LESSONS LEARNED FROM MAJOR LEAGUE BASEBALL Thomas J. Noonan, MD Steadman Hawkins Clinic Denver
1. GIRD isn t the holy grail Morgan/ Burkhart- most important pathologic process in throwers is loss of internal rotation in abduction (GIRD) caused by posteroinferior capsular contracture As shoulder externally rotates, contracted post band of IGHL will not allow head to fully ER around normal glenoid rotation point post/sup shift of hum head excessive ER
1. GIRD isn t the holy grail Shear forces at biceps anchor and post/sup labrum increase posterior SLAP tear via peel back mechanism Excessive ER increased stress of IGHL Increased ER increased shear and torsional stresses in post/sup rotator cuff undersurface fiber failure
1. GIRD isn t the holy grail Plenty of players get hurt without GIRD Humeral torsion strongly predictive of GIRD (bony changes may be responsible for ROM differences) Changes in ROM may be more important 25 Side to Side Differences in HT in Professional Pitchers with and without GIRD 20 15 10 11.1 20 5 0 No GIRD p=0.006 GIRD
2. Things may predispose these athletes to injury which are beyond our control Humeral torsion Too little- shoulder injury Too much- elbow injury Humeral Torsion (dgrees) 40 35 30 25 20 15 10 5 Elbow Injury No Injury Shoulder Injury 0 D HT ND HT
3. Treat the entire body Rotator cuff and periscapular strengthening critical but lower extremity and core also very important 88 professional pitchers 3 component of FMS in Spring Training (hurdle step, in line lunge, active straight leg test)
Results Functional Movement Risk Factors for an elbow injury in professional pitchers Stance Limb Stride Limb No. risk* % Injured RR P value N @ risk* % Injured RR P value Hurdle Step 2 58 17.2 0.86 0.48 53 24.5 2.9 0.05* = 3 30 20.0 1.0 35 8.6 1.0 In-Line Lunge 2 29 34.5 3.3 0.008* 21 23.8 1.5 0.32 = 3 59 10.3 1.0 67 16.4 1.0 Active SLR 2 32 31.3 2.9 0.02* 27 29.6 2.3 0.06 = 3 56 10.7 1.0 61 13.1 1.0 16 time-loss elbow injuries
4. Never underestimate what kind of pathology a player is able to tolerate
5. Shoulder surgery is not a good thing for a player Lintner et al (AJSM 2014) 68 players with SLAP tears Pitchers with non-op treatment- 40% RTP, 22% RPP Pitchers with surgical treatment- 48% RTP, 7% RPP Position players with non-op treatment- 39% RTP, 26% RPP Position players with surgical treatment- 85% RTP, 54% RPP Andrews- I ll do about anything I can to not operate on a shoulder
6. When it comes to shoulder surgery, less is more Trend toward debridement of SLAP tears Very few RCR performed Andrews- My results for rotator cuff repairs are worse than non-operative treatment of full thickness tears Andrews (AJSM 2006) 1 of 12 pitchers return to play after mini-open RCR 50% rule doesn t apply for RCT in throwers
7. UCL reconstructions are great but maybe not as great as we think they are Good results but how long do they last? Osbahr and Andrews 256 patients at >10 year follow-up 83% return to play Career longevity 3.6 years (2.9 at same or higher level of play) 86% retired for reasons other than elbow 34% had shoulder problems (25% surgery) UCL recon not necessarily the magic procedure it is perceived to be Unrealistic to assume you have a UCL recon and never any more problems Increased incidence of UCL graft rupture in MLB
8. Partial ACL tears may not do well, but partial UCL tears can 2006-2011 45 UCL injuries 8 complete tears surgery 37 partial tears 1 immediate surgery 3 rehab MRI surgery 33 treated with rehab 3 failed surgery 85% RTP with rehab
9. Kids getting surgery is not conducive to a Major League career Never seen a MLB pitcher with history of shoulder scope in high school Most MLB players played other sports growing up Justin Morneau- hockey DJ LeMahieu- All-state basketball player Troy Tulowitzki- All-state basketball player Nolan Arenado- soccer Carlos Gonzales- soccer Corey Dickerson- football, basketball Charlie Blackmon- football
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