Posterosuperior and anterosuperior impingement of the shoulder in overhead athletes-evolving concepts

Current Concepts on the Management of Shoulder Instability in Throwing Athletes

PURPOSE OF REVIEW

The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments.

RECENT FINDINGS

The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Is Workload Associated With Internal Impingement in Professional Baseball Pitchers? An Analysis of Days of Rest, Innings Pitched, and Batters Faced

Background

Internal impingement is a common cause of shoulder pain and dysfunction in baseball pitchers.

Purpose/Hypothesis

The purpose of this study was to determine if the amount of rest days between outings, the number of innings pitched in each outing, and the number of batters faced in each outing are risk factors for internal impingement in professional baseball pitchers. It was hypothesized that a higher workload would significantly increase a pitcher's risk of developing internal impingement.

Study Design

Case-control study; Level of evidence, 3.

Methods

All professional (Major and Minor League) baseball pitchers who were diagnosed with internal impingement between 2011 and 2017 were identified using the Major League Baseball's Health and Injury Tracking System. A separate player usage data set was used to determine workload. The authors compared workload variables (days of rest, innings pitched, and batters faced per game) between each of 4 injury-exposure groups (pitchers with documented internal impingement <2, <6, <12, and >12 weeks after a game) and a control group of pitchers with no internal impingement using Student t tests or Mann-Whitney U tests. In a within-pitcher paired analysis of the injury groups, the workload variables during 3 acute periods (<2, <6, and <12 weeks preinjury) were compared with the baseline values (>12 weeks preinjury).

Results

Overall, there were 624 professional baseball pitchers diagnosed with internal impingement during the study period. Compared with pitcher games (n = 213,964), pitchers in all 4 injury-exposure groups had significantly more innings pitched per game (P ≤ .003 for all) and faced significantly more batters per game (P < .001 for all). There were significantly more starting pitchers in each of the injury-exposure groups when compared with the controls (P < .001 for all). However, when comparing acute and baseline workloads in the pitchers diagnosed with internal impingement, there were no significant differences in the number of innings pitched, batters faced, or days of rest.

Conclusion

This analysis revealed significantly greater pitcher workload and percentage of starting pitchers in professional baseball players diagnosed with internal impingement when compared with healthy controls. However, this injury did not seem to be associated with an acute increase in workload.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis

Background

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players.

Purpose

To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary.

Results

Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar.

Conclusion

RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

GIRD syndrome in male handball and volleyball players: Is the decrease of total range of motion the turning point to pathology?

BACKGROUND

Adaptations in glenohumeral range of motion may affect overhead athletes and lead to shoulder pathologies.

OBJECTIVE

The purpose of this study was to evaluate glenohumeral internal rotation deficit (GIRD) and postero-superior impingement among male handball and volleyball players and the relationship between these pathologies and training level (amateur vs. professional), position (attack vs. no attack), experience (> 5 years vs. < 5 years) and sports.

METHODS

Sixty-seven handball players and 67 volleyball players with a mean age of 25 [± 5] years were included. The range of motion including external and internal rotation in 90∘ abduction of the dominant and non-dominant shoulder was measured of each examined athlete. Visual analogue scale, disabilities of the shoulder and hand score, constant score and subjective shoulder value were recorded. The athletes were examined for postero-superior impingement and abduction force was measured with an isokinetic dynamometer.

RESULTS

Internal rotation was significantly lower and external rotation was significantly greater in the dominant arm for both sports. 72% presented with GIRD. GIRD was more prevalent in athletes active for > 5 years (odds ratio (OR) 3), in those training > 3 times per week (OR 1.4) and in handball players (OR 2.7). 24% presented with postero-superior impingement. Players active for > 5 years (OR 1.22), professionals (OR 1.14), volleyball players (OR 1.19), offensive players (OR 2.2) and athletes with GIRD > 10∘ (OR 1.5) showed a higher prevalence of postero-superior impingement.

CONCLUSION

GIRD is a common phenomenon in handball and volleyball players. Offensive players are frequently suffering from postero-superior impingement. GIRD > 10∘ leads in nearly 75% of the athletes to a decrease of total range of motion and a high rate of postero-superior impingement. Thus, a decreased range of motion seems to be the turning point from adaptation to pathology. Therefore, regular controls of range of motion and countermeasures by means of stretching the posterior shoulder joint should be integrated in the training content.

Arthroscopic release of the pectoralis minor tendon from the coracoid for pectoralis minor syndrome

Purpose

The term “pectoralis minor syndrome” refers to this constellation of symptoms that can occur when the pectoralis minor (Pm) is shortened and contracted. Release of the tendon of the Pm from the coracoid has been reported to provide substantial clinical improvement to patients presenting with pectoralis minor syndrome. The purpose of this study was (1) to describe the technique for endoscopic release of pectoralis minor tendon at the subdeltoid space, (2) to classify the pectoralis minor syndrome according to its severity and (3) and to report the short-term outcomes of this procedure in a consecutive series of patients diagnosed with pectoralis minor syndrome.

Methods

Endoscopic release of the pectoralis minor tendon was performed in a series of 10 patients presenting with pectoralis minor syndrome. There were six females and four males with a median age at the time of surgery of 42 (range from 20 to 58) years. Four shoulders were categorized as grade I (scapular dyskinesis), and six as grade II (intermittent brachial plexopathy). Shoulders were evaluated for pain, motion, satisfaction, subjective shoulder value (SSV), quick-DASH, ASES score, and complications. The mean follow-up time was 19 (range, 6 to 49) months.

Results

Arthroscopic release of the tendon of the Pm led to substantial resolution of pectoralis minor syndrome symptoms in all but one shoulder, which was considered a failure. Preoperatively, the median VAS for pain was 8.5 (range, 7–10) and the mean SSV was 20% (range, 10% - 50%). At most recent follow-up the mean VAS for pain was 1 (range, 0–6) and the mean SSV 80% (range, 50% - 90%). Before surgery, mean ASES and quick-DASH scores were 19.1 (range, 10–41.6) and 83.1 (range, 71 and 95.5) points respectively. At most recent follow-up, mean ASES and quick-DASH scores were 80.1 (range, 40–100) and 19.3 (range, 2.3–68) points respectively. No surgical complications occurred in any of the shoulder included in this study.

Conclusions

Endoscopic release of the tendon of the pectoralis minor from the coracoid improves pain, function and patient reported outcomes in the majority of patients presenting with the diagnosis of isolated pectoralis minor syndrome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00491-x.

Epidemiology of injuries in track and field athletes: a cross-sectional study of specific injuries based on time loss and reduction in sporting level

OBJECTIVES

To prevent the occurrence of injury in a sport, exact knowledge of injury patterns is needed. To synthesize sport-specific injuries in track and field comparing elite and recreational level athletes, as well as gender. Furthermore, analyze the time loss due to injury and reduction in athletic performance.

METHODS

Injury type-specific frequencies were recorded according to discipline, gender and performance level. Injury severity was assessed by time loss duration and performance reduction.

RESULTS

64% of athletes suffered at least one injury. In the top 10 ranking, 83% (n = 524) were located in the lower extremities. A muscle strain of the thigh had the highest prevalence in sprint (34%, n = 41), jump (15%, n = 15) and middle-distance running (16%, n = 6). More injuries occurred during training (75%, n = 165) as compared to competition (25%, n = 56). The longest time loss was documented in throwing with a downtime of 36 weeks after a ligament injury of the elbow and 39 weeks after a muscle injury of the elbow. The injury with the highest number of athletes with a reduced level of performance was the foot ligament injury in sprint athletes at 100%.

CONCLUSION

Assessing time loss and performance reduction in athletics, there are discipline-specific injury patterns. This study points out the high prevalence of training injuries, highlighting the need for future investigations to adapt training management, improve medical care and rehabilitation with respect to every discipline.

[Rotator cuff tear : Indications and pathology-specific reconstructive procedures]

Rotator cuff (RC) tears comprise a broad spectrum of lesions ranging from partial to full thickness tears of a single tendon and massive cuff tears. Both glenohumeral trauma as well as degenerative processes can result in tearing of the RC. Treatment therefore requires a meticulous diagnosis as well as a differentiated approach by careful consideration of morphological and patient-specific factors. The pathogenesis, tear morphology, clinical symptoms and functional demands of the patient determine the therapeutic approach. Despite pathological and individual patient-related factors, early surgical repair is generally recommended for traumatic RC tears in young patients and in patients with high functional demands due to the high risk of tear progression. The results of RC repair are negatively correlated with the size of the lesion, the number of tendons involved, the degree of tendon retraction, muscular alteration and patient age. This article provides an overview of the various pathogenesis, indications and surgical repair of RC tears with respect to modern pathology-specific reconstructive procedures.

["Handball shoulder" in the focus of diagnosis and treatment]

Handball is one of the most popular team sports in Germany. In the diagnosis and treatment of shoulder injuries and shoulder complaints, a distinction must be made between sports-specific adaptation over many years and supposed decompensation. In contrast to throwing sports such as baseball or javelin, intended movement sequences in handball are often disrupted suddenly and abruptly by simultaneous contact with an opponent. This can result in a potential for further injuries. There is usually a gradual transition from a physiologically adapted handball shoulder to a pathological throwing shoulder requiring therapy. A throwing shoulder is characterised by a limitation of performance caused by pain in the shoulder during repeated sports-specific stress. In addition to a thorough clinical examination, MRI is the preferred method of examination due to the fact that changes in a handball shoulder are reflected in muscular tissue, tendons and bone in the form of overstrain reactions (bone bruise). Patients should not only take a break from sports and receive adequate pain treatment, but also undergo a specific physiotherapy regimen. MRI results should always be interpreted in due consideration of symptoms and clinical examination results. Surgery is indicated if there is a lack of improvement after specific pain treatment and physiotherapy, or structural damage corresponding to the symptoms without a chance of recovery or with a higher probability of symptoms and function improving in response to surgery. After surgical treatment, the subsequent rehabilitation plays a major role. Depending on the injury, up to 90 % of the patients may be able to return to sports.

Humeral Retroversion and Participation Age in Professional Baseball Pitchers by Geographic Region

CONTEXT

Baseball is played around the world, including in North America and Latin America. The repetitive and stressful act of throwing can lead to adaptations such as increased humeral retroversion (HR) in the throwing arm. This adaptation is often considered beneficial as it allows more glenohumeral external rotation during the cocking phase of pitching without soft tissue stretching. Therefore, it is speculated that throwing should be started at a young age to capitalize on this adaptation. Interestingly, athletes in different geographic regions of the world often begin organized baseball at different ages. However, range of motion (ROM), HR, and the starting age of baseball have never been examined based on geographic region.

OBJECTIVE

To determine if ROM, HR, and the starting age of baseball players differed between professional baseball pitchers from North America and Latin America.

DESIGN

Cross-sectional study.

SETTING

Clinical setting.

PATIENTS OR OTHER PARTICIPANTS

Thirty professional pitchers (North American = 19, Latin American = 11) with no current injury or surgery in the previous 6 months.

MAIN OUTCOME MEASURE(S)

Both ROM and HR were measured in the dominant and nondominant shoulder of each participant. The starting age for baseball was self-reported.

RESULTS

The Latin American group had more dominant-arm HR (8.7°; P = .034), more nondominant-arm external rotation (5.3°; P = .049), and a trend toward more nondominant-arm HR (6.5°; P = .058), yet they started playing baseball at a later age (by 3.7 years; P = .021) compared with the North American group.

CONCLUSIONS

Latin American players had greater HR but started playing baseball at an older age. These findings contradict current thinking that HR would be more pronounced if baseball was started at a younger age. Additional research is required to better understand HR and the genetic, environmental, and nutritional factors that contribute to its development.

Performance and return to sport following rotator cuff surgery in professional baseball players

BACKGROUND

While many injuries to the rotator cuff in professional baseball players can be managed nonoperatively, recovery fails to occur with nonoperative treatment in some players and surgery on the rotator cuff is performed in an attempt to return to sport (RTS).

METHODS

All professional baseball players who underwent rotator cuff surgery between 2010 and 2016 were included by use of the Major League Baseball injury database. Demographic and performance data (before and after surgery) for each player were recorded. Preoperative and postoperative performance metrics were then compared.

RESULTS

Overall, 151 professional baseball players underwent rotator cuff débridement (n = 130) or rotator cuff repair (n = 21). In the rotator cuff repair group, 6 (28.6%) underwent single-row repair, 5 (23.8%) underwent double-row repair, and 10 (47.6%) underwent side-to-side repair. Among the 11 players who underwent either single- or double-row repair, the average number of anchors used per repair was 2.09 ± 1.1 (range, 1-4). Most performance metrics declined following rotator cuff débridement. For players who underwent débridement, the RTS rate was 50.8% (42.3% at the same level or a higher level and 8.5% at a lower level). For players who underwent repair, the RTS rate was 33.3% (14.3% at the same level or a higher level and 19% at a lower level). Most players underwent at least 1 concomitant procedure at the time of rotator cuff surgery.

CONCLUSION

Rotator cuff débridement is significantly more common than repair in professional baseball players, with 86% of all rotator cuff surgical procedures reported as débridement. RTS rates following débridement and repair are disappointing, at 50.8% and 33.3%, respectively. For players who do return, performance declines after surgery.

Clinical characteristics of patients with posterosuperior labral tear: a comparison with patients with other shoulder disorders

Background

Among the various causes of shoulder pain, the glenoid labral tear is likely to be overlooked due to its ambiguous symptoms, especially if clinicians do not have a prior suspicion, making it difficult to diagnose, unlike adhesive capsulitis or a rotator cuff tear. Therefore, the aim of this study was to evaluate the clinical features of posterosuperior (PS) labral tear.

Methods

Of the patients who visited the clinic, the medical records of patients with shoulder pain who underwent shoulder magnetic resonance imaging or ultrasound after intra-articular injection (arthrosonography) were investigated retrospectively. Based on these criteria, a total of 120 patients with adhesive capsulitis, rotator cuff problem, or PS labral tear were included for analysis in this study.

Results

In the physical examination, all patients with a PS labral tear were positive on the O’Brien test (13/13, 100%) and the external rotation (ER) test with the upper arm in the abduction position (abduction and ER [ABER] test) (13/13, 100%), but they were negative on other tests, such as the Hawkins–Kennedy (1/13, 7.69%) and Neer (0/13, 0.00%) tests. Except one patient, all patients with a PS labral tear were negative on the ER test with the upper arm in the neutral position (ER test) (1/13, 7.69%). In the clinical history, all patients with a PS labral tear had a characteristic episode of shoulder pain occurring in the excessive ABER posture.

Conclusion

In patients with characteristic physical findings (no definite loss of motion of the shoulder joint, negative in an ER test, but positive in an ABER test and O’Brien test), and with a clinical history of PS labral tear (a history of pain occurring with the excessive ABER posture), clinicians need to have a suspicion of PS labral tear and to identify the PS labral tear using MRI or arthrosonography

The glenocapsular ligament and the posterosuperior part of the joint capsule of the shoulder are well vascularized

PURPOSE

A detailed structural anatomy of the posterosuperior shoulder capsule and "glenocapsular ligament" is still rather unknown. The purpose of this study was meticulously to investigate and describe the structure and blood supply of the glenocapsular ligament on the posterosuperior shoulder joint capsule.

METHOD

Sixteen fixed and twelve fresh cadaveric shoulder specimens with a mean age of 73.4 (±6.4) years were analysed. Dissection without arterial injection was performed on the 16 fixed specimens-using an alcohol-formalin-glycerol solution. Before dissection, the 12 fresh specimens received of arterial injection a 10% aqueous dispersion of latex solution. After the injection, these shoulders were also fixed in an alcohol-formalin-glycerol solution.

RESULTS

The glenocapsular ligament was found in all 28 specimens. Single or double parallel-running bundles of connective tissue fibres were found to form a capsular-ligamentous structure on the posterosuperior part of the joint capsule. One part of the ligament was mediosuperior, another posterosuperior. The mediosuperior part varied in shape, and in 12 of 28 cases, it was absent. The glenocapsular ligament arose from the supraglenoid tubercle and posterior part of the collum scapulae and inserted into the semicircular humeral ligament. The posterior ascending branch of the circumflex scapular artery directly fed small branches laterally and medially to the joint capsule, supplying the glenocapsular ligament and the deep layer of the joint capsule.

CONCLUSION

The glenocapsular ligament is a constant anatomical structure that consists of one or two different parts. The glenocapsular ligament and the posterosuperior part of the joint capsule appear well vascularized via the posterior ascending branch of the circumflex scapular artery.

CLINICAL RELEVANCE

It is the hope of the authors that this anatomical study can help surgeons who perform open or arthroscopic surgery to the posterior part of the shoulder. Knowledge of the vascular anatomy presented in this study may be especially important when incisions are made to the posterior part of the shoulder, and should minimize the risk of complications.

[Impingement syndromes of the shoulder]

In addition to tears of the rotator cuff, isolated impingement syndrome of the shoulder is the most common diagnosis in shoulder disorders. This is of high relevance in orthopedic sports medicine. In fact, impingement of the shoulder is not the diagnosis but rather a symptom of a functional or even a structural pathology. Detailed knowledge about the different types of impingement and the underlying causes is essential to provide adequate treatment. Primarily, impingement of the shoulder should be treated nonoperatively. However, if there is no clinical improve despite adequate conservative treatment, there is usually a structural pathology which cannot be adequately compensated for and surgical treatment may be necessary. In the case of severe structural pathologies, such as a full-thickness tear of the rotator cuff, a subsequent surgical treatment may be indicated.

Alterations in tendon microenvironment in response to mechanical load: potential molecular targets for treatment strategies

Rotator cuff (RC) tendons could beinflicted in many ways with an eventual outcome of pain, weakness and disability, which represent a large burden on health care cost. However, optimal healing, either conservatively or with surgical intervention, remains an issue that needs further investigation. Disorders of the RC tendons may result from external factors like trauma, or internal factors through physiologic and metabolic derangement. Most RC tendon disorders may be asymptomatic and may result from an over-activity of the inflicted shoulder and its tendons. Such tendon disorders are poorly diagnosed since patients do not seek medical attention until pain or weakness ensue. Immunological and biochemical events in RC disorders due to mechanical intolerance have not been investigated. Generally, the mechanical load drives normal physiological properties of the tendon. But, mechanical overload/burden exerts stress on tenocytes, and disrupts the tendon microenvironment by triggering a multitude of signaling pathways leading to extracellular matrix remodeling, disorganization, alteration in collagen composition and apoptosis. These events result in weak tendon which is highly susceptible to rupture or tear. In this article, we critically reviewed the intrinsic signaling pathways that are excessively triggered by continuous mechanical load and the counteracting physiological responses and associated derangements. The elucidation of the molecular events underlying mechanical stress-induced symptomatic/asymptomatic tendinopathy could provide information on potential target sites for translational application in the management of rotator cuff disorders.

Internal Impingement of the Shoulder: A Risk of False Positive Test Outcomes in External Impingement Tests?

Background

External impingement tests are considered as being particularly reliable for identifying subacromial and coracoid shoulder impingement mechanisms. The purpose of the present study was to evaluate if these tests are likely to provoke an internal shoulder impingement mechanism which, in cases of a pathologic condition, can lead to a positive test result.

Method

In 37 subjects, the mechanical contact between the glenoid rim and the rotator cuff (RC) was measured quantitatively and qualitatively in external impingement test positions using an open MRI system.

Results

Mechanical contact of the supraspinatus with the posterosuperior glenoid was present in 30 subjects in the Neer test. In the Hawkins test, the subscapularis was in contact with the anterosuperior glenoid in 33 subjects and the supraspinatus in 18. In the horizontal impingement test, anterosuperior contact of the supraspinatus with the glenoid was identified in 35 subjects.

Conclusion

The Neer, Hawkins, and horizontal impingement tests are likely to provoke the mechanism of an internal shoulder impingement. A posterosuperior internal impingement mechanism is being provoked predominately in the Neer test. The Hawkins test narrows the distance between the insertions of the subscapularis and supraspinatus and the anterosuperior labrum, which leads to an anterosuperior impingement mechanism.

Evaluation of Posterosuperior Labral Tear with Shoulder Sonography After Intra-articular Injection: A Case Series

Detection of a posterior glenoid labral lesion can be challenging. Clinicians may overlook this diagnosis because of its vague symptoms, unlike rotator cuff tear or adhesive capsulitis. Together with magnetic resonance (MR) imaging, shoulder MR arthrography is considered the imaging method of choice for the detection of posterior glenoid labral lesions. However, MR arthrography is associated with high cost and low accessibility, and to circumvent these shortcomings, efforts are being made to use sonography (US). However, prior experience in shoulder US is required to evaluate glenoid labrum using US because glenoid labrum is not located superficially and is surrounded by the rotator cuff musculature. There were a few studies that reported the potential for arthrosonography in finding the tear of anterior glenoid labrum and rotator cuff. Until now, however, there was no report regarding arthrosonography in posterosuperior glenoid labral tear and its efficacy and potential for overcoming the limitations of conventional US. In this report, we described 3 cases with posterosuperior glenoid labral tear that were not diagnosed by conventional US but by arthrosonography. In addition, the authors also present their history, physical examinations, and response to treatment, which may be helpful in the diagnosis of posterosuperior glenoid labral tear.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

BACKGROUND

Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space.

PURPOSE

To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores.

RESULTS

Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities.

CONCLUSION

In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Inferior glenohumeral ligament (IGHL) complex: anatomy, injuries, imaging features, and treatment options

The inferior glenohumeral ligament (IGHL) complex is comprised of three components supporting the inferior aspect of the shoulder. It consists of an anterior band, a posterior band, and an interposed axillary pouch. Injuries to the IGHL complex have a unifying clinical history of traumatic shoulder injury, which are often sports or fall-related, with the biomechanical mechanism, positioning of the arm, and individual patient factors determining the specific component of the ligamentous complex that is injured, the location of the injury of those components, and the degree of bone involvement. Several acronyms are employed to characterize these features, specifying whether there is involvement of a portion of the anterior band, posterior band, or midsubstance, and if there is avulsion from the humeral attachment, glenoid attachment, or both. Imaging recommendations for the evaluation of the IGHL complex include magnetic resonance imaging (MRI), and injuries to this complex are best visualized with magnetic resonance arthrography. Additionally, a brief description of clinical management of inferior glenohumeral ligament injuries is included.

[Surgical treatment of anterosuperior impingement of the shoulder]

OBJECTIVE

Therapy of intraarticular lesions and elimination of structural risk factors for those suffering from clinical manifest anterosuperiorer impingement (ASI) of the shoulder. This includes as a maximum version the arthroscopic repair of supraspinatus (SST) and subscapularis tendon (SCT) tears with subsequent subpectoral tenodesis of the long head of the biceps tendon (LBT) and arthroscopic coracoplasty.

INDICATIONS

Clinical manifest anterosuperiorer impingement of the shoulder with anterior shoulder pain, failed conservative treatment and clear intraarticular damage in radiological imaging. This involves in detail lesions of the SST, SCT and damage to the LBT.

CONTRAINDICATIONS

Lack of structural intraarticular lesions or massive osteoarthritis. Persistent dysfunction of active and passive glenohumeral and scapulathoracal motion, due to neurologic deficits or stiff shoulder. A hypertrophic or deformed healed coracoid process is seen as a structural risk factor for suffering from ASI and should be addressed surgically when causing impingement.

SURGICAL TECHNIQUE

Arthroscopic tenotomy of the LBT with subsequent repair of the SST and SCT. Arthroscopic coracoplasty if indicated and subpectoral tenodesis of the long head of the biceps.

POSTOPERATIVE MANAGEMENT

No biceps activity and intermittent immobilization in sling for 6 weeks. Limitation of abduction, flexion and external rotation for 6 weeks depending on rotator cuff tendon repair. Start of sport-specific training after 3 months, over-head sports 6 months postoperatively.

RESULTS

The arthroscopic repair of anterosuperior rotator cuff tears provides reliable results for improvement in function, decreases in pain and improvement in shoulder scores. The overall rate of adverse events is low.

[Surgical treatment of posterosuperior impingement (PSI)]

OBJECTIVE

To restore the physiologic anterior and posterior capsular volume to achieve an anatomic central contact point of the glenohumeral articulation and treatment of concomitant glenohumeral injuries due to posterosuperior impingement (PSI).

INDICATIONS

Plateauing of clinical improvement despite adequate nonsurgical treatment (for at least 6-12 months).

CONTRAINDICATIONS

General contraindications for elective arthroscopic surgery.

SURGICAL TECHNIQUE

Diagnostic arthroscopy of the glenohumeral joint through the posterior portal to assess stability of the biceps-labral complex even in the Abduction and External Rotation (ABER) position to confirm the diagnosis of PSI and to detect concomitant glenohumeral injuries. In most cases posterosuperior SLAP (superior labrum anterior posterior) repair or tenodesis of the long head of the biceps.

POSTOPERATIVE MANAGEMENT

Arm sling for 6 weeks with limited range of motion. Free active range of motion of elbow and wrist. Limited shoulder external rotation for 6 weeks. Free shoulder range of motion from week 7, full daily life activities after 12 weeks. Modification of the postoperative management according to intraoperative findings.

RESULTS

At our hospital 18 overhead athletes (6 women, 12 men, mean age 31 years) with PSI without SLAP lesion or rotator cuff tear underwent isolated plication of the anteroinferior capsule after primary nonsurgical treatment. At a mean period of 9 months, 16 patients returned to their pre-injury sports activity level, 2 patients had to give up their sports due to persisting shoulder problems. At a mean follow-up of 27 months (range 12-55 months) the Walch Duplay score was on average 82.9 ± 8.3 for men and 73.8 ± 5.9 for women.

Beyond the Cuff: MR Imaging of Labroligamentous Injuries in the Athletic Shoulder

Shoulder disease is common in the athletic population and may arise as a consequence of a single traumatic episode or multiple repeated events. Associated labroligamentous injuries can result in substantial disability. Specific athletic and occupational activities result in predictable injury patterns. Imaging in general and magnetic resonance (MR) imaging, in particular, are vital in establishing the correct diagnosis and excluding common mimicking conditions, to ensure timely and appropriate management. In this review, the utility of MR imaging and MR arthrography will be explored in evaluation of shoulder disease, taking into account normal variants of the labroligamentous complex. Subsequently, broad categories of labral lesions and instability, external and internal impingement, as well as nerve entrapment syndromes, will be discussed, while emphasizing their imaging findings in the clinical context and illustrating key features. More recent concepts of internal impingement and secondary subacromial impingement will also be clarified.

[Rehabilitation concepts and return to sport after interventions on the shoulder]

BACKGROUND

Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport.

OBJECTIVES

The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes.

METHODS

A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration.

RESULTS

This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion.

CONCLUSION

Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

[The throwing shoulder]

BACKGROUND

During the throwing motion high forces are placed on the athlete's shoulder and extreme positions of external rotation and abduction are reached. The dynamic and static stabilizers of the glenohumeral joint need to handle a delicate balance between shoulder mobility and stability.

CAUSES OF INJURY

Repetitive forces lead to adaptive osseous, capsular, ligament and muscular changes. This should increase external rotation of the shoulder and thus initially help to improve performance but ultimately could cause shoulder pathologies. For instance, tissue overuse can result in muscular imbalance, functional instability and posterior capsular contracture with the development of a glenohumeral internal rotation deficit.

INJURY PATTERNS

An internal impingement is often observed in throwing athletes which can be subdivided into the more common posterosuperior type and the rarer anterosuperior type. Typical lesions in the throwing shoulder are articular-sided partial rotator cuff tears, labrum and biceps tendon lesions and edema, cysts or osteochondral lesions of the humeral head or glenoid.

DIAGNOSTICS

For an accurate diagnosis it is important to include the history, a thorough physical examination and magnetic resonance arthrography. The correlation of clinical examination and imaging is critical to identify symptomatic lesions.

THERAPY

If conservative therapy fails or in cases of significant structural damage resulting in clinical symptoms, surgical treatment should be considered based on the underlying pathology and carried out using established techniques and criteria.

Return to sport following shoulder surgery in the elite pitcher: a systematic review

Context:

The ability to return to elite pitching, performance, and clinical outcomes of shoulder surgery in elite baseball pitchers are not definitively established.

Objective:

To determine (1) the rate of return to sport (RTS) in elite pitchers following shoulder surgery, (2) postoperative clinical outcomes upon RTS, and (3) performance upon RTS and to compare RTS rates in different types of shoulder surgery.

Data Sources:

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.

Study Selection:

Levels I-IV evidence were eligible for inclusion if performance-based (eg, RTS) and/or clinical outcome–based reporting of outcomes were reported following surgical treatment of shoulder pathology in elite pitchers (major or minor league or collegiate).

Data Extraction:

Subject, shoulder, and pre- and postoperative performance-based variables of interest were extracted. All shoulder surgery types were potentially inclusive (eg, open, arthroscopic, rotator cuff, labrum, biceps, acromioclavicular joint, fracture). Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS).

Results:

Six studies were analyzed (287 elite male pitchers [mean age, 27 years] who underwent shoulder surgery, with 99% on the dominant, throwing shoulder). MCMS was 38 (poor). Most pitchers were professional, with a mean career length of 6.58 years and postoperative clinical follow-up of 3.62 years. In 5 of 6 studies, multiple diagnoses were addressed concomitantly at surgery. Rate of RTS was 68% at mean 12 months following surgery. Twenty-two percent of Major League Baseball (MLB) pitchers never RTS in MLB. Overall performance did improve following surgery; however, this did not improve to pre-injury levels.

Conclusion:

In this systematic review, the rate of return to elite baseball pitching following surgery was established. Performance tended to decrease prior to surgery and gradually improve postoperatively, though not reaching pre-injury levels of pitching.

Level of Evidence:

IV (systematic review of studies level I-IV evidence), therapeutic.

Microinstability and internal impingement in overhead athletes

A complex interplay exists between the static and dynamic stabilizers in the glenohumeral joint, especially in overheard athletes who need a shoulder hypermobile enough to perform overhead activity yet stable enough to prevent joint subluxation. Concomitant shoulder pathologies commonly occur in the setting of microinstability and internal impingement. Before any surgical intervention, a 3- to 6-month course of conservative measures should first be attempted, with exercises focused on rotator cuff and scapular stabilizer strengthening combined with posterior capsule stretching. If surgery is needed, arthroscopic suture plication with treatment of concomitant lesions has been shown to provide the best clinical outcomes.

Imaging evaluation of the rotator cuff

The rotator cuff is a complex network of interwoven tendons that plays a key role in glenohumeral movement and stability. Cuff abnormality is a common source of shoulder pain, but the clinical presentation is often nonspecific and, as a result, diagnostic imaging, especially magnetic resonance imaging, plays a key role in evaluating these patients. This article reviews imaging modalities available for evaluating the cuff, normal cuff anatomy, and common pathologic conditions that affect it.

A physician's guide to the physical examination of the shoulder

Shoulder pain is the third most frequent musculoskeletal complaint presented to physicians. Often considered a benign entity by patients and even their physicians, shoulder disorders can have a devastating effect on a patient's ability to function, as well as serve as an indicator of poor general health. For these reasons, it is important for the physician to be able to identify the etiology of a patient's shoulder problem(s). However, making a correct diagnosis is often difficult because there can be many causes for a patient's shoulder pain, weakness, or loss of function. Moreover, the shoulder girdle is an intricate group of structures that work together to allow for the largest range of motion in the body. This complexity makes it difficult to diagnose a patient's condition(s) based on history alone. A thorough and well-performed physical examination is the key to making a correct diagnosis and helping to distinguish different etiologies of shoulder dysfunction. In this article, we review relevant shoulder anatomy and biomechanics, and general shoulder examinations with special tests for various shoulder pathologies. We provide an effective and methodical approach to the physical examination of the shoulder.