1 / 49

Injuries in the Throwing Shoulder

Injuries in the Throwing Shoulder. David Conner MD OrthoNortheast 4/25/15. Patient Population. Throwers Volleyball Swimmers Tennis Player. The Thrower. Concept of kinetic chain Legs and trunk-> generate power Shoulder->funnel and force regulator Arm-> force delivery system.

nadeauj
Download Presentation

Injuries in the Throwing Shoulder

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Injuries in the Throwing Shoulder David Conner MD OrthoNortheast 4/25/15

  2. Patient Population • Throwers • Volleyball • Swimmers • Tennis Player

  3. The Thrower • Concept of kinetic chain • Legs and trunk-> generate power • Shoulder->funnel and force regulator • Arm-> force delivery system

  4. The Throwing Shoulder • Perfect balance of mobility & stability • “Thrower’s Paradox” • Lax enough to allow excessive external rotation, but stable enough to prevent recurrent subluxation

  5. The Set Point or Slot • Excessive ER generates the velocity • Throwers know ER “set point” to throw hard---known as “The Slot”

  6. Phases of Throwing • Late cocking- 165 degrees ER, 300 N anterior shear force • Acceleration phase- 7,300 degrees/sec angular velocity • Deceleration- 1000 N distraction force

  7. Potential for Disaster • Significant motion • Significant forces

  8. Problem of the Throwing Shoulder • “Dead Arm Syndrome” • Any pathologic shoulder condition where the thrower is unable to throw with preinjury velocity and control because of combination of pain and subjective unease • SLAP lesion • Internal Impingement • Cuff tear

  9. SLAP Lesions ( Superior Labrum Anterior to Posterior) • Snyder Classification

  10. Internal Impingement • Contact of Supraspinatus/infraspinatus & posterior- superior labrum in ABER (abduction/ external rotation) • ? Physiologic or pathologic Humeral RetroversionCrockett et al, AJSM, 2002 • CT Scans bilateral shoulders • Humeral retroversion • Dom = 40 deg • Non dom = 23 deg. • Mean Diff between ER & IR Dom and Non dom, 7 & 9 deg

  11. Dead Arm Syndrome: Theories • Frank Jobe • Excessive ER causes micro stretch of anterior capsule • Anterior instability causes internal/external impingement • Internal Impingement causes SLAP lesion • Burkhart & Morgan • Posterior capsule problem • SLAP lesion cause dead arm • No anterior instability present

  12. Dead Arm Syndrome: Jobe Model • Hyperangulation in ABER-Humerus left behind scapula • Tensile overload of anterior capsule-subluxation

  13. Dead Arm Syndrome: Jobe Model • Muscles fatigue leading to pathologic internal impingement and subacromial impingement • Secondary labral or cuff tears

  14. Jobe Model • Treatment-Eliminate anterior laxity • Surgical results • Open capsular shift-> 50% return to play • Halbrecht • Anterior instability DECREASES internal impingement

  15. Burkhart-Morgan Model • Posterior capsular tightness • Posterior-superior instability • “Peel-back” mechanism-SLAP • Anterior pseudoinstability • Internal impingement • Result: SLAP & cuff pathology

  16. Throwers Develop Increased ER in Abduction • Humeral retroversion • Soft tissue adaptation • Gain in ER should equal loss of IR • Need 180 degree total arc

  17. G.I.R.D • Glenohumeral Internal Rotation Deficit • Loss of ER compared to nonthrowing side • Posteroinferior capsular contracture • THE ESSENTIAL LESION

  18. GIRD • Posteroinferior capsular tightness • Posterior band of inferoglenohumerallig. • Traction phenomenon

  19. GIRD-Tethered shoulder • Ant IGHL & Post IGHL act as sling

  20. GIRD-Tethered Shoulder • Tight post IGHL tethers contact point • Moves pivot posterosuperiorly • Allows GT to clear glenoid-> increases ER

  21. Tight posteroinferior capsule • Hyper ER • Hyper horizontal ABD • Drop elbow • Premature trunk rotation

  22. GIRD & Anterior Pseudolaxity • Result: Able to increase ER by clearing GT and effective laxity of anterior capsule Get to “The Slot”

  23. GIRD & The Slot • With GIRD, increase in ER puts major stress on structures • Biceps anchor • Labrum • Cuff

  24. “Peel-Back” Mechanism • ABER-> biceps vector moves vertical and posterior • Torsion to posterior superior labrum • Posterior Type II SLAP

  25. Peel-Back

  26. SLAP Repair • Simple suture at root better than tacks • Repair SLAP, eliminates anterior pseudo laxity DO NOT NEED ANTERIOR STABILIZATION

  27. SLAP Lesions • Surgical debridement • Cordasco 1993 • 27 pts • 2 yr 63% G/E • 45% return to sport • Altcheck 1992 • 70% moderate pain @ 2 years

  28. SLAP Lesion • Repair with Suture Anchor • Burkhart 2000 • 124 pts • 2 yr • 90% excellent 10% good • 100% pitching @ 2 yrs

  29. Dead Arm & the Rotator Cuff • Tension • Compression—Internal Impingement • Result: Partial Thickness Articular Sided RTC Tear

  30. Dead Arm and RTC • 31% of throwers with SLAP have RTC tear • 38% were complete RTC • 62% were PTRTC

  31. The Problem • Tight posterior capsule->posterosuperior shift-> Increased ER->Peel-back->Internal impingement/traction-> Cuff tear=Dead Arm • Answer: Prevent Posterior capsular tightness

  32. GIRD - Treatment • Non-op

  33. GIRD Non operative Treatment • 90% throwers with symptomatic GIRD > 25 degrees respond to stretching in 2 weeks • Best responders—young patients

  34. GIRD - Treatment • Operative Glenoid Capsule

  35. Conclusion • Dead arm- difficult clinical & radiographic diagnosis. Confirmed at arthroscopy • Culprit- GIRD • Best treatment- Prevention • If symptomatic, SLAP usually present • Look for cuff pathology • Anterior laxity may exist, but don’t treat as initial problem

  36. Young Throwing Shoulder Pain – not normal

  37. Common Problems Little League shoulder Mild instability Rotator cuff tendonitis

  38. Little League Shoulder • Adams, Calif Med 1966 • “osteochondrosis of proximal humeral physis” • Ages 11-14 • Time of maximal prox humeral growth • Rotational forces disrupt hypertrophic zone of physis • external rotation torque is estimated to be approximately 18 Nm • 400% that physeal cartilage can take • distraction force estimated to be approximately 214.7 Nm • 5% of what physis can tolerate • bone is much stronger in tension than with rotational stresses

  39. X-rays Widening of physis, metaphyseal demineralization and fragmentation, and periosteal reaction

  40. Little League Shoulder Physeal widening can persist after symptoms resolve

  41. MRI widening High intensity signal change adjacent to physis

  42. Treatment Relative rest (sling?) No throwing 2-3 mos Anti-inflammatory meds Controlled return once asymptomatic Pitch Count Rehab -Strengthen Trunk

  43. League Age 17-18 105 pitches per day 13-16 95 pitches per day 11-12 85 pitches per day 9-10 75 pitches per day 7-8 50 pitches per day Pitch Count Guidelines • Rest requirements • >61 pitches 3 days • 41-60 2 days • 21-40 1 day • 0-20  0 days rest

  44. Carson & Gasser. Little leaguer’s shoulder. A report of 23 cases. Am J Sports Med 1998; 26:575–580. • Excellent results protocol for return to play mentioned previous slide • 21 of 23 patients (91%) were able to return to baseball at an average of 3 months (range: 1 month to 1 year) with asymptomatic shoulders • Largest series to date

  45. Prevention Information / education Fitness exercises = general basis for all sports participation Avoid specialization Begin training early (before season) No more than 10% increase each week

More Related