The overhead athlete

The overhead athlete

• 1.
  The Throwing shoulder PuneetMonga Consultant Orthopaedic Shoulder Surgeon, Wrightington Upper Limb Unit
• 3.
  Scope of thetalk •Understanding the overhead athlete’s shoulder •Pathologies •Surgeon’s perspective •Outcomes •Management Algorithm
• 4.
  Evolutionary function ofthe shoulder Shoulder is designed to place the hand in a three dimensional space with the elbow acting as a length adjusting Caliper
• 5.
  In an overhead athlete Thepower is gained from the Trunk and the upper thighs and the shoulder fine tunes and controls the motion
• 7.
  Common features • Powergeneration • Position of the shoulder • Force transmission
• 8.
  Kinetic chain Mc Mullenand Uhl 2000
• 9.
  Overhead athlete Who isan overhead athlete?
• 10.
  Pathologies seen
• 11.
  Lesions • Specific tothe overhead athlete - Internal impingement - UPS (Unstable Painful Shoulder) • Not specific to the overhead athlete - SLAP tears - Anterior Instability - Sub-acromial impingement - Fractures/ dislocations
• 12.
  Internal Impingement
• 13.
  Pathology • Cardinal lesions •Articular sided rotator cuff tears • Postero-superior labral lesions • Landmark article: Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1992;1:238-245.
• 14.
  Image Courtesy: Shoulderdoc.co.uk
• 15.
  Symptoms • Overhead athletes: •Pain during maximal abduction/ external rotation • Posterior joint line / shoulder girdle pain • Progressive decrease in velocity. Loss of control / performance. • Symptoms of anterior instability (?)
• 16.
  Signs • Posterior glenohumeraljoint-line tenderness • Loss of Internal Rotation • Excessive External rotation • Special tests - for SLAP, biceps, Cuff and instability
• 17.
  Specific test • Internalimpingement test • Place arm in Abduction 90-110, Max ER, Ext 10-15. • Deep posterior shoulder pain • In non contact injuries; 95% sensitivity, 100% specificity Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop. 2004;33:412-415.
• 18.
  Specific test • Jobe’sRelocation test • Abduction and external rotation causes posterior joint line pain. • relieved by anterior pressure
• 19.
  UPS
• 20.
  UPS: Unstable Painful shoulder20patients Overhead athletes Symptoms of pain No symptoms of instability. Imaging / Arthroscopy suggestive of instability Apprehension test caused pain Retrospective Mean 38 months FU • 95% satisfied 75% return to sports. The unstable painful shoulder (UPS) as a cause of pain from Unrecognized Anteroinferior instability in the young athlete. J Shoulder Elbow Surg. 2011 Jan;20(1):98-106. Boileau P, Zumstein M, Balg F, Penington S, Bicknell RT. Hôpital de L'Archet, Nice, France.
• 21.
  Surgeon’s perspective
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  Decision making Sieve • Levelof participation • Sport • Motivation • Season
• 23.
  Decision making Surgeon Therapist Coach Patient
• 24.
  Role of Investigations Earlydiagnosis paramount • Consider Early definitive investigations • MR arthrogram (vs MR vs CT arthrogram vs Ultrasound)
• 25.
  Beware! • Cuff tearsin asymptomatic individuals ! • Labral tears in asymptomatic athletes ! • Pathologies which do not corelate with clinical picture ! • Low sensitivity of scans to pick PT cuff tears Avoid Excessive reliance on scans
• 26.
  Role of surgery •After exhausting rehab options. • “Trial of Therapy” vs “early surgery” = overuse vs acute trauma
• 27.
  Rehab • Core Strength •Scapular dyskinesia • Manage Internal rotation deficit • Restore RC force couple
• 28.
  Surgical input Precision strikeand not carpet bombing!
• 30.
  Outcomes
• 31.
  Summary of Evidence Thermal CapsulorraphyJansen et al, 2012 7 year follow up: significant deterioration 25% Capsular Plication Jones et al, 2012 Pts with cuff tear, unable to return to play 85% Capsular Plication in swimmers Montgomery et al, 2010 80% return to play, but at lower level 20% Pancapsular plication Ma et al, 2012 Improvement in symptoms in all 18% Review of SLAP 2 repairs Gorantla et al 2012 return to overhead sports challenging 22-64% Non op Mgx, SLAP 2 Edwards et al, 2010 Trail of non-op Mgx recommended 66% Biceps tenodesis for SLAP Boileau et al 2009 Higher return to play in tenodesis cohort 87% Tenodesis vs SLAP Ek et al2014 No difference 73%, 60% and many more ...............
• 32.
  Summary / Reflection •Predominantly SLAP lesion; 2/3 return to play • Associated large cuff tear / repair : Poor RTP (1/3) • Capsular shrinkage, plication: Poor RTP • SLAP repair if the tendon looks good, tenodese if looks diseased
• 33.
  Management Algorithm
• 34.
  Management Clinical suspicion ofinternal impingement MR Arthrogram including ABER views Other lesions FT Cuff tear Labral tear Subacromial impingement Features of Internal impingement PT Cuff tears Post-sup Labral changes
• 35.
  Internal Impingement Non operativeTrial Rest, NSAIDS, Post Cap stretching, Scap Strengthening Failure of Non Operative Trial EUA & A’scopy 1+ Laxity: No Capsular plication 2+ Laxity: Consider Capsular plication 3+ Laxity: Capsular plication Cuff Tear <50%: debride Cuff Tear >50%: repair SLAP: debride / repair/ tenodese