Lennard Funk Wrightington Upper Limb Unit Salford University

lenfunk@shoulderdoc.co.uk

ANATOMY

Deep Muscles

Glenohumeral Ligaments

Labrum

Posterior

Inferior

Superior

Bankart

Reverse Bankart

SLAP

Anterior

Common Injury Groups• Contact Athletes

– Rugby – Football

• Overhead Athletes – Swimming, Racquets, Climbing, Cricket, Track & Field

• Trauma – Motorsports – Cycling – Canoeing – Horseriding

• Strength Athletes – Powerlifting, weightlifting, Bodybuilding

Sport Popularity in UKSPORT TV

ViewingParticipation

InterestFootball 46% 10% 45%Rugby Union

21% 6% 27%Tennis 18% 3% 23%Cricket 18% 2% 19%Athletics 18% 2% 21%Snooker 17% 5% 24%Motorsport 16% NA 20%Rugby League

12% 2% 15%Boxing 11% NA 14%Golf 11% 6% 16%

My Elite Athletes (2010-2013) = 663

SPORT Percentage Commonest Path.

Rugby Union 37% (247) Anterior LabralRugby

League28% (182) Posterior

LabralFootball/Soccer

8% (54) Anterior LabralMotorsport 3% (22) Mixed Labral TearsClimbers 3% (20) SLAP

Swimming 3% (18) Int Imping/SLAPCricket 2% (14) Anterior

LabralParalympics 2% (13) Mixed Labral TearsOthers 14% (93)

Repetitive Overhead Acute Trauma

"In an instant I knew my tour was over and I could feel the tears coming,"

“I felt like a drowning man, I wanted to shout for help but nobody could hear me.”

How can we help him?• Technical Skills • Knowledge:

– Risk factors – Mechanism of Injury – Pathology – Effects of our surgery

• Recurrence Rates • Complications

Predisposing Factors• Player:

1.Laxity Cheng et al. JBJSB 2007; Akhtar & Robinson. BJSM 2010

2.ProprioceptionHerrington, 2011

3.Isokinetics Jones & Funk, 2010

4.Mass 5.Running Speed 6.Aerobic ability 7.Previous Injury

• Sport:

1. Speed of play

2. Timing

3. Fatigue

1. Physical

2. Mental

Forces

“The new GPS system which we wore during the Four Nations - attached to a man bra under our shirts - consistently showed us that we were taking impacts of 10 gs and upwards during a match.!

The gravity force of a car travelling at 100km/h that comes to a stop in 0.2 seconds is 14.2 gs. And we don't have airbags!” !

Jon Wilkin, Feb 2010

Injury Reduction Predispostion Model Meeuwisse

Common Sports

CONTACT / COLLISION

OVERHEAD

CONTACT / COLLISION

FLEXIBILITY

Recurrent Instability Rates (after arthroscopic stabilisation)

[Cho et al. Arthroscopy 2006]

CONTACT / COLLISION

OVERHEADFLEXIBILITY

29%

7%

Recurrent Instability Rates in Contact Sports

• Non-operative = 80% [Arciero, 1994] • Open Bankart repair = 12% • Arthroscopic Stabilisation = 14%

[Larrain, 2006] – First dislocation = 4% – Recurrent dislocations = 24% – Under 18yrs age = 30% [Nixon & Funk, 2013]

• RCT of Latarjet vs. Arthroscopic Bankart • Recurrence rate at 5 years:

– Latarjet = 12% – Arth. Bankart = 24%

• Return to sport the same! • Complication Rates higher (20%)

Latarjet Procedure [Bessier et al. JOST. 2013]

Recurrence Summary• Higher in contact/collision sport • Higher in young • Higher after surgery for recurrent

dislocations !

• Arthroscopic = Open Bankart • Lower after Latarjet procedure

WHY?

Overhead AthletesLo, Hsu & Chan - BJSM 1990

• Tackling Fatique = Reduced JPS • End of range only

Proprioception & FatigueHerrington et al. Phys Ther Sport. 2008

Laxity• ‘Lax’ shoulders = higher risk of

dislocation in rugby – Cheng et al. JBJSB 2007

• High Beighton Score = higher risk of dislocation in sports (not just contact)

– Akhtar & Robinson. BJSM 2010

Isokinetic StrengthNathan, Jones & Funk. SECEC. 2011

1. Those players that had rehabilitation following injury and surgery had better strength & stability than those without any shoulder injury. 2. Poor Isokinetic strength may be a risk factor for injury 3.Current rehabilitation methods are effective 4. Suggests this should applied to those that have not yet suffered injury.

Common Injuries

Mechanisms of Injury video analysis study

Direct Impact

Complex Labral

Bony Bankart PTCT

Flexed Fall

Posterior Labral

RHAGL

Try Scorer

Bankart SLAP

Rotator Cuff

Tackler

Bankart SLAP HAGL

Crichton, Jones & Funk - BJSM 2012

FOOTBALL• SHOULDER: !

• 2-4% of all injuries !

• BUT: – Longest period of time away from

Incidence Mills, Pritchard, Funk & Batty, 2010

0

27.5

55

82.5

110

2006 2007 2008 2009 2010

45 46

84

98104

34

63

91 9499

LeftRight

Player Position• 25 Professional Footballers

– 15 Field players – 10 Goalkeepers

Hart & Funk, KSSTA 2013

Clinical Examination: Instability in Athletes

• True Instability – Dislocation – Subluxation – Apprehension – Large lesions

• Subclinical Instability – Dead Arm in ABER – Pain in ABER – Clunking – No Apprehension – Smaller lesions

Investigations• No previous Surgery = MR

Arthrogram !

• Previous Surgery = CT Arthrogram

MR Arthrogram v. Scope

Sensitivity

Specificity Accuracy

SLAP 0.42 0.92 77%

Rotator Cuff Tear

0.50 0.86 83%

Hill Sachs 0.91 0.78 90%

Bankart 0.85 0.83 86%

N Karlson, J Geoghan, L Funk; 2008

• An experienced Shoulder Surgeon better

• Can correlate with clinical context

Classification of Lesions

Major ‘Minor’

• Bony Bankart!

• ALPSA!

• Rotator Cuff Tear!

• HAGL!

• Undisplaced Labral Tear!

• Partial Cuff Tear!

Timing of Surgery• Early Surgery:

– ‘Major’ lesions – Late in Season – Unable to Return

• Rehab & Return:

– ‘Minor’ lesions – Early season

Types of Surgery• Mostly Arthroscopic Direct Repairs • Latarjet for High-Risk/Revision

• Anterior Instability – Revision surgery (even without bone loss) – Chronic Bony Bankart (> 3months) – Any Bony Glenoid Loss – True dislocation in Front Row forward

(Rugby Union) – Higher level of sports

Latarjet in Athletes

• Player-specific - tailored to suit the player’s age, position, requirements, surgeon and therapists.

• Not ‘accelerated’ or ‘aggressive’ or ‘time specific’. • Surgery-specific - dependent on the quality and

type of fixation achieved. • Protocol is a ‘guide’ and not a prescription.

• Phase Progression - when the patient is able to perform all of the exercises in the previous phase without any discomfort or apprehension. Each phase is introduced progressively.

Ben Macdonald, Mike Lancaster, Meiron Jones, Doug Jones, Christine Holmes, Kathleen Tatlow, Lennard Funk - 2004

Sports Specific Rehab

lenfunk@shoulderdoc.co.uk

Sports Specific - Javelin

http://kellybram.wordpress.com/

Rugby Rehab Protocol

lenfunk@shoulderdoc.co.uk

Rugby Results ‘03-’05

Pain Satisfaction (%) Playing at previous level

Pre-op 5 11% 0%

3 months 10 87% 89%

6 months 12 93% 94%

L Funk , K Roney, CJSM, 2007

Time to return to play L Funk , K Roney, CJSM, 2007

Return to Play

Repair! Months-post.op!SLAP! 2.6!Ant.*&*SLAP! 3!Post.*&*SLAP! 4!Ant.*Post.*&*SLAP! 5.5!

L Funk , K Roney, CJSM, 2007

Arthroscopic Stabilisations

0"

1"

2"

3"

4"

5"

Ant" Post" Both"

Time"(months)"

Fourie & Funk, 2009

Return to play by time of

0"

1"

2"

3"

4"

5"

Begin" Mid" End" Out"

Time"(months)"

63% of all operations took place in the last three months or out of season

Fourie & Funk, 2009

0"

1"

2"

3"

4"

5"

6"

≤20" 21*29" ≥30"

Time"(months)"

Return to play by ageFourie & Funk, 2009

Creighton et al. CJSM 2010

Recurrences & Revisions• 8/143 = 5.6% at 2 years • All recurrent trauma • 4 treated with Latarjet Procedures

1. High demand; High forces; Fatigue 2. Increased Injuries & recurrence risk 3. Understand 4. Recognise5. Appropriate imaging6. Customised Surgery 7. Timing of Surgery 8. Sports-specific Rehabilitation

Athlete’s Shoulder

lenfunk@shoulderdoc.co.uk

THANK YOU