![Page 1: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/1.jpg)
State of the Art (standard of care?)
for Sports Shoulder Surgery
Slocum Sports Med Conference 2019
Lucas Korcek, MD
![Page 2: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/2.jpg)
Disclosures
• I have nothing to disclose
![Page 3: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/3.jpg)
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
![Page 4: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/4.jpg)
MSK Shoulder Anatomy
Bony:
- Clavicle
- Scapula
- Humerus
Supporting ligaments:
- Stabilize the AC joint
- Stabilize the GH joint
![Page 5: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/5.jpg)
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
![Page 6: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/6.jpg)
Neurologic:
Brachial plexus
MSK Shoulder Anatomy
![Page 7: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/7.jpg)
Vascular:
Brachial artery and its branches
- Circumflex humeral vessels
MSK Shoulder Anatomy
![Page 8: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/8.jpg)
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
![Page 9: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/9.jpg)
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
![Page 10: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/10.jpg)
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
![Page 11: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/11.jpg)
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Massive RC tear
![Page 12: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/12.jpg)
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Massive RC tear
RC tear arthropathy
![Page 13: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/13.jpg)
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
![Page 14: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/14.jpg)
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
![Page 15: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/15.jpg)
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
![Page 16: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/16.jpg)
RC tearPrognosis
• 50% of asymptomatic tears become symptomatic within 2-3 years
• 50% of symptomatic tears progress within 2 years
- bigger tears progress faster
![Page 17: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/17.jpg)
RC tear
Should we aggressively repair partial or small RC tears?
![Page 18: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/18.jpg)
RC tear
What is the single biggest consideration for treatment?
a. Smokingb. Medical comorbiditiesc. Aged. Functional statuse. Sex
![Page 19: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/19.jpg)
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
![Page 20: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/20.jpg)
RC tearRisk of re-tear after repair associated with:
Smoking Diabetes Muscular atrophy Large tear size Rehab non-compliance Age > 65
![Page 21: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/21.jpg)
RC tear
Should we aggressively repair partial or small RC tears?
Yes, in young active patients
Cautiously in other populations
![Page 22: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/22.jpg)
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
![Page 23: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/23.jpg)
AC Separation – injury to AC and CC ligaments
![Page 24: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/24.jpg)
AC Separation
• Type 1-2 (sprain) Conservative management
• Type 4-6 (major displacement) Always operate
• Type 3 (moderate displacement) Controversial
![Page 25: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/25.jpg)
AC Separation
Type 3 (moderate displacement)
Conservative management• Permanent bump• Sometimes residual AC instability, pain,
weakness
![Page 26: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/26.jpg)
AC Separation
Type 3 (moderate displacement)
Classic surgical treatment• Staged surgery with hook
plate/plate removal
• High incidence of complication (fracture)
![Page 27: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/27.jpg)
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
![Page 28: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/28.jpg)
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
![Page 29: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/29.jpg)
Instability
![Page 30: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/30.jpg)
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
![Page 31: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/31.jpg)
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
![Page 32: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/32.jpg)
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
![Page 33: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/33.jpg)
Instability
Traumatic anterior shoulder dislocation
The humeral head sitting on glenoid is analogous to a golf ball on a tee
![Page 34: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/34.jpg)
Instability
Traumatic anterior shoulder dislocation
Each dislocation event will cause some erosion of the anterior-inferior glenoid bone
![Page 35: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/35.jpg)
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
![Page 36: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/36.jpg)
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)
![Page 37: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/37.jpg)
Instability
Posterior shoulder dislocation
- Much less common than anterior (2% of dislocations)
- 50% of traumatic posterior dislocations seen in ED are undiagnosed
![Page 38: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/38.jpg)
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
![Page 39: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/39.jpg)
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
![Page 40: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/40.jpg)
Instability
Luxatio Erecta (Inferior glenohumeral dislocation)
• Very rare
• High risk of NV injury• brachial plexopathy• axillary artery injury
![Page 41: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/41.jpg)
InstabilityMDI: Multidirectional shoulder instability
Remember “AMBRI”
AtraumaticMultidirectionalBilateral (frequently)Rehabilitation (main treatment)Inferior capsular shift (best alternative to non-op)
![Page 42: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/42.jpg)
Overview
• Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
![Page 43: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/43.jpg)
Throwing Athlete Injuries
• Posterior Labral tear• Glenohumeral Internal Rotation Deficit (GIRD)• SLAP tear• Internal Impingement• Little Leaguer’s Shoulder
![Page 44: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/44.jpg)
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
![Page 45: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/45.jpg)
Throwing Athlete InjuriesSLAP = Superior Labrum Anterior to Posterior Injury
![Page 46: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/46.jpg)
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
![Page 47: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/47.jpg)
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
![Page 48: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/48.jpg)
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
![Page 49: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/49.jpg)
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
![Page 50: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/50.jpg)
Throwing Athlete InjuriesInternal Impingement
Treatment:
• PT and posterior capsular stretching is most effective treatment
• RC repair/debridement in recalcitrant cases
![Page 51: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/51.jpg)
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
![Page 52: State of the Art (standard of care?) for Sports Shoulder](https://reader034.vdocuments.us/reader034/viewer/2022051319/627aeef965aa2e2aa13aa6be/html5/thumbnails/52.jpg)
You made it!
• Shoulder Anatomy
• Impingement and Rotator Cuff
• AC separation
• Instability
• Injury in throwing athlete
• Later: shoulder exam and interesting cases