Sports Medicine



Sports Medicine


Bashir A. Zikria

Yalda Siddiqui



SHOULDER INSTABILITY


TUBS—Traumatic, Unidirectional instability with a Bankart lesion often requiring Surgery



  • Anterior instability



    • Patient age most important factor for recurrence


    • Trauma (contact sports)


    • Bankart lesion


    • Anterior inferior labral lesion


    • Inferior glenohumeral ligament (IGHL) main restraint to anterior in the abducted and external rotation (ER)


    • Neurologic examination



      • Axillary nerve <40 years of age


      • Suprascapular nerve


    • Range of motion (ROM)


    • Rotator cuff (RTC)—ability to lift arm



      • >40 years of age


      • 30% to 80% RTC injuries in patients aged >60 years


    • Specialized tests for anterior dislocation (Figure 6.1)



      • Apprehension


      • Relocation maneuver


    • Imaging



      • Radiographs—three views



        • Always need axillary


        • Westpoint view (anterior inferior glenoid)—similar to axillary but prone and beam directed 25° inferiorly and medial


      • Magnetic resonance imaging (MRI) with or without gadolinium (Figure 6.2)



        • 88% sensitivity and 100% specificity for diagnosing IGHL tears


        • Mandatory in chronic dislocations to rule out bony defects


      • Computed tomography (CT) to assess bone loss (Figure 6.3)






        Figure 6.1 Apprehension (A) and relocation (B) tests. From Dugas JR, Ryan MK. Shoulder instability and baseball players. In: Ahmad CS, Romeo AA, eds. Baseball Sports Medicine. Philadelphia, PA: Wolters Kluwer; 2019:197-212.







        Figure 6.2 Magnetic resonance imaging (MRI) scan showing both a Bankart lesion and a Hill-Sachs lesion.


    • Traumatic injuries (Figure 6.4)



      • Humeral avulsion of glenohumeral ligaments


      • Anterior labral periosteal sleeve avulsion



        • Medially displaced labroligamentous complex with absence of the labrum on the glenoid rim


      • Glenolabral articular disruption



        • Represents a partial tear of anterior inferior labrum with adjacent cartilage damage






          Figure 6.3 Bankart lesion bone loss seen on computed tomography (CT) scan. Arrow: Bony bankart and bone loss. From Greenspan A, Beltran J. Upper limb I: shoulder girdle. In: Orthopedic Imaging: A Practical Approach. 6th ed. Philadelphia, PA: Wolters Kluwer Health; 2015:107-163.







          Figure 6.4 Different lesions in anterior inferior shoulder instability. ALPSA, anterior labral periosteal sleeve avulsion; GLAD, glenolabral articular disruption; HAGL, humeral avulsion of glenohumeral ligament. From Lichtenberg S, Habermeyer P. Athroscopic repair of anterior instability. In: Craig EV, ed. Master Techniques in Orthopaedic Surgery: The Shoulder. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:67-88.


    • Associated injuries



      • Bone defects



        • Chronic dislocations


        • Most common cause of repair failure


        • If >25%, may need bone graft or Latarjet-type procedure


    • Nonoperative treatment



      • Closed reduction—first-time dislocation


      • Period of immobilization—Studies show use of small abduction pillow in neutral or ER decreases recurrence.


      • Supervised rehabilitation



        • Cuff strengthening


        • Scapular stabilizers


      • In-season dislocation



        • Consider bone loss after recurrent dislocations


        • May need CT at the end of season


    • Operative treatment



      • Repair labrum (Bankart lesion) and tension IGHL complex


      • Randomized studies show equivalent results when arthroscopy compared with open procedure.




        • Open—subscapularis tears


        • Arthroscopic—ROM might be slightly better (Figure 6.5).


      • Failure



        • Glenoid defects >25%


        • Engaging Hill-Sachs


    • Engaging Hill-Sachs lesion (>25%) with recurrent instability—remplissage (Figure 6.6)



      • Infraspinatus (IS) tendon sutured into the Hill-Sachs lesion


      • Arthroscopic


      • Slight loss of ER






        Figure 6.5 A, Bankart lesion off glenoid. B, Repaired lesion.







        Figure 6.6 Remplissage for Hill-Sachs lesion. From Boileau P, O’Shea K, Vargas P, et al. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012;94(7):618-626.


    • Chronic dislocations—Deficiency >25% of the glenoid joint surface treated with soft-tissue repair only is associated with high recurrence rates (Figure 6.7).



      • Latarjet (Figure 6.8)



        • Coracoid transfer—glenoid depth


        • Soft-tissue sling—conjoint tendon


        • Musculocutaneous nerve at risk


  • Posterior instability



    • Blocking in football—lineman


    • Flexion, adduction, and internal rotation (IR)


    • Posterior instability tests—key in examination



      • Load and shift


      • Jerk test (Figure 6.9)






        Figure 6.7 Anterior inferior bone loss on computed tomography (CT) (A) and magnetic resonance imaging (MRI) (B). If bone loss is greater than 25%, bony procedure must be undertaken before soft-tissue procedure. From Piasecki DP, Verma NN, Romeo AA, et al. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.







        Figure 6.8 Latarjet procedure. From Piasecki DP, Verma NN, Romeo AA, et al. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.



        • 90° of abduction and IR, axially loads the humerus in a proximal direction and horizontally across the body


        • Positive with “clunk”


      • Kim test (Figure 6.10)



        • 90° of abduction, axial loading force to arm






          Figure 6.9 Jerk test. 90° of abduction and IR, axial load the humerus in a proximal direction and horizontally across the body. From Palmer ML, Epler ME. Fundamentals of Musculoskeletal Assessment Techniques. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1998.







          Figure 6.9 (continued)


        • With arm elevated 45°, downward and backward force is applied to proximal arm.


        • Positive with pain


      • Positive jerk test combined with a positive Kim test—97% sensitivity for posterior instability


    • Primary stabilizers posteriorly



      • Superior glenohumeral ligament (SGHL)


      • Coracohumeral ligament


      • Posterior IGHL


    • Up to 50% misdiagnosed



      • Always need axillary view


      • Key phrases to know for testAny of the phrases or words should lead you to posterior instability.






        Figure 6.10 Kim test. With arm elevated 45°, downward and backward force is applied to proximal arm. From Leonard JP, Kuhn JE. Natural history of posterior shoulder instability. In: Dodson CC, Dines DM, Dines JS, et al, eds. Controversies in Shoulder Instability. Philadelphia, PA: Lippincott Williams & Williams; 2014:197-206.




        • Seizures


        • Electrical shock


        • Offensive lineman


        • Push-ups


    • Treatment



      • Always treat conservatively first.


      • Posterior Bankart lesion



        • Open or arthroscopic repair


        • Recurrence—most common complication


      • Open capsular plication


      • Chronic locked dislocation



        • <6 months—McLaughlin procedure



          • Subscapularis and lesser tuberosity transfer to reverse Hill-Sachs defect


          • Hill-Sachs >20% but <50%


        • >6 months



          • Hemiarthroplasty


          • Hill-Sachs defect >50%


AMBRI—Atraumatic, Multidirectional, Bilateral instability that Often Responds to Rehabilitation First; Inferior capsular Shift if Surgery Needed



  • Global laxity


  • Two classic lesions



    • Patulous inferior capsule


    • Functional deficiency of rotator interval


  • Presentation highly variable



    • Shoulder popping, weakness, and paresthesias


    • + Sulcus


    • RTC tendonitis or impingement <20


  • Treatment



    • Exhaustive conservative treatment (6 months)—closed chain physical therapy (PT)


    • Arthroscopic application or inferior capsular shift—positive drive-through sign


    • Rotator interval



      • Indicated in multidirectional instability


      • Closure of rotator interval decreases ER in shoulder adduction and posterior inferior translation


  • Complications of surgery for instability



    • Recurrence


    • Axillary nerve injury


    • Loss of motion


    • Late degenerative disease


    • Open procedures—Subscapularis repair may fail.


SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS AND INTERNAL IMPINGEMENT


SLAP Tears



  • Mechanism—traction or compression injury related to a fall on outstretched arm


  • Most common in throwing athletes—repetitive motion



    • Pitchers—GIRD >20°


  • Deep pain with catching or locking with overhead activities


  • Contracture of posterior IGHL



    • Shifts contact point posterior superior


    • Increase shear causes a SLAP tear







      Figure 6.11 Superior labrum anterior to posterior (SLAP) tear on magnetic resonance (MR) arthrography. From Snyder SJ, Karzel RP, Getelman MH, et al. Superior labrum (SLAP) injuries and repair. In: Shoulder Arthroscopy. 3rd ed. Philadelphia, PA: Wolters Kluwer Health; 2015:101-118.


  • Testing



    • Obrien test


    • Crank test


    • 85% of patients have a positive apprehension or relocation test.


  • MR arthrography—best imaging modality (Figure 6.11)


  • Biceps anchor—Most significant tears are posterior to 12 o’clock position.


  • Arthroscopy test—Evaluate the labrum and determine whether the labrum will “peel back.”



    • Abduction and ER


  • Nonoperative treatment—first line



    • RTC strengthening to stabilize shoulder


    • Scapula stabilizers—dyskinesia


    • GIRD—posterior capsular stretching


  • Surgical treatment



    • Incidental finding—no need to repair


    • Treatment based on classification (Figure 6.12)



      • Type I—labral fraying, anchor intact; debridement


      • Type II—detached biceps anchor; repair surgically (Figure 6.13)


      • Type III—bucket-handle, anchor intact; debridement


      • Type IV—bucket-handle into tendon; detached anchor



        • Less than one-third biceps anchor—incise fragment


        • More than one-third biceps anchor—tenotomy versus tenodesis


Internal Impingement



  • Internal versus external impingement



    • External impingement—With cuff fatigue/injury, the bursal cuff is impinged by the coracoacromial arch on abduction.


    • Internal impingement—Increased anterior capsular laxity allows increased ER, impinging the articular side of the cuff on the posterior glenoid.







      Figure 6.12 A, Type I superior labrum anterior to posterior (SLAP) lesions are characterized by a significant fraying or degeneration of the superior labrum. B, Type II SLAP lesions are characterized by detachment of the superior labrum and biceps tendon from the glenoid rim. C, Type III SLAP lesions are seen as a bucket-handle tearing of the superior labrum. The remaining labral tissue maintains the biceps as anchored to the glenoid rim. D, Type IV SLAP lesions consist of an extension of the bucket-handle labral tear into the substance of the biceps tendon. From Yamaguchi K, Keener J, Galatz LM. Disorders of the biceps tendon. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Management. Vol 1. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:217-260.







      Figure 6.13 Commonly used suture configurations for repair of type II superior labrum anterior to posterior (SLAP) tears. A, Single simple suture. B, Two suture anchors with one simple suture each located anterior and posterior to the biceps origin. C, Single suture anchor with a horizontal mattress suture through the biceps anchor. From Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17(10):627-637.


  • Mechanism (Figure 6.14)



    • Mechanical impingement of the articular side of the rotator on the posterior superior aspect of glenoid rim


    • “Pitcher reports the recent onset of decreased velocity and posterior shoulder pain.”


    • Late cocking/early acceleration phase of throwing






      Figure 6.14 Internal impingement: In the throwing motion, as the shoulder goes into external rotation and abduction, the posterior supraspinatus and anterior infraspinatus may experience impingement with the posterosuperior glenoid and labrum, leading to articular-sided tear. From Makhni EC, ElAttrache NS, Ahmad CS. Rotator cuff tears in baseball players. In: Ahmad CS, Romeo AA, eds. Baseball Sports Medicine. Philadelphia, PA: Wolters Kluwer; 2019:181-186.



  • Examination



    • GIRD—20°


    • Bennett lesion—mineralization of posterior inferior glenoid seen on CT or x-ray


    • Articular-sided RTC tear (Figure 6.15)


  • Treatment—most treated nonoperatively



    • Nonoperative



      • Posterior capsule stretching


      • RTC strengthening


      • Changing mechanics of throwing






        Figure 6.15 Magnetic resonance imaging (MRI) arthrogram (A) and arthroscopic view (B) showing partial articular-sided rotator cuff tear. Arrow: MRI-articular sided rotator cuff tear. From Makhni EC, ElAttrache NS, Ahmad CS. Rotator cuff tears in baseball players. In: Ahmad CS, Romeo AA, eds. Baseball Sports Medicine. Philadelphia: PA: Wolters Kluwer; 2019:181-186.



    • Surgical



      • Repair of SLAP lesion


      • Debridement of RTC


Scapulothoracic Dyskinesis



  • Snapping scapula with overhead activity


  • Causes



    • Bursitis


    • Elastofibroma


    • Osteochondroma


  • Diagnosis



    • Crepitus


    • Scapula stabilization relieves pain.


  • Treatment



    • Nonoperative—Nonsteroidal anti-inflammatory drugs (NSAIDs), scapular strengthening, and injection of corticosteroid with lidocaine can be diagnostic and therapeutic.


    • Surgical—bursectomy (open or arthroscopic) or resection of superomedial scapular border


LITTLE LEAGUER SHOULDER



  • Overuse of the throwing shoulder


  • Hypertrophic zone of the growth plate



    • Salter-Harris type I


    • Tension and shear on physis


  • Radiographs show widening proximal physis (Figure 6.16).






    Figure 6.16 Little Leaguer shoulder. Arrow: Proximal physis widening. From Rajiah P, Holden D, Schils J, Polster JM. Imaging of the sports injury: indications and findings. In: Miniaci A, ed. Disorders of the Shoulder: Diagnosis and Management: Sports Injuries. Vol 2. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:31-60.



  • Treatment—nonoperative



    • Rest and no throwing—3 months


    • Prevention


IMPINGEMENT AND RTC TEARS



  • Diagnosis



    • Patient age



      • Instability in young patients (<45 years)—impingement


      • Increasing age—RTC tear more likely



        • >60 years old—28%


        • >70 years old—65%


    • Shoulder pain with overhead activity that radiates to arm


    • Painful arc 60° to 140°


    • Night pain


    • Impingement test—lidocaine


    • Atrophy


    • Tests for weakness



      • Jobe sign (empty can; Figure 6.17)—supraspinatus (SS)


      • ER at side—IS


      • Hornblower—teres minor


      • IR—subscapularis



        • IR weakness, excessive ER


        • Lift-off, cheat, Napoleon test, bear-hug test


      • Acute versus chronic RTC tears


    • Acute



      • Often traumatic in younger patients


      • Immediate loss of function


      • Lack atrophy


      • Usually repair early for examination purposes


    • Chronic



      • Often atraumatic with insidious onset


      • Older, less active patients






        Figure 6.17 Jobe test. From Anderson MK, Parr GP. Injury assessment. In: Foundations of Athletic Training: Prevention, Assessment, and Management. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2013:102-150.



      • Muscle atrophy


      • Weakness, though some retain elevation strength


      • Generally begin with PT


  • Staging



    • Stage I—impingement


    • Edema, inflammation



      • Younger patients (<30 years)


      • Changes believed to be reversible


    • Stage II—partial RTC tear



      • Middle-aged patients (40s)


      • Incompletely reversible


    • Stage III—full-thickness RTC tear



      • Tendon tear


      • Older patients (50s)


      • Not reversible


  • Imaging



    • Radiography (Figure 6.18)



      • Humeral head elevation


      • Narrowing of subacromial space



        • <7 mm—consistent with RTC tear


        • <5 mm—massive RTC tear


    • MRI



      • Can assess presence of tear, partial versus full thickness, retraction, atrophy (Goutallier classification)






        Figure 6.18 Neutral anteroposterior radiograph of a shoulder with a chronic massive rotator cuff tear. Although there is reduction of the acromiohumeral space and the humeral head is elevated relative to the glenoid, there is no glenohumeral arthritis. From Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11(5):321-331.




        • Can determine status of RTC muscles and size of tear


        • Small—0 to 1 cm


        • Medium—1 to 3 cm


        • Large—3 to 5 cm


        • Massive—>5 cm (involves multiple tendons)


        • 100% sensitivity, 95% specificity for full-thickness RTC tears (Figure 6.19)


      • Coronal oblique—SS retraction and muscle quality


      • Sagittal oblique—AP extent of tear, muscle quality


      • Axial—biceps tendon, subscapularis, and IS tear


    • Ultrasonography



      • Increasingly used for diagnosis, assessment of postoperative healing and retearing






        Figure 6.19 A full-thickness rotator cuff tear. Coronal oblique (A) and sagittal (B) MRI for full thickness supraspinatus tear.



      • Some centers report high sensitivity and specificity.



        • No difference in detection or accuracy when compared with MRI


        • Highly operator dependent


        • Dynamic


  • Treatment



    • Nonoperative—chronic atraumatic tears



      • Rest, activity modification


      • NSAIDs and injections—Lidocaine with cortisone is diagnostic and therapeutic.



        • PT—strengthen RTC and periscapular muscles and deltoid


    • Surgical indications



      • Acute traumatic tears


      • Complete tears in patients aged <50 years within 6 weeks


      • Failure of conservative treatment after 4 to 6 months


      • Pain relief most predictable


    • Surgical techniques



      • Open, arthroscopic, mini-open


      • Anchors, transosseous tunnels



        • Gold standard—open transosseous repair


        • Arthroscopic at least equivalent to open in newer studies


        • Single-row anchors, double-row anchors—no significant difference in clinical outcomes


      • Advantages of arthroscopic versus open repair



        • No deltoid detachment


        • Intra-articular pathology


        • Less soft-tissue dissection


        • Less pain and blood loss


    • Partial tears—surgical indication



      • Failure of conservative management—PT



        • Articular-sided (Figure 6.20A)—more common; repair if >6 mm (50%)


        • Bursal-sided (Figure 6.20B)—less common; repair if >3 mm (25%)


    • Small and medium tears—surgery decreases pain and improves motion.


    • Large tears—high surgical failure rate owing to tissue quality






      Figure 6.20 Partial-thickness rotator cuff tears. A, Coronal fat saturated T2 (FST2) magnetic resonance (MR) image of a partial-thickness articular-sided rotator cuff tear in the supraspinatus tendon (arrow). B, Coronal FST2 MR image of a partial-thickness bursal-sided rotator cuff tear in the supraspinatus tendon (arrow). From Beltran LS. MRI of shoulder injuries. In: Chew FS, ed. Musckuloskeletal Imaging: The Essentials. Philadelphia, PA: Wolters Kluwer; 2019:107-133.



    • Massive tears



      • Conservative management—older patients



        • Normal motion, strength may be maintained if posterior RTC and subscapularis intact.


        • Preservation of force couples


        • These patients still have progressive migration of humeral head with arm elevation but are asymptomatic.


      • Arthroscopic debridement


      • Preserve coracoacromial (CA) ligament and arch


      • Tendon transfers—latissimus combined SS and IS


      • Hemiarthroplasty—able to raise arm


  • Outcomes



    • Good function/strength if tendon heals



      • Tendon does not heal until approximately 12 weeks.


      • Factors for healing—atrophy, retraction, patient age, tendon, quality, and smoking


      • Less favorable outcomes after RTC surgery related to:



        • Worker’s Compensation status


        • Tear size



          • Fatty degeneration of RTC musculature


        • Age at time of intervention


Subscapularis Tears



  • Fall after open shoulder surgery


  • Most commonly missed RTC


  • Examination



    • Increased ER with arm at side, positive lift-off (Figure 6.21) or positive belly-press sign


    • Axial MRI—medial subluxation of biceps (Figure 6.22)


    • Arthroscopy—SGHL comma






      Figure 6.21 Lift-off test. From Anderson MK. Shoulder conditions. In: Foundations of Athletic Training: Prevention, Assessment, and Management. 6th ed. Baltimore, MD: Wolters Kluwer; 2017:544-599.







      Figure 6.22 Axial gradient-echo image demonstrating an empty biceps groove (arrow) with medial dislocation of the biceps tendon (arrowhead). From Berquist TH, Peterson JJ. Shoulder and arm. In: Berquist TH, ed. MRI of the Musculoskeletal System. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:597-705.


  • Treatment

Dec 19, 2019 | Posted by in ORTHOPEDIC | Comments Off on Sports Medicine
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