Overview. Masters participation. Overview. Host factors to consider. Masters participation. Traumatic Injuries of the Shoulder in Masters Athletes

Transcription

1 Traumatic Injuries of the Shoulder in Masters Athletes Gregory N. Lervick, MD Instructor, Shoulder and Elbow Surgery Minnesota Orthopedic Sports Medicine Institute (MOSMI) Fellowship Program Twin Cities Orthopedics Eden Prairie, MN Overview Epidemiology Host factors Discuss the most common injuries Evaluation Treatment decisions How is this similar or different from the younger athlete Particular emphasis on: Overview World population is aging 2006: 65+ = 500 million 2030: estimated 1 billion US Dept of State, 2007 The masters athlete defined: 35+ to middle to advanced age Participation v. training v. competition Intensity level variable We all see these patients Many benefits Lower comorbidities Mazzeo et al, Med Sci Sport Exercise 1998 Improved physical and mental health Masters participation Origins in the mid 1960 s Track and field Swimming Notable performances Dara Torres (Beijing, 2008) Tom Watson (British Open, 2009) World Masters Games (WMG) First held Toronto ,305 participants in 22 sports Sydney ,000+ participants in 28 sports Masters participation Low velocity / non-collision activities Swimming, running, tennis, golf Degenerative conditions related to repetitive use High velocity / collision type activities Water skiing Alpine skiing Cross country skiing Ice hockey Speed or in-line skating Bicycling Potential for higher energy injury mechanism Host factors to consider Underlying soft tissue degeneration Age related Repetitive use Asymptomatic rotator cuff tears: 25-50% in 60+ age Sher et al, JBJS-A 1990 Ligament / tendon stiffness: maturational stabilization Decreased bone mass Trabecular bone loss: female > male Comorbidities Medications Lifestyle choices EtOH Tobacco 1

2 Host factors to consider Biology of fracture healing Age has negative effect Not well understood Cellular levels vs. induction (BMP, etc.) Kwong / Harris, JAAOS 2008 Medication NSAIDs: lower inflammatory response Animal data: impaired healing Simon et al, J Bone Min Res 2002 Mechanical environment (fracture fixation) Traumatic shoulder injury Stability Rotator cuff Others: Acromioclavicular dislocation Sternoclavicular dislocation Proximal humerus fracture Pectoralis major rupture 5% of all fractures Midshaft most common (80%) Distal and medial less common Skiing, bicycling, skating Generally obvious, direct mechanism Clinical evaluation Rule out associated injury Screen head / neck Thorough NV exam Chest / scapula Other exam findings Posture Skin condition Abrasions Skin tenting General status / distress Plain imaging diagnosis True AP of entire clavicle tilt AP of entire clavicle Ensure AC and SC joints visualized Look for concomitant injury Scapula fx Rib fx pneumothorax Anatomic factors in the masters athlete Periosteum thin Bone less dense Comminution more common Displacement more common Lower biologic healing potential Different injuries than those in young HS/college athletes! 2

3 47 year old female Runner, avid cyclist Isolated mid shaft injury Otherwise healthy Treatment? Nonsurgical Surgical Nonsurgical options Sling for comfort v. figure of 8 Progress motion as able Formal PT prn Avoid secondary stiffness / disuse Other options Bone stimulator Data limited Delayed treatment Are we burning a bridge? Subtle differences with regard to strength / endurance (Acute slightly better) Potter et al, J Shoulder Elbow 2007 Frustration level of patient Loss of time, treatment restart Discuss up front - give patient the options Review pros and cons - no absolutes Issues: Healing Function What about primary surgical treatment? Canadian Multicenter Study (JBJS-A 2007) Frequently quoted Controversial Results generally favor operative treatment Earlier union Lower nonunion rate (slight) Higher patient satisfaction Applicable to the masters athlete? Large percentage were skiing, cycling, other sports Mean age 33 years 20% were smokers Conclusion: Primary surgical treatment has a role in the masters age athlete Consider all factors Age, gender, displacement, comminution Females at higher risk? Full disclosure Robinson et al, JBJS-A 2004 Optimal surgical method debated Plate fixation more common More common in the younger population (ie under age 40) Research and epidemiology reflects this Hovelius et al, JBJS-A 1996 / 2008 Owens et al, AJSM 2007 Far less data in the masters athlete Anterior still the most common direction Recurrent instability not the main concern Other factors to consider: Initial treatment Definitive treatment 3

4 What is different in the masters athlete? Host factors Tissue compliance Pre-existing degeneration Cartilage Rotator cuff Labrum Bone density Higher frequency of associated: Fracture Soft tissue injury (other than labrum) Neurologic injury Initial management Prompt joint reduction Plain radiographs essential to rule out fracture Glenoid rim Anatomic or surgical neck of humerus Tuberosities (rotator cuff attachment) Closed methods usually acceptable Exception: fracture of humeral neck Formal anesthesia may be required Peripheral block v. general Consider other imaging if successful reduction not achieved (CT / MRI) Always assess neurovascular status Especially true in the older athlete Neuropraxic injury more common with increased age Axillary nerve Evaluate pre and post-reduction Risk likely increases with delay in reduction Consider electrodiagnostic evaluation Rotator cuff evaluation also critical Perform after reduction obtained Belly press / lift off Rotational lag signs Internal rotation External rotation Hornblower s MRI recommended when confirmed first time dislocation in 40+ age group Cause v. effect Concavity compression Age related changes in rotator cuff Traumatic rotator cuff tear What to look for on the MRI to confirm Acute hemorrhagic signal Muscle quality Atrophy Fat infiltration Tendon quality / retraction Tendon coiling Important to determine Definite treatment implications Traumatic rotator cuff tear What to look for clinically Absence of prodromal or prior symptoms Acute loss of function Pseudoparalysis Rotational lag signs Bruising / swelling 4

5 62 year old Water skiing First time anterior glenohumeral dislocation ER reduction roughly 2 hours after injury Exam: reported bruising, swelling Deltoid intact Positive ER lag sign, hornblower s Pseudoparalytic: unable to reach over 90 Remaining examination benign Initially started in PT If not progressing, likely will need shoulder replacement Not all RCTs in the 60+ age group are chronic or non-repairable Look carefully at the MRI and the history If the rotator cuff is torn: acute v. chronic Nonoperative treatment may still be reasonable Pre-existing stable tear Symptoms minimal If acute, then repair generally preferred Earlier than later (better if within 2-3 months) Options: arthroscopic v. open Depends on surgeon preference, tear size, configuration, etc. Individualize tx Focus on rotator cuff Nonsurgical treatment Appropriate for most patients Absence of: Acute rotator cuff tear Significant fracture displacement Compromised stability after initial reduction Not the same injury as the HS/collegiate athlete Higher degree of inflammation Post injury capsulitis more common Discuss up front set realistic expectations Nonsurgical treatment Brief immobilization (comfort) Early rehabilitation Functional progression as tolerated Return to sport criteria Minimal pain Re-established ROM Normal strength May be as long as 3-5 months, depending upon specific activities / demands Recurrent instability Not as frequent based on age Labral surgery rarely required over the age of 40 Consider arthroscopic management if other risk factors Bone injury Hill-sachs Glenoid (bony bankart) Tissue hyperlaxity Anticipated activity 5

6 Proximal humerus fracture Contribution of athletic activity Different goals for the active population Not just fracture healing Function important as well Operative treatment if displaced and optimal function preferred Sternoclavicular dislocation Hockey Posterior dislocations: operative treatment recommended Anterior dislocations: generally nonoperative Late reconstruction if necessary Surprisingly subtle Must have high index of suspicion Acromioclavicular dislocation Hockey, skiing, cycling Diagnosis typically straightforward Radiographic classification Treatment algorithm similar to other age groups I-III generally nonoperative IV-V surgery Pectoralis major rupture Water skiing Weight lifting Frequently missed Axillary bruising Cosmetic deformity Standard shoulder MRI will not detect Discuss natural history Cosmesis, strength Many opt for surgery Summary Many traumatic shoulder injuries seen in the masters level athlete Underlying host factors may influence treatment decisions Activity level Underlying tissue factors Are not necessarily the same injuries as in young athletes Particularly true: s Masters athletes in training Area of future study 6