Shoulder Injuries in Throwing Athletes | Peter Millett MD - Shoulder Surgeon Colorado
LESS COMMON THROWING INJURIES · 2018-04-01 · LESS COMMON THROWING INJURIES...
Transcript of LESS COMMON THROWING INJURIES · 2018-04-01 · LESS COMMON THROWING INJURIES...
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LESS COMMON THROWING INJURIES
Mitchel Storey, DO Team Physician-‐ Seattle Mariner’s The Sports Medicine Clinic (206-‐368-‐6100)
• Adolescent injuries • Throwing Injuries in Adults • Common causes • Other Injuries
SUBJECTS
• Little league shoulder • Little league elbow • Ligament injury of the elbow • SICK scapula
ADOLESCENT INJURIES
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• Main cause is overuse • Muscle imbalance • Poor preparation • Playing on more than one team
• Playing all year • Pitcher and catcher • Throwing the wrong pitches
CAUSES
Age 2006 USA Baseball Guidelines 2010 Little League Baseball Regulations
Daily Limits
17-‐18 N/A 105/day
15-‐16 N/A 95/day
13-‐14 75/game 95/day
11-‐12 75/game 85/day
9-‐10 50/game 75/day
7-‐8 N/A 50/day
Weekly Limits
15-‐18 N/A
31-‐45 pitches = 1 day rest 46-‐60 pitches = 2 days rest 61-‐75 pitches = 3 days rest 76+ pitches = 4 days rest
13-‐14 125/week; 1000/season; 3000/year
21-‐35 pitches = 1 day rest 36-‐50 pitches = 2 days rest 51-‐65 pitches = 3 days rest 66+ pitches = 4 days rest
11-‐12 100/week; 1000/season; 3000/year
9-‐10 75/week; 1000/season; 2000/year
7-‐8
ASMI Position Statement for Youth Pitchers Example limits for number of pitches thrown in games 4/13
• Poor lower extremity and core strength • Poor scapular strength • GIRD • Poor mechanics and technique
EVALUATION
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SICK SCAPULA
• Ages 10 to 14 common • Generalized shoulder pain • Nonspecific RC findings • Reproduced by crank testing • Tenderness of humeral region • Usually gradual
LITTLE LEAGUE SHOULDER
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• Valgus extension overload • Usually medial pain at epicondyle, not sublime tubercle
• Not easily reproduced by milking • Tenderness all around medial epicondyle • Sometimes history of pop or sudden onset but usually gradual onset
• Lateral pain less common • Loss of motion and effusion common
LITTLE LEAGUE ELBOW
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• Always consider the neck for shoulder pain • Suprascapular nerve entrapment • Thoracic outlet syndrome
NERVE PROBLEMS
• Sphinoglenoid notch • Aching and dead arm • Sometimes acute scapular pain • Progressive weakness of the cuff • Gradual atrophy of the scapular fossa • Often permanent • Does not seem to affect long term
SUPRASCAPULAR NERVE
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• Unexplained shoulder or arm pain • Neuralgia’s usually ulnar distribution • May have tinel’s at cubital tunnel • EMG generally not positive • Doppler of thoracic outlet may help • Venous and arterial issues rare • Surgery generally not needed
THORACIC OUTLET
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LATISSIMUS INJURY Rare-‐ few reported cases in the literature Generally conservative care with good results Surgery results still an unknown due to small sample Generally at the MT junction C/O axillary discomfort
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• Internal rotation of the humerus • Adduction of the shoulder • Lies adjacent to the teres major • Both have similar functions • Often injured together
FUNCTION
• Tenderness in the axilla • Avulsions often with palpable mass • Occasional tenderness on humeral attachment
EXAM FINDINGS
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MARINER’S EXPERIENCE
2 injuries in past 2 years Both pitcher’s with very overhead delivery Primary fastball pitcher’s Both treated with PRP 1 required surgery due to reinjury-‐ still not preinjury 1 with 12 week full recovery
• Arthroscopic Findings: Relocation Test 100% Contact of RTC and Glenoid 93% Undersurface RTC Tear 88% Posterosuperior Labrum Fray 36% Anterior Labrum Fraying Paley, Jobe, Pink et al. Arthroscopy 2000
INTERNAL IMPINGEMENT
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• Jobe – Loss of anterior stability can permit anterior translation of the humeral head from within the glenoid fossa.
– Associated with a normal subacromial space.
CAUSES OF INTERNAL IMPINGEMENT
• Evaluation: – Routine history – Younger Patient (18-‐36) – No specific injury
INTERNAL IMPINGEMENT/INSTABILITY
• Internal Impingement-‐Jobe
INSTABILITY RAMIFICATIONS
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IMPINGEMENT - POSTERIOR
• Walch G et al. (1992) • Jobe CM (1996) • Expanded Spectrum • 1-‐ “throwing injury”
• “To know the offender…..Study the crime” • • John Douglas FBI Profiler
INTERNAL IMPINGEMENT-PHYSIOLOGIC?
• Glenohumeral • Internal • Rotation • Deficit
GIRD
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GIRD
SCIENCE BEHIND THE CONCEPT
• .
The effect of posterior capsule tightening in glenohumeral translation in the late cocking phase of throwing. Koffler, Moyer, Kelley, et al. Possm 2001, Sub. for pub., 2002
Tightening of the posterior capsule resulted in significant superior translation with flexion of the shoulder. Harryman et al JBJS 1990
WHAT IS SIGNIFICANT?
• 38 Post. slaps in throwers • All had IRD > 25˚
Mean = 32.50˚ Range = 26-‐58˚
Kibler 1995-1998
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• All with > 25 IR • 63% Shoulder problems • 58% Elbow problems • 37% Shoulder + elbow • 26% Shoulder + LBP • 15% No problems
• 3 year results: • No innings lost • No intraarticular lesions • No surgical procedures
Verna 1991: 39 Prof. Pitchers
Cooper ‘97 - ‘99 22 Major League Pitchers
Stretched Daily
THE PATHOLOGIC CASCADE
• Internal Rotation Deficit • Post Sup. GH Shift In Abd &
Ext. Rot.
• Biceps Tension & Peel Back Mech.
• Slap Lesion • Internal Impingement
• RTC Tear
PRODROME
• “Posterior stiffness or tightness”
• ± post pain in cocking • No mechanical symptoms • Marked IRD at 90˚
• Post. Tightness
Post. Pain
Slap Event
Mechanical Sx’s Pain
Loss of Velocity
Inability to Pitch
PRESENTATION
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• Burkhart-‐Results: Dead Arm – SLAP repairs 87% Return to Pre-‐injury level for two or more seasons.
Repair the SLAP=Repair instability
PEEL BACK
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