RETURN TO PLAY (RTP) SHOULDER AND ELBOW

July 29, 2016

Mark Sytsma, MD

Bronson Sports Medicine Specialists

• I have no conflicts of interest of relevant financial relationships relating to this talk.

Disclosure

Return to Play (RTP)

• Background

• Shoulder injuries

– Fracture, dislocations, stinger, AC injuries, Clavicle fractures

• Elbow injuries

– Dislocation, fracture, ligament injuries

• Youth and overuse injuries

Why We Cover Sports

• Most injuries do not have serious consequences…but some do!

• Hours of preparation, observation and training for a few critical moments.

• ALWAYS be prepared!

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Why We Cover Sports

• OUR PRIMARY GOAL

– The health and wellbeing of our athletes

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Goals of Sideline Management

• Assess the athlete quickly and diagnose the problem

• Is this an injury that will allow the player to return?

– Finger dislocation vs ankle fracture

Return to Play (RTP)

• Depends on the sport

– Contact vs non-contact

– Specific position

• Depends on the body part injured

– Example: Non-dominant hand in a soccer player

• Depends on the level of sport

– Higher levels may absorb more risk

Above All Else

• Protect the athlete

– More important than the desires of the athlete, coach, parent, etc…

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Shoulder Injuries

• Stinger/Burner (Dr. Jensen)

– Dead arm, numbness and tingling from shoulder to hand

– Caused by direct contact and stretch to the brachial plexus (nerves exiting neck)

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Stinger/Burner

• Always evaluate for pain in the shoulder joint

– May indicate shoulder instability event

• Return to play?

– Sensation returns

– Normal shoulder strength (Rotator cuff test)

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Shoulder Dislocation

• Most common major joint dislocation

• 90+% anterior

• Mechanism

– Force or fall on Abducted, ER arm: anterior dx

– Force or fall on Adducted, IR arm: posterior dx

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Shoulder Dislocation

• Many spontaneously reduce. Pain

– “shift” or “slip”

• Locked dislocation

– Reduce

– Transfer to hospital if not reducible

• RTP?

Shoulder Dislocation

• Return to play?

– Sport, body part, level

– Consider surgery after first dislocation (new evidence)

• Often 3-6+ weeks

• Shoulder brace?

Shoulder Dislocation

• Younger Athletes (<25)

– High risk for recurrent dislocations/instability

• Mature athletes (>40)

– Must evaluate for acute rotator cuff tears

AC Separation

• Most common shoulder injury in contact sports

– Tenderness (+/-swelling/deformity) directly at AC joint

• Continuum of severity

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AC Separation

• Mechanism: direct hit to or fall on shoulder

• If lower grade (Type 1,2), may RTP if shoulder strength and motion are normal

AC Separation

• Most have weakness within shoulder due to pain on day of injury

– No return on day of injury

• RTP: 1-4 weeks

• For persistent pain without weakness

– Low grade injury (Type 1 or 2)

– Local anesthetic injections can be useful

• Do not inject with steroids

• Surgery: out of contact for 5+ months

Sternoclavicular Dislocation

• Much less common than AC injuries

• Mechanism: usually a direct blow to chest

• Anterior dislocation (more common)

– Deformity

• Posterior dislocation (more consequences)

– Difficulty breathing or swallowing

Sternoclavicular Dislocation

• May be a fracture through growth plate

– Fuses at age 20-25

• No return to play

– Seek medical care

– DO NOT reduce

Clavicle Fracture

• 35% of shoulder fractures involve the clavicle

• Mechanism: direct contact or fall on shoulder

• Most commonly involve the middle 1/3

Clavicle Fracture

• Clavicle fractures

– Diagnosis

• Deformity?

• Tenderness to palpation directly over the clavicle

– Unable to return to play

• Strength will be decreased

• If minimally displaced, still at significant risk for displacement

– Sling and X-ray evaluation

Clavicle Fracture

• If non-displaced or minimally displaced

– Nonoperative

– RTP?

• Midshaft, displaced, shortened

– Operative, RTP?

Clavicle Fracture

• Clavicle Fractures

– Distal fractures may mimic AC injuries

– If significantly displaced, usually managed operatively

Elbow Ligament Injuries

• Ulnar collateral ligament (Tommy John Ligament)

Elbow Ligament Injuries

• Throwing athletes

– Pop or acute pain along inside of elbow

– Remove from play immediately

• Medical evaluation

– RTP?

• Direct contact

– May brace (depending on sport)

– RTP?

Elbow Dislocation

• Second most common major joint dislocation

– 80% posterolateral

• Mechanism:

– Fall or direct blow

• Simple dislocation (50-60%)

– Ligament injury only

• Complex dislocation

– Fracture + ligament injury

Elbow Dislocation

• NO immediate return to play

– Usually 2+ months before return to contact sports if it is a simple dislocation

Elbow Fractures

• Mechanism: Fall or direct contact

Pediatric Elbow Fractures

• Usually involve growth plates

• Ligaments usually don’t tear, growth plates separate/fracture

Elbow Fractures

• Exam

– Deformity, swelling, or loss of motion

– Pain with direct palpation over the bone

• Remove from play

– Splint

– Obtain X-rays or appropriate studies

Elbow Fractures RTP

• Never return a young athlete immediately to play if they have bone or joint tenderness

• Need full motion and strength

• RTP 6+ weeks

– Longer for contact sports and articular fractures

– Sport, location, level

Overuse Injuries

• Primarily with overhead sports

– Baseball, volleyball, Tennis, Etc…

• You can NOT play through pain

– Remove from competition

– Medical evaluation

http://www.stopsportsinjuries.org/

Questions?

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