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Instability of the Overhead Thrower:Should We Do More?

Michael T. Freehill M.D.Assistant Professor of Orthopaedic Surgery

Wake Forest University Baptist Medical Center

Orthopaedic SummitLas Vegas, NevadaDecember 9, 2016

Disclosures

Consultant: Smith and Nephew, Mitek

Fellowship support: DJO, Mitek, Smith & Nephew

Research support: Smith & Nephew

Committee member : AOSSM, AAOS, AANA, ISAKOS

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Can the throwing shoulder be unstable?

Physiologic Adaptations– Increased ER at 90o abduction

• Increased arc of motion= increased time to accelerate ball

• Increased time to accelerate ball= increased velocity

Physiologic AdaptationsIncreased ER, decreased IR, and maintenance of

total ROMBigliani LU et al. AJSM 1985 Borsa PA et al. MSSE 2006Borsa PA et al. AJSM 2005Brown LP et al. AJSM 1988Crockett H et al. AJSM 2002Downar JM et al. JAT 2005Ellenbecker TS et al. MSSE 2002Freehill et al. Sports Health 2011Johnson L et al. JAT 1992Lintner D et al. AJSM 2007Meister K et al. AJSM 2005Myers JB et al. AJSM 2006Osbahr DC et al. AJSM 2002Reagan KM et al. AJSM 2002Reinold MM et al. AJSM 2008Ruotolo C et al. JSES 2006 Sauers EL et al. JAT 2003Wilk KE et al. AJSM 2002

Can a Throwing Shoulder Really Be Unstable?

• Need increased laxity to throw

• When does laxity become instability?

• Are changes really normal or pathologic

– when to repair, do we need to?

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Disabled Throwing Shoulder

• GIRD– Posterior band tightness

• Scapular dyskinesis• Internal impingement

– SLAP– PASTA

• Increased laxity– Instability?

Glenohumeral Internal Rotation DeficitGIRD

How much is too much?– 124 pitchers type-2 SLAP surgery

• all GIRD >25o

Burkhart SS et al. Arth 2003

– GIRD >18.7o= 2.4x increase in injuryWilk KE et al. AOSSM Annual Meeting. 2008

– 67 college baseball pitchers GIRD >20o

• 45% arm or shoulder painRuotolo C et al. JSES 2006

– No unanimous threshold number • GIRD >20o (generally accepted)

Scapular Dyskinesia

SICK Scapula:– Scapula malposition– Inferior medial

border prominence– Corocoid pain &

malposition– dysKinesis of

scapular movement

Internal Impingement

• Pathological contact postsuperior glenoid (labrum) & articular-sided RTC & GT during late cocking

• PASTA• SLAP

Walch G et al. JSES 1992

Anterior Laxity

• Insufficiency anterior capsuloligamentous structures:– Significant anterior translational forces

• Late cocking/early acceleration

Jobe et al. Orthop Review 1989

– 18o increase ER• Capsular elasticity increase 30%

Schneider et al. JSES 2005

– Anterior IGHL elongates w/ excessive ER Mihata et al. AJSM 2004

Anterior Laxity

Injury:– HH translates anteriorly w/ late cocking

• Increased tension of RTC– Draping/abrasion of RTC on glenoid

– Deceleration• Abrasion/degeneration/delamination

Andrews et al. AJSM 1995

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Expert Opinion

• , Payne etc

JobeJobe/Andrews/Andrews

#1Anterior capsularstretching

Scapular dyskinesis Labral tears Tight posterior capsule

RCT

Morgan/BurkhartMorgan/Burkhart

#1Tightened

PIGHL

RCT Shift center Post-sup labral tear of rotation

Anterior“pseudolaxity”

KiblerKibler#1

Scapular dyskinesis

RCT Anterior instability/ Labral tear

Tightposterior capsule

Is There Instability In The Throwing Shoulder?

Yes! They are all unstable, but that doesn’t mean we need to operate on them

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How Do We Know What to Treat?

• Age• Throwing History• Clinical Findings• Activity Level

Thrower <12 y/o

• History– Activity level/throwing– Usually overuse/fatigue problem

• Education about sports specialization– Minimum time off from throwing

• Low weight/perfect form exercises• Throwing programs/pitching coaches

Sports Specialization

• Intensive year round (8+ months/yr) training and competition in single sports to the exclusion of all other organized sports

Sports Specialization

• There is some limited evidence early sports specialization may increase risk of injury– Early specialization to pitching and unlimited

pitching volume may increase risk of UCL injury (Romeo 2016)

– Single sport baseball players with increased risk of UCL injury

(Bruce 2014)

Thrower 12Thrower 12--15 15 y/oy/o

• Muscle imbalance– Look at posture!

• Core strength• Check mechanics • Kibler Integrated exercises

– Avoid surgery– Check growth plates: elbow!

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Core StrengthCore Strength

• Trunk strength and stability

• Allows lower extremity power to transmit to the arm – (Kibler’s kinetic chain)

• Often not well developed in children and adolescents, leading to increased injury

Thrower 15Thrower 15--20 20 y/oy/o

InjuriesLabrumMicro instabilityGIRD

Muscle imbalanceProtractionCore weakness

Fatigue? Rest/rehab

• This is the one area where surgery can actually be beneficial

• they have time to “outgrow” the repair and recover function

Techniques & ThoughtsType IIB SLAP- thrower

– Transtendon (medial to cable) if needed– Knotless

Other Surgical Thoughts

Yes:

Debridement only

No:

ThermalCapsulorraphy

Maybe so:

Posterior capsule release

Elite ThrowersElite Throwers

• Subluxation “normal”• Rest/rehab may be best

option • Internal impingement also

normal? – IS tear– Peel back lesion– Posterior tightness

28 yo MLB Pitcher

22 y/o pitcherPTRTC

Connor P et al. AJSM 2003

SLAP Surgical Outcomes

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SLAP Surgical Outcomes

• Systematic review• 506 athletes overall

– 198 overhead athletes• 73% overall return to previous level of play• 63% in overhead athletes• Anchor repair 63% vs tack 57%

SLAP Surgical Outcomes

– 23 pro/ college pitchers– Mean f/u 38 mo’s

• Overall Return to same level= 57%

– SLAP NO PTRTC tear (15/23)• Return to same level= 80%

– SLAP with PTRTC tear (8/23)• 10-40% thickness, debridement in all• Return to same level= 12.5 %

Throwing Shoulder Key Concepts Throwing Shoulder Key Concepts

• Scapular position = key

• Core exercises – maintain scapular retraction

• Scapular retraction – allows maximum RTC function

• Proper mechanics/posture– protects elbow

Strengthen/ Rebalance/ Maintain

Non-operative management:• Rest from throwing• NSAIDs• Injection• Plyometrics/proprioception• 6 weeks for response

(minimum)

Courtesy Xavier Duralde M.D.

Summary

• Pathology can vary with age of thrower• Rehabilitation of the entire kinetic change• Surgery should be minimalistic if essential

– all of them are unstable– fix only what “tipped them over the edge”

• Prevention questions– How much (specialization and when)?– Maintenance and recovery (long toss)?

Thank You