common shoulder injuries in the athlete€¦ · goals review normal shoulder anatomy discuss...
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Common Shoulder Injuries in the Athlete
HILARY MALCARNEY, MD
PROJECT ECHO
S E P T E M B E R 2 8 , 2 0 1 7
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Goals
Review normal shoulder anatomy
Discuss biomechanics and how injury occurs
Understand treatment options for common injuries
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Normal Shoulder Anatomy
Bones
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Normal Shoulder Anatomy
Muscle / Tendon Units
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Normal Shoulder Anatomy
Ligaments
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Normal Shoulder Anatomy
Glenoid Labrum
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Normal Shoulder Anatomy
Glenohumeral joint
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Anatomy and Biomechanics
The glenohumeral joint is a balance between stability and mobility.
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Laxity and Instability
Laxity is physiologic. Instability is pathologic.
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Shoulder Instability
Why does it occur?
Congenital
Generalized joint laxity may lead to multi-directional instability in the shoulder.
Glenoid dysplasia.
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Shoulder Instability
Why does it occur?Trauma - 85% of shoulder dislocations are anterior
Anterior Dislocation Posterior Dislocation
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Shoulder Instability
Anterior Dislocation
What happens?
Bankart• soft-tissue labral tear +/- bone from anterior glenoid rim
Hill-Sachs lesion• traumatic bony divot at posterior humeral head
Other –• HAGL, greater tuberosity fracture, rotator cuff tear, neurovascular
injury
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Anterior Dislocation
Statistics:
90% recurrence rate in patients < 20 y.o. 10% recurrence rate in patients > 40 y.o.
80% incidence of RC tear in patients > 60 y.o.
30% incidence of axillary neuropathy in 1st time dislocators.
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Axillary Neuropraxia
Axillary Nerve Function:
Motor – Deltoid, Teres MinorSensory – Lateral Arm
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Shoulder Instability
Posterior dislocation
What happens?
Reverse Bankart = Posterior labral tearReverse Hill-Sachs lesion
Other: Reverse HAGL, lesser tuberosity fracture, RC tear, neurovascular injury
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Shoulder Instability –How should we treat it?
Reduction Sling Imaging studies Physical therapy Surgery
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Shoulder Instability -How should we treat it?
Consider surgery for patients < 30 yo with shoulder instability.
Why? High recurrence rate, and with repeated dislocations, bone loss and articular cartilage damage progresses.
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Shoulder Instability –How should we treat it?
Open versus Arthroscopic?
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Arthroscopic Labral Repair
Suture Anchor Insertion for Labral Repair
Suture LassosCannulasSuture Anchors
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Arthroscopic Labral Repair
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SLAP lesions
Superior Labrum Anterior – Posterior Lesions
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SLAP lesions
Peel-back mechanism causing a SLAP lesion
Superior View of Left Shoulder in a Thrower
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SLAP lesions
As a result, the biceps anchor is peeled back under tension (SLAP lesion), which allows for further anterior laxity and torsional failure of the undersurface rotator cuff fibers.
Peel-back labral injury
Superior view of the shoulder.
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SLAP lesion – O’Brien’s test
Shoulder forward flexed 90 degrees, and adducted 10 degrees, internally rotated (thumb down)
Repeat in externally rotated position (palm up)
ALLEVIATEDPAIN
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SLAP lesion
MR arthrogram
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SLAP lesions
Beware of the MRI report!
Age or activity related degenerative change in labraltissue
Normal labral recess (>50%)
Sublabral foramen(11%)
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SLAP lesions… Baseball’s Most Feared Injury
“Return to play after treatment of superior labral tears in professional baseball players.”
Rate of return to prior level of performance
Pitchers Non-operative 22%Operative 7%
Positional Players Non-operative 26%Operative 54% AJSM, May 2014
Fedoriw, et.al.Houston, TX
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Treatment
Non-operative. Non-operative. Non-operative.
Surgery only if failed non-operative treatment and well-defined pathology.
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Rotator Cuff Tears
Rotator cuff tears in overhead athletes are usually PASTA lesions.
PASTA = Partial Articular-Sided Tendon Avulsion
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Impingement
Classic (subacromial) Secondary Internal
Impingement - To collide or strike. To encroach upon.
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Classic Impingement
Pressure on the rotator cuff by a part of the surrounding anatomy. Subacromial Subcoracoid
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Secondary Impingement
Rotator cuff impingement due to increased glenohumeral joint motion from capsular laxity and/or muscle fatigue.
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Internal Impingement
Hyperangulation of humerus during acceleration phase, causing the undersurface of the rotator cuff to abut the glenolabral margin.
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Impingement
Treatment
Rehabilitation Improve throwing mechanics Core strengthening Scapular control Stretch posterior capsule if tight
Arthroscopic Surgery Address labral pathology Debride undersurface rotator cuff tear Treat anterior capsular laxity, and/or posterior capsular contracture
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Acromioclavicular Joint Injuries
Anatomy
Coracoclavicular ligaments (Conoid and Trapezoid)
Acromioclavicular ligaments
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AC joint injuries
Mechanism of Injury – Direct impact
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AC joint injury
Clinical Presentation
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AC joint injuries
Classification
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AC joint injuries
Treatment
Grade 1,2 – Non-operative, sling for comfort Grade 3 – Controversial, mostly non-operative Grade 4,5,6 - Operative
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AC joint injuries
Rehabilitation / Return to Play
Non-operative – Sling for comfort, ice, ROM/strengthening, RTP 1-4 weeks
Operative – Sling for 6 weeks, RTP 4-6 months
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AC joint injuries
Surgery Reduce AC joint with fixation device between coracoid and clavicle Add graft support if chronic to allow for biological healing
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In summary…
Listen to the patient.
Inspection Range of Motion Strength Instability Neurovascular
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Thank you.
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