State of the Art (standard of care?) for Sports Shoulder ...
Transcript of 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).
MSK Shoulder Anatomy
Neurologic:
Brachial plexus
MSK Shoulder Anatomy
Vascular:
Brachial artery and its branches
- Circumflex humeral vessels
MSK Shoulder Anatomy
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Massive RC tear
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
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
Subacromial Impingment
Treatment
Relieve impingement of the rotator cuff tendon under the acromion
Cortisone or LP-PRP injection: Decrease inflammation of the subacromial bursa
* Evolving understanding of steroid effect on RC tendon
Subacromial Impingment
Treatment
Relieve impingement of the rotator cuff tendon under the acromion
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
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
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
Type 3 (moderate displacement)
Classic surgical treatment• Staged surgery with hook
plate/plate removal
• High incidence of complication (fracture)
AC Separation
Type 3 (moderate displacement)
State of the art = repair or reconstruct arthroscopically
Single procedure Minimally invasive Rapid return to work/sport compared
with non-operative treatment
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
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
Traumatic anterior shoulder dislocation
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
Traumatic anterior shoulder dislocation
The humeral head sitting on glenoid is analogous to a golf ball on a tee
Instability
Traumatic anterior shoulder dislocation
Each dislocation event will cause some erosion of the anterior-inferior glenoid bone
Instability
Traumatic anterior shoulder dislocation
- 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
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
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
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
Throwing Athlete InjuriesSLAP = Superior Labrum Anterior to Posterior Injury
Presentation:
• Deep ache often difficult to define on exam or link to specific injury event
• Diminished athletic performance
Throwing Athlete InjuriesSLAP = Superior Labrum Anterior to Posterior Injury
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
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
• Later: shoulder exam and interesting cases