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10/8/2013
1
Shoulder Pathology in the
Overhead Athlete
Timothy S. Johnson, MD
Disclosures
Speakers bureau/paid
presentations for Arthrex
Relevant Disclosures
• Coagulation ???
• I like baseball
• I like shoulders
• I grew up in NY
• My childhood
insecurity
10/8/2013
2
My WBC 2013
“living like a kid again !”
International Baseball
10/8/2013
3
The case
• Pre-Game Day 1
• SHOWTIME!: Venezuela vs Dominicana
• Team Venezuela
• The day after Hugo Chavez dies
• 23 yo male MLB pitcher @ WBC
• Shoulder pain x 5-6 days
Outline• Overhead Athlete
• Shoulder Anatomy
• Pathology of Throwing Athlete
– Musculoskeletal – “horses”
• Labrum
• Rotator Cuff
– NeurovascularVascular Problems – “zebras”
• Neurologic – 95%
• Venous – 4%
• Arterial – 1%
OVERHEAD
ATHLETES
– Throwers
– Tennis Players
– Volleyball players
– Team handball
– Water polo
– Javelin
– Badminton
– Boxing
– Weightlifting
– Mountain climbing
10/8/2013
4
Factor Contributing to Stability
• Static
– Osteology
– Capsule & Labrum
• Dymanic
– Rotator Cuff
– Periscapular Muscles
Static Restraints
• Articular Version
• Articular Conformity
• Glenoid Labrum
• Negative Intraarticular Pressure
• Capsuloligamentous Structures
Articular Version
10/8/2013
5
Osteology
• Glenohumeral Mismatch
Warner & Caborn , 1992
Labrum
• Increased surface area = Increased Stability
Warner & Caborn 1992
Negative Intraarticular Pressure
• Vaccuum effect
• Adhesion-cohesion
Cole & Katolik, 2002
10/8/2013
6
Capsuloligamentous Structures
Superior Glenohumeral Ligament
• Present in >90% of people
• Reinforces the rotator interval
• Limits inferior translation
• Limits ER– Adduction
• Limits posterior translation in– Flexion
– Adduction
– IR
Warner et al, 1992
Middle Glenohumeral Ligament
• Present in 60-80% of people
• Variable presentation
• Limits inferior translation– Adduction
– ER
• Limits ER– Adduction
• Limits AP translation in– Abducted (45º)
– ER
Warner et al, 1992
10/8/2013
7
Inferior Glenohumeral Ligament
Complex• Anterior Band
• Posterior Band
• Axillary Pouch
• Functions in Abduction >45º
– Anterior translation in ER
– Posterior translation in IR
Warner etal, 1992
AXILLARY POUCH
Warner et al, 1992
IGHL “Hammock”
• Reciprocal tightening
and loosening of the
IGHLC
Posterior Capsule
• Thinnest portion (< 1mm thick)
• Limits posterior translation in:
– Flexion
– Adduction
– IR
10/8/2013
8
Dynamic Restraints
•Concavity-Compression Effect
–Head centralization via cuff and biceps
•Rotator Cuff
•Periscapular Stabilizers
•Long Head of the Biceps
•Proprioception
Periscapular Muscles
Pectoralis
Minor
Pectoralis
Minor
Anatomy• Rotator cuff
– subscapularis
– supraspinatus
– infraspinatus
– teres minor
10/8/2013
9
Function of Rotator Cuff
• humeral head position control
• glenohumeral joint stability
Biomechanics
• Force couple
– maintain humeral head within glenoid
• compressive forces
– elevation and rotation
• Rotator Cuff Tear
– disruption of the force couple
– abnormal and unstable mechanical
• elevation with translation
Neuroanatomy
10/8/2013
10
Vascular Anatomy
Vascular Anatomy
Seroyer et al
SPORTS HEALTH
Vol. 1 no.2
Pathophysiology
10/8/2013
11
Overhead / Throwing Athlete
Population at Risk
• Overhead athletes
– Throwers
– Tennis Players
– Volleyball players
– Team handball
– Water polo
– Javelin
– Badminton
– Boxing
– Weightlifting
– Mountain climbing
Pathophysiology
10/8/2013
12
Pathophysiology
Seroyer et al
SPORTS HEALTH
Vol. 1 no.2
History
• What?
• When?
• How ?
• Where ?
• Why ?
10/8/2013
13
HPI
Seroyer et al
SPORTS HEALTH
Vol. 1 no.2
Musculoskeletal Injury
• Labrum
– Instability
– SLAP Tear• Rotator Cuff Disease
Labral Tear- Instability
Nevaiser, 1990
Warner etal, 1992
AXILLARY
POUCH
10/8/2013
14
Labral Tear - Instability
• Onset
– Acute
– Chronic exertional
• Symptoms:
– Subluxation/dislocatio
n
• Signs:
– apprehension
Instability Physical Exam
Ligamentous Laxity
10/8/2013
15
Ligamentous Laxity
Sulcus Sign
dimpling
External Rotation Apprehension Test
Tennent, 2003
10/8/2013
16
Jobe Relocation Test
Gaunche, 2003
Accuracy: Pain = 50% Apprehension = 80%Speer et al , 1994
Anterior Release
Test
Load & Shift TestSillman & Hawkins, 1993
Miller, 2002
10/8/2013
17
Load & Shift TestFaber, 1999
Miller et al, 2003
Load &
Shift
Test
Grading
Hawkins, 1990
Posterior Apprehension
Warner et al, 1992
10/8/2013
18
Labral Tear - Instability
• Treatment
– Physical Therapy
– Surgery
• Repair
Labral Tear - Instability
• Diagnostic Tests:
– X-Ray
– MRI
Imaging
10/8/2013
19
X-RAY
• Trauma views
– AP, Scapular-Y, Axillary
• Instability Series
– True AP, West Point Axillary, Stryker Notch
West Point Axillary View
Warner et al, 1992
West Point Axillary View
Warner et al,
1992
10/8/2013
20
Stryker Notch View
Hill Sachs
Lesion
Warner et al, 1992
Hill Sachs Lesions
MRI
10/8/2013
21
SLAP Tear
• Onset
– Acute
– Chronic exertional
• Symptoms:
– Joint Line Pain
• Signs:
– Adduction Compression
– Shear maneuver
Internal Impingement
• Posterosuperior Glenoid impingement
– Symptomatic contact between the deep surface of the
rotator cuff tendons and the posterosuperior glenoid
Pathophysiology
• Contact occurs during
the late cocking/early
acceleration phase of
throwing with the arm
abducted and
externally rotated
10/8/2013
22
Pathophysiology“Subtle” anterior translation allows
further rotation
(“hyperangulation”-Jobe) and
impingement
Possible sources
RC
weakness(Subscap)
IGHL failure(Bankart,
Capsular stretch)
SLAP lesions
Cuff and Labral Tears
Range of Motion
10/8/2013
23
Classic Clinical Presentation
• Loss of IR
• Loss of Cuff strength
• Atrophy
• Scapular dyskinesis
SICK Scapula
“Impingement Signs”
10/8/2013
24
Posterior Impingement Sign
• Late cocking position– 90-100 degrees of ABD
– 10-15 degrees of FF
– Maximal ER
• + when reproduces posterior pain
• 90% sensitive for tears of posterior labrum or partial thickness RC
• Meister K, AOSSM 1998.
SLAP Tear
• Diagnostic Tests:
– X-Ray
– MRI*
– Arthroscopy
MRI Findings
•Undersurface Partial Cuff Tear
•Labral Tear/ Detachment
•Cysts
10/8/2013
25
SLAP Tear
• Treatment
– Activity Modification
• volume
• technique
– Physical Therapy
– Surgery
• Repair
Arthroscopic Pathology
• Contact (100%)
• Articular-sided partial thickness tears of the supraspinatus and sometimes infraspinatus tendons (76-93%)
• Posterosuperior labral tears (71-88%)– Jobe, Arthroscopy 1995;11:530-536.
– Walsh G, JSES 1992;1:238-245.
– Paley J (Jobe), Arthroscopy 2000;16:35-40.
Associated Pathology
10/8/2013
26
Repair Unstable SLAPs
SLAP Tear
3 - Anchor Repair
Before After
10/8/2013
27
SLAP Repair
glenoid humerus
biceps
Partial Tears
• Controversial-
debridement vs
repair
Intra-articular View from
Posterior Portal - right shoulder
normal
abnormal
PASTA REPAIR
10/8/2013
28
Full Thickness Cuff tear
* Left Shoulder * –View from lateral portal
NeuroVascular Injury
Neurologic Injury
• Cervical
– HNP
– Cervical Spondylosis
– Burner/Stinger
• Peripheral
– Ulnar neuritis
– Thoracic Outlet
Syndrome*
10/8/2013
29
Cervical Radiculopathy• Onset
– Exertional
– Post exertional
• Symptoms:
– dermatomal
• Signs:
– Radicular
Cervical Radiculopathy
• Diagnostic Tests:
– X-Ray
– MRI
Cervical Radiculopathy
• Treatment
– NSAIDs
– Physical Therapy
– Corticosteroid injection
– Surgical
decompression/fusion
10/8/2013
30
Ulnar Neuritis
• Onset
– Exertional
– Post exertional
• Symptoms:
– Ulnar nerve
distribution
• Signs:
– Tinel’s
Ulnar Neuritis
• Diagnostic Tests:
– EMG/NCS
Ulnar Neuritis
• Treatment
– NSAIDs
– Physical Therapy
– Surgical
decompression/transpo
sition
10/8/2013
31
Vascular Injury
• Arterial
– Arterial Thoracic
Outlet Syndrome
– Quadrilateral Space
Syndrome (PCHA
entrapment)
• Venous
– Effort Thrombosis:
Venous Thoracic
Outlet (Paget
Schroetter syndrome)
Arterial TOS• Onset
– Overuse related
– Position dependent
• Symptoms:
– Vague pain
– Claudication
– paresthesias
• Signs:
– Diminished radial pulse
– BP and/or delayed capillary
refill
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
Arterial Anatomy
• Sites of Compression
– A: interscalene traingle
– B: costoclavicular space
– C: infrapectoral region
– D: humeral head
– E: quadrilateral space
Diagnosis and Management of Vascular Injuries Reeser, 2007
10/8/2013
32
Arterial Anatomy
• Sites of Compression
– A: interscalene traingle
– B: costoclavicular space
– C: infrapectoral region
– D: humeral head
– E: quadrilateral space
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
Adson Maneuver
Snead et al
JOURNAL OF ATHLETIC TRAINING
Volume 44, Number 1
Wright Maneuver
Snead et al
JOURNAL OF ATHLETIC TRAINING
Volume 44, Number 1
10/8/2013
33
Arterial TOS• Diagnostic Tests:
– Positional Contrast Angiography
– Positional MRA
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
Arterial TOS
• Treatment
– Thrombectomy & surgical reapir
– Surgical decompression (cervical ribs common)
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
10/8/2013
34
Quadrilateral Space Syndrome• Onset
– Due to repetetive abduction &
external rotation
• Symptoms:
– Position dependent shoulder pain
– Paraesthesias that may refer
distally
• Signs:
– Axillar neuropraxia
– Inoterance to sustained ABER
Quadrilateral Space Syndrome• Diagnostic Tests:
– Positional arteriography
– EMG/NCS
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
Quadrilateral Space Syndrome• Treatment
– Biomechanical
modification of
overhead skills
– Surgical
decompression of
quadrilateral space
Duwayri et al
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 5
McAdams and Dillingham
The American Journal of Sports Medicine
Volume 36, Number 3
10/8/2013
35
Venous TOS
(Paget Schroetter syndrome)
• Onset
– Post exertional
• Symptoms:
– Diffuse, poorly
localized
– Arm heaviness
• Signs:
– Swelling
– venous distention
Virchow’s Triad• Stasis
• Endothelial Injury
• Hypercoagulability
Seroyer et al
SPORTS HEALTH
Vol. 1 no.2
Venous TOS
• Diagnostic Tests:
– Doppler ultrasound
– Contrast venograpy
Valentine
JOURNAL OF VASCULAR SURGERY
Volume 47, Number 4
10/8/2013
36
Venous TOS
• Treatment
– Anticoagulation
– Surgical
decompression
– First rib resection
Valentine
JOURNAL OF VASCULAR SURGERY
Volume 47, Number 4
t=0
t= p ballon angioplasty
t=2 mo
T= p patch graft/rib resection
Venous TOS
• Treatment
– Anticoagulation
– Surgical
decompression
– First rib resection
Valentine
JOURNAL OF VASCULAR SURGERY
Volume 47, Number 4
10/8/2013
37
Case Outcome
• Treatment
– Air Transport to FL
– Anticoagulation
– Surgical thrombectomy
– Subclavian vein
reconstruction
– First rib resection
– RTP in 2013
Summary• Pathology of Throwing Athlete
– Musculoskeletal – “horses”
• Labrum
• Rotator Cuff
– NeurovascularVascular Problems – “zebras”
• Neurologic – 95%
• Venous – 4%
• Arterial – 1%
My WBC 2013
“living like a kid again !”
• Coagulation ?
• I like baseball
• I like shoulders a lot
• I “spend to much
time in the US and
need to come home
and learn to speak
Spanish !!! ”
10/8/2013
38
Questions?
19455 Deerfield Ave
Suite 312
Lansdowne, VA 20176
Tel: 703 729-5010
http://www.nationalsportsmed.com/