Shoulder Pathology in the Overhead Athlete

10/8/2013

1

Shoulder Pathology in the

Overhead Athlete

Timothy S. Johnson, MD

Disclosures

Speakers bureau/paid

presentations for Arthrex

Relevant Disclosures

• Coagulation ???

• I like baseball

• I like shoulders

• I grew up in NY

• My childhood

insecurity

10/8/2013

2

My WBC 2013

“living like a kid again !”

International Baseball

10/8/2013

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The case

• Pre-Game Day 1

• SHOWTIME!: Venezuela vs Dominicana

• Team Venezuela

• The day after Hugo Chavez dies

• 23 yo male MLB pitcher @ WBC

• Shoulder pain x 5-6 days

Outline• Overhead Athlete

• Shoulder Anatomy

• Pathology of Throwing Athlete

– Musculoskeletal – “horses”

• Labrum

• Rotator Cuff

– NeurovascularVascular Problems – “zebras”

• Neurologic – 95%

• Venous – 4%

• Arterial – 1%

OVERHEAD

ATHLETES

– Throwers

– Tennis Players

– Volleyball players

– Team handball

– Water polo

– Javelin

– Badminton

– Boxing

– Weightlifting

– Mountain climbing

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Factor Contributing to Stability

• Static

– Osteology

– Capsule & Labrum

• Dymanic

– Rotator Cuff

– Periscapular Muscles

Static Restraints

• Articular Version

• Articular Conformity

• Glenoid Labrum

• Negative Intraarticular Pressure

• Capsuloligamentous Structures

Articular Version

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Osteology

• Glenohumeral Mismatch

Warner & Caborn , 1992

Labrum

• Increased surface area = Increased Stability

Warner & Caborn 1992

Negative Intraarticular Pressure

• Vaccuum effect

• Adhesion-cohesion

Cole & Katolik, 2002

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Capsuloligamentous Structures

Superior Glenohumeral Ligament

• Present in >90% of people

• Reinforces the rotator interval

• Limits inferior translation

• Limits ER– Adduction

• Limits posterior translation in– Flexion

– Adduction

– IR

Warner et al, 1992

Middle Glenohumeral Ligament

• Present in 60-80% of people

• Variable presentation

• Limits inferior translation– Adduction

– ER

• Limits ER– Adduction

• Limits AP translation in– Abducted (45º)

– ER

Warner et al, 1992

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Inferior Glenohumeral Ligament

Complex• Anterior Band

• Posterior Band

• Axillary Pouch

• Functions in Abduction >45º

– Anterior translation in ER

– Posterior translation in IR

Warner etal, 1992

AXILLARY POUCH

Warner et al, 1992

IGHL “Hammock”

• Reciprocal tightening

and loosening of the

IGHLC

Posterior Capsule

• Thinnest portion (< 1mm thick)

• Limits posterior translation in:

– Flexion

– Adduction

– IR

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Dynamic Restraints

•Concavity-Compression Effect

–Head centralization via cuff and biceps

•Rotator Cuff

•Periscapular Stabilizers

•Long Head of the Biceps

•Proprioception

Periscapular Muscles

Pectoralis

Minor

Pectoralis

Minor

Anatomy• Rotator cuff

– subscapularis

– supraspinatus

– infraspinatus

– teres minor

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Function of Rotator Cuff

• humeral head position control

• glenohumeral joint stability

Biomechanics

• Force couple

– maintain humeral head within glenoid

• compressive forces

– elevation and rotation

• Rotator Cuff Tear

– disruption of the force couple

– abnormal and unstable mechanical

• elevation with translation

Neuroanatomy

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Vascular Anatomy

Vascular Anatomy

Seroyer et al

SPORTS HEALTH

Vol. 1 no.2

Pathophysiology

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Overhead / Throwing Athlete

Population at Risk

• Overhead athletes

– Throwers

– Tennis Players

– Volleyball players

– Team handball

– Water polo

– Javelin

– Badminton

– Boxing

– Weightlifting

– Mountain climbing

Pathophysiology

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Pathophysiology

Seroyer et al

SPORTS HEALTH

Vol. 1 no.2

History

• What?

• When?

• How ?

• Where ?

• Why ?

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HPI

Seroyer et al

SPORTS HEALTH

Vol. 1 no.2

Musculoskeletal Injury

• Labrum

– Instability

– SLAP Tear• Rotator Cuff Disease

Labral Tear- Instability

Nevaiser, 1990

Warner etal, 1992

AXILLARY

POUCH

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Labral Tear - Instability

• Onset

– Acute

– Chronic exertional

• Symptoms:

– Subluxation/dislocatio

n

• Signs:

– apprehension

Instability Physical Exam

Ligamentous Laxity

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Ligamentous Laxity

Sulcus Sign

dimpling

External Rotation Apprehension Test

Tennent, 2003

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Jobe Relocation Test

Gaunche, 2003

Accuracy: Pain = 50% Apprehension = 80%Speer et al , 1994

Anterior Release

Test

Load & Shift TestSillman & Hawkins, 1993

Miller, 2002

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Load & Shift TestFaber, 1999

Miller et al, 2003

Load &

Shift

Test

Grading

Hawkins, 1990

Posterior Apprehension

Warner et al, 1992

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• Treatment

– Physical Therapy

– Surgery

• Repair


• Diagnostic Tests:

– X-Ray

– MRI

Imaging

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X-RAY

• Trauma views

– AP, Scapular-Y, Axillary

• Instability Series

– True AP, West Point Axillary, Stryker Notch

West Point Axillary View

Warner et al, 1992

West Point Axillary View

Warner et al,

1992

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Stryker Notch View

Hill Sachs

Lesion

Warner et al, 1992

Hill Sachs Lesions

MRI

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SLAP Tear

• Onset

– Acute

– Chronic exertional

• Symptoms:

– Joint Line Pain

• Signs:

– Adduction Compression

– Shear maneuver

Internal Impingement

• Posterosuperior Glenoid impingement

– Symptomatic contact between the deep surface of the

rotator cuff tendons and the posterosuperior glenoid

Pathophysiology

• Contact occurs during

the late cocking/early

acceleration phase of

throwing with the arm

abducted and

externally rotated

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Pathophysiology“Subtle” anterior translation allows

further rotation

(“hyperangulation”-Jobe) and

impingement

Possible sources

RC

weakness(Subscap)

IGHL failure(Bankart,

Capsular stretch)

SLAP lesions

Cuff and Labral Tears

Range of Motion

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Classic Clinical Presentation

• Loss of IR

• Loss of Cuff strength

• Atrophy

• Scapular dyskinesis

SICK Scapula

“Impingement Signs”

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Posterior Impingement Sign

• Late cocking position– 90-100 degrees of ABD

– 10-15 degrees of FF

– Maximal ER

• + when reproduces posterior pain

• 90% sensitive for tears of posterior labrum or partial thickness RC

• Meister K, AOSSM 1998.

SLAP Tear


– X-Ray

– MRI*

– Arthroscopy

MRI Findings

•Undersurface Partial Cuff Tear

•Labral Tear/ Detachment

•Cysts

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SLAP Tear

• Treatment

– Activity Modification

• volume

• technique


– Surgery

• Repair

Arthroscopic Pathology

• Contact (100%)

• Articular-sided partial thickness tears of the supraspinatus and sometimes infraspinatus tendons (76-93%)

• Posterosuperior labral tears (71-88%)– Jobe, Arthroscopy 1995;11:530-536.

– Walsh G, JSES 1992;1:238-245.

– Paley J (Jobe), Arthroscopy 2000;16:35-40.

Associated Pathology

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Repair Unstable SLAPs

SLAP Tear

3 - Anchor Repair

Before After

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SLAP Repair

glenoid humerus

biceps

Partial Tears

• Controversial-

debridement vs

repair

Intra-articular View from

Posterior Portal - right shoulder

normal

abnormal

PASTA REPAIR

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Full Thickness Cuff tear

* Left Shoulder * –View from lateral portal

NeuroVascular Injury

Neurologic Injury

• Cervical

– HNP

– Cervical Spondylosis

– Burner/Stinger

• Peripheral

– Ulnar neuritis

– Thoracic Outlet

Syndrome*

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Cervical Radiculopathy• Onset

– Exertional

– Post exertional

• Symptoms:

– dermatomal

• Signs:

– Radicular

Cervical Radiculopathy


– X-Ray

– MRI

Cervical Radiculopathy

• Treatment

– NSAIDs


– Corticosteroid injection

– Surgical

decompression/fusion

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Ulnar Neuritis

• Onset

– Exertional

– Post exertional

• Symptoms:

– Ulnar nerve

distribution

• Signs:

– Tinel’s

Ulnar Neuritis


– EMG/NCS

Ulnar Neuritis

• Treatment

– NSAIDs


– Surgical

decompression/transpo

sition

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Vascular Injury

• Arterial

– Arterial Thoracic

Outlet Syndrome

– Quadrilateral Space

Syndrome (PCHA

entrapment)

• Venous

– Effort Thrombosis:

Venous Thoracic

Outlet (Paget

Schroetter syndrome)

Arterial TOS• Onset

– Overuse related

– Position dependent

• Symptoms:

– Vague pain

– Claudication

– paresthesias

• Signs:

– Diminished radial pulse

– BP and/or delayed capillary

refill

Duwayri et al

JOURNAL OF VASCULAR SURGERY

Volume 53, Number 5

Arterial Anatomy

• Sites of Compression

– A: interscalene traingle

– B: costoclavicular space

– C: infrapectoral region

– D: humeral head

– E: quadrilateral space

Diagnosis and Management of Vascular Injuries Reeser, 2007

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Arterial Anatomy

• Sites of Compression

– A: interscalene traingle

– B: costoclavicular space

– C: infrapectoral region

– D: humeral head

– E: quadrilateral space

Duwayri et al


Volume 53, Number 5

Adson Maneuver

Snead et al

JOURNAL OF ATHLETIC TRAINING

Volume 44, Number 1

Wright Maneuver

Snead et al

JOURNAL OF ATHLETIC TRAINING

Volume 44, Number 1

10/8/2013

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Arterial TOS• Diagnostic Tests:

– Positional Contrast Angiography

– Positional MRA

Duwayri et al


Volume 53, Number 5

Arterial TOS

• Treatment

– Thrombectomy & surgical reapir

– Surgical decompression (cervical ribs common)

Duwayri et al


Volume 53, Number 5

Duwayri et al


Volume 53, Number 5

10/8/2013

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Quadrilateral Space Syndrome• Onset

– Due to repetetive abduction &

external rotation

• Symptoms:

– Position dependent shoulder pain

– Paraesthesias that may refer

distally

• Signs:

– Axillar neuropraxia

– Inoterance to sustained ABER

Quadrilateral Space Syndrome• Diagnostic Tests:

– Positional arteriography

– EMG/NCS

Duwayri et al


Volume 53, Number 5

Quadrilateral Space Syndrome• Treatment

– Biomechanical

modification of

overhead skills

– Surgical

decompression of

quadrilateral space

Duwayri et al


Volume 53, Number 5

McAdams and Dillingham

The American Journal of Sports Medicine

Volume 36, Number 3

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Venous TOS

(Paget Schroetter syndrome)

• Onset

– Post exertional

• Symptoms:

– Diffuse, poorly

localized

– Arm heaviness

• Signs:

– Swelling

– venous distention

Virchow’s Triad• Stasis

• Endothelial Injury

• Hypercoagulability

Seroyer et al

SPORTS HEALTH

Vol. 1 no.2

Venous TOS


– Doppler ultrasound

– Contrast venograpy

Valentine


Volume 47, Number 4

10/8/2013

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Venous TOS

• Treatment

– Anticoagulation

– Surgical

decompression

– First rib resection

Valentine


Volume 47, Number 4

t=0

t= p ballon angioplasty

t=2 mo

T= p patch graft/rib resection

Venous TOS

• Treatment

– Anticoagulation

– Surgical

decompression


Valentine


Volume 47, Number 4

10/8/2013

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Case Outcome

• Treatment

– Air Transport to FL

– Anticoagulation

– Surgical thrombectomy

– Subclavian vein

reconstruction


– RTP in 2013

Summary• Pathology of Throwing Athlete

– Musculoskeletal – “horses”

• Labrum

• Rotator Cuff

– NeurovascularVascular Problems – “zebras”

• Neurologic – 95%

• Venous – 4%

• Arterial – 1%

My WBC 2013

“living like a kid again !”

• Coagulation ?

• I like baseball

• I like shoulders a lot

• I “spend to much

time in the US and

need to come home

and learn to speak

Spanish !!! ”

10/8/2013

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Questions?

19455 Deerfield Ave

Suite 312

Lansdowne, VA 20176

Tel: 703 729-5010

[email protected]

http://www.nationalsportsmed.com/

Shoulder Pathology in the Overhead Athlete

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