Fig. 31.1
Articular partial tear
Fig. 31.2
Long head of the biceps (LHB) tenosynovitis and fraying associated to biceps Instability.
At the subacromial space, a careful but complete bursectomy should be performed and the suture marker identified. The quality of the tendon on the bursal side should be accessed, and indirect signs of impingement like fraying of the coracoacromial arch should be noted (Fig. 31.3). If the tear is 7 mm or less deep, debridement alone and subacromial decompression must be considered associated with stabilization of the LHB if necessary. If the tear is deeper than 7 mm, a repair using a suture anchor should be performed.
Fig. 31.3
Subacromial view
The surgeon must decide whether to do a trans-tendon repair or to remove the remaining tissue and treat the rupture as a complete tear. Some authors believe that the remaining cuff tissue in continuity is of poor quality, which increases the likelihood of postoperative pain and retear [18]. If completion of the rupture has been decided, configuration of the fixation, such as single-row, double-row, or transosseous equivalent, should be designed according to the extent of the tear, tissue quality, and elasticity.
Surgical approach results for partial-thickness supraspinatus tears have been extensively reported [18–21]. For instance, Park showed that surgical repair yields 93% of all patients with good or excellent results, and 95% demonstrated satisfactory outcome with regard to pain reduction and functional outcome.
Subscapularis tendon tears are less common than supraspinatus tears but more prone to cause significant disability, producing an unbalanced shoulder and originating an unstable LHB by lesion of the anterior pulley. Lesions may be classified according to Lafosse et al. [22], and the ruptured tendon should be repaired to the bone, using, for example, suture anchors. According to the same author, arthroscopic repair of subscapularis isolated tears can yield marked improvements in shoulder function and pain reduction.
31.3.1.2 Total Rotator Cuff Tears
Total rotator cuff tears in this young and sporty population must be surgically approached as soon as possible. Supraspinatus is more frequently involved. Arthroscopic treatment and repair using suture anchors is the “gold standard.” The use of single-row, double-row, or transosseous equivalent has been a matter of discussion. In order to decide the best type of tendon repair, the surgeon might have taken into consideration the young age and sport activity of this population, the type of tear, and the quality of the tendon.
31.3.1.3 Labral Tears
Four types of superior labrum anterior to posterior (SLAP) lesions were initially described according to Snyder et al. [23]. However in the last years, several classifications have reported an increasing number of different types of SLAP lesions. The clinical usefulness of these last is not well established [23, 58].
As said previously, undisplaced tears of all the glenoid quadrants may be dealt conservatively during the season, and if signs of instability subside, they can be surgically repaired at the end of the season.
Surgical repair is accomplished arthroscopically, and stabilization can be done repairing the labrum using suture anchors. However, some authors prefer to treat SLAP 2 lesions with a LHB tenodesis in order to obtain a better control of pain and functional impairment [24]. This method may also be applied to type 3 and 4 lesions that involve the LHB or turn this structure instable. Tenodesis should be performed with a strong primary stabilization method, and an interference screw is a good option for this high-demanding population [25].
31.3.2 Elbow
The elbow joint is a trochoginglymoid joint, between the humerus, radius, and ulna, with two degrees of freedom [26]. Stability is provided by a complex and interrelated structure of bony and ligamentous anatomy, and the restraints are often classified as either primary or secondary. The primary stabilizers are the anterior bundle of the medial collateral ligament (MCL), the ulno-humeral joint congruency, and the lateral collateral ligament (LCL) complex, and the secondary stabilizers are the anterior joint capsule, the forearm musculature, and radial head [27–29].
The LCL is a complex of ligaments, composed of four distinct structures: the annular ligament, radial collateral ligament (RCL), accessory lateral collateral ligament, and lateral ulnar collateral ligament (LUCL) [30]. The LUCL in particular has been credited with a great clinical significance as a constraint against posterolateral rotatory instability and its reconstruction after lesion is advised [31, 32].
The MCL has anterior, posterior, and transverse bundles [33, 34] where the former originating in the medial epicondyle and inserting into the medial aspect of the coronoid process is the primary restraint to valgus and internal rotation [35, 36].
The muscles around the elbow joint are dynamic constraints, which help to provide stability [29, 37, 38]. The wrist extensors originate from the lateral epicondyle of the humerus, whereas the flexors originate from the medial epicondyle.
31.3.2.1 Epicondylar Pain
Epicondylar pain is a frequent complaint that commonly is referred to as tennis elbow (in the lateral side) and golfer’s elbow (in the medial side). These entities are overuse injuries related to sport activities where repetitive movements and micro traumatisms of the wrist flexor and extensor tendons are thought to be the mechanism for injury. Moreover, repetitive movements with eccentric contraction (muscle-tendon unit lengthening while contracting) increase susceptibility to epicondylitis [39].
Despite the name suggesting inflammation as the origin of the pathology, the hallmark of this disease is microvascular damage, degenerative cellular processes, and disorganized healing, and so “tendinosis” is considered a more appropriate name for this clinical entity. Moreover, histologic examination of the extensor carpi radialis brevis (ECRB) in lateral epicondylitis has demonstrated chronic degeneration with few inflammatory cells, many immature fibroblasts, disorganized vascular elements, and disorganized collagen [40].
Overall, lateral epicondylitis is 7–10 times more common than medial epicondylitis [41].
Clinically, the elbow pain at the lateral or medial side that can radiate a few centimeters down the forearm according to the group of tendons affected is usually the presenting complaint. It has an insidious onset that is worsened with activity and relieved by rest. Patients may also feel weakness in the hand or difficulty carrying items.
Physical examination is important to confirm the diagnosis and exclude other differential diagnoses affecting the cervical spine, shoulder, elbow, and wrist. Tenderness in the lateral epicondyle and the origin of the wrist extensor muscles is suggestive of lateral epicondylitis and pain more distally located, approximately 5 cm from the lateral epicondyle is suggestive of a posterior interosseous nerve syndrome. Palpation of the medial aspect of the elbow aids diagnosing medial epicondylitis, an ulnar nerve entrapment, a MCL sprain, or a combination of the three entities. Palpation of the medial epicondyle and muscle bellies of the wrist flexor tendons elicits tenderness in a case of medial epicondylitis. In the wrist, pain with resisted wrist extension is suggestive of lateral epicondylitis and pain with resisted wrist flexion is suggestive of medial epicondylitis.
Epicondylitis is a clinical diagnosis, but imagiological examinations (e.g., X-ray, ultrasonography, or MRI) are used after a failure of conservative therapy to rule out other clinical entities [39]. Even though a radial nerve entrapment can be a dynamic situation, electromyography studies are used to help identifying this condition [42].
The treatment is summarized in the acronym PRICEMM (protection, rest, ice, compression, elevation, medication, modalities) [39]. Protection means that overuse activity that resulted in tendon injury should be avoided to stop the vicious cycle and to prevent further damage. Relative rest is important because some therapeutic exercise can help healing the damaged tendon. Ice massage can assist in pain control. A counterforce elbow strap for compression approximately 2 cm below the painful epicondyle can help offload the proximal tendon during wrist extension or flexion. The effectiveness in pain control can be evaluated during the clinical examination, asking the patient to perform the movements that elicit pain (e.g., wrist or finger extension) and feel if the manual compression by the examinator’s hand decreases the visual analog scale (VAS) for pain.
Medications are used only for pain control. Physical therapy modalities, such as electrical stimulation, phonophoresis, and iontophoresis, are effective in assisting on pain control but are unable to correct the underlying tendinosis. To accomplish this, stretching and strengthening exercises are performed on the flexor-pronator group or the extensor-supinator group according the affected tendons. Progression to eccentric exercises is the goal, because this is thought to reestablish normal tendon architecture [43].
A corticosteroid injection is frequently used and safe for trial in refractory cases of epicondylitis and can relieve pain of neurogenic origin [44]. However the natural course of the disease may be unaltered or potentially worsened by this intervention [39]. Moreover, in professional practitioners, its use must be communicated in advance for the Doping Control Commission to avoid legal problems for the athlete.
Autologous blood injections and platelet-rich plasma (PRP) injections have been used to treat epicondylitis, and the results are promising but inconsistent [45, 46]. The rationale for its use is the hypovascular and noninflammatory nature of epicondylitis. Both autologous blood injections and PRP injections are thought to use platelet-derived growth factors and angiogenic mediators to aid in the healing response by recruiting vascularity to the damage tissue [47].
Extracorporeal shock wave therapy (ECSWT) has been used in refractory cases, and the procedure uses acoustic waves to treat tendinosis. The mechanism of action is thought to be related to the activation of the inflammatory cycle, release of local growth factors, and the recruitment of appropriate stem cells to the affected area [48]. However a systematic review of ECSWT concluded that there was little to no benefit from this procedure in the treatment of lateral elbow pain [49].
When conservative treatment fails to improve the symptoms, then surgery is advised. Releases of the tendon origins by percutaneous, open, or arthroscopic means are proposed surgical options in recalcitrant cases. All methods have good results in pain relief, but if posterior interosseous nerve compression is associated, then the open approach offers the opportunity to associate the decompression of the nerve in the same procedure.
31.3.2.2 UCL Injury
Ulnar collateral ligament (UCL) injury may be acute or chronic, and the latter is associated with movements like throwing a ball with the hand, which is a typical action of GK when passing the ball to teammates. The classic presentation is medial elbow pain worsened during throwing maneuver, and physical exam can often diagnose this entity with the “milking” maneuver. To confirm the diagnosis, radiography, which may be normal initially, may demonstrate changes associated with chronic laxity and valgus extension overload. Medial joint opening >2 mm on valgus views is consistent with instability. MRI is the gold standard diagnosing UCL sprain or tearing with 100% sensitivity for complete tears of the anterior band of the UCL. However, MRI has a low sensitivity (14%) for partial-thickness tears, whereas magnetic ressonance imaging (MRA) has a sensitivity of 86% and specificity of 100% for partial tears [50].
Physical therapy, evaluation of throwing mechanics, and a hinged elbow brace are part of the conservative treatment. Persistent valgus instability after 6 months of nonsurgical management may indicate a need for surgical intervention with anterior bundle UCL reconstruction, often using palmaris longus autograft, to restore valgus stability [51]. In addition, UCL calcification or tears typically require surgical intervention, again via UCL reconstruction [52].
31.3.2.3 Osteochondritis Dissecans (OCD) of the Capitellum
Repetitive impact injuries to the elbow of GK caused by the ball hitting the fully extended distal part of a forearm have been well described [53, 54]. It is supposed that elbow valgus loading is the likely cause of such impact injuries to the elbow [55].
OCD of the capitellum is a flap of cartilage typically with a bone attached that is lifted off its underlying bony bed (Fig. 31.4) and can result also from that repetitive valgus force applied to the capitellum [56]. The valgus loads at the time of ball blockade during the ball hitting and mechanical mismatch between the central radial head and lateral capitellum could be considered as the reason for the disease. Although the OCD is primarily a disorder of adolescents, adults can also develop the problem, and incomplete cure of acute elbow injuries may result in OCD due to inadequate treatment [54].
