state of the art (standard of care?) for sports shoulder

State of the Art (standard of care?)

for Sports Shoulder Surgery

Slocum Sports Med Conference 2019

Lucas Korcek, MD

Disclosures

• I have nothing to disclose

Overview

• Anatomy

• Impingement and Rotator Cuff

• AC separation

• Instability

• Injury in throwing athlete

MSK Shoulder Anatomy

Bony:

- Clavicle

- Scapula

- Humerus

Supporting ligaments:

- Stabilize the AC joint

- Stabilize the GH joint

Muscle/Tendon:

- Rotator cuff

4 scapular based muscles that attach around the humeral head

Optimally positions the humeral head for shoulder motion powered by larger muscles (pec major, latisimus, deltoid, etc).


Neurologic:

Brachial plexus


Vascular:

Brachial artery and its branches

- Circumflex humeral vessels


Overview

• Anatomy


• AC separation

• Instability


Impingement and Rotator Cuff

Disease Continuum

Impingement and bursitis


Disease Continuum


Partial to full-thickness RC tear


Disease Continuum



Massive RC tear


Disease Continuum



Massive RC tear

RC tear arthropathy

Subacromial Impingment

Treatment

Relieve impingement of the rotator cuff tendon under the acromion

Surgery: create more space by resecting bone from the undersurface of acromion

- rarely indicated


Treatment


Cortisone or LP-PRP injection: Decrease inflammation of the subacromial bursa

* Evolving understanding of steroid effect on RC tendon


Treatment


PT for Scapular stabilization: Muscle balance/strengthening to change the position of the acromion over the RC at rest and with movement

First line treatment and often definitive

RC tearPrognosis

• 50% of asymptomatic tears become symptomatic within 2-3 years

• 50% of symptomatic tears progress within 2 years

- bigger tears progress faster

RC tear

Should we aggressively repair partial or small RC tears?

RC tear

What is the single biggest consideration for treatment?

a. Smokingb. Medical comorbiditiesc. Aged. Functional statuse. Sex

RC tearRC tear prevalence by age:• 60-70 years: 28%• >70 years: 65%

RC tear type by age:Traumatic tendon avulsion

Vs

Degenerative tissue breakdown and muscular atrophy

RC tearRisk of re-tear after repair associated with:

Smoking Diabetes Muscular atrophy Large tear size Rehab non-compliance Age > 65

RC tear

Should we aggressively repair partial or small RC tears?

Yes, in young active patients

Cautiously in other populations

Overview

• Anatomy


• AC separation

• Instability


AC Separation – injury to AC and CC ligaments

AC Separation

• Type 1-2 (sprain) Conservative management

• Type 4-6 (major displacement) Always operate

• Type 3 (moderate displacement) Controversial

AC Separation

Type 3 (moderate displacement)

Conservative management• Permanent bump• Sometimes residual AC instability, pain,

weakness

AC Separation


Classic surgical treatment• Staged surgery with hook

plate/plate removal

• High incidence of complication (fracture)

AC Separation


State of the art = repair or reconstruct arthroscopically

Single procedure Minimally invasive Rapid return to work/sport compared

with non-operative treatment

Overview

• Anatomy


• AC separation

• Instability


Instability

Instability

Traumatic anterior shoulder dislocation:

One of the most common shoulder injuries

Annual incidence = 1.7% in general population

High recurrence rate which correlates with age at dislocation

• 90% chance for recurrence if age <20

Instability

Traumatic anterior shoulder dislocation

Associated injuries• Bankart (anterior labrum/capsule injury)• Rotator cuff tear in older populations• Fracture• Hill-Sachs (dent in humeral head)• Bone erosion of anterior glenoid• Axillary nerve injury

Instability


Treatment: Management of first-time dislocators is controversial

Traditional treatment of reduction, rest, and rehab may not be best practice, especially in young patients

Instability


The humeral head sitting on glenoid is analogous to a golf ball on a tee

Instability


Each dislocation event will cause some erosion of the anterior-inferior glenoid bone

Instability


- Once bone loss has reached a “critical amount” simple arthroscopic soft-tissue repair (Bankart surgery) is unlikely to be successful

InstabilityTraumatic anterior shoulder dislocation

- Once bone loss has reached a “critical amount” simple arthroscopic soft-tissue repair (Bankart surgery) is unlikely to be successful

- Open surgery to rebuild the bone loss is done (Latarjet surgery)

Instability

Posterior shoulder dislocation

- Much less common than anterior (2% of dislocations)

- 50% of traumatic posterior dislocations seen in ED are undiagnosed

InstabilityPosterior shoulder dislocation

Sometimes benign-appearing AP-view x-ray

- Look for “light bulb sign”

- Get lateral x-ray view

Normal x-ray

Posterior dislocation

InstabilityPosterior shoulder micro-instability

• “Deep ache” within the shoulder that is often difficult to define on physical exam.

• Exact injury event sometimes unknown.

• Often able to participate in sport but with pain/deficit

Instability

Luxatio Erecta (Inferior glenohumeral dislocation)

• Very rare

• High risk of NV injury• brachial plexopathy• axillary artery injury

InstabilityMDI: Multidirectional shoulder instability

Remember “AMBRI”

AtraumaticMultidirectionalBilateral (frequently)Rehabilitation (main treatment)Inferior capsular shift (best alternative to non-op)

Overview

• Anatomy


• AC separation

• Instability


Throwing Athlete Injuries

• Posterior Labral tear• Glenohumeral Internal Rotation Deficit (GIRD)• SLAP tear• Internal Impingement• Little Leaguer’s Shoulder

Throwing Athlete InjuriesGlenohumeral Internal Rotation Deficit (GIRD)

• A condition resulting in the loss of internal rotation

• Occurs primarily in overhead athlete (especially pitchers)

• Constant throwing leads to posterior-inferior capsular tightness

• Humeral head is translated in opposite directions• Can lead to internal impingement, SLAP

Throwing Athlete InjuriesSLAP = Superior Labrum Anterior to Posterior Injury


Pathophysiology:• Posterior-inferior capsular tightness common in

throwers (GIRD)

• Shifts glenohumeral contact and causes shear force across superior labrum

• SLAP lesion occurs which further increase inferior capsular strain and compromises shoulder stability


Presentation:

• Deep ache often difficult to define on exam or link to specific injury event

• Diminished athletic performance


Treatment:

• PT/training to address GIRD and any scapular dyskinesia

• Surgery in refractory cases• SLAP repair vs biceps tenodesis• Age >36 favors tenodesis

Throwing Athlete InjuriesInternal Impingement

• Shoulder pain in overhead athlete caused by repetitive impingement on the undersurface of the rotator cuff

• Occurs during late cocking – early acceleration phase of throwing

• Associated with GIRD, scapula dyskenesia

Throwing Athlete InjuriesInternal Impingement

Treatment:

• PT and posterior capsular stretching is most effective treatment

• RC repair/debridement in recalcitrant cases

Throwing Athlete InjuriesLittle Leaguer’s Shoulder

• Overuse injury to the proximal humerus physis(Salter Harris type 1 injury)

• Usually male adolescent pitcher/tennis player

History:• Decrease pitch velocity, pain with late cocking and/or deceleration

• Number of pitches thrown is most important factor

• Treatment: 3 months no throwing, PT, then progressive throwing program

You made it!

• Shoulder Anatomy


• AC separation

• Instability


• Later: shoulder exam and interesting cases

state of the art (standard of care?) for sports shoulder

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