Treatment of Shoulder Instability in the Throwing Athlete

Treatment of Shoulder Instability in the Throwing Athlete Caspari Institute of Arthroscopy Treatment of Shoulder Instability in the Throwing Athlete The Caspari Clinic Introduction • Art of throwing places extreme demands on shoulder’s soft tissues • Labrum, capsule, rotator cuff---> stabilize humeral head in glenoid Introduction • Injury to any of these structures---> instability • Instability = any increase in G-H translation producing Sx Introduction • Nonthrowing athletes - less torque across joint • Sx of instability only w/ severe capsulolabral injury (dislocation) Introduction • Throwing athlete - place high torque across joint repetitively • Even moderate injury to cuff/labrum will ---> Sx • Sx due to repetitive microtrauma Introduction • Sx of instability in thrower more subtle • Sx in throwing athlete are those of pain or “dead arm syndrome” Biomechanics of Throwing • Cocking phase - 175 deg. ext. rot. • Follow through - 105 deg. int. rot. • Anterior translation force on humeral head = 40% B.W. w/cocking Biomechanics of Throwing • Distraction force = 80% B.W. in follow through • Forces on head are resisted by labrum, capsule, & cuff • Shoulder stabilizers absorb significant energy Diagnosis of Instability in Throwing Athlete • Hx of pain assoc. w/ decreased performance • Hx of clicking, “shoulder coming apart” Diagnosis of Instability in Throwing Athlete • c/o “dead arm” • Rarely c/o actual subluxation or dislocation Diagnosis of Instability in Throwing Athlete • Pain posterior at joint line due to “internal impingement” • Posterior cuff abuts posterior labrum during cocking phase • Due to excessive ant. capsular stretch (microinstability) in pitchers Diagnosis of Instability in Throwing Athlete • • • • Pain in follow through = Sx of instability Arm max. I.R. & adducted Cuff & capsule under max. tension If stabilizers injured, severe pain-shoulder “coming apart” Diagnosis of Instability in Throwing Athlete • Pain in anterolateral deltoid referred from supraspinatus • Pain at anterior joint line often due to SLAP lesion Physical Exam • Most pitchers have increased A-P laxity in dominant arm • Must differentiate this “normal laxity” from instability • Is this increased laxity causing Sx? Physical Exam • Relocation test - internal impingement vs. A-P instability • Supine Stress Test • O’Brien test for SLAP lesion Rotator Cuff • Can be directly or indirectly injured with repetitive throwing Rotator Cuff • Directly injured by extreme tensile forces in follow-through • Tensile forces--->cuff weakness & tendinitis over time Rotator Cuff • Indirectly injured with unstable shoulder ---->A-P & superior laxity---> head impinges cuff on CA arch • (IMPINGEMENT SYNDROME) Physical Exam • Must assess all throwers for cuff injury – Impingent sign – Tests for Cuff strength – Has cuff been directly injured or is it secondary to unstable shoulder? Imaging • MRI = most sensitive • Allows evaluation of cuff, labrum, capsule, subacromial bursa Rehabilitation • Pitchers w/ anterior instability have decreased EMG activity in pec. major, subscap., serratus ant., lat. dorsi • cocking & acceleration phases Rehabilitation • This muscular imbalance contributes to, and propagates, the instability syndrome Rehabilitation • Initial period of rest • Anti-inflammatories / PT modalities • Pitchers show excessive ext.rot.& loss of int.rot. (tight posterior capsule) Rehabilitation • Stretch posterior capsule • Cross-body adduction & abduction/IR • Strengthening serratus ant., pec. major, subscap., latissimus Rehabilitation • Push-ups w/ a plus • Forward punch w/ pulley • Emphasize eccentric contractions to strengthen for deceleration phase Rehabilitation • Return to throwing if full ROM, no impingement or apprehension, and equal strength to opposite shoulder • Graduated throwing program • Continue strengthening program Surgical Treatment • Operate only if rehab has not reduced symptoms to degree where athlete can compete effectively Surgical Treatment • Goal = repair labrum, capsule, and rotator cuff • return athlete to preinjury level Surgical Treatment • Final plan made after thorough exam under anesthesia and diagnostic scope • How unstable is shoulder on exam? Surgical Treatment • Is cuff torn when examined w/ scope? • SLAP lesion? • Subacromial bursitis? Surgical Treatment • • • • Group I - Capsular Laxity only No cuff tear on scope Open vs. arthroscopic ant. capsular shift Capsular shrinkage w/ thermal probe Surgical Treatment • • • • • Group II - Capsular Laxity + Cuff tear Address both surgically Anterior capsular shift If cuff tear < 50% full thickness = debride If cuff tear > 50% = mini-open cuff repair Surgical Treatment • Group III - Internal Impingement – Posterior joint line pain – Fraying of posterior cuff and labrum due to anterior instability – Debride cuff and labrum – Anterior capsular shrinkage thru scope? Surgical Treatment • Group IV - SLAP lesion • Treatment depends on type • If detached labrum, fix arthroscopically Surgical Treatment • • • • Group V - Cuff tear only Minimal instability Debride tear if < 50% thickness Decompression, Arthroscopic or mini-open repair if > 50% thickness Post-Op Rehab • • • • • Depends on surgery performed Motion should be restored at 8 wk Strengthening after return of motion Throwing when strength 80% of NL Graduated throwing The Female Athlete: Treatment of Sports-Related Problems Chette Institute of Womanology Introduction • Tremendous rise in number of female athletes • Increased focus on injuries occurring exclusively or more commonly in female athlete Knee Injuries • Female basketball players w/ 4x as many ACL ruptures than males • Female soccer players w/ 2x as many ACL ruptures than males • Reason = ?? ACL Injuries • • • • Increased joint laxity in female athletes? Different limb alignment? Different bony anatomy? Lesser quadriceps muscle strength? ACL Injuries • Usually noncontact injuries • Athlete commonly feels “pop” in knee & cannot finish game • Severe swelling initially • Bloody “tap” in office ACL Injuries • Surgical reconstruction required to allow return to sports • Hamstring graft vs. patellar tendon graft • Surgeon should be comfortable w/ either graft Patellofemoral Pain • Pain under kneecap • Far more common in women athletes • Aggravated by squatting, kneeling, sitting w/ knees flexed for extended time Patellofemoral Pain • Often due to a maltracking of kneecap with flexion of knee • Often due to “softening” of cartilage on undersurface of kneecap Patellofemoral Pain • Treatment = Quad strengthening exercises • Avoid aggravating activities !!! • McConnell taping may relieve pain during sports Patellofemoral Pain • Surgery only after failed conservative treatment • Surgery only if there is maltracking of kneecap Bunions • Very common in dancers, sprinters, and gymnasts • Can be painful and debilitating • Should never be treated surgically until career is over Bunions • • • • Treatment = proper shoewear !! Wide toe box Deep toe box Orthoses Spondylolysis • • • • Stress fracture of lumbar spine Rare after adolescence Common in divers, gymnasts, and dancers Repetitive hyperextension of spine Spondylolysis • Athlete with recurrent low back pain associated w/ specific activity • Tight hamstrings common • Diagnosis based on x-ray Spondylolysis • Treatment = REST +/- bracing • Physical therapy for stretching low back and strengthening abdominal muscles • Return to play only after symptoms completely subsided Spondylolysis • Rarely, fracture allows slippage of one vertebrae over another • If slippage is severe, athlete may require surgery Stress Fractures • Due to overuse or “over-training” • Commonly seen in amenorrheic athlete • Micro-fractures not often seen on plain xray (need bone scan) Stress Fractures • Two common places in female athletes: –pubic bone –femoral neck (hip joint) Pubic Stress Fractures • Common in runners with: – tight adductors – leg-length discrepancy – cross-over running style – overstriding (taller running partner) Pubic Stress Fractures • Increased pull of adductor muscles on pubic bone • Present w/ groin pain • Pain w/ stretching adductor muscles • Dx = x-ray or bone scan Pubic Stress Fractures • Treatment = cessation of impact sports until asymptomatic (6-12 wks) • Shoe-lift if leg length discrepancy present • Progressive adductor strengthening and running in pool Femoral Neck Stress Fractures • • • • Micro-fracture in hip joint Pain in groin or front of thigh Pain w/ range of motion of hip More common in amenorrheic athlete Femoral Neck Stress Fractures • Diagnose with x-ray, bone scan, or mri • Must exercise extreme caution to prevent stress fracture ----> complete fracture of hip Femoral Neck Stress Fractures • Treatment depends on fracture site • If on “tension side” of femoral neck, athlete needs hip pinning in O.R. • Otherwise, non-wt. bearing with crutches for 3-4 weeks Athletic Amenorrhea • Amenorrhea - absence of menstruation • 20% of vigorously exercising women • 50% of elite runners & ballet dancers Athletic Amenorrhea • Due to an insufficient amount of body fat • Athletes w/ normal body fat but who consume insufficient calories to maintain intense training • Results in OSTEOPOROSIS Athletic Amenorrhea • Athletes w/ amenorrhea > 6 months have bone density similar to 60 y.o. women • Restoration of menses will prevent further bone loss but cannot replace bone already lost Athletic Amenorrhea • Osteoporosis may lead to stress fractures • Treatment = nutritionist, hormone replacement, adequate calcium (1500mg/day) Exercise During Pregnancy • Regular exercise (3x per wk) is preferable to intermittent activity • Avoid exercise in supine position after first trimester • Stop exercising when fatigued Exercise During Pregnancy • Maintain adequate nutrition (extra 3000 cal/day) • Avoid temp. elevation (stay hydrated, wear appropriate clothing) • High blood pressure, diabetes, Hx of miscarriage are contraindications to exercise! Exercise During Pregnancy • Types of exercises should minimize risk of injury • Consult physician prior to choosing program Exercise During Pregnancy • Third trimester - consider water aerobics • Buoyant effect of water reduces stress of weight bearing • Third trimester - increased back pain!!! – abdominal support straps – “angry cat” exercises