The overhead athlete
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This document discusses the throwing shoulder from an orthopaedic surgeon's perspective. It begins by outlining common overhead athlete pathologies like internal impingement and unstable painful shoulders. Internal impingement occurs when the rotator cuff impinges against the glenoid rim and can cause articular sided tears and labral lesions. Unstable painful shoulders present with pain but no instability symptoms. The document then reviews surgical decision making, the role of non-operative treatment and imaging, and finally presents a management algorithm focusing on internal impingement.
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The overhead athlete
- 1. The Throwing shoulder Puneet Monga Consultant Orthopaedic Shoulder Surgeon, Wrightington Upper Limb Unit
- 3. Scope of the talk •Understanding the overhead athlete’s shoulder •Pathologies •Surgeon’s perspective •Outcomes •Management Algorithm
- 4. Evolutionary function of the shoulder Shoulder is designed to place the hand in a three dimensional space with the elbow acting as a length adjusting Caliper
- 5. In an overhead athlete The power is gained from the Trunk and the upper thighs and the shoulder fine tunes and controls the motion
- 7. Common features • Power generation • Position of the shoulder • Force transmission
- 8. Kinetic chain Mc Mullen and Uhl 2000
- 9. Overhead athlete Who is an overhead athlete?
- 10. Pathologies seen
- 11. Lesions • Specific to the overhead athlete - Internal impingement - UPS (Unstable Painful Shoulder) • Not specific to the overhead athlete - SLAP tears - Anterior Instability - Sub-acromial impingement - Fractures/ dislocations
- 13. Pathology • Cardinal lesions • Articular sided rotator cuff tears • Postero-superior labral lesions • Landmark article: Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1992;1:238-245.
- 15. Symptoms • Overhead athletes: • Pain during maximal abduction/ external rotation • Posterior joint line / shoulder girdle pain • Progressive decrease in velocity. Loss of control / performance. • Symptoms of anterior instability (?)
- 16. Signs • Posterior glenohumeral joint-line tenderness • Loss of Internal Rotation • Excessive External rotation • Special tests - for SLAP, biceps, Cuff and instability
- 17. Specific test • Internal impingement test • Place arm in Abduction 90-110, Max ER, Ext 10-15. • Deep posterior shoulder pain • In non contact injuries; 95% sensitivity, 100% specificity Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop. 2004;33:412-415.
- 18. Specific test • Jobe’s Relocation test • Abduction and external rotation causes posterior joint line pain. • relieved by anterior pressure
- 19. UPS
- 20. UPS: Unstable Painful shoulder20 patients Overhead athletes Symptoms of pain No symptoms of instability. Imaging / Arthroscopy suggestive of instability Apprehension test caused pain Retrospective Mean 38 months FU • 95% satisfied 75% return to sports. The unstable painful shoulder (UPS) as a cause of pain from Unrecognized Anteroinferior instability in the young athlete. J Shoulder Elbow Surg. 2011 Jan;20(1):98-106. Boileau P, Zumstein M, Balg F, Penington S, Bicknell RT. Hôpital de L'Archet, Nice, France.
- 22. Decision making Sieve • Level of participation • Sport • Motivation • Season
- 24. Role of Investigations Early diagnosis paramount • Consider Early definitive investigations • MR arthrogram (vs MR vs CT arthrogram vs Ultrasound)
- 25. Beware! • Cuff tears in asymptomatic individuals ! • Labral tears in asymptomatic athletes ! • Pathologies which do not corelate with clinical picture ! • Low sensitivity of scans to pick PT cuff tears Avoid Excessive reliance on scans
- 26. Role of surgery • After exhausting rehab options. • “Trial of Therapy” vs “early surgery” = overuse vs acute trauma
- 27. Rehab • Core Strength • Scapular dyskinesia • Manage Internal rotation deficit • Restore RC force couple
- 28. Surgical input Precision strike and not carpet bombing!
- 30. Outcomes
- 31. Summary of Evidence Thermal Capsulorraphy Jansen et al, 2012 7 year follow up: significant deterioration 25% Capsular Plication Jones et al, 2012 Pts with cuff tear, unable to return to play 85% Capsular Plication in swimmers Montgomery et al, 2010 80% return to play, but at lower level 20% Pancapsular plication Ma et al, 2012 Improvement in symptoms in all 18% Review of SLAP 2 repairs Gorantla et al 2012 return to overhead sports challenging 22-64% Non op Mgx, SLAP 2 Edwards et al, 2010 Trail of non-op Mgx recommended 66% Biceps tenodesis for SLAP Boileau et al 2009 Higher return to play in tenodesis cohort 87% Tenodesis vs SLAP Ek et al2014 No difference 73%, 60% and many more ...............
- 32. Summary / Reflection • Predominantly SLAP lesion; 2/3 return to play • Associated large cuff tear / repair : Poor RTP (1/3) • Capsular shrinkage, plication: Poor RTP • SLAP repair if the tendon looks good, tenodese if looks diseased
- 34. Management Clinical suspicion of internal impingement MR Arthrogram including ABER views Other lesions FT Cuff tear Labral tear Subacromial impingement Features of Internal impingement PT Cuff tears Post-sup Labral changes
- 35. Internal Impingement Non operative Trial Rest, NSAIDS, Post Cap stretching, Scap Strengthening Failure of Non Operative Trial EUA & A’scopy 1+ Laxity: No Capsular plication 2+ Laxity: Consider Capsular plication 3+ Laxity: Capsular plication Cuff Tear <50%: debride Cuff Tear >50%: repair SLAP: debride / repair/ tenodese