ACL plastik, erfarenheter av. tidig kirurgisk behandling. tidig kirurgisk behandling 6/12/2013

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1 in sports Per Renström, MD, PhD Professor emeritus,,, Sweden Member ATP and ITF Sports Science and Medical Committees Physician Swedish Football Association Presentation at the IOC Advanced team physician course at Vår Gård, Saltsjöbaden, May Well functioning shoulders are key to success in many Overhead Sports Tennis Baseball Badminton Swimming Volleyball Javelin Water Polo Football (QB) Handball Throwing and serving motions in sports erfarenheter av Injury profile Shoulder overhead injury Most tennis occur in Lower extremity (31% 67%), Upper extremity (20% 49%) Trunk (3% 21%) Abrams, Renström, Safran Br J Sports Med Jun;46(7): Commonly related to scapular dyskinesis, rotator cuff pathology or glenohumeral internal rotation deficit which results in internal impingement and/or labral pathology. Neuman et al Am J Sports Med 2011;39: in sports erfarenheter av Throwing and serving overhead motions 1

2 The overhead serve motion The serve was the predominant stroke accounting for 45% in French Open and 60% in Wimbledon of strokes during service games. Johnsson et al. Br J Sports Med, 187: 901, 2006 Optimal shoulder function requires good kinetic chain function, optimal stability, and coordination of the scapula in the overhead action. Van der Hoven, Kibler: Br J Sports Med, May;40(5):435, 2006 Importance of kinetic chain in overhead activities 50% of total kinetic energy and total forces of the overhead throw and tennis serve are developed in the leg, hip, trunk while the shoulder has 21% contribution to total force Toyoshima, Miyashita, Res.Q. Mar;44(1): This means that throwing and serving involves most of the 640 skeletal muscles and 4000 tendons in the human body Overhand Mechanics Stance or Ready Phase Phases Ready Wind-Up Cocking Early & Late Accleration Early & Late Follow Through Wind-Up Phase Early Cocking Phase 2

3 Late Cocking Phase Tennis Serve --Cocking Phase Begins after ball toss and terminates with point of maximal external rotation Risks for injury Competitive throwing can stretch out the shoulder capsule and increase shoulder flexibility Late Cocking Position Tennis Serve Pathomechanics - SLAP I II Late Cocking Position SLAP Lesion? Tennis Serve Pathomechanics - Cuff Repeated Rotation SLAP Lesion?? III IV Increased Laxity Increased Reliance On Rotator Cuff Overload Cuff Tennis Serve Acceleration Phase Tennis Serve --Acceleration Phase Begins at maximal external rotation The explosive phase as trunk flexes forward Ends when the ball is released Risks for injury The shoulder internal rotator muscles contract to produce maximal internal rotation velocity The rotator cuff muscles are highly active 3

4 Follow Through Phase Tennis serve Deceleration and Follow-Through Phase Begins at maximal shoulder internal rotation Ends when the arm is across the body The risk for injury is increased Maximal internal rotation of the shoulder The back muscles are subjected to large load The elbow is extended maximally and affected The wrist is forced forward in the serve Pathomechanics - Cuff Pathomechanics - Cuff Follow Through Joint Distraction Stretch Capsulo- Ligamentous Structures Overload Cuff Rotator Cuff Overload Cannot Maintain Humeral Head In Glenoid Deltoid Pull X Secondary Impingement Can Occur Outlet Impingement Outlet Impingement Without Rotator Cuff Overload / Dysfunction 4

5 Outlet Impingement CoracoAcromial Arch Acromial Morphology Pathomechanics - Cuff Type I Flat Type II Curved Type III Hooked Maladaptation and instability key factors Physical maladaptation of the shoulder Maladaptation = adaptation that cause more harm than help Exists in 60-86% of all tennis players In the dominant shoulder Increased external rotation Decreased internal rotation This maladaption Cause biomechanical changes that will result in injury in shoulder and elbow Biomechanics Mechanism Debated Tennis Greater Arc Over Which To Accelerate the Arm, Ball or Racquet More external rotation More Motion Enhanced Function Less Stability Two schools of thought causing further injury Instability based 2 0 Cuff problems Capsular tightness Internal Impingement 5

6 Instability and cuff pathomechanics Pathomechanics - Instability Anterior Translation With Late Cocking Anterior capsular laxity Labral injury Pathomechanics Cuff Loss of Internal Rotation Inflammation & Scarring Posterior Shoulder Capsule Maladaptation (increased with external rotation) Instability and labrum pathomechanics Ant-Sup Translation & Impingement Pathomechanics - Labrum Pathomechanics - Labrum Late Cocking Position Load Labral Rim Labral Tear Loss of labral function Further instability Further overload to rotator cuff 6

7 Pathomechanics - Instability Serratus Anterior Stabilizes Scapula Moves Scapula on Chest Wall Rotate Coraco- Acromial Arch Dynamic Stabilizers play some role Allows Stable Base for Shoulder Motion Impingement Instability Paradigm Pathomechanics Internal Impingement Internal Impingement What Is The Cause? What Is It? Pinching of Posterior Rotator Cuff Postero-Superior Glenoid Greater Tuberosity 1. Unknown 2. Occurs Normally 3. Pathologic Contact Overhead Athletes Tennis Volleyball Baseball 7

8 Etiology Rotational / Retroversion What is the cause of Internal Impingement? What is the cause of Internal Impingement? Etiology --Scapular Dyskinesis Loose Anterior Capsule Tight Posterior Capsule Courtesy of Marc Safran, Stanford University, USA Video Courtesy of W. Benjamin Kibler, MD What is the cause of Internal Impingement? Glenohumeral Internal Rotation Deficit (GIRD) Decreased Scapular Upward Rotation Increased Protraction GIRD Affects Scapular Position & Motion Management Tight Posterior Capsule Thomas, et al, CORR 2010 Management Tight Posterior Capsule Roll-Over Sleeper Stretch Door Way Stretch Management Tight Posterior Capsule Cross Body Stretch 8

9 Post Capsule Stretch Results Prospective Study of High Level Tennis and pitching over 2 years 2 Groups: Posterior Inferior Capsular Stretch + Control - No Stretch Results group 1 with stretching: Significant Increase IR & Total rotation 38% Decrease in Shoulder Problems Conclusion: Stretching Successful in Preventing Shoulder Problems Burkhart, Morgan, Kibler, Arthroscopy Apr;19(4): Post Capsule Stretch Surgery Results 124 Baseball Pitchers 2-7 yrs After SLAP Repair, Cuff Debridement, GIRD Reduction Results after 2 years All Resumed Pitching 90% Excellent, 10% Good Pre-op GIRD: 53 deg Post-op GIRD: 18 deg 1-7 yr Results Same Morgan, unpublished Management without surgery Partial Thickness Cuff Tear Non-Operative Management without surgery Management without surgery Loose Anterior Capsule Non-Operative Rehab Rehab Rehab Management without surgery Scapular Dyskinesis Scapular Stabilizers Scapula Stabilizers 9

10 Management without surgery Bracing Alignmed S3 Scapular Stabilization Proprioception Role for surgery?? Role for surgery?? Loose Anterior Capsule Role for surgery?? Results Capsular Plication Return to sport variable Open 68 92% Jobe 1995 & 1996 Risks Loss of Motion Loss of Velocity Loss of Career 60% RTS Same Level Take home message Strengthen Scapula Stabilizers Rotator Cuff Subscapularis Stretch Posterior Cuff Take home message When to scope the shoulder? Debridement SLAP Repair If GIRD >25 0 Posterior Capsulotomy 10

11 Let us put all this in perspective!! Be aware!! Global Warming is Real! Thanks for organising such an interesting course. Thanks for your attention!! To learn more and get a good update there are good news Invitation. As interested in tennis medicine you are all invited to participate in 1. Tennis Medicine Conference December 14-15, ATP Tournament Physicians conferense December16, 2013 At Hospital for Special Surgery in New York, USA Bonus: Excellent shopping times!!! Welcome. See you there!! Book the date!! 11