Transcript Shoulder & Elbow Injuries in the Athlete - HenFord

Shoulder & Elbow Injuries in
the Athlete
Matthew Copple, DO
August 2011
Elbow Questions
261. (Sports Medicine)
With the diagnosis of valgus extension
overload of the elbow, radiographs often
show osteophyte formation on the
1.
2.
3.
4.
5.
radial head.
posteromedial olecranon fossa.
posterolateral olecranon fossa.
tip of the olecranon process.
medial humeral epicondyle.
261. Answer 2 – posteromedial olecranon fossa
 Answer 2, “posteromedial olecranon fossa,” is correct. Valgus extension overload is often found
in baseball pitchers. They experience elbow pain between the acceleration and follow-through
phase. A significant osteophyte on the posteromedial aspect of the olecranon is seen. This causes
impingement with the articular wall of the olecranon fossa and creates an area of
chondromalacia. The physical exam finding is a positive “valgus extension overload” test,
performed by repeated flexion and extension while applying a valgus load producing pain. This is
the most common diagnosis requiring surgery in baseball players (78%). Non-op treatment
includes active rest and rehab of the elbow and shoulder. Surgical excision (open or arthroscopic)
can allow return to pitching the next season, but results can be short-lived with up to 41%
requiring reoperation including repeat debridement, ulnar collateral ligament reconstruction, or
ulnar nerve transposition within 24 months post-op.

 Answer 1, “radial head,” injury could occur through compression with a valgus force on the
elbow. Also at risk are the capitellum, such as in “Panner disease” which is osteochondrosis of the
capitellum in children aged 7-12 years.
 Answer 3, “posterolateral olecranon fossa,” is not classic for valgus extension overload.
 Answer 4, “tip of the olecranon process” is not classic for valgus extension overload, but can be
seen in elbow “traction osteophytes” often resulting in a painful boggy bursa at the olecranon.
 Answer 5, “medial humeral epicondyle,” can be involved in “Little Leaguer’s elbow”. During the
throwing motion, valgus stress is placed on the elbow. This valgus stress results in tension on the
medial structures (ie, medial epicondyle, medial epicondylar apophysis, medial collateral ligament
complex) and compression of the lateral structures (ie, radial head, capitellum). Recurrent
microtrauma of the elbow joint can lead to little league elbow, a syndrome that encompasses (1)
delayed or accelerated growth of the medial epicondyle (medial epicondylar apophysitis), (2)
traction apophysitis (medial epicondylar fragmentation), and (3) medial epicondylitis. Ulnar nerve
neuritis can also occur with this syndrome.
(Varshney)
http://emedicine.medscape.com/article/97101-overview
261. Answer 2 – posteromedial
olecranon fossa
Question #: 129
A 12-year-old right-hand dominant boy has medial right elbow pain that is made worse
by
overhand throwing. There are no mechanical symptoms. AP and lateral elbow
radiographs and a T2-weighted MRI scan are shown in Figures 129a through 129c.
Treatment should consist of
12345-
corrective humeral osteotomy.
screw fixation of the medial epicondyle.
rest followed by a gradual return to activities.
elbow arthroscopy and removal of the loose body.
arthroscopic drilling of the osteochondral lesion.
Preferred Response: 3
This kid has little league elbow
Treatment is activity modifications, with less throwing. The extent of which is determined based on the
exact injury. It can be an avulsion fracture of the medial epicondyle, or medial epicondylar apophysitis, and
can result in accelerated apophyseal growth with delayed closure of the epicondylar growth plate
Taken from the ReferenceLittle League elbow results from repetitive valgus stresses and tension overload of the medial structures.
Repetitive contraction of the flexorpronator musculature stresses the chondro-osseous origin, leading to
inflammation and subsequent apophysitis.
Usually younger than age 10 years and typically report a triad of medial elbow pain, decreased throwing
effectiveness, and decreased throwing distance.
Patients may exhibit medial swelling, focal tenderness over the medial epicondyle, and occasional flexion
contractures.
Although results of plain radiography are sometimes normal, radiographic changes include irregular
ossification of the medial epicondylar apophysis early in the disease process, followed by accelerated growth,
marked by apophyseal enlargement, separation, and eventually fragmentation.
Treament consists of 2 to 4 weeks of rest and NSAIDs, followed by stretching and strengthening exercises of
the elbow, with gradual return to throwing at 6 weeks if the athlete is symptom free.
Recommended Reading(s):
Chen FS, Diaz VA, Loebenberg M, et al: Shoulder and elbow injuries in the skeletally
immature athlete. J Am Acad Orthop Surg 2005;13:172-185.
Limpisvasti O, ElAttrache NS, Jobe FW: Understanding shoulder and elbow injuries in
baseball. J Am Acad Orthop Surg 2007;15:139-147.
Farber
105 Which of the following is considered the most
important portion of the kinetic chain in protecting the
thrower’s elbow from valgus loads?
1- Forearm pronation
2- Scapular retraction
3- Scapular protraction
4- Glenohumeral internal rotation
5- Glenohumeral external rotation
105 Preferred Response: 4
• Kinetic chain muscle action relates to the preprogrammed muscle
activations that result in anticipatory postural adjustments in order to
produce faster/stronger/efficient and safe motion. They create proximal
stability for distal mobility and originate from central body segments and
are key to proper motion at distal joints, minimizing internal loads on
joints.
• During throwing motion, maximal shoulder internal rotation force is
developed in interaction with trunk rotation. Max fastball speed is
correlated with shoulder activation stabilizing shoulder and elbow
distraction and producing elbow angular velocity. Accuracy of ball
throwing is related to interactive moment at the wrist produced by shoulder
movement.
• In regards to this question, maximal elbow varus torque to protect against
elbow valgus strain is produced from interaction with shoulder internal
rotation.
Vasileff, Sports
References:
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2002, pp 101-111.
Marshall RN, Elliott BC: Long-axis rotation: The missing link in proximal-to-distal sequencing. J Sports Sci 2000;18:247-254.
69) Rehabilitation following elbow dislocation in which the
distal humerus was ‘perched’ on the coronoid at the time of
injury should include which of the following?
1- Seated shoulder abduction and internal rotation
2- Immediate physical therapy focusing on passive range of motion
through a stable arc
3- Four weeks immobilization followed by physical therapy focusing on
passive range of
motion through a stable arc
4- Immediate active or active-assisted range of motion through a stable
arc
5- Immediate physical therapy focusing on passive range of motion
through a stable arc with the forearm supinated
• Posterolateral Rotatory Instability
• O’Driscoll’s stages of soft tissue disruption (from
medial to lateral)
– Called Horii circle
– Stage 1
• UCL disruption with or without disruption or
remaining LCL
• Results in posterolateral rotatory subluxation
that reduces spontaneously
• PE: + lateral pivot shift
– Stage 2 (Elbow subluxation)
• Add’l posterior and anterior soft tissue
disruption
• “Perched” coronoid on lateral XR
– Stage 3 (Elbow dislocation)
• 3a: Anterior band MCL intact. Elbow stable to
valgus stress after reduction
• 3b: Anterior band MCL ruptured. Elbow
unstable to valgus stress after reduction
• 3c: All soft tissues stripped from humerus.
Grossly unstable from 0 – 90°
Horii Circle
Lateral Pivot Shift
• Restraints
– Primary Static : Ulnohumeral articulation/MCL/LCL (especially ulnar portion)
– Secondary Static: Radial head/Common flexor/extensor origins/Capsule
– Dynamic: Anconeus (major restraint)/Triceps/Brachialis
• Management after reduction
– Check arc of stability after reduction
– Splint if unstable or splint or sling if stable for 3-5 days (may be up to 2 weeks if severe
dislocation). Reevaluate in clinic.
– Early assisted/active ROM has reduced incidence of stiffness without affecting stability
• Active because dynamic stabilizers aid in maintaing concentric reduction
• Can be done with adjustable hinge splint
• Start withing few days with ice, elevation, and compression
– Full ROM then allowed at 2-4 weeks
– Protected motion continued for 6 weeks
– If elbow subluxes in extension or noncongruent on XR then reassess in pronation
• If stable then apply hinged brace with elbow in pronation
• May need extension block (If >30° block needed, then consider surgery)
Recommended Reading(s):
Smith J, Morrey BF. Principles of elbow rehabilitation. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders, 4th ed. Philadelphia, PA: Elsevier Saunders; 2009:152-159.
O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6. PubMed PMID: 2002081.
Assenmacher
#216
A 24-year-old throwing athlete reports medial elbow pain with throwing
activities for the past 6 months despite activity modification and
rehabilitation. Examination reveals a positive moving valgus stress
test. He has no signs or symptoms of cubital tunnel syndrome. What
is the most appropriate treatment at this time?
1- Isolated ulnar collateral ligament (UCL) repair
2- Isolated UCL reconstruction
3- UCL reconstruction with ulnar nerve transposition
4- Ulnar nerve transposition
5- Excision of abnormal degenerative tissue within the flexor pronator
origin and reapproximation of healthy tissue
2. Isolated UCL reconstruction
• The anterior bundle of the UCL is the primary constraint to valgus
•
•
•
•
•
•
•
•
force of the elbow. A tear to the Anterior bundle can result in
instability of the elbow which can be detected through valgus stress
placed through elbow.
Radiology of CT arthrogram or MRI arthrograms
can be used to diagnose or confirm
Repairs are generally not recommended
Ulnar nerve transpositions are not necessary unless
symptoms are present (although the article used as source
did transpose all ulnar nerves.)
Sports
Azar, Frederick; et al; Opertative treatment of Ulnar Collateral Ligament Injuries of the elbow in Athletes. The Americal Journal of sports
Medicine. 28(1). 2000.
Woods
Question 252
Posterior medial instability of the elbow is most commonly characterized by which of
the following findings?
1- Type III coronoid fracture and radial head fracture
2- Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injury
3- Lateral epicondyle and medial epicondyle fractures
4- MCL injury and anteromedial coronoid facet fracture
5- Anteromedial coronoid facet fracture and LCL injury
Answer 4
Larkin
•
Posteromedial elbow instability involves an injury to the MCL and an
anteromedial coronoid fracture
•
The coronoid fracture is what sets this apart from a posterolateral elbow
dislocation were a standard coronoid chip is seen
•
Primary stabilizers to the elbow are the MCL (main stabilizer) and the
ulnohumeral articularion (coronoid and olecranon)
•
Secondary stabilizers include the radiohumeral articulation, capsule, and
musculature
•
Incorrect answers:
1.
Type III coronoid fracture and radial head fracture: this is two parts of a
terrible triad injury, but these elbow injuries do not have posteromedial
instability alone
2.
Medial collateral ligament (MCL) and lateral collateral ligament (LCL)
injury: this would cause impressive instability and not directed in a
posteromedial direction
3.
Lateral epicondyle and medial epicondyle fractures: epicondyle
fractures aren’t usually associated with questions about elbow
instability
4.
MCL injury and anteromedial coronoid facet fracture: correct answer
5.
Anteromedial coronoid facet fracture and LCL injury: this combination
may be seen in posterolateral instability but not the classic pattern
O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113-34. Review. PubMed PMID: 12690844.
Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006 Oct;88(10):2216-24. PubMed PMID: 17015599.
Shoulder
• Throwing Mechanics
– Discrete phases
– Greatest injury (Maximum torque)
• Late cocking – Shoulder in Max ER position
• Acceleration
• Deceleration
Throwing Mechanics
• Post pitching muscle strength
– Significant decreases in compared to baseline
• Shoulder flexion
• IR
• Adduction
• Adaptive changes in overhead throwers
– What are they?
Adaptive Changes
• Increased external rotation
• Decreased internal rotation
• Increased humeral retroversion
• Why does the above occur?
Adaptive Changes
• Lengthening of the anterior capsular restraints
• Tightening of the posterior capsular restraints
• Decreases in the normal derotation of the
proximal humeral physis
– Repetitive stress of throwing alters normal remodeling
process of the proximal humerus
• This adaptive shift
– Begins and progresses through adolescence
– Concern if this compromises static stability of
shoulder
Adaptive Change
• Posterior capsular tightness
– Increased PS humeral head migration in late
cocking
• Allowing increased ER
• Decreased risk of impingement of GT on glenoid
• Increased External rotation
– Greater torsional stress on the biceps anchor
• Potential SLAP
History
• Exact nature of symptoms
• Onset
• Duration
• Response to tx
• Location of pain
– Its relationship to phase of throwing
PE
• Evaluate C-spine and elbow
• Inspection
– Look for asymmetries
– Atrophy
• Posterior rotator cuff – suprascapular neuropathy
– How do we isolate the lesion
• Observe scapular mechanics
– Dyskinesia and winging
• Reflects weakness
• Possible GH instability
– What causes medial and lateral winging?
PE
• Active ROM
– Isolate where pain is generated
– Identify adaptive changes
– Quantify IR and ER at 90 degrees of
abduction
• Always compare to non-throwing shoulder
Imaging
•
•
•
•
AP
Grashey
Axillary
Outlet views of the shoulder
– Bennett lesion
• Mineralization of PI glenoid
– Occurs in response to traction of the capsule
– Unknown clinical significance
• MRI
– Modality of choice for soft tissue
– MR arthrogram improves accuracy
•
•
•
•
•
Labral tears
Articular cartilage damage
Biceps tendon abnormalities
RCT
SLAP tears variable
Instability
• Anterior Instability
– Late cocking phase
• Significant stretch on anterior GH stabilizers
– Anterior band of inferior GH ligament
 Increase laxity
 Unlikely to have bankarts lesion w/o hx of trauma
– Tingling in the arm or dead arm suggest this
– Overhead throwers
• Report looseness or shifting with the arm cocked
– Apprehension test
• How do you do it?
• What test confirms this?
Anterior Instability
Positive test – elicits sensation of
instability
Anterior Instability
• Treatment
– Severity of instability
– Timing in the competitive season
– Surgery
• Those that fail conservative management
– Strengthening of rotator cuff
• Recurrent instability
• Open or arthroscopic techniques
– Young athletes in contact sports
 High risk group for recurrent instability
 10-25% for repair of bankart lesion
Anterior Instability
• When are the highest rates of recurrent
instability in contact athletes reported
following arthroscopic repair?
• <20 years = 50-80% redislocation rate
• >40 years = increased risk for RCT
• 2007 study with large (>5mm) displaced
(>2mm) bony bankart lesions had no
dislocations and excellent outcome if joint
was concentrically reduced.
Anterior Instability
• 82% risk reduction for recurrent instability
and 76% risk reducion for dislocation 2
years after initial injury if treated with
arthroscopic stabilization at time of first
dislocation.
J Bone Joint Surg Am. 2008 Apr;90(4):708-21.
Primary arthroscopic stabilization for a first-time anterior dislocation
of the shoulder. A randomized, double-blind trial.
Robinson CM, Jenkins PJ, White TO, Ker A, Will E.
Question #: 150
A 17-year-old volleyball player has pain and weakness in her dominant shoulder with
overhead use during her most recent season. She has been able to voluntarily subluxate
the shoulder since the age of 10 and has no history of direct trauma to the shoulder.
Appropriate management at this time should include
•
•
•
•
•
1- open capsular shift.
2- arthroscopic rotator interval closure.
3- thermal capsulorrhaphy.
4- shoulder stabilization bracing.
5- initiation of a dynamic stabilization therapy
program.
Novak
Question #: 150
Preferred Response: 5, initiation of a dynamic stabilization therapy program
•
•
The patient has instability of the shoulder. There is no history of trauma and she has been able to
voluntarily subluxate since the age of 10. She has multidirectional instability of the shoulder.
Patients with MDI often have global (anterior, inferior, and posterior) excessive laxity of the
glenohumeral joint capsule and a rotator interval defect.
It doesn’t sound like she’s had any type of treatment for this yet. Most patients can be
successfully treated nonoperatively with exercise/therapy program. This should be implemented
for about 6 months before surgery is considered. If surgery is eventually decided on, then an
open inferior capsular shift is the standard procedure. Other procedures talked about are glenoid
osteotomy and arthroscopic inferior capsular shift.
– AMBRII = Atraumatic, Multidirectional, Bilateral laxity, Rehab, if surgery
then tighten Inferior capsule and rotator Interval
– TUBS = Traumatic, Unidirectional, Bankart lesion, Surgery
Recommended Reading(s):
•
Lee SB, Kim KJ, O’Driscoll SW, et al: Dynamic glenohumeral stability provided by the
•
rotator cuff muscles in the mid-range and end-range of motion: A study of cadavera. J
•
Bone Joint Surg Am 2000;82:849-857.
•
Schenk TJ, Brems JJ: Multidirectional instability of the shoulder: Pathophysiology,
•
diagnosis, and management. J Am Acad Orthop Surg 1998;6:65-72.
Novak
Unidirectional (Posterior)
Instability
• Traumatic
– Posterior directed force to FF extremity
• Dislocation or subluxation
– Detachment of posterior glenoid labrum
• Avulsion of posterior capsuloligamentous restraints
• Instability symptoms
– Flexed and adducted extremity
• Pain may be primary symptom
Posterior Instability
• Posterior dislocations are rare compared to anterior
•
•
•
•
dislocations, but are missed.
Reduce and immobilize in external rotation with PT and
ROM to follow.
Surgery for continued pain with loading in forward
flexion
After several weeks of a missed posterior dislocation,
bone loss is likely and CT is recommended. Open
reduction is likely needed.
Bone loss >50% is likely to need humeral head
replacement to restore stability and treat the arthritis
(versus TSA)
PE findings for posterior instability
• Posterior Load and
•
shift test
Jerk test
– Post force with arm
add and FF
Posterior load-shift test. The longitudinal
force subluxates the humeral head which
relocates as the arm is brought back to the
patient's side.
Multidirectional Instability
• Atraumatic posterior instability
– Progressive stretching of the posterior stabilizers and
rotator interval
• Symptomatic instability in more than one
direction
– Inferior glenohumeral joint hyperlaxity
• Classified
– Anterior
– Posterior
• Based on most symptomatic direction of instability
Multidirectional Instability
• More common
– Younger athletes
– Females
– No history of dislocation or trauma
– Difficult diagnosis
• Primary symptom can be pain
• Early fatigue, dead arm
What is this and what does it indicate?
Multidirectional Instability
• Sulcus sign demonstrated by applying
longitudinal traction on the arm
– Increased inferior translation of humeral head
– Always compare to opposite shoulder
Multidirectional Instability
Treatment
• AMBRI
• Cornerstone – REHAB
• Surgery after failed 6 months of rehab
– Inferior capsular shift or plication
• TUBS
• Cornerstone - Surgery
An 18-year-old high school football player has bilateral
shoulder pain associated with bench and military press
activities. He does not recall any acute injuries but
reports that since age 10 years he has actively caused
his shoulders to “pop” out of joint. Examination
bilaterally shows posterior instability with jerk testing, 1
cm of inferior sulcus testing, and +1 anterior instability
with load and shift testing. Anterior apprehension and
relocation tests are negative. An MRI arthrogram shows
no discrete labral or capsular injury, and the glenoid is
intact. Management should consist of
1.
2.
3.
4.
5.
open posterior capsular shift.
arthroscopic posterior capsular placation.
rotator cuff interval closure.
thermal capsulorrhaphy.
physical therapy.
5
Patients with posterior glenohumeral instability are usually men
between the ages of 20-30 who are either active or competitive
athletes.
Recurrent instability most commonly presents with episodes of
subluxation with no history of injury. Most patients with recurrent
posterior instability notice lessening or eradication of their
symptoms following a shoulder physiotherapy rehab program. This
is particularly true for patients with evidence of hyperlaxity.
Thus physical therapy remains the initial treatment of choice,
irrespective of predisposing causes. Conservative treatment
includes pain management, activity modification, and strengthening
of the scapulothoracic and rotator cuff muscles.
Robinson CM, Aderinto J: Recurrent posterior shoulder instability. J Bone Joint Surg
Am 2005; 87:883-892
Internal Impingement
• Occurs when in what shoulder position?
• Associated with GIRD
• Abnormal contact – repetitive trauma
– Posterosuperior labrum
– Articular sided rotator cuff tears
• In contrast to external impingement on
the bursal surface of the rotator cuff
• Theory
– Increased horizontal abduction of the shoulder occurs
with fatigue
• Resulting in greater contact of the greater tuberosity of
posterosuperior glenoid
Internal Impingement
• History
– Pain in posterior aspect of shoulder
• PE
• Early acceleration phase
– Posterior shoulder pain reproduced
• Anterior apprehension test
• Relieved with the relocation test
• Xrays
– Cystic changes and sclerosis of greater tuberosity
• MRI
– Posterosuperior labral fraying, glenoid sclerosis, RC tendon
fraying
Internal Impingement
• Treatment
– Rehab
• Focus on stretching of posterior capsule
• Strengthening RC and scapular stabilizers
– Surgery for those failing rehab and rest
• Debridement of RC tears and fraying (inconsistent results)
• Anterior hyperlaxity – plication
• Posterior capsule release with excessive tightness – loss of
GH IR of 20-25 degrees
• Peel back phenomenon of the superior labrum
– Evaluated with arm abducted and ER
• Internal impingement” is a pathologic condition seen in
throwing athletes when the posterior rotator cuff directly
impinges on what anatomic structure?
•
•
•
•
•
1.
2.
3.
4.
5.
Coracoid process
Long head of the biceps
Posterosuperior glenoid labrum
Subscapularis tendon
Posterior band of the inferior glenohumeral ligament
3
• It has recently been recognized that throwers can feel posterior shoulder pain
during the late cocking phase, specifically at end ranges of external rotation.
Unlike subacromial impingement, classically described by Neer, (in which the
the rotator cuff is impinged upon by the anterior one-third of the acromion, the
coracoacromial ligament, and the acromioclavicular joint) it is believed that this
pain results from impingement of the supraspinatus (and occasionally
infraspinatus) tendon, between the greater tuberosity and the posterior aspect
of the humeral head with the posterosuperior glenoid labrum. Although it is
believed that contact between the humeral head and the posterior glenoid rim
is a normal physiological occurrence, the biomechanics of the throwing motion
is believed to intensify this contact and its effect on the underlying anatomical
structures. Thus, pathologic internal impingement can result. Using
arthroscopy, clinicians have identified undersurface lesions on the posterior
aspect of the supraspinatus tendon and/or anterior portion of the infraspinatus
tendon as well as posterosuperior glenoid labrum fraying (type I or II superior
labral anterior posterior [SLAP] lesion) in overhead-throwing athletes.
Cleland
•
•
•
References:
Myers, JB, Laudner, KG, Pasquale MR Glenohumeral range of motion defecits and posterior shoulder tightness in
throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391
Paley KJ, Jobe FW, Pink MM: Arthroscopic findings in the overhand throwing athlete: Evidence of posterior internal
impingement of the rotator cuff. Arthroscopy 2000; 16:35-40
Rotator Cuff Disease
• Significant demands by overhead athletes
– Full thickness tendon tears uncommon
– Repetitive loads lead to
• Microdmage
• Inflammation
• Loss of tendon integrity
• Rotator cuff
– Actively stabilizes the humeral head during late
cocking and acceleration
– Tensile loaded during deceleration phase of throwing
Rotator Cuff Disease
• Most problems involve what part of the cuff?
• Treatment
– Dictated by severity of injury
– Rehab
• Posterior capsular stretching and RC and scapular stabilizer
strengthening and endurance
– Surgery
• Partial thickness tears – controversial
– >50% of tendon thickness – debride or transtendinous repair
• Full thickness tears – Conservative Tx, Repair
– Unlikely to RTP
Rotator Cuff Disease
• Associated Lesions
– AC arthritis
– Os acromiale (8% population)
– Suprascapular nerve compression
• Retraction >2cm, mimick tendon tears
• Diagnostic injections can help
• Tendon Transfers for <60 with irreparable
large and massive tears.
– Lat dorsi – for posterosuperior tears
SLAP
• Detachment of superior labrum and biceps root
•
from superior glenoid attachment
Three proposed mechanisms
– Increased ER of the shoulder with late cocking
• Dynamic peel back load to posterosuperior labrum
– Posterior capsular contracture
• Increase stress to labrum b/c of posterosuperior migration of
the humeral head
– Degenerative fraying
• May result from repetitive mechanical contact of the
posterosuperior labrum with the undersurface of the rotator
cuff
SLAP
• What throwing phase has been shown to
provide the greatest strain on the superior
labrum?
SLAP
• Late Cocking
SLAP
• History
– Deep shoulder pain in late cocking position
– Loss of velocity
• PE
– Name a test we use?
SLAP
• O’Brien’s test
– Test is + if if pt
experiences deep or
anterior shoulder pain
with resisted FF that is
relieved with ER
SLAP
• Imaging Modalities
– Most accurate – arthroscopy
– MR arthrogram – preferred but not very
accurate
SLAP
SLAP
• Treatment
– Rehab
– Surgery if failed rehab
– 70-80% return to preinjury performance with
arthroscopic repair
37 In standard superior labral anterior posterior (SLAP)
lesion repair, postoperative rehabilitation usually dictates
that
1. maximal external rotation of 90 degrees of abduction should be emphasized
2. open chain elbow flexion exercises against resistance should begin immediately
3. Strengthening exercises have attained maximal effect by 12 weeks postoperatively
4. strict sling wear should be emphasized at all times except during PT for the first 8
weeks
5. during the return – to- sport phase, the athlete continues to perform rehabilitative
exercises as an active as a warm up to the interval program
37 In standard superior labral anterior posterior (SLAP) lesion repair, postoperative
rehabilitation usually dictates that
Response #5
1. maximal external rotation of 90 degrees of abduction should be emphasized
2. open chain elbow flexion exercises against resistance should begin immediately
3. Strengthening exercises have attained maximal effect by 12 weeks postoperatively
4. strict sling wear should be emphasized at all times except during PT for the first 8
weeks
5. during the return – to- sport phase, the athlete continues to perform
rehabilitative exercises as an active as a warm up to the interval program
Recommended Reading(s):
Ellenbecker TS, Reinold MM, Davies GJ. Rehabilitation principles following rotator cuff and superior labral repair. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4.
Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:217-227.
Ellenbecker TS, Sueyoshi T, Winters M, et al. Descriptive report of shoulder range of motion and rotational strength 6 and 12 weeks following arthroscopic rotator cuff repair. North Am J
Sports Phys Ther; 2008;3:95-106.
37 In standard superior labral anterior posterior (SLAP) lesion repair, postoperative
rehabilitation usually dictates that
1. maximal external rotation of 90 degrees of abduction should be emphasized
- This would place undue stress on the anterior part of the repair. Passive ER is allowed
but is usually limited to 15 degrees in the first week PO.
2. open chain elbow flexion exercises against resistance should begin immediately
- Open chain (distal part of limb is NOT fixed, or can vary in direction of motion), place
increased loads to joint and surrounding tissue.
3. Strengthening exercises have attained maximal effect by 12 weeks postoperatively
- This makes no sense…..
4. strict sling wear should be emphasized at all times except during PT for the first 8
weeks
- Only if you are interested in having your patient develop adhesive capsulitis! Pt can do
own simple PT out of sling once taught by PTist immediately PO.
5. during the return – to- sport phase, the athlete continues to perform
rehabilitative exercises as an active as a warm up to the interval program
T. North
AC Joint Pathology
• Hyperemic response at distal clavicle
– Inflammation
– Bone resorption
– Secondary arthritic changes of the AC joint
• History
– More common with contact sports, rare in overhead
atheletes
– Local pain with terminal overhead motions
• Reaching across body
– If they report trauma
• What should be on our Differential?
AC Joint Pathology
• PE
– Pain with cross body adduction
– TTP at AC joint
• Xrays
– What is the name of the view for the AC joint?
AC Joint Pathology
Zanca View
Beam:Xray beam aimed at
the AC joint in 10° to 15°
cephalic tilt. Xray
penetration should be 1/2
normal to avoid
overpenetration of AC
joint.
AC Joint Pathology
• Treatment
– Conservative Measures
• Steriod Injection
– Surgery
• Mumford
– Arthroscopic vs open
– Most common cause of failed surgery is inadequate
posterior-superior resection
– Do not excise >1cm WHY?
A patient is seen in the emergency department for
evaluation of shoulder pain following a fall. Initial
attempts at imaging the acromioclavicular (AC) joint
result in a poor image with overlap between the distal
clavicle and acromion. To properly evaluate the AC joint,
how should the radiology technician direct the x-ray
beam?
12345-
10-degree
10-degree
10-degree
10-degree
10-degree
cephalad at 50% normal penetrance
cephalad at 150% normal penetrance
caudad at 50% normal penetrance
caudad at 100% normal penetrance
caudad at 150% normal penetrance
OITE 2008 Nemitz
1- 10-degree cephalad at 50% normal
penetrance
Suprascapular Neuropathy
• More common in overhead throwing
athletes
• Where is the nerve compressed?
Suprascapular Neuropathy
• Suprascapular and spinoglenoid notches
• How do you distinguish where the nerve is
compressed?
• Paralabral cysts from labral tears
– Extend into the spinoglenoid notch
Spinoglenoid and Suprascapular
Notch
Suprascapular Neuropathy
• Atrophy of both infraspinatus and
supraspinatus
– Compressed at suprascapular notch
• Atrophy of infraspinatus alone
– Compression at spinoglenoid notch
Suprascapular Neuropathy
• Treatment
– If early atrophy, focal compression or
anatomic lesion
• Surgical decompression
– Release of transverse scapular ligament
– Paralabral cysts
• Decompress arthroscopically and repair labrum
107. The clinical problem of suprascapular
nerve entrapment at the spinoglenoid notch
most often results in isolated atrophy of the
• 1. teres minor
• 2. infraspinatus
• 3. posterior deltoid
• 4. serratus anterior
• 5. supraspinatus
2
• Suprascapular neuropathy can cause dysfunction of the
•
•
supraspinatus and infraspinatus.
Proximal entrapment of the nerve at the suprascapular
notch causes wasting and involvement of both
supraspinatus and infraspinatus.
Distal involvement at the spinoglenoid notch or distal to
it causes isolated involvement of the infraspinatus
muscle. It is hypothesized that with extreme abduction
and external rotation of the shoulder (throwing athletes)
the medial tendinous margin between the infraspinatus
and supraspinatus muscles impinges strongly against the
scapular spine, compressing the intervening
infraspinatus branch of the suprascapular nerve. (MUH)
Vascular Injuries
• Quadrilateral space syndrome
– Unique to throwers
– What makes up the boundaries?
– What passes through this space?
Quadrilateral Space Syndrome
• Boundaries
– Teres minor superiorly
– Teres major inferiorly
– Long head of triceps medially
– Humeral shaft laterally
• Posterior humeral circumflex A. and
axillary nerve
• Compression occurs with LATE COCKING
Quadrilateral Space
Quadrilateral Space Syndrome
• Neurologic findings are rare
• Subclavian arteriography may reveal
obstruction of Posterior Hum Circum A.
• Treatment
– Rest and rehab
• Stretch posterior soft tissues of shoulder
– Decompression if fail conservative tx
Sports - Q 72: A baseball pitcher reports posterolateral shoulder pain
and lateral shoulder paresthesias
when in the cocking position of throwing. What is the most likely
diagnosis?
• 1- SLAP lesion
• 2- Anterior instability
• 3- Internal impingement
• 4- Posterior capsule tightness
• 5- Quadrilateral space syndrome
Devitt
A 72: 5- Quadrilateral space
syndrome
• This syndrome involves compression of the axillary nerve in the quadrilateral space
•
•
•
•
•
hence the symptoms of posterolateal shoulder pain and lateral shoulder parasteshias
Uncommon condition but most frequently affects overhead throwing athletes
Compression of the space and the axillary nerve can occur with abduction, extension,
and external rotation of the humerus as would be the case in the late cocking phase
The diagnosis is mainly clinical with insidious onset of the vague symptoms described
in the question, usually have point tenderness over the space near the teres minor
insertion and symptoms may be reproduced by holding the arm in abduction and
external rotation for 1 minute
Treatment is first nonsurgical with emphasis on stretching the posterior capsule and
teres minor
For those with failure of nonsurgical treatment, surgical decompression of fibrous
bands crossing the quadrilateral space has been reported to provide good to
excellent symptomatic relief in up to 89% of patients
Quadrilateral space
• Bordered by long
head of the triceps
medially, the shaft of
the humerus laterally,
the teres major
inferiorly and teres
minor superiorly
• The Axillary nerve
and the Posterior
circumflex humeral
artery traverse this
space
References 72
• Fischgrund JS (ed): Orthopaedic
Knowledge Update 9. Rosemont, IL,
American Academy of Orthopaedic
Surgeons, 2008, pp 273-285.
• DeLee JC, Drez D Jr, Miller MD (eds):
Orthopaedic Sports Medicine, ed 2.
Philadelphia, PA, WB Saunders, 2002, p
1247.
233
A patient diagnosed with quadrilateral space syndrome would exhibit
weakness in which of the following muscles?
1- Teres minor
2- Teres major
3- Subscapularis
4- Latissimus dorsi
5- Short head of the triceps
233
•
•
1 – Teres minor
Nerve/Vessel
Quadrangular
(quadrilateral)
space
Axillary/Post
humeral circumflex
Triangular space
None/Circumflex
scapular
Quadrilateral (quadrangular) space syndrome
causes transient blockage of the posterior humeral
Triangular
circumflex artery and axillary nerve. This typically
interval
occurs when the arm lies in position of abduction,
extension, and external rotation. Pts note shoulder
pain and parasthesias down the arm, especially
with overhead activity.
Ultimately, this is an anatomy question. The axillary
nerve is affected by this syndrome…teres minor (1)
is innervated by the axillary nerve and therefore
would demonstrate weakness.
• Teres major – lower subscap n.
• Subscapularis – upper & lower subscap n.
• Lat dorsi – thoracodorsal n.
TS
• Short head triceps – radial n.
• Cahill BR, Palmer RE. Quadrilateral space syndrome. J Hand Surg Am. 1983 Jan;8(1):65-9.
• McClelland D, Hoy G. A case of quadrilateral space syndrome with involvement of the long
head of the triceps. Am J Sports Med. 2008 Aug;36(8):1615-7.
Iorio
Space
TI
Radial/Profunda
brachii
QS
Little Leaguer’s Shoulder
• Proximal Humerus
– Salter Harris Type I fracture
• Secondary to overuse
• Xrays
– Widening of proximal humeral physis
• Treatment
– Rest and activity modification
– Table 4-17 pitch count
Question 77
A rock climber injured his dominant shoulder. Based on the MRI arthrograms
shown in Figures 77a and 77b, what is the most likely pathology?
12345-
Humeral avulsion of the glenohumeral ligaments (HAGL)
Superior labrum anterior posterior (SLAP) tear
Anterior labral tear
Posterior labral tear
Rotator cuff tear
Question 77
Figure 77a
Figure 77b
Question 77 - Answer
Preferred response: 1- Humeral avulsion of the glenohumeral ligaments (HAGL)
Humeral avulsion of the glenohumeral ligaments is a cause of recurrent shoulder instability
after a shoulder injury. The inferior glenohumeral ligament is the primary anterior stabilizer
of the shoulder when the arm is at 90 degrees of abduction and external rotation. It is
composed of an anterior and posterior band.
The next slide shows a radiograph of a HAGL lesion with the avulsed glenohumeral ligament
fragment inferomedial to the humeral head. The first MRI image is T1-weighted fat
saturation after intra-articular administration of gadolinium. The first MRI image is
demonstrating a normal fluid-distended U-shaped axillary pouch representing an intact
inferior glenohumeral ligament. The second MRI image is T2-weighted fat saturation after
intra-articular administration of gadolinium. The second image demonstrates conversion of
the normal U-shaped axillary pouch to a J-shape secondary to a torn inferior glenohumeral
ligament with contrast extravasating across the ligament where it is torn from its humeral
attachment site. The MRI of the patient in this question demonstrates contrast
extravasating across the ligament suggesting a HAGL.
Recommended Reading(s):
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review.
PubMed PMID: 17420506.
Rhee YG, Cho NS. Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):188-92. PubMed PMID:
17399624.
Sports
Charters
Question 77 - Answer
Preferred response: 1- Humeral avulsion of the glenohumeral ligaments (HAGL)
Recommended Reading(s):
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review.
PubMed PMID: 17420506.
Rhee YG, Cho NS. Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):188-92. PubMed PMID:
17399624.
Sports
Charters
Question 102
Figure 102 shows the MRI scan of a 20-year-old football lineman.
What is the most likely positive examination finding?
1.
2.
3.
4.
5.
Jerk test
O’Brien’s test
Relocation test
Belly-press test
Apprehension sign
Question 102
Figure 102
1.
Question 102 – Preferred answer: 1
Jerk test
•
The jerk test is a test of posterior instability. It is similar to the
posterior apprehension test in terms of position. The arm is taken
into the horizontally adducted position, attempting to subluxate the
shoulder posteriorly. When the arm is then moved rapidly into a
horizontally abducted position the shoulder is reduced with a
palpable and often visible jerk
•
Figure 102 shows a posterior glenoid labrum tear. The cited paper
by Escobedo concluded that posterior glenoid labrum tears are
more prevalent in football players than in non–football players,
hence the reference to a 20-year-old lineman in the vignette.
Posterior shoulder instability is less common than anterior
instability; it typically results from either a single traumatic event or
repetitive microtrauma as in weightlifters, swimmers, and football
linemen. Posterior glenohumeral instability can be a difficult entity
to diagnose and treat. Traumatic posterior dislocation usually
results from a fall on the outstretched arm with the arm positioned
in adduction and internal rotation. In this position, the posterior
capsule becomes taut, and any force directing the humeral head
posteriorly can result in disruption of the posterior capsule or
labrum. Similar lesions are seen in anterior and posterior
glenohumeral instability, but the term reverse is typically applied to
the lesions associated with posterior instability (reverse Bankart or
reverse Hill-Sachs lesion). MR arthrography accurately depicts a
posterior labral tear as high signal contrast extending into the tear
with displacement and abnormal morphologic features of the
labrum.
Question 102 – Preferred answer: 1
2.
O’Brien’s test
•
O'Brien recommended the active compression test for
diagnosis of AC joint abnormalities. O'Brien's test may be
particularly helpful when attempting to differentiate
symptoms of AC joint arthrosis from intra-articular disease,
especially with lesions of the superior glenoid labrum. The
test is performed with the arm elevated to 90 degrees, the
elbow in extension, adduction of 10 to 15 degrees, and
maximal pronation of the forearm. The examiner applies a
downward force resisted by the patient. Symptoms referred
to the top of the shoulder and confirmed by examiner
palpation of the AC joint indicate damage to this structure.
Symptoms referred to the anterior glenohumeral joint
suggest labral or biceps disease. They would probably
show a radiograph of the AC joint (Zanca view) if this were
the answer to the question.
Question 102 – Preferred answer: 1
3.
•
•
4.
5.
•
•
Relocation test
Provocative tests for anterior instability include the anterior
apprehension test and the relocation test. The anterior apprehension
test is performed with the patient upright or seated with the examiner
positioned at the side. The examiner stabilizes the scapula with one
palm, placing the thumb on the posterior aspect of the shoulder joint
while the opposite hand is used to bring the patient's arm into
abduction and external rotation. The result is positive when the test
elicits a feeling of apprehension with or without pain in this position.
The relocation test is performed with the patient supine. The examiner
performs the apprehension test in this position and then repeats the
test with one hand applying a posteriorly directed force to the anterior
shoulder. A resultant decrease in apprehension with this maneuver
represents a positive test.
Belly-press test
The subscapularis is tested with both a lift-off test and the belly press
test. It is performed by placing the patient’s palm against the
abdomen, with the arm in the coronal plane and the elbow flexed to 90
degrees. The examiner’s hand is placed between the patient’s hand
and abdomen so that the strength of the subsequent pressure can be
felt. The patient is then instructed to press the hand firmly against the
abdomen. Normally, the patient should be able to exert strong
pressure. In the presence of significant subscapularis weakness, the
pressure will be weak and the patient will often move the elbow
forward from the coronal plane in an attempt to gain more leverage.
Apprehension sign
See answer 3 above.
Question 102 – Preferred answer: 1
• Recommended Reading(s):
• Wright RW, Brophy RH, McCarty EC, Bishop JY. Acute
shoulder injuries. In: Kibler WB, ed. Orthopaedic
Knowledge Update: Sports Medicine 4. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 2009: 317.
• Escobedo EM, Richardson ML, Schulz YB, Hunter JC,
Green JR 3rd, Messick KJ. Increased risk of posterior
glenoid labrum tears in football players. AJR Am J
Roentgenol. 2007 Jan; 188(1): 193-7. PubMed PMID:
17179364.
So
137. Plication of the rotator interval produces the most
significant decrease in range of motion of the shoulder in
which of the following directions?
1- External rotation with the arm at the side
2- External rotation with the arm at 90° of abduction
3- Forward flexion with the arm in the plane of scapula
4- Internal rotation with the arm at the side
5- Internal rotation with the arm at 90° of abduction
1. External Rotation with the arm at the side
• The rotator interval is the
space between the
Supraspinatus and
Subscapularis and contains
the superior glenohumeral
ligament, the coracohumeral
ligament and the long head of
the biceps runs through it.
• The study cited closed the
interval on cadaver shoulders
by suturing the superior
glenohumeral ligament to the
subscapularis upper border
and middle glenohumeral
ligament
• They found a 30 degree
decrease in external rotation
• The differences in internal
rotation, ant and post
translation, and flexion were
not significant
Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective
capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint
Surg Am. 2003 Jan;85-A(1):48-55. PubMed PMID: 12533571.
Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic
rotator interval closure: effect of sutures on glenohumeral motion and anteriorposterior translation. Am J Sports Med. 2006 Oct;34(10):1656-61. Epub 2006 Jul 10.
PubMed PMID: 16832127.
supraspinatus
SGHL
subscap
MGHL
Harrison
#174 Sports
Which of the following findings is found more frequently in the
shoulder of a collegiate overhead throwing athlete compared with
a non-throwing athlete?
1.
2.
3.
4.
5.
A tight rotator interval
A tight posteroinferior capsule
A cord-like middle glenohumeral ligament
Bony deficiency of the anterior inferior glenoid
Increased humeral anteversion
#174 Answer: 2. A tight posteroinferior capsule
•
•
•
•
•
The questions is describing Internal Impingement which is abnormal
contact between the posterior rotator cuff and the posterior margin
of the glenoid, which results in fraying of the undersurface of the
rotator cuff/labrum
Pts are predominately overhead athletes who report pain while
throwing
Physical exam shows a decrease in passive internal rotation (in
abduction) which indicates excessive tightness of the posterior
capsule
A cord like middle glenohumeral ligament with an absent
anterosuperior labrum is a rare variant of the MGHL called a Buford
complex. If this is not recognized in a shoulder scope and confused
with a sublabral hole or pathologic laberal detachment and
reattached to the neck of the glenoid, painful restriction of rotation
and elevation will occur.
Bony deficiency of the anterior inferior glenoid is a Bony Bankart.
This is typically the result of an anterior shoulder dislocation and
may result in continued instability.
Mechanism of internal impingement.
The position of abduction and extreme
external rotation that occurs during
overhead throwing compresses the
supraspinatus and infraspinatus
muscles and their tendons between the
posterosuperior glenoid rim, the
posterior humeral head, and the
greater tuberosity, causing fraying of
the deep layers of the infraspinatus
Burkhart SS. Internal impingement of the shoulder. Instr Course Lect. 2006;55:29-34. Review. PubMed PMID: 16958436.
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics.
Arthroscopy. 2003 Apr;19(4):404-20. Review. PubMed PMID: 12671624.
137. Plication of the rotator interval produces the most
significant decrease in range of motion of the shoulder in
which of the following directions?
1- External rotation with the arm at the side
2- External rotation with the arm at 90° of abduction
3- Forward flexion with the arm in the plane of scapula
4- Internal rotation with the arm at the side
5- Internal rotation with the arm at 90° of abduction
1. External Rotation with the arm at the side
• The rotator interval is the
space between the
Supraspinatus and
Subscapularis and contains
the superior glenohumeral
ligament, the coracohumeral
ligament and the long head of
the biceps runs through it.
• The study cited closed the
interval on cadaver shoulders
by suturing the superior
glenohumeral ligament to the
subscapularis upper border
and middle glenohumeral
ligament
• They found a 30 degree
decrease in external rotation
• The differences in internal
rotation, ant and post
translation, and flexion were
not significant
Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective
capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint
Surg Am. 2003 Jan;85-A(1):48-55. PubMed PMID: 12533571.
Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM.
Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and
anterior-posterior translation. Am J Sports Med. 2006 Oct;34(10):1656-61. Epub 2006
Jul 10. PubMed PMID: 16832127.
supraspinatus
SGHL
subscap
MGHL
Harrison
197. Sports/shoulder&elbow
At the time of shoulder arthroscopy, a partial-thickness tear of the anterior fibers of the
supraspinatus is detected. Tearing of the footprint extends 7 mm from the articular margin of
the humeral head. This represents what percentage of the rotator cuff insertion in this
location?
1- 10%
2- 25%
3- 50%
4- 75%
5- 90%
Answer 3: 50%
• The area of insertion of
the rotator cuff onto the
greater tuberosity is sizeable,
at an average greater than 6
cm.
• The mean distance across the
insertion is 14.7 mm
according to the cited article
• 7/14.7= 50% (closest answer)
Dugas JR, Campbell DA, Warren RF, Robie BH, Millett PJ. Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):498-503.
PubMed PMID: 12378171.
Ruotolo C, Fow JE, Nottage WM. The supraspinatus footprint: an anatomic study of the supraspinatus insertion. Arthroscopy. 2004 Mar;20(3):246-9. PubMed PMID:
15007313.
Khalil
264. (Sports) A 25-year-old man with a history of two
previous open anterior stabilization procedures has
persistent recurrent instability. He denies any recent
trauma. A radiograph is seen in Figure 264a and MRI
scans are seen in Figures 264b and 264c. What is the
most likely reason for his continued instability?
12345-
Voluntary instability
Bony Bankart
Subscapularis tendon tear
Hill-Sachs lesion
Middle glenohumeral ligament tear
•
•
•
•
•
1- Voluntary instability
2- Bony Bankart
3- Subscapularis tendon tear
4- Hill-Sachs lesion
5- Middle glenohumeral ligament
tear
3-
Subscapularis tendon tear
• Voluntary instability (answer 1) is a diagnosis of exclusion if the
pathology doesn’t fit the clinical situation.
• A bony Bankart (answer 2) is a defect in the anteroinferior
glenoid rim, where it may engage with a Hill-Sachs lesion of
the humeral head (answer 4). Neither of these are seen in the
2 images that show the humeral head and glenoid. The
Bankart lesion is usually an avulsion of the INFERIOR GH
ligament (not the middle GHL - answer 5).
• What you do see in the 3rd image is atrophy and fatty infiltration
due to a tear of the subscapularis (Answer 3). Even if the MRI
cut is not familiar to you, you should be able to identify the
scapula and recognize that the muscle that looks “different” is
the one that is deep to the scapula.
• Lin
Question #: 22
Shoulder & Elbow / Sports Medicine
What is the incidence of full-thickness rotator
cuff tears in patients undergoing arthroplasty for
the treatment of primary glenohumeral
osteoarthritis?
•
•
•
•
•
12345-
1% to 2%
5% to 10%
10% to 15%
15% to 20%
20% to 25%
Duncan 2009
Question #: 22
Shoulder & Elbow / Sports Medicine
• Preferred Response: 2
5% to 10%
Minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do
not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty
performed for the treatment of primary osteoarthritis.
Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature
adversely affects many of these parameters.
Primary osteoarthritis of the shoulder is characterized by stiffness, glenohumeral joint-space
narrowing, and the formation of osteophytes on the humeral head. The rotator cuff is almost
always intact or has minimal lesions
Large rotator cuff tears are recognized as a negative prognostic indicator for shoulder arthroplasty in
diagnoses other than primary osteoarthritis
Recommended Reading(s):
•
Edwards TB, Boulahia A, Kempf JF, et al: The influence of rotator cuff disease on the results of shoulder arthroplasty for primary
osteoarthritis: Results of a multicenter study. J Bone Joint Surg Am 2002;84:2240-2248.
•
Norris TR, Iannotti JP: Functional outcome after shoulder arthroplasty for primary osteoarthritis: A multicenter study. J Shoulder Elbow
Surg 2002;11:130-135.
Duncan 2009
Question #: 58
With the development of glenohumeral internal rotation deficit in a pitcher, the humeral
head is shifted in what direction during the cocking phase of throwing?
1.
2.
3.
4.
5.
Anteroinferior
Anterosuperior
Posterosuperior
Posteroinferior
No change in position occurs
3- Posterosuperior
Overhead throwers, particularly pitchers, have well recognized adaptive
changes that occur at the glenohumeral joint. Pitchers display increased
external rotation and decreased internal rotation of the throwing shoulder
with the total arc of motion remaining similar to the opposite shoulder.
Although the increased external rotation likely enhances throwing
performance, speculation exists whether these changes compromise the
stability of the joint or predispose the shoulder to other types of soft tissue
injury. It has been demonstrated that posterior capsular tightness results in
increased posterosuperior migration of the humeral head in the late cocking
phase, possibly reducing the impingement of the greater tuberosity against
the posterior glenoid allowing increased external rotation range of motion.
Cleland
Recommended Readings:Grossman MG, Tibone JE, McGarry MH, et al: A cadaveric model of the throwing shoulder:
A possible etiology of superior labrum anterior-to-posterior lesions. J Bone Joint Surg Am
2005;87:824-831.
Lintner D, Mayol M, Uzodinma O, et al: Glenohumeral internal rotation deficits in
professional pitchers enrolled in an internal rotation stretching program. Am J Sports Med
2007;35:617-621.
106. Figure 106 shows the MRI arthrogram of an 18-yearold football player who injured his shoulder. What physical
examination finding is most likely to demonstrate his
pathology?
1- Jerk test
2- Gerber lift-off test
3- O’Brien test
4- Sulcus sign
5- Apprehension sign
Figure 106
106 Preferred Response: 1
• MRI shows signal change in posterior
•
•
labrum/behind labrum consistent with labral tear
Jerk test: Evaluation for posterior instability. Pt
sitting upright, arm flexed to 90deg, internally
rotated, elbow flexed to 90 deg. Posterior force
applied through axial load on humerus through
elbow. If there is significant laxity, shoulder will
dislocate or subluxate posterior. As arm is
extended, shoulder will reduce with a jerk. Test
is positive with a painful relocation
Posterior stress test and load/shift test also
specific for posterior instability
• Gerber lift-off test: pt upright with dorsum of hand behind L-spine,
hand is raised off back through internal rotation and extension.
Inability to do so suggests subscap dysfunction.
• O’Brien test: flex arm to 90deg with elbow extended, adduct arm
10-15 deg medial. Arm is internally rotated and downward force is
resisted, then repeated in supination. Pain with first maneuver that
is improved with the second suggests AC joint pain as well as
superior labrum
• Sulcus sign: arm is held relaxed at the side and an inferior traction
force is applied above the elbow. Dimpling between greater
tuberosity and acromion is noted. Greater than 2cm is almost
pathognominic for multidirectional instability. If the sulcus does not
reduce with external rotation, suggests rotator interval defect
• Apprehension sign: arm is abducted and externally rotated. Patient
will complain of sensation that shoulder is going to “go out”.
Decrease in sensation with pressure over humeral head or increase
when pressure is released after further extension is positive
relocation test
Vasileff, Sports
References:
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2004, pp 53-77.
Millett PJ, Clavert P, Hatch GF III, et al: Recurrent posterior shoulder instability. J Am Acad Orthop Surg 2006;14:464-467.
Question #: 143 (Shoulder/Elbow)
The initial injury responsible for the shoulder pathology shown in Figure 143 is
typically best diagnosed on what radiographic view?
1- Axillary
2- Serendipity
3- Supraspinatus outlet
4- AP of the acromioclavicular joint
5- AP of the shoulder
Preferred Response: 1
• Reverse Hill-Sachs: initial injury is posterior
•
•
•
dislocation. Gold standard to diagnose it is
Axillary radiograph
Serendipity (Answer 2): SC joint pathology
Supraspinatous outlet view (Answer 3): To look
at acromial morphology
Other important views:
– Westpoint: to look at anteroinferior rim: good for
bony Bankart
– Stryker notch: good for Hill-Sachs
Scapular Y
West point
Stryker
notch
Question #212 (S/E)
• A 42-year-old man sustained a shoulder injury after falling
from a ladder. The MRI scan shown in Figure 212 reveals an
injury to the structure marked with a white asterisk (*).
Which of the following physical examination findings will most
likely reveal weakness in this patient?
1- Shoulder external rotation with the arm at the side
2- Shoulder abduction
3- Belly-press maneuver
4- Forward elevation in the scapular plane
5- Elbow flexion
1-
Shoulder
external
rotation with
the arm at the
side
2- Shoulder
abduction
3- Belly-press
maneuver
4- Forward
elevation in the
scapular plane
5- Elbow flexion
3 - Belly-press maneuver
• Straightforward anatomy question: what are these
•
muscles and what do they do. The first step is to orient
yourself with this MRI cut. They tell you it’s a shoulder;
that’s a good start. Sometimes it’s easiest to identify the
osseous structures first. The starred structure is deep to
the scapula body. Boom - subscapularis. We test this with
the Belly-press and Lift-off tests (#3).
External rotation tests supra/infraspinatus/teres minor
(#1), abduction tests deltoid/supraspinatus (#2), forward
elevation tests impingement (#4), elbow flexion tests
biceps/brachialis (#5).
supraspinatus
coracoid
acromion/scapular spine
infraspinatus
scapular body
•
•
Lin
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging
interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:10881105. Tennent TD, Beach WR, Meyers JF: A review of the special tests associated with
shoulder examination: Part I: The rotator cuff tests. Am J Sports Med 2003;31:154-160.
Question #: 273 - Sports
• The rotator cable, seen arthroscopically at the
margin of the avascular zone, is an extension of
the:
•
•
•
•
•
12345-
biceps tendon sheath.
teres minor tendon.
subscapularis tendon.
coracohumeral ligament.
superior labrum.
Preferred Response: 4
Taken directly from the paper we review in sports conference….
“The intact rotator cuff demonstrates an arching, cable-like
thickening surrounding a thinner crescent of tissue that inserts into
the greater tuberosity of the humerus; this is known as the cablecrescent complex. This cable-like structure represents a thickening
of the coracohumeral ligament and consistently is located at the
margin of the avascular zone. The rotator cable extends from its
anterior attachment just posterior to the biceps tendon to its
posterior attachment near the inferior border of the infraspinatus
tendon.”
Burkhart SS, Lo IK: Arthroscopic rotator cuff repair. J Am Acad Orthop Surg
2006;14:333-346.
Question #: 273 - Sports
• The rotator cable, seen arthroscopically at the
margin of the avascular zone, is an extension of
the:
•
•
•
•
•
12345-
biceps tendon sheath.
teres minor tendon.
subscapularis tendon.
coracohumeral ligament.
superior labrum.
Preferred Response: 4
Taken directly from the paper we review in sports conference….
“The intact rotator cuff demonstrates an arching, cable-like
thickening surrounding a thinner crescent of tissue that inserts into
the greater tuberosity of the humerus; this is known as the cablecrescent complex. This cable-like structure represents a thickening
of the coracohumeral ligament and consistently is located at the
margin of the avascular zone. The rotator cable extends from its
anterior attachment just posterior to the biceps tendon to its
posterior attachment near the inferior border of the infraspinatus
tendon.”
Burkhart SS, Lo IK: Arthroscopic rotator cuff repair. J Am Acad Orthop Surg
2006;14:333-346.
End Shoulder, Begin Elbow
Elbow
• Throwing biomechanics during
acceleration/late cocking phase
– Three major stresses with valgus torque and
rapid extension
• Tensile stress along medial side (UCL)
• Shear stress in the posterior compartment
– Posteromedial tip of the olecranon and trochlea
• Compressive stress laterally
Elbow Throwing Biomechanics
• Medial Muscle dynamic stabilization
– Protects UCL
• FCU – primary dynamic stabilizer to valgus stability
• FDS – secondary stabilizer
• Posterior compartment
– Development of osteophytes
• Repetitive and forceful driving of the olecranon into the olecranon
fossa
• Valgus extension overload
– Posterior compartment shear
– Medial compartment tension
• Variety of injuries occur
Elbow Throwing Biomechanics
• Studies show
– Both olecranon and UCL contribute valgus
stability
What phase of throwing places maximum
stress on the medial collateral ligament
of the elbow?
1. Late cocking and acceleration
2. Early cocking
3. Deceleration
4. Windup
5. Release
1
• Pure definition – perennial OITE favorite.
• The combination of valgus torque and rapid extension generates 3 main stresses:
– Tensile along the medial side (UCL, flexor/pronator mass, medial epicondyle apophysis
– Shear in the posterior compartment (posteromedial tip of olecranon)
– Compression as high as 500N in the lateral compartment (radiocapitellar)
• Muscle dynamic stabilization protects the medial side (protects UCL)
– FCU – primary dynamic contributor in cadaveric study
– FDS – secondary contributor
• ‘Valgus extension overload’ – from posterior compartment shear and medial
•
compartment tension – be careful not to take too much osteophyte off
posteromedial olecranon or you will place UCL at risk ( stress)
Fastball and slider put highest force on shoulder/elbow, curveball generates the
highest valgus stress, change-up produces least torque
What is the position of maximal stress of the
MCL complex of the elbow in the overhead
throwing motion (baseball)?
• 1. Wind-up
• 2. Early cocking
• 3. Late cocking/early acceleration
• 4. Ball release
• 5. Follow-through
3
• Repetitive high velocity, valgus stress to the medial aspect of the elbow
results in attention or rupture of the anterior band of the ulnar collateral
ligament (UCL). Late cocking and acceleration phases of throwing are
periods of highest stress generation.
•
• The UCL (or MCL) consists of 3 bundles; anterior, posterior, and variable
•
transverse oblique. The anterior bundle is the primary restraint to valgus
force of the elbow from 30-120 degrees of flexion and is subjected to nearfailure tensile stresses during the acceleration phases of throwing.
• EL Cain et al. Elbow Injuries in Throwing Athletes: A current concepts review. AM J
•
•
Spots Med 2003; 31:621-635.
Miller Review of Orthopaedics. 4th edition pg 244.
Williams
Elbow History & PE
• Focus
– UCL
• Valgus instability
– Flex elbow to 20-30 degrees to unlock olecranon
 Valgus stress then applied
• Milking maneuver
• Moving valgus stress test
– Modification of milking maneuver
– Medial epicondyle
– Flexor pronator mass
Elbow History & PE
• Posterior Compartment
– Exam focuses on olecranon
• Pain elicited in the posterior compartment with
pronation, valgus and extension forces indicate
– Valgus extension overload
Elbow Imaging
• AP
• Lateral
• Oblique views
• Valgus stress radiographs
– Quantify medial joint line opening
• Greater than 3 mm of opening on side to side
comparison
– Diagnostic of valgus instability
Elbow Imaging
• MRI
– Indicates tears of UCL
– Helpful in finding traumatic tears of flexor
pronator mass
• US
– Inexpensive method to evaluate UCL
– Operator dependent
Medial Elbow Pain
• UCL injury – what makes up this complex?
– Valgus instability is demonstrable in only 50%
of patients
• Dynamic phenomenon
– Moving valgus stress test
 High sensitivity and specificity
– Treatment
• Nonsurgical
– 6-12 wks of rest
– 42% of athletes return to previous level of play
UCL Injury
• Treatment
– Surgery
• Only in high level
athlete
• Ligament reconstruction
favor over direct repair
• 75-80% RTP at same or
better level 1year after
repair
• What tendon do we
use to reconstruct
ligament?
UCL Injury - Surgery
• Jobe’s original UCL
reconstruction technique
– Tendinous transection and
reflection of flexor pronator
mass
– Submuscular transposition
of ulnar nerve
– Creation of humeral
tunnels - posterior
humeral cortex
Morbidity of procedure:
Excellent exposure at expense of
flexor pronator mass and Ulnar
Nerve
UCL Injury - Surgery
• Modified Jobe Technique
– Muscle splitting approach developed
– Modifications in bone tunnels
– Considered the gold standard
• Docking Technique
– Another modification of Jobe technique
• Simplifies graft passage, tensioning and fixation
• Muscle splitting
• Ulna tunnel creation similar to Jobe technique
• Figure 4
UCL Injury - Surgery
• Interference Screw Fixation Technique
–
–
–
–
Reconstructs central isometric fibers of native UCL
Achieves fixation with interference screws
Less technically demanding
Less dissection
• Muscle splitting approach
• Single central tunnel on ulna
– Graft passage
• Less difficult with interference screw in single tunnel
UCL Injury - Surgery
Hybrid UCL
reconstruction with
interference screw on
ulna and docking
technique on epicondyle
Posterior Elbow Pain
aka – Pitcher’s Elbow
• Isolated Valgus extension overload
• Elbow pain localized on olecranon
– Posterior aspect
– Medial aspect
• Present in deceleration phase of throwing
– Elbow reaches terminal extension
• History – locking and catching
– Pain with extension
• PE
– Pain localized to posterior compartment
Posterior Elbow Pain
• Radiographs
– Posteromedial olecranon osteophytes
– Loose bodies
• Treatment
– Nonsurgical
• Activity modification
• Steriod injection
• NSAIDS
– Surgical
• Arthroscopic debridement
• Limited incision arthrotomy to decompress posterior
compartment
Posterior Elbow Pain
• Relative contraindication to debride olecranon
– Presence of UCL insufficiency
– Olecranon resection
• Increases valgus angulation of the elbow and strain on UCL
• UCL insufficiency
– Contact alterations in posteromedial compartment
• Symptomatic chondrosis
• Osteophyte formation
– Manifest as valgus extension overload syndrome
Olecranon Stress Fracture
• What muscle inserts on the olecranon?
• This muscle contracts forcefully
– During acceleration phase
• Children
– Olecranon apophysitis
 Repeated contractions causing shear and distraction
forces to physis
– Adolescents with closed physes
 Stress fractures of olecranon apophysis can occur
Olecranon Stress Fracture
• Initial treatment
– Activity modification
– NSAIDS
– Ice
– PT
• Chonic apophysitis > 6 wks
– Single cancellous screw placed down IM canal
crossing fracture site or unfused apophysis
Lateral Elbow Pain
• Capitellar OCD (Panners)
– More common in skeletally
immature athletes
• Lateral compression
•
•
during throwing
Genetic predisposition
Tenuous end artery
vascular supply
– Two end arteries supply
capitellum
 Radial recurrent
artery
 Interosseous
recurrent artery
POSTERIOR SUPPLY!!!!
Panners
• PE
– Capitellar tenderness
– Limited ROM
• Treatment
– Initial
• Activity modification
• NSAIDS
• Short period of bracing
– Surgery
• Failure of nonsurgical tx
• Diagnostic arthroscopy
– Confirms stability of lesion
 Drilling of lesion with 2mm smooth pin
Panners
• Surgery
– For partially or fully detached lesions
• Immediate surgery
–
–
–
–
Loose bodies removed
Cartilage contoured to stable rim
Antegrade drilling of lesion performed
Mosaicplasty for multiple OCD lesions of capitellum
Little Leaguer’s Elbow
• Stress Fracture of medial epicondyle
• Treatment
– Rest
– Limitation on number of inning pitched per
week