Athletic Shoulder Injuries Sean F. Bak, MD Sports Medicine and Shoulder Reconstruction Novi, MI

Shoulder Injuries-Overview 1. Chronic Shoulder Pain 2. Acute Shoulder Injuries and Fractures

Chronic Shoulder Injuries “My shoulder hurts. Must be that rotator cuff…”

Anatomy

Causes of Chronic Shoulder Pain 1.Rotator Cuff Tendonitis/Bursitis 2.AC arthritis 3.Labral tear 4.Shoulder arthritis 5.Rotator Cuff tear

Impingement/Bursitis Most common cause of shoulder pain Usually temporary Generally does not need surgery Age 20-70

Impingement/Bursitis

Impingement Rotator cuff tendonitis Bursitis Spur thought to be principal cause

Impingement

Internal Impingement Overhead athletes Cuff between humeral head and posterior glenoid Articular sided cuff tension

Impingement Stage 1: Bursitis Stage 2: Tendonitis Stage 3: Rotator cuff tear Without treatment, stages progress with age

Impingement Process can be stopped! 70-80% resolve without surgery – Motrin, Aleve, etc. – Physical therapy – Injections

Impingement Surgery – Arthroscopic – Clean out inflammation – Remove spur – Sling 3-5 days

Impingement

AC Joint Arthritis

Pain on top of shoulder NOT the ball-socket joint Male predominance Weightlifters Age 20-70

AC Joint Arthritis Rest, modify activities Injection Surgery: Remove the end of the collarbone – Scope or open

Labral Tears

Labral Tear Deep shoulder pain Pain with rotation Throwing athletes Shoulder dislocations

Labral Tears Pathoanatomy Glenoid labrum – GHL attachment Depth and conformity Detachment – Anteroinferior – Superior-SLAP

Labral Tears Bankart Tear – Traumatic dislocation – Anteroinferior labrum

Labral Tears SLAP tears – Superior labrum – More chronic – Overhead athletes

Labral Tear Physical Therapy – Post capsule stretch Injection Arthroscopic treatment recommended for younger patients

Labral Tear-Postop Rehab Sling 4-6 wks PT for 2-3 mos Normal activities 3 mos Return to sports 5 mos

Rotator Cuff Tear

Pain with movement Night pain Not always associated with weakness Develops with time, age Age 50-80

Rotator Cuff Tears Rotator cuff tears age- related Rarely traumatic Years of gradual degeneration

Rotator Cuff Tears Injury may aggravate a previously asymptomatic tear Tear enlarges with time Symptoms may not match progression

Rotator Cuff Tears All full thickness rotator cuff tears enlarge with time Rate of progression varies widely

Rotator Cuff Tears Physical therapy very successful – Bursitis – Rotator cuff tendonitis – Rotator cuff tears

Rotator Cuff Tears Therapy alleviates symptoms, does not heal tear Not everyone requires surgery

Rotator Cuff Repair “The smaller the incision the quicker the recovery”

Rotator Cuff Repair Open rotator cuff repair 1930’s - 90’s Miniopen 1990’s Arthroscopic 2000’s

Rotator Cuff Repair

Success rate of arthroscopic repair only recently has equaled traditional methods Less pain Less complications

Rotator Cuff Repair-Recovery Initial arthroscopic results substandard – Better techniques today Patients removed slings – Strict adherence to therapy

Rotator Cuff Repair-Recovery No change in time to healing of rotator cuff Open: Sling for 6 wks Arthroscopic: Sling for 6 wks Full Recovery: 6-12 mos NO CHANGE IN RECOVERY WITH ARTHROSCOPY!

Shoulder Trauma-Acute Shoulder Injuries

Clavicle Fracture Trauma to lateral shoulder with arm adducted Pain, clavicle deformity +/- neurovascular injury

Clavicle Fracture Nonoperative treatment – Sling for 2 wks followed by ROM – Return to normal activities 6-8 wks – Traditional treatment

Shoulder Trauma Clavicle Fractures Most clavicle fx heal Most pts have no disability Most patients have a “bump”

“All clavicles heal well” More recent studies have shown a % nonunion rate

“All clavicles heal well”?? Union does not equate with good result 46% did not consider themselves fully recovered by 10 years post-injury

Clavicle Fracture-Surgery?? Operative Treatment – Nonunion – Open fractures – Markedly displaced/No cortical contact – > 2 cm shortening – ? Better Function

Clavicle Fracture Operative Treatment-Plates – Direct compression – Anatomic reduction Con’s – Plate irritation – Large dissection

Clavicle Fracture Rehab – Sling for 2 weeks – Weeks 2-6: Begin motion – Weeks 6-12: Full motion, strength

AC Separation

Fall onto lateral shoulder with arm adducted Pain directly at AC joint Prominent distal clavicle in higher grades

AC Separation Classification Progressive Injury Type I-VI increasing severity

AC Separation Treatment Recommendations Nonoperative Management Type I/II Separation – Analgesia – Sling for comfort – Early ROM

AC Separation Treatment Recommendations Acute Surgical Management Type IV/V/VI

AC Separation Treatment Recommendations Type III AC Separation – No clear benefit of acute surgery – Consider surgery for: High demand patients Chronic pain after separation

AC Separation Primary AC Joint Fixation Complications Intraarticular injury Hardware Complications – Breakage – Migration

AC Separation Primary AC Joint Fixation Plate Fixation Maintains AC Joint Soft Tissue Repair Require Plate Removal Clavicular Hook Plate

AC Separation Secondary Stabilization Coracoclavicular Reconstruction Tibialis allograft around base of coracoid thru bone tunnels on clavicle Recreate anatomy

AC Separation Rehab (Operative) – Sling for 6 weeks – Pendulums/Wall walk at 4 wks – Active ROM 6 wks – Strengthening 12 wks

Proximal Humerus Fractures

Neer Classification-Fracture Parts Articular segment Greater Tuberosity Lesser Tuberosity Humeral shaft

Proximal Humerus Fractures Non-displaced80% Displaced20%

Proximal Humerus Fractures Neuro Injury Not uncommon Axillary nerve Cannot test for months Upper trunk plexopathy PAIN

Proximal Humerus Fractures Sling, swathe Early ROM (7-10 days) Stable fracture pattern Frequent xrays and exam

Proximal Humerus Fracture Operative Options – Percutaneous pinning – ORIF Suture vs Plate/screw fixation – Replacement- Hemiarthroplasty Glenoid replacement contraindicated

Proximal Humerus Fractures Wires Sutures Plates/screws IM Nails

Proximal Humerus Fracture Operative Options – Age – Bone quality – Fx pattern – Have various options available and consented for

Minimally Invasive Surgery Percutaneous reduction Percutaneous fixation Indications – Specific fx patterns – Compliance!

PH Fx 45 y.o. RHD female

PH Fx Reduction

PH Fx Provisional Fixation

PH Fx Articular Surface-Shaft Fixation

PH Fx 2 nd Pin Fixation

PH Fx Final Reconstruction

PH Fx Management Outpatient Interscalene anesthesia F/U POD #4 Check x-rays

PH Fx Perc Pinning – Rehab?  No rehab while pins in  Pin removal in OR at 4 weeks  Begin PT