RETURN TO PLAY (RTP) SHOULDER AND ELBOW

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1 RETURN TO PLAY (RTP) SHOULDER AND ELBOW July 29, 2016 Mark Sytsma, MD Bronson Sports Medicine Specialists

2 Disclosure I have no conflicts of interest of relevant financial relationships relating to this talk.

3 Return to Play (RTP) Background Shoulder injuries Fracture, dislocations, stinger, AC injuries, Clavicle fractures Elbow injuries Dislocation, fracture, ligament injuries Youth and overuse injuries

4 Why We Cover Sports Most injuries do not have serious consequences but some do! Hours of preparation, observation and training for a few critical moments. ALWAYS be prepared! 4

5 Why We Cover Sports OUR PRIMARY GOAL The health and wellbeing of our athletes 5

6 Goals of Sideline Management Assess the athlete quickly and diagnose the problem Is this an injury that will allow the player to return? Finger dislocation vs ankle fracture

7 Return to Play (RTP) Depends on the sport Contact vs non-contact Specific position Depends on the body part injured Example: Non-dominant hand in a soccer player Depends on the level of sport Higher levels may absorb more risk

8 Above All Else Protect the athlete More important than the desires of the athlete, coach, parent, etc 8

9 Shoulder Injuries Stinger/Burner (Dr. Jensen) Dead arm, numbness and tingling from shoulder to hand Caused by direct contact and stretch to the brachial plexus (nerves exiting neck) 9

10 Stinger/Burner Always evaluate for pain in the shoulder joint May indicate shoulder instability event Return to play? Sensation returns Normal shoulder strength (Rotator cuff test) 10

11 Shoulder Dislocation Most common major joint dislocation 90+% anterior Mechanism Force or fall on Abducted, ER arm: anterior dx Force or fall on Adducted, IR arm: posterior dx 11

12 Shoulder Dislocation Many spontaneously reduce. Pain shift or slip Locked dislocation Reduce Transfer to hospital if not reducible RTP?

13 Shoulder Dislocation Return to play? Sport, body part, level Consider surgery after first dislocation (new evidence) Often 3-6+ weeks Shoulder brace?

14 Shoulder Dislocation Younger Athletes (<25) High risk for recurrent dislocations/instability Mature athletes (>40) Must evaluate for acute rotator cuff tears

15 AC Separation Most common shoulder injury in contact sports Tenderness (+/-swelling/deformity) directly at AC joint Continuum of severity 15

16 AC Separation Mechanism: direct hit to or fall on shoulder If lower grade (Type 1,2), may RTP if shoulder strength and motion are normal

17 AC Separation Most have weakness within shoulder due to pain on day of injury No return on day of injury RTP: 1-4 weeks For persistent pain without weakness Low grade injury (Type 1 or 2) Local anesthetic injections can be useful Do not inject with steroids Surgery: out of contact for 5+ months

18 Sternoclavicular Dislocation Much less common than AC injuries Mechanism: usually a direct blow to chest Anterior dislocation (more common) Deformity Posterior dislocation (more consequences) Difficulty breathing or swallowing

19 Sternoclavicular Dislocation May be a fracture through growth plate Fuses at age No return to play Seek medical care DO NOT reduce

20 Clavicle Fracture 35% of shoulder fractures involve the clavicle Mechanism: direct contact or fall on shoulder Most commonly involve the middle 1/3

21 Clavicle Fracture Clavicle fractures Diagnosis Deformity? Tenderness to palpation directly over the clavicle Unable to return to play Strength will be decreased If minimally displaced, still at significant risk for displacement Sling and X-ray evaluation

22 Clavicle Fracture If non-displaced or minimally displaced Nonoperative RTP? Midshaft, displaced, shortened Operative, RTP?

23 Clavicle Fracture Clavicle Fractures Distal fractures may mimic AC injuries If significantly displaced, usually managed operatively

24 Elbow Ligament Injuries Ulnar collateral ligament (Tommy John Ligament)

25 Elbow Ligament Injuries Throwing athletes Pop or acute pain along inside of elbow Remove from play immediately Medical evaluation RTP? Direct contact May brace (depending on sport) RTP?

26 Elbow Dislocation Second most common major joint dislocation 80% posterolateral Mechanism: Fall or direct blow Simple dislocation (50-60%) Ligament injury only Complex dislocation Fracture + ligament injury

27 Elbow Dislocation NO immediate return to play Usually 2+ months before return to contact sports if it is a simple dislocation

28 Elbow Fractures Mechanism: Fall or direct contact

29 Pediatric Elbow Fractures Usually involve growth plates Ligaments usually don t tear, growth plates separate/fracture

30 Elbow Fractures Exam Deformity, swelling, or loss of motion Pain with direct palpation over the bone Remove from play Splint Obtain X-rays or appropriate studies

31 Elbow Fractures RTP Never return a young athlete immediately to play if they have bone or joint tenderness Need full motion and strength RTP 6+ weeks Longer for contact sports and articular fractures Sport, location, level

32 Overuse Injuries Primarily with overhead sports Baseball, volleyball, Tennis, Etc You can NOT play through pain Remove from competition Medical evaluation

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34 Questions?

35 Thank you! bronsonhealth.com