Shoulder Injuries in Overhead Sports: Prevention and Treatment

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1 Shoulder Injuries in Overhead Sports: Prevention and Treatment Jocelyn Wittstein,, MD Bassett Shoulder and Sports Medicine Research Institute Baseball Hall of Fame Community Lecture May 18, 2011

2 Shoulder dislocations Traumatic, atraumatic Outline Overuse injuries shoulder Little leaguer s s shoulder Scapular dyskinesia, SLAP tears Elbow Injuries- Dr. Lassiter Stress fractures Osteochondral injuries Ulnar collateral ligament tears Prevention

3 Shoulder Instability TUBS (traumatic, unilateral, Bankart, surgery) Anterior Posterior AMBRI (atraumatic, multidirectional, bilateral, rehab) >80% respond to rehab

4 Dislocations The shoulder is the most commonly dislocated joint. Usually antero-inferior Mechanism- abduction, ER ie- quarterback arm gets blocked while throwing Posterior instability less common

5 Anterior sub-coracoid shoulder dislocation

6 Reduction

7 Anterior Instability- delayed presentation Hx of self reduction on field or in ER Continued apprehension or recurrence Positive apprehension sign Shoulder Arthroscopy, Snyder, 2003

8 MRA MRI with contrast is the study of choice to evaluate for labral tears!!

9 Pathoanatomy Bankart tear Hill Sachs lesion 1 st time dislocator <20 yo 80% recurrence of instability Shoulder Arthroscopy, Tibone et al ortho.com

10 Treatment-Traumatic Anterior Instability Depends on timing of injury, needs of athlete Sully brace to finish season Arthroscopic labral repair Rehabandfitness.com

11 Arthroscopic Repair Shoulder Arthroscopy, Tibone et al 2003

12 Why Arthroscopic? decrease in surgical time decrease in blood loss smaller incision less loss of motion better visualization of pathology costs less outpatient surgery under regional

13 Posterior Shoulder Dislocation Less common Men High Energy Trauma At risk sports- offensive linemen, bench press

14 Mechanism- posterior instability

15 Treatment- Posterior Instability 50% respond to conservative treatment Arthroscopic posterior labral repair

16 Arthroscopic posterior labral repair Similar technique to anterior labral repair

17 Post op labral repair Same day ambulatory surgery 4 weeks in sling PROM 0-6 weeks 6-8 weeks active ROM Strengthen 8-12 weeks Contact sports 4 months

18 Overuse Injury Surveillance- Little League Lacking in overhead youth sports Large scale study under way at Bassett Gugenheim et al AJSM pitchers- 17% elbow sxs,, 12 % contractures Larson et al AJSM pitchers, 20% elbow sxs,, 10% contractures, 12% with xray abn medial epicondyle,, 5% radiocapetellar abn

19 Little Leaguer s s Shoulder Stress related injury to proximal humeral growth plate in young teen throwers Tenderness, painful throwing Xray show growth plate widening, adjacent fragmentation Resolves with rest, conservative rx

22 Physeal (growth plate) Alterations Repetitive throwing may lead to increased torsion though the physis Older throwers have increased ER, decreased IR Altered growth plate anatomy Tightness in back of the shoulder Burkhart et al Arthroscopy vol 19(4): pgs , 2003

23 Scapular Dyskinesia Repetitive throwing follow through tight tight posterior capsule Abnormal scapulothoracic motion to achieve IR, GH IR defecit Pec minor tightens Scapular protraction and tilt Subacromial Impingement Rotator cuff injury and SLAP tears tears Burkhart et al Arthroscopy vol 19(4): pgs , 2003

24 Not just about baseball Other overhead athletes have very similar injury patterns Tennis- serving Volleyball- serving, spiking Lacrosse Footballquarterbacks Swimming Tennismindcamp.com Webstersonlinedictionary.com

25 SICK Scapula Scapular malposition Inferior medial border prominence Coracoid pain dyskinesia Burkhart et al Arthroscopy vol 19(6) 2003

26 Physical Exam Decreased IR Pec minor tightness, coracoid tender Protracted scapula Orthobullets.com Burkhart et al Arthroscopy vol 19(4): pgs , 2003

27 Physical Exam May have + impingment signs Provacative tests for SLAP tears Hawkins et al Guanche et al Arthroscopy 19(5), pgs , 2003

28 Conservative RX of dyskinesia Physical therapy Posterior capsular stretching Burkhart et al Arthroscopy vol 19(6) 2003

29 Conservative Rx of dyskinesia PT Pec minor stretching

30 Conservative Rx of dyskinesia PT- cuff and periscapular strengthening Thrower s s ten Isometrics Ts, Ys,, arrows

31 SLAP tears Tight posterior capsule Shifts center of rotation peel back of biceps anchor Burkhart et al, Arthroscopy vol 19(5) pgs , 2003

32 SLAP tears Burkhart et al, Arthroscopy vol 19(5) pgs , 2003

33 Arthroscopic SLAP Repair Nam et al AJSM vol 31(5) 2003

34 Arthroscopic SLAP repair Nam et al AJSM vol 31(5) 2003

35 Arthroscopic Repair of SLAP tears Burkhart et al Arthroscopy vol 19(5) pgs , 2003.

36 Poor mechanics labral tears, internal impingment Burkhart et al Arthroscopy vol 19(4) 2003

37 Throwing Mechanics- Bad Burkhart et al Arthroscopy vol 19(6) 2003

38 Throwing mechanics- good Arm abducted in plane of scapula Elbow higher- above horizontal plane Burkhart et al Arthroscopy vol 19(6) 2003

39 Prevention of shoulder and elbow overuse injuries Proper throwing mechanics Periscapular and rotator cuff strengthening Pec minor stretching Posterior Capsular stretching Core strengthening UE is end of kinetic chain- off load with strong LE and core!

40 More Prevention Pitch counts Yearly 3 month rest periods for throwers Treat symptoms early!

41 Thank You! On to the elbow

SHOULDER INSTABILITY. E. Edward Khalfayan, MD

SHOULDER INSTABILITY. E. Edward Khalfayan, MD SHOULDER INSTABILITY E. Edward Khalfayan, MD Instability of the shoulder can occur from a single injury or as the result of repetitive activity such as overhead sports. Dislocations of the shoulder are