1/26/2017

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WHERE ARE WE?

East Amherst

East Aurora

Hamburg x2

West Seneca

Williamsville

Boulevard

“HEY, STEVE. MY SHOULDER HURTS. WHY?” • Rotator Cuff

• Frozen Shoulder

• Thoracic Outlet Syndrome

• Osteoarthritis

• Bursitis

• Tendinitis

• Impingement Syndrome

• Fibromyalgia

• Heart Attack

• Labral Tear

• Cervical Radiculopathy

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SHOULDER BASICS

• Scapulohumeral Rhythm • 2:1 Ratio for Motion • Upward Rotation • Protraction • Posterior Tilt

• 9:1 Ratio with altered position

• Pressure Through Range (90)

• Blood Flow • Zone of Hypovascularity = common site for

degeneration

Palmerud G, Forsman M, Sporrong H. Intramuscular pressure of

the infra- and supraspintus in relation to hand load and arm

position. Eur J Appl Physiol. 2000;83:223-230.

SUBACROMIAL SPACE

• Subacromial Space • 7-14mm • Static vs. Dynamic Narrowing

• Narrowing with Motion • Measure of muscle function • MRI studies reveal decreased

space during elevation with RC tendinopathy

PUBLIC ENEMY #1

• Thoracic Spine • 40 hours a week • 160 hours a month • 1920 hours a year

• What doesn’t this include? • Leisure Sitting • Meals • Driving

• Scapular Posterior Tilt

• Risk for Slouched Exercise

Kebaetse M, McClure E Pratt NE. Thoracic position effect on shoulder range of motion,

strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil 1999;80:945-50.

Gumina S, Di Giorgio G, Postacchini F. Subacromial Space in adult patients with thoracic

hyperkyphosis and in healthy volunteers. La Chirurgia degli Organi di Movimento. Feb

2008;91(2):93-96.

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SHOULDER PAIN IS OFTEN A DOWNSTREAM ISSUE

G G G

SHOULDER NECK / MID BACK

G G

PUBLIC ENEMY #2: SELECTIVE TIGHTNESS

• Pec Minor • Posterior Tilt

• Inferior Capsule • Limits downward movement

• Posterior Capsule • Excessive Superior-

Anaterior translation • Testing for Tightness

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PUBLIC ENEMY #3: WEAKNESS

• Scapular Stability • Dec. Serratus Anterior &

Lower Trap • Decreased force output,

latency, imbalance found in RC tendinopathy

• Rotator Cuff Strength • Fiber orientation • Counter Acts Deltoids

TAKE HOME MESSAGE

• A shoulder program is multifactorial

• A shoulder program needs to work the supporting cast

• Free Weights vs. Machines

• What’s right for me?

SOME EXERCISES TO CONSIDER

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SOME EXERCISES TO CONSIDER

Wall Push Up Table / Bench Push Up Push Up on Knees Standard Push Up

DO THIS, NOT THAT

Machines <

Free Weights <

Kettlebells

DO THIS, NOT THAT

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DO THIS, NOT THAT

DO THIS, NOT THAT

ONE MORE EXERCISE TO CONSIDER

Start on Knees Progress to Toes

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TO SUM IT UP….

Shoulder pain is not likely your shoulders fault…

1. STRONG FOCUS ON MOBILITY AT YOUR SPINE

2. THERE’S MORE RISK WITH OVERHEAD ACTIVITIES

3. WORK WITH FREE WEIGHTS AND CABLES, NOT MACHINES

THANK YOU!

THANK YOU!

Buffalo Rehab Group Physical Therapy, P.C.

Sidelying Upper Trunk Rotation

Lie on your R/L side as shown in left picture. Keep the top knee

TOUCHING THE TABLE as you rotate through your trunk.

Take deep breaths and rotate further as you exhale.

Repeat 10x

Repeat on other side

2012 Buffalo Rehab Group 2012 Buffalo Rehab Group

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Northtowns Orthopedics

Buffalo Rehab Group

1/25/17

Peter L. Gambacorta, DO

Northtowns Orthopedics

Medical Director, Department of Sports Medicine

Women and Children’s Hospital of Buffalo

Peter L. Gambacorta, DO

Northtowns Orthopedics

– Orthopedic Surgeon

– Fellowship Trained Sports Medicine Specialist

Arthroscopic Surgery

Minimally invasive surgery

Knee, Shoulder, Hip, Elbow, Ankle

Northtowns Orthopedics

Office Locations East Amherst

8750 Transit Road Suite 105 East

Amherst, New York 14051

Williamsville

36 North Union Road Williamsville, NY 14221

Holiday Valley

6133 U.S. Route 219 Suite 1001 Ellicottville, New York 14731

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After-Hours Orthopedic Service No appointment is necessary!

8750 Transit RoadSuite 105East Amherst, New York 14051

After-Hours Urgent Orthopedics Available:

Monday through Friday, 4 pm to 8 pm

Saturday, 12 pm to 4 pm

Sunday, 12 pm to 4 pm

Most major insurance carriers are accepted.

(716) 839-2230

Agenda

• Introduction

• Anatomy

• Shoulder

• Sports Injury

Prevention

Anatomy 101

• Bone-

– Skeleton

– Supports the body

– Protects organs

– Allows movement

– Stores minerals

– Makes blood cells

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Anatomy 101

• Muscle

– “Engine”

– Produce motion

– Provide

stabilization

– Generate heat

Anatomy 101

• Tendon

– Connects Muscle to Bone

• Ligament

– Connects Bone to Bone

Flexibility versus Laxity

• Flexibility

– Stretch of muscle and

tendon

• Laxity

– Looseness of

ligaments

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Agenda

• Introduction

• Anatomy

• Shoulder

• Sports Injury

Prevention

Shoulder Anatomy

Bones

Adult versus Pediatric Shoulder

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Shoudler Anatomy

• Cartilage

Shoulder Anatomy

Muscles

Shoulder Anatomy

Nerves and blood vessels

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Why Does My Shoulder Hurt?

• Tendonitis

• Impingement Syndrome

• Capsulitis

• Rotator Cuff Tears

• Labral Tears

• Arthritis

Tendonitis

• Inflammation of a tendon

– Rotator cuff muscles

– Biceps

• How does it happen

– Overuse

– Acute injury

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Tendonitis

• What does it feel like?

– Pain with activity

– Better with rest

– Rotator cuff pain

• Lateral arm

– Biceps pain

• Anterior arm

Tendonitis

• Treatment

– Rest

– NSAIDS

– Ice

– Physical Therapy

– Injections

Impingement syndrome

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Impingement Syndrome

Impingement syndrome

Impingement syndrome

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Impingement syndrome

• Do you have Impingement syndrome?

– Pain anterior and lateral arm

– Pain with over head and cross body motion

– Sometime clicking, grinding or catch

– Positional weakness

Impingement syndrome

• Treatment

– Rest

– NSAID’s

– Ice

– Physical Therapy

– Injections

– Surgery

Adhesive Capsulitis

• Frozen Shoulder syndrome

• Inflammation of the shoulder capsule

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Adhesive Capsulitis

Do I have a frozen shoulder?

– Women> Men

– Usually 40-60 years old

– Pain with motion

• You can move it and neither can I

– Associated with injury, thyroid, diabetes,

immobilization

Adhesive Capsulitis

• Three phases of disease

• Freezing – In the"freezing" stage, you slowly have more and more

pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

• Frozen – Painful symptoms may actually improve during this stage,

but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

• Thawing – Shoulder motion slowly improves during the "thawing"

stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Adhesive Capsulitis

• Treatment

• More than 90% of patients improve without

surgery

– NSAID’s

– Steroid injections

– Physical therapy

Patience is necessary

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Adhesive Capsulitis

• Surgery

– Manipulation

– Arthroscopic Lysis of Adhesions

Rotator Cuff Tears

• Rotator cuff

– Group of tendons (4) that form a cuff of

tendon around the Glenohumeral joint (Ball

and Socket)

• Supraspinatus

• Infraspinatus

• Subscapularis

• Teres minor

Rotator Cuff Tears

• Types of tears – Partial thickness

– Complete

• Causes – Acute Injury

• MVA, Fall, lifting something heavy with a jerking motion

– Degenerative • Repetition- exercise or work

• Blood supply lessens with age

• Bone spurs- impingement

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Rotator Cuff Tears

• Do I have a Rotator Cuff Tear?

– Age>40 years

– Repetitive lifting or exercise

– Acute fall or injury

– Pain at rest and at night

– Pain with lifting motions

– Weakness

– Cracking and popping noises

– Pain with activities of daily living

Rotator Cuff Tear

• Treatment – 50% of patients can improve pain and function

with conservative treatment

– Rest

– Activities

– NSAID’s

– Physical Therapy

– Injections

*Shoulder strength usually does not improve with non surgical treatment

Rotator Cuff Tear

• Surgical treatment

– Continued pain is the main indication for

surgery

– Your symptoms have lasted 6 to 12 months

– You have a large tear (more than 3 cm)

– You have significant weakness and loss of

function in your shoulder

– Your tear was caused by a recent, acute injury

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Arthritis

• Breakdown of articular cartilage in a joint

– Osteoarthritis

• “Wear and tear”

– Rheumatoid Arthritis

• Chronic disease attacking multiple joints in the body

• Synovium swelling

– Post traumatic arthritis

– Rotator cuff arthropathy

– Avascular necrosis

Arthritis

• Symptoms

– Pain

• With activity and gets

progressively worse

• Decreased motion

• Grinding, popping and clicking

• Night pain

Arthritis

Treatment:

• Rest or change in activities to avoid provoking pain.

• Physical therapy exercises

• Nonsteroidal anti-inflammatory medications (NSAIDs)

• Corticosteroid injections in the shoulder can dramatically reduce the inflammation and pain. However, the effect is often temporary.

• Moist heat

• Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain.

• If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate.

• Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain

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Arthritis

• Surgical Treatment

Shoulder Instability

• “Ball popped out of

socket”

• Dislocation or

Subluxation

• Anterior >>> Posterior

• Injury

– <40 y/o Labral injury

– >40 y/o Rotator cuff

injury

Labral Tear

• Glenoid labrum

– Cartilage ring in

shoulder

around Glenoid

(cup)

– Suction seal

– Stability

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Shoulder Dislocations

• Skeletally immature-

– 12-17 yrs old

– Labral tear (Bankart) less frequent

• Skeletally mature-

– Labral tear (Bankart) -97%

– Hill sachs -91%

Postachinni J shoulder Elbow Surg

2000 Taylor J sports Med 1997

Recurrence of Dislocation Rates

• Classic Literature – Marans 100% re-dislocation rate

• 21 patients, mean age 13

– Wagner 80% re-dislocation rate • 9 patients, mean age 13.5

• Current Literature – Deitch Redislocation rate

• 53% Open physis (age 13)

• 88% Closed physis

– Lampert Redislocation rate • < 14- 0

• > 14 – 69%

Marans 1992, Wagner 1983, Dietch 2003, Lampert 2003

Shoulder Dislocation Treatment

• Non Operative

– Immobilization • Sling ( Arm position)

• 1-6 weeks

– Physical therapy • Gradual strengthening

program

• Limited benefit with regards to future instability

– Brace • Decrease re-dislocation

rate – 37%

Buss AJSM 2004

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Shoulder Dislocation Treatment

• Operative Treatment

– Goal- minimize recurrent dislocations

– Open or arthroscopic suture fixation

• Labral repair and capsulorhaphy

– Excellent outcomes have been reported in skeletally mature and immature patients

Kraus Eur J Ped Surg 2010

Little League Shoulder

• Stress fracture of the

humerus growth

plate

Little League Shoulder

• Caused by the

repetitive stress

applied to the arm

growth plate during

a throwing

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Examination

• Proximal humerus tenderness

– Anterior and lateral

• Reproducible pain with resisted

throwing

• Diagnosis

– Radiograph- widening of proximal

humeral physis

Little League Shoulder

Treatment

• Rest

• No throwing until symptoms resolve completely

• Interval throwing program upon return – Physical Therapy

(Stretching and Strengthening)

• Strict pitch count

• Age appropriate pitches

Agenda

• Introduction

• Anatomy

• Shoulder

• Sports Injury

Prevention

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Injury Prevention

According to the CDC, more than half of all

sports injuries in children are preventable

Sports Trauma and Overuse

Prevention

STOP Sports Injuries

• Prevention starts with EDUCATION

• Information for: – Athletes

– Parents

– Coaches

– Healthcare providers

Sport specific injury prevention tips

www.stopsportsinjuries.org

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STOP Sports Injuries

• General Sports Injury Prevention Tips:

– Obtain a pre-season physical examination

– Encourage warm ups and cool downs

– Encourage proper strength training routines

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– Use and maintain proper equipment

– Encourage athletes to speak to a coach, trainer,

parent or physician when they are experiencing

PAIN

Thank You Northtowns Orthopedics

(716) 636-1470

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13 year old baseball

player presenting with

increasing arm pain

over the last month.

No acute injury. He

can no longer throw

without pain

Pediatric and Adolescent

Sports Medicine

Epidemic Problems

Youth Sports Statistics >30 -45 million children and

adolescents participate in youth sports in US

2 million high school students sustain injuries yearly

More than 3.5 million children ages 14 and under receive medical treatment for sports injuries each year

50%of youth sports injuries are preventable

By the age of 13, 70% of kids drop out of youth sports

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Why are Injuries on the Rise?

• Title IX - the federal civil rights law that prohibits sex discrimination in education.

• Enacted in 1972

1972 2012

Ratio of HS

participation

1 in 17 1 in 3

# High School

Athletes

300,000 3,000,000

# College

Athletes

25,000 180,000

Additional Changes since 1972

• 50% increase in 16-24 YO women enrolling in college (43 to 63%)

• 50% increase in % women

graduating from college (18 to 27%) • 80% increase in percentage

of doctoral degrees awarded to women (25 to 44%)

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Increased participation: Increased rates of injury

Why are Injuries on the Rise?

• Less free play

• More sports offered

• Single sport concentration

• All star, travel teams

• Year round participation

• Higher levels of competition

• Means to an end 0

2000000

4000000

6000000

8000000

1972 2006

80 % Increase!

Sports

Participation

“Child is not a

little adult.”

“Child athlete is

not a little adult

athlete.”

Understanding the Difference

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Historic Prospective

Kids do not experience

major sports related injuries

Kids will heal if you put

them in a cast or brace

Agenda

• Introduction

• Anatomy

• Shoulder

• Sports Injury Prevention

Unique Challenges

• Age Specific Injuries

– Growth plates

• Expectations

• Delayed treatment can

lead to other problems

• Surgical Techniques

– Limb length

– Angular deformity

– Growth arrest

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Pediatric Sports Medicine

Pediatric Orthopedics • Hip Dysplasia

• Perthes disease

• Scoliosis

• Spondylolysis

• Club foot

• Congenital deformities

• Cerebral palsy

• Spina bifida

• Hand anomalies

• Limb length deficiencies

• Fracture care

Adult Sports Medicine

• Ligament injuries (ACL,PCL,UCL)

• Articular cartilage injuries

• Tendon injuries

• Meniscus tear

• Dislocated shoulder

• Labral/ SLAP tear

• Rotator cuff tear

• Tennis elbow

• Hip labral tear

• Snapping hip syndrome

• Ankle sprains

• Fracture care

• Knee: • ACL, meniscus, OCD, chondral injuries, patellofemoral

dysplasia, tibial spine fractures, patella instability, growth deficiencies, fractures

• Shoulder: • Labral tears, multidirectional instability, SLAP tears,

impingement, little leaguer shoulder, rotator cuff tears

• Elbow: • Loose bodies, OCD, UCL injuries, olecranon

apophysitis, pediatric elbow fractures

• Hip: • Femoroacetabular Impingement, loose bodies, chondral

injuries, dysplasia, SCFE, apophysitis

• Wrist and Hand: • TFCC, fractures, tendon injuries, fractures

• Ankle and Foot: • OCD, instability, os trigonum, anterior/posterior

impingment, tarsal coalitions, fractures

• Spine • Back Pain, Spondylolysis, Scoliosis, muscular strains

• Medical Conditions • Concussion, Heart, Psych, Nutrition

Scope of Pediatric Sports Medicine