full activity level High Shoulder Loads Aerial silk Trapeze Bungee jump trapeze catch Catching colonne Banquine Aerial Silk Trapeze Bungee Jump Trapeze Catch Catching Colonne Banquine Areas to Focus Rotator cuff strength Scapular strength Core Rotator cuff External/Internal rotation PNF Patterns: D1/D2 Closed chain and functional open chain movements Focus on building endurance Building Endurance Preferred Tools o Bands and tubing o Flexbar o Body blade o Training ropes Body Weight activites Building Endurance Very high reps o Up to 100 Long duration o Up to several minute Scapular Strength Six pack scapular exercise Swiss ball T,Y,I s Serratus punches Scapular depression o Power band pull o Lat bar scapula pull

7 o Seated o Dip bars o Pull-up bar or peg wall Pull-ups Scapular Strengthening Bent over row Body weight rows o Bar o TRX straps o Rings Scaption Scapular/Core Strengthening Wall or Modified Plantigrade Quadraped Planks o Extremity lifts o Unstable surfaces o Rotational component o External perturbations o Resistance Bands Scapular Arm Circles Wall or Modified Plantigrade Quadraped Plank Plank Unstable surface Scapular Arm Circles Trapeze Specific Activities Trapeze Pull Reverse roll up Abs with Rings Rope climb Trapeze Bar Swing Trapeze Bar Catch Trapeze Swing Progression Swiss Ball Perturbations Dumbbell Scap Retraction Followed by Perturbations Medicine Ball Catches Sequencing Exercises Warm up Skill movement or Power Strength and endurance Isolation 27 y.o. trapeze artist who was caught awkwardly by the catcher.

8 History Continued to perform for 3 months Minimal complaints Treated with rehab Eventually complained of significant pain Exam FROM 5/5 rotator cuff strength Negative labral tests Rehab No Significant Difference from an isolated SLAP lesion because it is a small Rot cuff tear Considerations for Medium to Large Rotator Cuff Tears Sling maybe utilized in public up to 6 wks. First 3 weeks post op is a protective period with HEP focused on limited range activities o Pendulums o Wrist, hand and elbow No significant strengthening until 12 weeks post op to allow adequate heeling of the repair 25 y.o. F trapeze artist with gradual development in shoulder pain. History No specific injury event Anterior shoulder pain Increasing despite rehab, activity modification, NSAIDs Night time pain Exam FROM Normal cuff strength Positive active compression test Rehab Principles Predicated on SLAP repair Synovial chondromatosis No specific issues 42 y.o. performer injured shoulder catching a dancer on shoulders. History Had pain prior to injury Injury greatly worsened pain Anterior shoulder pain Night time pain No relief with rest & NSAIDs Exam FROM Normal cuff strength Tenderness over LH biceps Positive Speed s test

9 Pain with both components of active compression test Colonne Specific Activities Kneeling Arm pull Bench Pull over Overhead Ball Perturbations IR Ball Roll Overhead Med Ball Catch Colonne Training Banquine Specific Exercise Push Press Squat Single Arm Press Banquine Band Exercise Summary SLAP Lesion Injuries Overhead throwing Fall on outstretched hand Traction SLAP Lesion Diagnosis History Exam MRI arthrography SLAP Lesion Repair Arthroscopic Suture anchors Address all pathology Basic Rehab Principles Sling immobilization Regain ROM Cuff & scapular stabilizer strengthening Dynamic stability Unique High Demand Rehab Shoulder stabilizer power work Core strengthening Shoulder endurance Overall conditioning Functional rehab with training Thank You