Common Shoulder Injuries in the Throwing Athlete: Amateur ...€¦ · Rothman Institute of Orthopaedics at Thomas Jefferson University Historical Kennedy, Hawkins, Krusoff 1978 AJSM

Common Shoulder Injuries in the Throwing

Athlete: Amateur to Professional

Steven B. Cohen, MD Associate Professor: Dept Orthopedic Surgery

Thomas Jefferson University / 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

Rothman Institute of Orthopaedics at Thomas Jefferson University

Disclosure

Consultant: ConMed Linvatec

Consultant / Royalties: Zimmer

Research Funding: Arthrex, Inc

Research Funding: MLB

Royalties – SLACK, Inc



Phases of Throwing


EMG Activity With Throwing

¤














External Rotation Set

Point

IR velocity in elite pitcher =

7000˚ /second

Increased ER

Increased IR velocity

“the slot”


Historical

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

Impingement?

True subacromial (outlet) impingement is not the problem


Historical

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

Cuff Tear?


Historical

Jobe et. al. Orthop. Rev. 18;963-975:1989

Repetitive throwing

Laxity of anterior capsule

Humeral head migrates anteriorly

Rotator cuff / labral pathology

Laxity?


Historical

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


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


SLAP Tears?

1990

Snyder et. al.

Arthroscopy 6:274-279

Historical


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

Decreases biceps stabilizing ability

Increases stresses on IGHL

Increased laxity

S

L

A

P


Peel-Back Phenomenon

Burkhart and Morgan

AJSM 1998

Acquired tight posterior capsule

Peel back of biceps/labral anchor

Posterior/superior GH instability

& anteroinferior pseudolaxity


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


Catching

Pain

Anterior Tenderness

Looseness

Complaints


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

Sleeper Stretch 2Roll-Over


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


• If non surgical treatment

fails, then:

• Reduce and fix labrum

• Evaluate posterior

capsular contracture

• Evaluate anterior laxity –

but do not tigthen

Operative Treatment


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



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



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



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



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 articular-sided 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

THANK YOU. 2008 AOSSM

Traveling Fellowship

Documents

Common Shoulder Injuries in the Throwing Athlete: Amateur ...€¦ · Rothman Institute of Orthopaedics at Thomas Jefferson University Historical Kennedy, Hawkins, Krusoff 1978 AJSM