Rehabilitation of the Athlete's Shoulder

Midterm Clinical Outcomes After Arthroscopic Rotator Cuff Repair in Olympic Volleyball Players: Return to Sports and Return to Performance

Background

The decision-making process and predicting the time to return to sport (RTS) and return to performance (RTP) after arthroscopic rotator cuff repair (ARCR) in elite volleyball players are difficult issues to address, even among experienced shoulder surgeons.

Purpose/Hypothesis

The purpose of the study was to evaluate the results in Olympic-level volleyball players treated with arthroscopic supraspinatus repair and to report the RTS and the RTP. It was hypothesized that these athletes had higher RTS and faster RTP.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 17 elite volleyball athletes (11 male, 6 female; mean age, 26.2 years) who underwent ARCR for partial- and full-thickness supraspinatus tears that did not improve despite nonoperative treatment. The clinical results were evaluated at 12 months postoperatively. The authors compared the athletes' preoperative, 6-month, and 12-month Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and the visual analog scale (VAS) for pain after competition and conducted 6- and 12-month isometric strength analyses. The athletes' RTS and RTP times were recorded.

Results

All tears were on the dominant side (15 right, 2 left), and 82% were partial tears (14 partial thickness, 3 full thickness). The mean time from the onset of symptoms to surgery was 11.3 ± 6.7 months. While the mean Kerlan-Jobe Orthopaedic Clinic score was 31 preoperatively, it was 89 after 6 months (P < .001 vs preoperative) and 96 after 12 months (P = .003 vs 6 months). The mean VAS for pain was 7.9 preoperatively, 0.4 at 6 months (P < .001 vs preoperative), and 0.1 at 12 months (P = .02 vs 6 months). All athletes were able to reach their preinjury level, with RTS at a mean of 6.9 months and RTP at a mean of 12.4 months.

Conclusion

ARCR appears to be an effective option for Olympic-level volleyball players who do not benefit from nonoperative treatment. All athletes returned to their preinjury level of sports. The surgeon and athlete can plan surgical decision-making and timing based on the mean RTS time of 6.9 months and mean RTP time of 12.4 months.

Konservative Therapie von Verletzungen des Akromioklavikulargelenks

Niedriggradige Verletzungen (Grad I und II nach Rockwood) des Akromioklavikulargelenks (ACG) können in den meisten Fällen mit gutem Outcome konservativ behandelt werden. Hierbei gibt es keine Methode der Immobilisation, welche sich als Überlegen herausgestellt hätte. Höhergradige Verletzungen (Grad IV und V), welche eine relevante Instabilität und konsekutiv häufig eine Dyskinesie des skapulothorakalen Rhythmus zur Folge haben, profitieren von einer chirurgischen Rekonstruktion. Kein Konsens trotz breiter akademischer Diskussion besteht bei Grad-III-Verletzungen. In Langzeitstudien und im Rahmen von Metaanalysen zeigten sich keine Vorteile eines operativen Vorgehens gegenüber der konservativen Behandlung nach 1 bis 2 Jahren, während einzelne Fallserien Vorteile in der anatomischen Rekonstruktion aufzeigten, insbesondere wenn für das ACG spezifische Outcome-Scores verwendet wurden. In Grenzfällen sollte das individuelle Arbeits- und Sportprofil, insbesondere regelmäßige Überkopfaktivität, in die therapeutische Entscheidungsfindung einfließen. Sowohl bei niedrig- wie auch hochgradigen Verletzungen des ACG kann durch eine fokussierte Therapie zur Verbesserung der skapulothorakalen Mobilität und Stabilität eine Skapuladyskinesie in vielen Fällen (gelegentlich auch ≥ Grad III nach Rockwood) vermieden oder erfolgreich behandelt werden.

INFLUENCE OF LIMB DOMINANCE AND SHOULDER INJURY ON STRENGTH AND EXPLOSIVE FORCE IN US MARINES

Background

The specialized roles of many military personnel require specific skills and high physical demands, placing unique stresses on the shoulders and increasing risk of injury. As normal dominant/nondominant shoulder asymmetries have been established in military personnel, bilateral strength comparisons must be understood in context of daily physical demands to monitor patients' progress or readiness to return to duty.

Purpose

This study aims to assess bilateral differences in strength and explosive force in United States Marines with a history of dominant or nondominant shoulder pathology.

Study Design

Cross-Sectional.

Methods

A total of 52 full-duty, male US Marines with a shoulder injury within the prior year participated. Bilateral isokinetic shoulder internal (IR) and external (ER) rotation strength, and peak force (Peak Force) and average rate of force production (Avg Rate) during an explosive push-up were collected. Dominant versus nondominant side data were independently examined within each group (DOM: dominant injury, NOND: nondominant injury). Comparison between DOM and NOND, as well as previously published CON (no history of shoulder injury) was also completed.

Results

NOND (n = 26) demonstrated significantly less IR (p < 0.001) and ER (p = 0.003) strength and Peak Force (p = 0.001) and Avg Rate (p = 0.047) on the injured side, while DOM (n = 26) demonstrated no bilateral differences in strength or push-up performance. Comparison between the three groups showed that NOND demonstrated significantly less ER strength than CON (p = 0.022).

Conclusions

Military personnel demonstrate asymmetric strength patterns likely due to increased demand of the dominant shoulder. US Marines with a history of injury to the nondominant shoulder performed differently than those with a dominant side injury, presenting with both strength and push-up asymmetries. They also demonstrated significant ER strength deficits compared to CON. Common clinical practice and previous literature often compare injured and uninjured limbs or injured individuals to healthy controls, but further distinction of dominant or nondominant side may provide more accurate information needed to develop targeted treatment strategies.

Clinical Relevance

Recognizing unique occupational demands and how patients may present differently with dominant versus nondominant side shoulder injuries are important considerations for ensuring accurate assessment and effective individualized rehabilitation.

Level of Evidence

3.

Platelet-Rich Plasma for Primary Treatment of Partial Ulnar Collateral Ligament Tears: MRI Correlation With Results

Background:

Jobe revolutionized the treatment of medial ulnar collateral ligament (MUCL) tears with his reconstruction technique. However, not all MUCL injuries require operative management; Rettig showed that 42% of MUCL injuries respond to conservative management. This was improved by Podesta, who showed that augmentation of nonoperative management with platelet-rich plasma (PRP) and magnetic resonance imaging (MRI) for detecting partial MUCL tears resulted in significantly higher success rates. Their series used a single injection of leukocyte-rich PRP. However, to our knowledge, no study has established optimal dosing and composition of PRP for augmentation of soft tissue healing. We present a series of patients with partial MUCL tears of the elbow treated with a series of 2 leukocyte-rich PRP injections, bracing, physical therapy, and a structured return-to-throwing protocol.

Hypothesis:

Nonoperative management of acute or subacute partial MUCL tears of the elbow with a formal treatment protocol will allow the injured ligament to heal without surgery and will permit a rapid return to sport.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients with symptomatic MUCL instability and magnetic resonance arthrography demonstrating grade 2 MUCL tears at the proximal or distal aspect were treated with varus-loading elbow bracing, activity restriction, and physical therapy, supplemented by 2 injections of PRP. The injections were separated by 2 weeks. Two weeks after the second injection, a repeat examination and magnetic resonance arthrogram were obtained to evaluate the response to treatment.

Results:

A total of 25 athletes (23 baseball athletes, 2 softball athletes [1 participant also danced]) underwent PRP injections and guided rehabilitation. Of these patients, 23 were diagnosed with primary grade 2 injuries of the MUCL; 22 patients with primary injuries (96%) demonstrated stability of the MUCL after treatment and returned to play at the same or higher level of competition without further intervention. Repeat MRI demonstrated reconstitution of the ligament in all patients, although 2 patients demonstrated only partial reconstitution. Patients were released to play at 6 weeks; due to vagaries of sports seasons, the mean time to return to competitive play was 82 days. Two of the 25 patients had undergone prior surgery (1 MUCL reconstruction and 1 repair). These patients remained unstable and symptomatic on examination after this treatment regimen, did not show complete reconstitution of the ligament on subsequent MRI, and required MUCL reconstruction.

Conclusion:

Ouf of 23 primary injury patients who received PRP injections and nonoperative measures, 22 (96%) were able to return to play and demonstrated reconstitution of the MUCL on MRI. Two of the 3 patients for whom PRP therapy failed had undergone previous MUCL surgery. We conclude that a 2-injection regimen of leukocyte-rich PRP is a safe and effective treatment for partial MUCL tears, but it appears to be less effective in patients with previous surgery for MUCL repair or reconstruction.

Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space

BACKGROUND

Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes.

METHODS

We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index.

RESULTS

The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038).

CONCLUSION

Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.

[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.

Scapular muscle activity from selected strengthening exercises performed at low and high intensities

A balanced level of muscle strength between the different parts of the scapular muscles is important in optimizing performance and preventing injuries in athletes. Emerging evidence suggests that many athletes lack balanced strength in the scapular muscles. Evidence-based recommendations are important for proper exercise prescription. This study determines scapular muscle activity during strengthening exercises for scapular muscles performed at low and high intensities (Borg CR10 levels 3 and 8). Surface electromyography (EMG) from selected scapular muscles was recorded during 7 strengthening exercises and expressed as a percentage of the maximal EMG. Seventeen women (aged 24-55 years) without serious disorders participated. Several of the investigated exercises-press-up, prone flexion, one-arm row, and prone abduction at Borg 3 and press-up, push-up plus, and one-arm row at Borg 8-predominantly activated the lower trapezius over the upper trapezius (activation difference [Δ] 13-30%). Likewise, several of the exercises-push-up plus, shoulder press, and press-up at Borg 3 and 8-predominantly activated the serratus anterior over the upper trapezius (Δ18-45%). The middle trapezius was activated over the upper trapezius by one-arm row and prone abduction (Δ21-30%). Although shoulder press and push-up plus activated the serratus anterior over the lower trapezius (Δ22-33%), the opposite was true for prone flexion, one-arm row, and prone abduction (Δ16-54%). Only the press-up and push-up plus activated both the lower trapezius and the serratus anterior over the upper trapezius. In conclusion, several of the investigated exercises both at low and high intensities predominantly activated the serratus anterior and lower and middle trapezius, respectively, over the upper trapezius. These findings have important practical implications for exercise prescription for optimal shoulder function. For example, both workers with neck pain and athletes at risk of shoulder impingement (e.g., overhead sports) should perform push-up plus and press-ups to specifically strengthen the serratus anterior and lower trapezius.

Trapezius muscle timing during selected shoulder rehabilitation exercises

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To examine the timing of the 3 portions of the trapezius muscle in relation to the posterior deltoid (PD) muscle and in relation to one another during 4 selected shoulder exercises: (1) prone extension, (2) forward flexion in side lying, (3) external rotation in side lying, and (4) prone horizontal abduction with external rotation.

BACKGROUND

Deficiencies in trapezius muscle recruitment have been identified in patients with shoulder pain. Alterations in the trapezius muscle activation level and timing have been identified in previous research. Scapular muscle exercises in which the middle trapezius (MT) and lower trapezius (LT) muscle showed optimal activity with minimal upper trapezius (UT) muscle participation have been recently identified. However, it is currently unknown if these exercises also promote early activation of the scapular stabilizing musculature.

METHODS

The intermuscular and intramuscular timing of muscle activation (based on an activation level of greater than 10% maximum voluntary contraction beyond basic activity) of the 3 portions of the trapezius muscle during 4 exercises were examined by surface EMG in 30 healthy subjects on the dominant side (14 males, 16 females). A 1-sample t test was used to determine which portions of the trapezius muscle were activated significantly earlier or later than the PD (intermuscular timing). An analysis of variance for repeated measures (3 levels) was used for each exercise to determine possible timing differences among the 3 portions of the trapezius muscle (intramuscular timing).

RESULTS

Intermuscular and intramuscular differences in timing of the portions of the trapezius muscle were found. The UT was activated significantly later than the PD (P<.01), and the MT was activated significantly earlier than the PD (P<.01), during the prone extension exercise. During the horizontal abduction with external rotation exercise, the MT (P<.01) and the LT (P = .01) were activated significantly earlier than the PD. During prone extension, side-lying external rotation, and prone horizontal abduction with external rotation, significant differences were found between the UT and MT, between the UT and LT, but not between the MT and LT. In these exercises the MT and LT were activated significantly earlier than the UT. During forward flexion in side lying, no significant timing differences were found between the activation of the portions of the trapezius.

CONCLUSIONS

With the exception of the LT during prone extension, the prone extension exercise and the prone horizontal abduction with external rotation exercise promote early activation of the MT and LT in relation to the scapular and glenohumeral prime mover. Taking into account the limited generalizability of the results due to a narrow age range, these exercises are potentially promising for the treatment of intermuscular and intramuscular timing disorders of the trapezius muscle.