Common Shoulder Injuries in the Throwing Athlete: Amateur to Professional Steven B. Cohen, MD Associate Professor: Dept Orthopedic Surgery / Rothman Institute Asst Team Physician Philadelphia Phillies Asst Team Physician Philadelphia Flyers AsstTeam Physician St. Joseph s University Philadelphia, PA EATA Conference Jan 10, 2015
Disclosure Consultant: ConMed Linvatec Consultant / Royalties: Zimmer Research Funding: Arthrex, Inc Research Funding: MLB Royalties SLACK, Inc
Phases of Throwing
EMG Activity With Throwing
EMG Activity With Throwing
EMG Activity With Throwing
EMG Activity With Throwing
EMG Activity With Throwing
EMG Activity With Throwing
EMG Activity With Throwing
External Rotation Set Point IR velocity in elite pitcher = 7000 /second Increased ER Increased IR velocity the slot
Historical Impingement? Kennedy, Hawkins, Krusoff 1978 AJSM 6:309-22 Poor results with CA ligament division in swimmers Tibone, Jobe, Kerlan et al 1985 CORR 188:134-40 Open SAD in throwers 50% failure rate 22% return to pre-injury level True subacromial (outlet) impingement is not the problem
Historical Cuff Tear? Andrews, Carson, McLoed - 1985 AJSM 13:337-340 High level throwing athletes Rotator cuff tears Superior labral injuries Suggested that attrition was secondary to repetitive tension overload on rotator cuff and biceps tendon
Historical Laxity? Jobe et. al. Orthop. Rev. 18;963-975:1989 Repetitive throwing Laxity of anterior capsule Humeral head migrates anteriorly Rotator cuff / labral pathology
Historical Internal Impingement? Walsh et. al. JSES 1:238-45:1992 internal impingement rotator cuff impinged by posterior / superior glenoid rim in extremes of abduction and external rotation Jobe Arthroscopy 1995 and CORR 1996
Internal Impingement Physiologic, but increases with anterior micro-instability
Internal Impingement Meister K et al; Aspects of Sports Med. Aug 2004 p 412-415
Common Conditions Labrum Superior / SLAP most common Anterior / posterior Rotator cuff Tendonitis Partial-thickness tear Full-thickness tear Biceps tendon Tendonitis Subluxation / tear Scapular Dyskinesia
Historical SLAP Tears? 1990 Snyder et. al. Arthroscopy 6:274-279
Functional Importance Biceps anchor stabilizes humeral head (Anterior + Superior) Ext. rotation = labral strain SLAP = strain I.G.H. Itoi et al JBJS 93; Rodosky et al, AMJS 94; Grauer et al Arthro 92
Dysfunction Long Head of Biceps Humeral head depressor 2 restraint to GH translation in Abd. & ER Increased EMG activity in pitchers with instability S L A P Decreases biceps stabilizing ability Increases stresses on IGHL Increased laxity
Peel-Back Phenomenon Acquired tight posterior capsule Peel back of biceps/labral anchor Posterior/superior GH instability & anteroinferior pseudolaxity Burkhart and Morgan AJSM 1998
Peel-Back Phenomenon
Tight Posteroinferior Capsule - Deceleration - distraction force 750 N (80% body wt.) - Repetitive microtrauma to posteroinferior capsule leading to contracture
GIRD Glenohumeral Internal Rotation Deficit Def: loss in degrees of glenohumeral internal rotation of the throwing shoulder compared to non-throwing shoulder
GIRD 124 baseball pitchers 40 pro, 43 college, 41 HS Type II SLAP (arthroscopic) Avg. GIRD 53 (25-80 ) 19 asymptomatic professional GIRD 13 preseason and 16 postseason
Complaints Catching Pain Anterior Tenderness Looseness
SLAP Tests Examine for GIRD Compression - rotation Anterior Slide Test Hawkins / Neer Apprehension / Relocation O Brien Sign (Active compression) Mayo Shear Test No one test is perfect
Diagnosis of SLAP Tears MRI arthrogram is gold standard (specificity & sensitivity > 90%)
Treatment
Nonoperative Rest Sleeper stretches Cuff strengthening Scapular strengthening & scapular stabilizing Core / Kinetic Chain Roll-Over Sleeper Stretch 2
1. Acceptable GIRD is <20 or 10% of total rotation in the non-throwing shoulder 2. Prophylactic posteroinferior capsular stretching program minimizes GIRD and can prevent 2 problem
Non-op treatment is successful Edwards et al (Columbia). Nonoperative treatment of SLAP tears: Improvements in pain, function, and quality of life. AJSM July 2010. 39 patients documented SLAP with non-op tx Non-op tx = NSAIDs, PT (scap stabilization + post caps stretching) 20 (51%) failures of non-op tx F/U = 3.1 yrs VAS (4.5 2.1), ASES (58.5 84.7), Euro Qual life, SST (8.3 11.0) All returned to sports 71% return to preparticipation levels 66% of overhead athletes returned to same or higher level
Operative Treatment If non surgical treatment fails, then: Reduce and fix labrum Evaluate posterior capsular contracture Evaluate anterior laxity but do not tigthen
Arthroscopic SLAP Repair
Arthroscopic SLAP Repair
Arthroscopic SLAP Repair DO NOT OVER CONSTRAIN THE BICEPS
Release of Tight Capsule For patients who have failed IR stretching with persistent GIRD
What is the right way to fix it? Controversies Number of anchors Location of anchors Single or double loaded Simple or mattress stitch Knotless vs. knot tying Approach Tenodesis??????? Concomitant pathology what to do with cuff?
Early Results of SLAP Repair Morgan and Burkhart Arthroscopy 1998 53 baseball players, 44 pitchers Types 2b and 2c SLAP tears 87% return to pre-injury level
Results of SLAP Repair Kim et al. Results of arthroscopic treatment of superior labral lesions. JBJS 2002. 34 patients 94% good to excellent results 91% to pre-injury level 22% return to same level of sporting activity
Results of SLAP Repair Outcome of Type II SLAP Repairs in Elite Overhead Athletes: Effect of Concomitant Partial Thickness Cuff Tear Neri, ElAttache, Yocum et al, AJSM 2011 13 of 23 returned to pain free pre-injury level Good / excellent results ASES score 96% KJOC score 52% Inability to return to full participation linked to cuff tear
Results of SLAP Repair Cohen SB, Sheridan S, Ciccotti MG. Return to Sports for Professional Baseball Players after Surgery of the Shoulder or Elbow. Sports Health 2010. 22 professional baseball players underwent labral repair Specific analysis of return to level (MLB, AAA, AA, A) 7 of 22 (35%) returned to same or higher level 5 return to lower level; 10 retired from pro baseball Surgeries done both in and out of organization
Results of SLAP Repair Neuman B; Boisvert CB; Reiter B; Lawson K; Ciccotti MG; Cohen SB. Results of Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes: Assessment of Return to Pre-Injury Playing Level and Satisfaction. AJSM 2011 35 overhead athletes F/U = 3.6 years Avg age = 28.6 yrs 24 baseball / softball ASES & KJOC evaluation
Results of SLAP Repair Neuman B; Boisvert CB; Reiter B; Lawson K; Ciccotti MG; Cohen SB. Results of Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes: Assessment of Return to Pre-Injury Playing Level and Satisfaction. AJSM 2011 Athletes perception - they returned to 84.1% of their pre-injury level of function - mean time to return to play = 12.5 months Other overhead athletes perception of return to their pre-injury level was significantly greater than baseball/softball players (94% vs. 79.6%) Drop from the ASES to KJOC score for the baseball/softball players (89 & 72.1) Patients reported an overall satisfaction rate of 94.3%
Systematic Review Return to Play after Type II SLAP Lesion Repairs in Athletes Sayde, Cohen, Ciccotti et al, CORR 2012 506 patients with type II SLAP repair Minimum 2 year follow-up 83% good / excellent subjective results 73% overall return to athletics 63% OH athletes return to prior level
Rotator Cuff Due to repetitive microtrauma / internal impingement Partial thickness tears are extremely common Full thickness tears are rare with improved treatment of labral pathology, scapular dyskinesia, and improved mechanics
Rotator Cuff Symptoms Pain Fatigue Catching Stiffness Weakness Instability? Poor performance / loss of velocity
Rotator Cuff Examination Inspection evaluate atrophy and scapula position Tenderness anterolateral ROM usually normal except dec IR Strength may demonstrate weakness Stability relative anterior instability / internal impingement Tests Impingement signs O Brien s sign
Rotator Cuff X-rays of limited utility MRI very helpful However, almost all elite level throwers and most collegiate and high school pitchers will have abnormal imaging MRI Arthrogram = most accurate study Treatment Active rest Cessation of throwing Cuff / scapular strengthening IR Stretching + / - subacromial injection
Rotator Cuff Repair Arthroscopic evaluation of tear Subacromial decompression only for outlet impingement Cuff Debridment < 50% tear Repair > 50% tear PASTA repair Complete and standard repair
Debridement of PT Tears in Athletes Andrews JR et al. CORR 2008 67 professional pitchers with partial thickness tears 76% RTP professionally 55% RTP at same or higher level 74% of tears < 25% of thickness Only 8.2% > 50% of thickness
Surgical Repair In situ transtendon repair outperforms tear completion and repair for partial articularsided supraspinatus tendon tears Gonzalez-Lomas et al (Columbia). JSES 2008 2 repair techniques >50% tears in cadavers Cyclic loading showed less gapping with in situ repair and higher ultimate failure strength
Surgical Repair Repair of partial-thickness cuff tears: a biomechanical analysis of footprint contact pressure and strength in an ovine model Peters & Murrell. Arthroscopy 2010 3 repair techniques 1) transtendon, 2) completion & single row repair, 3) completion & double row repair Ultimate load to failure greatest in trans-tendon repair by 3x
Surgical Repair Itoi & Tabata. CORR 1992 Review of 36 pts with completion & open repair 82% good / excellent results Kamath, Yamaguchi et al. JBJS 2009 42 shoulders > 50% tear with completion & arthroscopic repair 88% intact by U/S @ 11 months post-op 93% satisfaction ASES scores 46.1 82.1
Surgical Repair Ide et al. AJSM 2005 Transtendinous repair in 17 pts Improved post-op scores 2 of 6 overhead athletes return to same level Mazoue & Andrews. AJSM 2006 8% of pitchers (1 of 12) able to return to same professional baseball level after mini-open repair of full thickness tears at 67 month follow-up 3 of 4 position players returned (1 of 2 dom arm)
Biceps Tendon Symptoms Similar to cuff generally more anterior and distal Examination Tenderness in bicipital groove Tendon instability passive abd with IR / ER + pop + Speeds / Yerguson s tests Failed SLAP repair??? Biceps is a pain generator
Biceps Tendon Biceps function in Throwing Low level activity in throwing No EMG activity if elbow fixed during shoulder motion Yamaguchi K, et al, CORR 1997;(336):122-9 Levy AS, et al, JSES 2001; 10(3):250-5 Jobe FW, et al, AJSM 1984; 12(3):218-20
Biceps Tendon Imaging Routine x-rays including outlet view MRI / Arthrogram Evaluate quality of tendon on axial and coronal views
Biceps Tendon Treatment Nonoperative Active rest Stretching Cuff / scapular strengthening NSAIDs Return to throwing program / sport
Biceps Tendon Treatment Operative Debridement of partial tear Tenodesis*** - for overhead athletes Repair in subacromial space, in groove, or subpectoral Tenotomy Usually reserved for lower demand Not likely used for young OH throwers Very limited literature on biceps treatment in throwers
Role of Superior Labrum Following Tenodesis Role of Superior Labrum following Tenodesis in GH Stability Strauss, Bush-Joseph, Cole, Romeo et al, JSES 2014 Biceps tenodesis did not impact GH translation Posterior SLAP repair restores baseline translation
Analysis of Pitching Motion after Tenodesis Upper Extremity Motion in the Overhead Pitch: Evaluation of Tenodesis & Repair of SLAP Tears Chalmer, Cole, Romeo et al. AJSM in press 2014 12 patients: 7 control, 6 SLAP, 5 tenodesis Both BT & SLAP repair restore neuromuscular activation patients BT more normal restoration than SLAP repair
SICK Scapula
Scapular Dyskinesia Kinetic Chain Kibler Shoulder does not function in isolation Alterations in any of the other links of can affect the shoulder, and alterations in the shoulder can affect other links in the kinetic chain Optimum restoration of shoulder function requires activation of all kinetic chain segments Ultimate velocity of the distal segment is highly dependent on the velocity of the proximal segments
Scapular Dyskinesia Kinetic Chain Kibler Proximal segments accelerate the entire chain and sequentially transfer force and energy to the next distal segment Proximal segments are responsible for the majority of force and kinetic energy that is generated Lower extremity force production is more highly correlated with ball velocity than is upper extremity force production
Scapular Dyskinesia Kinetic Chain Kibler Re-establishment of the muscle activation patterns for optimal kinetic chain function can be achieved through rehabilitation protocols, which target all aspects of the kinetic chain Preventative or prospective exercises to minimize future loading stresses should be included at the end of rehabilitation as part of the return to function
Conclusion Throwing injuries are common Labrum > Rotator Cuff > Biceps Prevention of injuries Avoid IR deficit Improve scapula function Proper mechanics Core strengthening
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