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Myers NL, Kennedy SM, Arnold AJ, Gehring ZA, Kruseman KJ, Conway JE, Paine RM, Bailey LB, Garrison JC. A narrative review of little league shoulder: proximal humeral physis widening is only one piece of the puzzle, it is time to consider posterior glenoid dysplasia. JSES Int 2024; 8:724-733. [PMID: 39035657 PMCID: PMC11258838 DOI: 10.1016/j.jseint.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Baseball athletes across all levels of play are at an increased risk for upper extremity injury due to the supraphysiologic demands on the shoulder and elbow during overhead throwing. Little league baseball players present with a unique subset of injuries that can affect the growth plate, commonly at the shoulder or the elbow. Ascertaining a diagnosis and plan of care for little league shoulder (LLS) historically focuses on the proximal humeral physis in skeletally immature throwing athletes presenting with shoulder pain. However, while not a current standard of care, posterior glenoid dysplasia is often present in youth baseball athletes presenting with LLS, warranting a shift in the way clinicians evaluate for and treat the youth baseball athlete's pathologic shoulder. Therefore, purpose of this narrative review is 2-fold: first, to describe the current standard of care as it relates to a diagnosis of LLS, and second, to critically describe a comprehensive evaluation process for youth throwing athletes with shoulder pain that includes screening for evidence of posterior glenoid dysplasia. This paper summarizes the current state of the available evidence for anatomic considerations of LLS in the baseball athletes throwing shoulder. Additionally, we provide a framework for clinical evaluation using a multidisciplinary approach to evaluate the entire kinetic chain of the youth baseball athlete presenting with LLS and posterior glenoid dysplasia. A case study is presented to describe common presentations, clinical and objective examinations, and a plan of care from time of evaluation to return to throwing.
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Affiliation(s)
- Natalie L. Myers
- Memorial Hermann’s Rockets Sports Medicine Institute, Houston, TX, USA
| | - Sean M. Kennedy
- Memorial Hermann’s Rockets Sports Medicine Institute, Houston, TX, USA
| | - Amanda J. Arnold
- Texas Woman’s University, School of Physical Therapy, Houston, TX, USA
| | - Zachary A. Gehring
- UTHealth Houston McGovern, Medical School Orthopedic Surgery, Houston, TX, USA
| | | | - John E. Conway
- UTHealth Houston McGovern, Medical School Orthopedic Surgery, Houston, TX, USA
| | - Russ M. Paine
- UT Ortho Physical Therapy, Department of Orthopedic Surgery, Houston, TX, USA
| | - Lane B. Bailey
- Memorial Hermann’s Rockets Sports Medicine Institute, Houston, TX, USA
| | - J Craig Garrison
- Memorial Hermann’s Rockets Sports Medicine Institute, Houston, TX, USA
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Thacher RR, Varady NH, Khilnani T, Camp CL, Dines JS. Current Concepts on the Management of Shoulder Instability in Throwing Athletes. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09910-1. [PMID: 38918331 DOI: 10.1007/s12178-024-09910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Abstract
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.
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Affiliation(s)
- Ryan R Thacher
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Tyler Khilnani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Joshua S Dines
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Tramer JS, Lizzio VA, Schickendantz MS. Batter's Shoulder: Diagnosis, Management, and Outcomes. J Am Acad Orthop Surg 2024:00124635-990000000-01020. [PMID: 38935585 DOI: 10.5435/jaaos-d-24-00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024] Open
Abstract
Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition.
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Affiliation(s)
- Joseph S Tramer
- From the Department of Orthopaedic Surgery, Division of Sports Medicine, Cleveland Clinic Foundation, Cleveland, OH
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Hurley ET, Aman ZS, Doyle TR, Levin JM, Jazrawi LM, Garrigues GE, Namdari S, Hsu JE, Klifto CS, Anakwenze OA, Dickens JF. Posterior Shoulder Instability Part II - Glenoid Bone-Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play - An International Expert Delphi Consensus Statement. Arthroscopy 2024:S0749-8063(24)00340-2. [PMID: 38735411 DOI: 10.1016/j.arthro.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE The purpose of this study was to establish consensus statements on glenoid bone-grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability. METHODS A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating based on their level of expertise in the field. Experts were assigned to one of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their higher risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain. CONCLUSION The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone-grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone-block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired. LEVEL OF EVIDENCE Level V Expert Opinion.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.
| | - Zachary S Aman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Tom R Doyle
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jason E Hsu
- Department of Orthopedics and Sports Medicine, University of Washington, , Seattle, Washington, USA
| | | | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, Maryland, U.S.A
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Khaleel M, Oladeji LO, Smith CA, DeFroda SF, Nuelle CW. Two-Portal Arthroscopic Knotless All-Suture Anchor Posterior Labral Repair. Arthrosc Tech 2024; 13:102928. [PMID: 38835471 PMCID: PMC11144742 DOI: 10.1016/j.eats.2024.102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/23/2023] [Indexed: 06/06/2024] Open
Abstract
Isolated posterior shoulder instability accounts for approximately 10% of shoulder instability cases. Patients may present after an acute trauma or with insidious onset and associated posterior shoulder pain. Knotless and all-suture anchor devices have become increasing popular and are often used in arthroscopic shoulder instability cases to avoid knot stacks and allow for the ability to re-tension the fixation. This technical note describes our technique for 2-portal posterior labral repair using knotless all-suture anchors with the patient in the lateral decubitus position.
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Affiliation(s)
- Mubinah Khaleel
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
| | - Conor A. Smith
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
| | - Steven F. DeFroda
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
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Sciascia AD. Rehabilitation of the painful shoulder. J Shoulder Elbow Surg 2024; 33:494-506. [PMID: 37573929 DOI: 10.1016/j.jse.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/05/2023] [Accepted: 07/09/2023] [Indexed: 08/15/2023]
Abstract
Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.
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Affiliation(s)
- Aaron D Sciascia
- Institute for Clinical Outcomes and Research, Lexington Clinic, Lexington, KY, USA.
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Kibler WB, Sciascia AD, Grantham WJ. The shoulder joint complex in the throwing motion. J Shoulder Elbow Surg 2024; 33:443-449. [PMID: 37499784 DOI: 10.1016/j.jse.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/07/2023] [Accepted: 06/24/2023] [Indexed: 07/29/2023]
Abstract
The shoulder joint complex in the overhead athlete is organized to effectively transfer the proximally generated forces distally into the arm. The organization also protects the joints and anatomic structures against the repetitive high velocities, large ranges of motions, and compressive, shear, translational, and distraction loads in the overhead motion while placing the hand in the "launch window." Coupling of the movements of the scapula, clavicle, and humerus results in scapulohumeral rhythm (SHR). Effective SHR requires the clavicle and scapula-and, at times, the mechanically linked claviscapular segment-to move the arm into the task-specific position and motion and requires the humerus to move through the ranges of motion to achieve the specific task in the throwing motion. Alterations in SHR can negatively affect effective shoulder joint complex function in the overhead throwing motion and increase injury risk. There are 4 phases of clavicular, scapular, and claviscapular motion that are coupled with arm motion in SHR. The first 3 phases occur in arm elevation motions from 0°-90° and result in the claviscapula and humerus being placed in task-specific positions. The fourth phase is coupling of claviscapular motion with humeral motion to maintain ball-and-socket kinematics throughout the throwing motion. Alterations in this composite motion are termed "scapular dyskinesis." The dyskinesis is considered an impairment of the efficient mobility of the claviscapular segment of the shoulder complex. The most prevalent problem with scapular dyskinesis is the association of scapular protraction and consequent glenoid antetilt with alterations in humeral rotation and posterior humeral head translation to produce shoulder joint internal impingement. Task effectiveness in overhead throwing is also based on and determined by humeral range of motion, precision of humeral motion, and velocity of humeral motion, as well as humeral and arm position in 3-dimensional space. This activity requires maximum ball-and-socket kinematics to create the highest amount of concavity-compression that creates stability for the joint. There are bony and soft-tissue contributions to this stability. Injuries to the glenoid labrum are among the most common deficits that alter concavity-compression. Clinical evaluation of the shoulder joint complex in the injured throwing athlete should be comprehensive and systematic, following an evaluation pathway for proximal and distal causative factors and including observation of humeral motion. This type of evaluation can result in intervention protocols that address the pathoanatomic, pathophysiological, and pathomechanical deficits identified.
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Affiliation(s)
- W Ben Kibler
- Shoulder Center of Kentucky, Lexington Clinic, Lexington, KY, USA
| | - Aaron D Sciascia
- Institute for Clinical Outcomes and Research, Lexington Clinic, Lexington, KY, USA.
| | - W Jeff Grantham
- Shoulder Center of Kentucky, Lexington Clinic, Lexington, KY, USA
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8
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Boden SA, Arner JW, Bradley JP. Understanding Shoulder and Elbow Injuries in the Windmill Softball Pitcher. J Am Acad Orthop Surg 2024; 32:e53-e62. [PMID: 37852241 DOI: 10.5435/jaaos-d-22-00944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 08/20/2023] [Indexed: 10/20/2023] Open
Abstract
Although pitching-related injuries in the overhead athlete have been studied extensively, injuries associated with windmill pitching are not as clearly elucidated. Windmill pitching produces high forces and torques in the upper extremity, and studies have shown it creates similar shoulder and elbow joint loads to those reported in baseball pitchers. Studies have shown that the windmill pitching motion generates high levels of biceps activation with an eccentric load, placing the biceps at increased risk for overuse injuries. Although the American Orthopaedic Society for Sports Medicine published prevention guidelines including recommendations for maximum pitch counts in softball, these recommendations have not been adopted by most United States softball governing bodies. The repetitive windmill motion in conjunction with high pitch count demands in competitive softball creates notable challenges for the sports medicine physician. As with overhead throwing athletes, identifying and preventing overuse is crucial in preventing injuries in the windmill pitcher, and prevention and rehabilitation should focus on optimizing mechanics and kinematics, core, hip, and lower body strength, and recognition of muscle fatigue. With more than two million fastpitch softball participants in the United States, it is essential to better understand the etiology, evaluation, and prevention of injuries in the windmill pitching athlete.
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Affiliation(s)
- Stephanie A Boden
- From the Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush University, Chicago, IL (Boden), Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Amer), Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Bradley)
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9
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Romero-Morales C, López-López D, Almazán-Polo J, Mogedano-Cruz S, Sosa-Reina MD, García-Pérez-de-Sevilla G, Martín-Pérez S, González-de-la-Flor Á. Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review. Dis Mon 2024; 70:101629. [PMID: 37716840 DOI: 10.1016/j.disamonth.2023.101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
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.
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Affiliation(s)
- Carlos Romero-Morales
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain
| | - Daniel López-López
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Industrial Campus of Ferrol , Universidade da Coruña, 15403 Ferrol, Spain.
| | - Jaime Almazán-Polo
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain
| | - Sara Mogedano-Cruz
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain
| | - María Dolores Sosa-Reina
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain
| | | | - Sebastián Martín-Pérez
- Faculty of Health Sciences, Universidad Europea de Canarias, La Orotava, Santa Cruz de Tenerife 38300, Spain
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10
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Solomon DJ. Editorial Commentary: Patients May Have Posterior Glenoid Labral Tears in the Absence of Instability or Magnetic Resonance Imaging Findings. Arthroscopy 2024; 40:68-70. [PMID: 38123274 DOI: 10.1016/j.arthro.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 12/23/2023]
Abstract
Posterior labral tears occur more often than imagined 25 years ago. Although such tears are generally identified in patients with posterior shoulder instability, the spectrum of labral tears in patients without instability creates a challenging diagnosis. Both physical examination and magnetic resonance imaging interpretation are difficult. Pathology encompassing posterior labral tears without instability notably reveals differences compared with throwers with posterior labral tears and patients with posterior instability. Recent research has identified 3 tear types: occult (type 1), incomplete (type 2), and complete (type 3). Attention to diagnosis deserves critical attention, in addition to tailoring of repair techniques to address the appropriate conditions in the shoulder. Even in patients without posterior instability and with ambiguous magnetic resonance imaging or magnetic resonance arthrography findings, posterior shoulder pain during daily activities or sports may indicate a posterior labral tear. Arthroscopic posterior labral repair without capsular plication provides good clinical outcomes and high rates of return to sport and labral healing.
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11
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Watson L, Hoy G, Wood T, Pizzari T, Balster S, Barwood S, Warby SA. Posterior Shoulder Instability in Tennis Players: Aetiology, Classification, Assessment and Management. Int J Sports Phys Ther 2023; V18:769-788. [PMID: 37425109 PMCID: PMC10324327 DOI: 10.26603/001c.75371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/14/2023] [Indexed: 07/11/2023] Open
Abstract
Background Micro-traumatic posterior shoulder instability (PSI) is an often missed and misdiagnosed pathology presenting in tennis players. The aetiology of micro-traumatic PSI in tennis players is multifactorial, including congenital factors, loss of strength and motor control, and sport-specific repetitive microtrauma. Repetitive forces placed on the dominant shoulder, particularly combinations of flexion, horizontal adduction, and internal rotation contribute to the microtrauma. These positions are characteristic for kick serves, backhand volleys, and the follow-through phase of forehands and serves. The aim of this clinical commentary is to present an overview of the aetiology, classification, clinical presentation, and treatment of micro-traumatic PSI, with a particular focus on tennis players. Level of Evidence 5.
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Affiliation(s)
- Lyn Watson
- Melbourne Shoulder Group, 305 High Street, Prahran, Victoria, Australia, 3181
| | - Gregory Hoy
- Melbourne Orthopaedic Group, 33 The Avenue Windsor, Victoria, Australia, 3181
- Monash University, Department of Surgery, Monash Medical Centre Level 5, Block E 246 Clayton Road Clayton, Victoria, Australia, 3168
- Glenferrie Private Hospital, 25 Linda Crescent, Hawthorn, Victoria, Australia, 3122
| | - Timothy Wood
- Glenferrie Private Hospital, 25 Linda Crescent, Hawthorn, Victoria, Australia, 3122
| | - Tania Pizzari
- Melbourne Shoulder Group, 305 High Street, Prahran, Victoria, Australia, 3181
- Mill Park Physiotherapy, 22/1 Danaher Dr, South Morang, Victoria, Australia, 37522
- La Trobe University, Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, Corner of Kingsbury Drive and Plenty Road Bundoora, Victoria, Australia, 3080
| | - Simon Balster
- Melbourne Shoulder Group, 305 High Street, Prahran, Victoria, Australia, 3181
| | - Shane Barwood
- Melbourne Orthopaedic Group, 33 The Avenue Windsor, Victoria, Australia, 3181
| | - Sarah Ann Warby
- Melbourne Shoulder Group, 305 High Street, Prahran, Victoria, Australia, 3181
- La Trobe University, Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, Corner of Kingsbury Drive and Plenty Road Bundoora, Victoria, Australia, 3080
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12
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Arguello AM, Till SE, Reinholz AK, Okoroha KR, Barlow JD, Camp CL. Managing Shoulder Instability in the Overhead Athlete. Curr Rev Musculoskelet Med 2022; 15:552-560. [PMID: 36223035 PMCID: PMC9789295 DOI: 10.1007/s12178-022-09796-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Shoulder instability in the overhead athlete is a difficult problem because of the balance between necessary laxity for athletic movements and stability of the joint. The purpose of this review is to provide an overview of the clinical evaluation of shoulder instability in the overhead athlete and present evidence-based management strategies for each subtype of shoulder instability, including novel techniques and outcomes. RECENT FINDINGS Recent investigation has shown that throwers and other overhead athletes are more likely to present with subtle subluxation events rather than discrete dislocations as their primary symptom. While overhead athletes with discrete anterior dislocation events are likely to begin with non-operative management, many progress on to surgical intervention. Surgical management of glenohumeral joint instability continues to pose challenges due to the potential for over-tensioning for the sake of stability at the expense of the adaptive laxity that often confers performance benefits in the overhead athlete. Novel, individualized, and sport/position specific approaches are needed to address this complex issue. The optimal management of shoulder instability in the overhead athlete continues to be a controversial topic due to the complex work-up, an increasing number of surgical options with varying indications, and low volume of high-quality studies comparing any of the treatment options. The Anterior Shoulder Instability International Consensus Group guidelines from February 2022 offer the most updated guidelines on work-up and management. Overall, high-quality randomized controlled trials are required to determine the optimal treatment for specific pathologies and aid in creating patient-centered management plans.
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Affiliation(s)
- Alexandra M Arguello
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara E Till
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anna K Reinholz
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA.
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13
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Boileau P, Van Steyn PM, Czarnecki M, Teissier S, Gasbarro G, Galvin JW. The Thumb Test: A Simple Physical Examination Maneuver for the Diagnosis of Symptomatic Posterior Shoulder Instability. Arthrosc Tech 2022; 11:e1613-e1616. [PMID: 36185110 PMCID: PMC9520018 DOI: 10.1016/j.eats.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/18/2022] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability is becoming increasingly recognized in young active patient populations. Diagnosing posterior instability can be challenging because patients commonly present with a complaint of pain without a history of a dislocation or subluxation event. Additionally, a posterior labral tear is not always clearly visualized on advanced imaging studies. As such, physical examination is critical to the diagnosis. We report a simple physical examination maneuver for the diagnosis of symptomatic posterior shoulder instability. The thumb test attempts to replicate a posterior bone block procedure, helping to re-establish stability and relieve pain. The examiner places his or her thumb over the posterior glenohumeral joint line while the patient actively forward elevates the affected arm overhead. Improvement in pain and stability with this maneuver is diagnostic for symptomatic posterior shoulder instability. This test augments current physical examination maneuvers to assist with correctly diagnosing posterior shoulder instability.
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Affiliation(s)
- Pascal Boileau
- ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute For Sports and Reconstructive Bone & Joint Surgery), Nice, France
- Address correspondence to Pascal Boileau, M.D., Ph.D., ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute for Sports and Reconstructive Bone & Joint Surgery), 7, Avenue Durante, 06004 Nice, France.
| | - Peter M. Van Steyn
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
| | - Michael Czarnecki
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
| | - Sylvain Teissier
- ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute For Sports and Reconstructive Bone & Joint Surgery), Nice, France
| | - Gregory Gasbarro
- The Shoulder, Elbow, Wrist, and Hand Center, Mercy Medical Center, Baltimore, Maryland, U.S.A
| | - Joseph W. Galvin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
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14
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Galvin JW, Yu H, Slevin J, Turner EK, Eichinger JK, Arrington ED, Grassbaugh JA. High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability. Arthrosc Sports Med Rehabil 2021; 3:e1441-e1447. [PMID: 34712982 PMCID: PMC8527323 DOI: 10.1016/j.asmr.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/25/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up. Methods A retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis. Results We identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis. Conclusions There is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain. Level of Evidence Level IV, retrospective diagnostic case series.
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Affiliation(s)
- Joseph W Galvin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Henry Yu
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - John Slevin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Eric K Turner
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Josef K Eichinger
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Edward D Arrington
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jason A Grassbaugh
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
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15
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Bodendorfer BM. CORR Insights®: Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players. Clin Orthop Relat Res 2021; 479:701-703. [PMID: 32925239 PMCID: PMC8083798 DOI: 10.1097/corr.0000000000001485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 01/31/2023]
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