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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; 17:353-364. [PMID: 38918331 PMCID: PMC11336015 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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2
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Maggini E, Tedah Djemetio MD, Husband I, Paganelli L, Saccomanno MF, Milano G. Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery. Sports Med Arthrosc Rev 2024; 32:22-32. [PMID: 38695500 DOI: 10.1097/jsa.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.
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Affiliation(s)
- Emanuele Maggini
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
| | - Mac Donald Tedah Djemetio
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
| | - Isabella Husband
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
| | - Luca Paganelli
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
| | - Maristella F Saccomanno
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
- Department of Bone and Joint Surgery, Spedali Civili, Brescia, Italy
| | - Giuseppe Milano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia
- Department of Bone and Joint Surgery, Spedali Civili, Brescia, Italy
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3
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Chalmers PN, Mcelheny K, D’Angelo J, Ma K, Rowe D, Erickson BJ. Is Workload Associated With Internal Impingement in Professional Baseball Pitchers? An Analysis of Days of Rest, Innings Pitched, and Batters Faced. Orthop J Sports Med 2023; 11:23259671231191223. [PMID: 37655255 PMCID: PMC10467392 DOI: 10.1177/23259671231191223] [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: 04/15/2023] [Accepted: 05/03/2023] [Indexed: 09/02/2023] Open
Abstract
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.
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Affiliation(s)
- Peter N. Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - John D’Angelo
- Major League Baseball Commissioner’s Office, New York, New York, USA
| | - Kevin Ma
- Major League Baseball Commissioner’s Office, New York, New York, USA
| | - Dana Rowe
- Major League Baseball Commissioner’s Office, New York, New York, USA
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4
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Horowitz EH, Aibinder WR. Shoulder Impingement Syndrome. Phys Med Rehabil Clin N Am 2023; 34:311-334. [PMID: 37003655 DOI: 10.1016/j.pmr.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Shoulder impingement is the most common diagnosis for shoulder pain. Shoulder impingement syndrome has been scrutinized as a misleading "umbrella" term, due to its vague and nonspecific context. It is better subcategorized into subacromial, internal, and subcoracoid impingement. The evaluation and treatment algorithm for each is grossly similar. A thorough history, focused physical examination, and standard radiographs are the first steps. Advanced imaging with MRI or ultrasound may be useful. The mainstay of treatment includes physical therapy, anti-inflammatory medications, and injections. Surgical treatment is reserved for refractory cases, and includes decompression, debridement, and/or repair of injured structures.
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Affiliation(s)
- Evan H Horowitz
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY 11203, USA. https://twitter.com/EvanHorowitzMD
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, USA.
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5
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Funakoshi T, Furushima K, Takahashi T, Miyamoto A, Urata D, Yoshino K, Sugawara M. Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes. J Shoulder Elbow Surg 2022; 31:1463-1473. [PMID: 35063639 DOI: 10.1016/j.jse.2021.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder pain and dysfunction are common in baseball players, and although "internal impingement" is recognized as one of the most common pathologies of shoulder dysfunction, the optimal surgical treatment for internal impingement with anterior instability of the shoulder remains controversial. This study evaluated baseball players' preliminary outcomes following anterior glenohumeral capsular ligament reconstruction for internal impingement with anterior instability of the shoulder. METHODS Twelve baseball players (all male; mean age, 20.5 ± 2.2 years) with internal impingement and anterior instability managed via anterior glenohumeral capsular ligament reconstruction were examined. The mean follow-up period was 25.3 ± 4.6 months. Anterior glenohumeral capsular ligament reconstruction was performed with a knee hamstring autograft for balanced stability and laxity with two major targets: to prevent hyperangulation and translation in horizontal abduction and to mimic the individual arm cocking position at the final decision of tension. Preoperative and final follow-up evaluations were performed using Jobe's postoperative grading system; the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; Disabilities of the Arm, Shoulder and Hand sports module; plain radiographs; and magnetic resonance imaging. RESULTS Jobe's postoperative grading system score, the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score, and the Disabilities of the Arm, Shoulder and Hand sports module score improved significantly from 20.4 ± 12.2, 28.4 ± 8.3, and 80.2 ± 11.1 points preoperatively to 88.8 ± 13.6, 80.8 ± 7.7, and 22.4 ± 18.7 points postoperatively, respectively (P < .001, .0025, <0.001, respectively). Both clinical and imaging evaluations revealed improved internal impingement with anterior instability after anterior glenohumeral capsular ligament reconstruction. The mean external rotation at abduction significantly decreased from 113° preoperatively to 104° postoperatively. At follow-up, 10 of the 12 athletes (83.3%) returned to their prior competitive level. Plain radiographs and magnetic resonance imaging revealed no obvious loosening of the graft or screws. CONCLUSIONS Anterior glenohumeral capsular ligament reconstruction resulted in preferable clinical outcomes for young baseball players who experienced pain during the throwing motion. Stabilization of the glenohumeral joint with autografting of the knee hamstring may thus represent a solution for internal impingement with anterior instability in overhead throwing athletes.
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Affiliation(s)
| | | | | | | | - Daigo Urata
- Keiyu Orthopaedic Hospital, Tatebayashi, Japan
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Abstract
» The thrower's shoulder has been a subject of great interest for many decades. Different theories have been proposed to clarify the pathophysiology, clinical presentation, and treatment options for this condition. In this review article, we summarize the relevant anatomy and pathophysiology and how these translate into signs, symptoms, and imaging findings. Also, a historical review of the treatment methodologies in the setting of an evolving concept is presented. » The initial event in the cascade is thickening and contracture of the posteroinferior capsule resulting from repetitive tensile forces during the deceleration phase of throwing. This is known as "the essential lesion" and is clinically perceived as glenohumeral internal rotation deficit (GIRD), and a Bennett lesion may be found on radiographs. » Change in the glenohumeral contact point leads to a series of adaptations that are beneficial for the mechanics of throwing, specifically in achieving the so-called "slot," which will maximize throwing performance. » The complexity of the throwing shoulder is the result of an interplay of the different elements described in the cascade, as well as other factors such as pectoralis minor tightness and scapular dyskinesis. However, it is still unclear which event is the tipping point that breaks the balance between these adaptations and triggers the shift from an asymptomatic shoulder to a painful disabled joint that can jeopardize the career of a throwing athlete. Consequences are rotator cuff impingement and tear, labral injury, and scapular dyskinesis, which are seen both clinically and radiographically. » A thorough understanding of the pathologic cascade is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common. » The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder.
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Affiliation(s)
- Giovanna Medina
- Jefferson Health 3B Orthopaedics, Philadelphia, Pennsylvania
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Ochiai D. Editorial Commentary: Thermal Pie-Crusting the Hip Capsule Improves Exposure: But Is it Safe? Arthroscopy 2021; 37:2838-2839. [PMID: 34481624 DOI: 10.1016/j.arthro.2021.04.064] [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: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 02/02/2023]
Abstract
Thermal pie-crusting of the capsule can increase hip arthroscopy surgical exposure in the peripheral compartment. Recent time-zero biomechanical research suggests that repairing the capsule after pie-crusting yields similar strength and increased stiffness when compared to a T-capsulotomy. However, the risks of thermal damage to the capsule should be weighed against the biomechanical advantages of repairing a pie-crusted capsule versus a T-capsulotomized capsule. In addition, if a surgeon wants to inject an intra-articular orthobiologic such as platelet-rich plasma (PRP), I would not recommend pie-crusting because the full-thickness slits in the capsule could allow the PRP to escape, even after capsular repair. I will still use traction sutures for 100% of my hip arthroscopy procedures. However, in the very rare setting when traction sutures alone yield inadequate exposure, I will perform pie-crusting instead of a T-capsulotomy.
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Bolia IK, Collon K, Bogdanov J, Lan R, Petrigliano FA. Management Options for Shoulder Impingement Syndrome in Athletes: Insights and Future Directions. Open Access J Sports Med 2021; 12:43-53. [PMID: 33880071 PMCID: PMC8053512 DOI: 10.2147/oajsm.s281100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/13/2021] [Indexed: 01/02/2023] Open
Abstract
Athletes participating in overhead sports are at particularly high risk of shoulder impingement syndrome. Subcoracoid impingement is defined as impingement of the anterior soft tissues of the shoulder between the coracoid process and the lesser tuberosity. Subacromial impingement syndrome (SIS) occurs due to extrinsic compression of the rotator cuff between the humeral head and coracoacromial structures or intrinsic degeneration of the supraspinatus tendon and subsequent superior migration of the humerus. Internal impingement is a major cause of shoulder pain in overhead athletes, and it occurs due to repetitive impingement of the articular surface of the rotator cuff with the glenoid during maximum abduction and external rotation of the arm. When examining athletes with suspected impingement of the shoulder, it is important to discuss the sport-specific motion that regenerates the symptoms and perform a combination of physical examination tests to improve the diagnostic accuracy. Radiographic evaluation is recommended, and the extent of soft tissue abnormalities can be assessed on ultrasound or magnetic resonance imaging of the shoulder. Management of shoulder impingement syndrome can be conservative or operative, based on the severity and chronicity of symptoms and the associated structural abnormalities. This review provides an update on the management of SIS, subcoracoid impingement, and internal impingement in the athletic population.
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Affiliation(s)
- Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Kevin Collon
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jacob Bogdanov
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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9
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Mihata T, Morikura R, Hasegawa A, Fukunishi K, Kawakami T, Fujisawa Y, Ohue M, Neo M. Partial-Thickness Rotator Cuff Tear by Itself Does Not Cause Shoulder Pain or Muscle Weakness in Baseball Players. Am J Sports Med 2019; 47:3476-3482. [PMID: 31609639 DOI: 10.1177/0363546519878141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Partial-thickness rotator cuff tears are common shoulder injuries in baseball players. For some tears, the symptoms can be relieved through physical therapy or debridement without rotator cuff repair. PURPOSE To assess whether partial-thickness rotator cuff tear by itself causes shoulder pain and muscle weakness in baseball players. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We studied 87 university baseball players (age, 19.5 ± 0.8 years; baseball career, 11.5 ± 1.6 years). All data were obtained during a full-participation annual medical check in 1 team. Rotator cuff tendons were examined ultrasonographically and allocated to 4 groups: (1) no tear, (2) supraspinatus tendon tear, (3) infraspinatus tendon tear, and (4) both supraspinatus and infraspinatus tendon tears. Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared by using chi-square and t tests. All players could play baseball with or without shoulder pain in this study. RESULTS Of the 87 players, 41 (47%) had articular-sided partial-thickness rotator cuff tears diagnosed on ultrasonography; the remaining 46 athletes were tear-free. Of the 41 affected patients, 19 had tears in the supraspinatus, 13 in the infraspinatus, and 9 in both the supraspinatus and infraspinatus tendons. Tear depth (mean ± SD) was 4.6 ± 2.3 mm in the supraspinatus and 6.2 ± 3.6 mm in the infraspinatus. Neither the rate of shoulder pain nor muscle strength differed significantly among the 4 groups (P = .96 and P = .15-.70, respectively). CONCLUSION Articular-sided partial-thickness rotator cuff tear-by itself-did not cause shoulder pain and muscle weakness in university baseball players. Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears.
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Affiliation(s)
- Teruhisa Mihata
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan.,First Towakai Hospital, Takatsuki, Osaka, Japan.,Katsuragi Hospital, Kishiwada, Osaka, Japan
| | - Rei Morikura
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Akihiko Hasegawa
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kunimoto Fukunishi
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | | | - Yukitaka Fujisawa
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | | | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
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10
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Chauhan A, Tam JH, Porter AJ, Challa S, Early S, D'Angelo J, Keefe D, Hoenecke H, Fronek J. Professional advancement, performance, and injury characteristics of baseball players entering the Major League Baseball draft after treatment for shoulder injuries. J Shoulder Elbow Surg 2019; 28:220-226. [PMID: 30290986 DOI: 10.1016/j.jse.2018.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/21/2018] [Accepted: 07/25/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND How shoulder injuries treated before the Major League Baseball (MLB) draft affect the player's performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees. METHODS Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared. RESULTS Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement. CONCLUSIONS Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.
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Affiliation(s)
- Aakash Chauhan
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Jason H Tam
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Anthony J Porter
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Sravya Challa
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA; University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - Samuel Early
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA; University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | | | - Daniel Keefe
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Heinz Hoenecke
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Jan Fronek
- Division of Sports Medicine, Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA.
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11
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Abstract
Overhead athletes subject their shoulders to extreme repetitive torque, compression, distraction, and translation stresses, resulting in adaptive changes of the soft tissues and osseous structures within and around the glenohumeral joint. These anatomic adaptations result in biomechanical enhancements, which improve performance. Understanding the difference between necessary and adaptive changes and pathologic findings is critical when making treatment decisions. Injuries to the shoulder of the overhead athlete can be generally classified into three groups: internal impingement, internal impingement with acquired secondary anterior instability, and primary anterior or multidirectional instability. Although advances in surgical techniques have allowed surgeons to address the pathology in these groups, merely attempting to restore the shoulder to so-called normal can adversely alter adaptive changes that allow high levels of performance.
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12
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Comparative outcomes of extracorporeal shockwave therapy for shoulder tendinitis or partial tears of the rotator cuff in athletes and non-athletes: Retrospective study. Int J Surg 2018; 51:184-190. [PMID: 29408642 DOI: 10.1016/j.ijsu.2018.01.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/20/2017] [Accepted: 01/25/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Refractory shoulder tendinitis or partial thickness rotator cuff tears (PTRCTs) are common findings in overhead athletes. Previous studies have examined the effectiveness of extracorporeal shockwave therapy (ESWT) for shoulder tendinitis. MATERIALS AND METHODS In the current study, we recruited 36 shoulders and performed a comparison between the professional athletes (13 shoulders, athletic group; AG) and the non-athletic population (23 shoulders, non-athletic group, NAG) with PTRCTs or shoulder tendinitis of the shoulder after ESWT. Patients with symptomatic tendinitis of the shoulder with or without a partial tear of the rotator cuff tendon and failed oral medication and physical therapy for more than 3 months were treated with electrohydraulic mode of ESWT. All patients that met the inclusion criteria were categorized into two groups according to their pre-treatment activity level. RESULTS We found that NAG exhibited significant aging and degenerative change around the glenohumeral joint and subacromial space. After ESWT treatment, the patients in AG were with 53.8% high satisfaction rating and patients in NAG were 52.1% by one-year followed up. CONCLUSION The results showed ESWT was equally effective treatment in both AG and NAG. In light of its efficacy and less-invasive nature, we suggest ESWT can be used to treat athletes with refractory tendinitis or PTRCTs before proceeding to arthroscopic intervention.
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13
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Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. World J Orthop 2016; 7:776-784. [PMID: 28032029 PMCID: PMC5155252 DOI: 10.5312/wjo.v7.i12.776] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
One of the most common pathologic processes seen in overhead throwing athletes is posterior shoulder pain resulting from internal impingement. “Internal impingement” is a term used to describe a constellation of symptoms which result from the greater tuberosity of the humerus and the articular surface of the rotator cuff abutting the posterosuperior glenoid when the shoulder is in an abducted and externally rotated position. The pathophysiology in symptomatic internal impingement is multifactorial, involving physiologic shoulder remodeling, posterior capsular contracture, and scapular dyskinesis. Throwers with internal impingement may complain of shoulder stiffness or the need for a prolonged warm-up, decline in performance, or posterior shoulder pain. On physical examination, patients will demonstrate limited internal rotation and posterior shoulder pain with a posterior impingement test. Common imaging findings include the classic “Bennett lesion” on radiographs, as well as articular-sided partial rotator cuff tears and concomitant SLAP lesions. Mainstays of treatment include intense non-operative management focusing on rest and stretching protocols focusing on the posterior capsule. Operative management is variable depending on the exact pathology, but largely consists of rotator cuff debridement. Outcomes of operative treatment have been mixed, therefore intense non-operative treatment should remain the focus of treatment.
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14
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Abstract
Throwers, or athletes who engage in repetitive overhead motions, are a unique subset of athletes that experience distinct shoulder injuries. Athletes engaged in baseball comprise the majority of patients seeking orthopedic care for throwing related injuries. Injuries specific to throwers most commonly involve the labrum and the undersurface of the rotator cuff. In addition, tissue changes in both the anterior and posterior glenohumeral capsule are common with repetitive overhead motions. These capsular changes alter. This article will examine the pathomechanics of injuries to throwers, elaborate means of diagnoses of cuff and labral injury and discuss recent advances in both non-operative and operative interventions, including preventative principles.
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Affiliation(s)
- Stuart D Kinsella
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Stephen J Thomas
- Division of Nursing and Health Sciences, Neumann University, 1 Neumann Drive, Aston, PA 19104, USA
| | - G Russell Huffman
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA
| | - John D Kelly
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA.
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16
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Harris JD, Frank JM, Jordan MA, Bush-Joseph CA, Romeo AA, Gupta AK, Abrams GD, McCormick FM, Bach BR. Return to sport following shoulder surgery in the elite pitcher: a systematic review. Sports Health 2014; 5:367-76. [PMID: 24459557 PMCID: PMC3899910 DOI: 10.1177/1941738113482673] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Joshua D Harris
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Jonathan M Frank
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Mark A Jordan
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Charles A Bush-Joseph
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Anthony A Romeo
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Anil K Gupta
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Geoffrey D Abrams
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Frank M McCormick
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Bernard R Bach
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
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17
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Abstract
CONTEXT The mature athlete's shoulder remains a challenging clinical condition to manage. A normal natural history of the shoulder includes stiffness, rotator cuff tears, and osteoarthritis, all of which can become increasingly more symptomatic as an athlete ages. EVIDENCE ACQUISITION PubMed (1978-2013). STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 3-4. RESULTS Rotator cuff pathology increases with age and activity level. Partial tears rarely heal, and debridement of significant partial tears results in poorer outcomes than those of repair. Repair of partial-thickness tears can be accomplished with completion and subsequent repair or in situ repair. The most successful result for treatment of osteoarthritis in the shoulder remains total shoulder arthroplasty, with more than 80% survival at 20 years and high rates of return to sport. Caution should be taken in patients younger than 60 years, as they show much worse results with this treatment. Adhesive capsulitis of the shoulder can be successfully treated with nonoperative management in 90% of cases. CONCLUSION Mature athletes tend to have rotator cuff pathology, osteoarthritis, and stiffness, which may limit their participation in athletic events. Age is a significant consideration, even within the "mature athlete" population, as patients younger than 50 years should be approached differently than those older than 65 years with regard to treatment regimens and postoperative restriction.
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Abstract
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.
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19
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Mihata T, Jun BJ, Bui CNH, Hwang J, McGarry MH, Kinoshita M, Lee TQ. Effect of scapular orientation on shoulder internal impingement in a cadaveric model of the cocking phase of throwing. J Bone Joint Surg Am 2012; 94:1576-83. [PMID: 22992848 DOI: 10.2106/jbjs.j.01972] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although deviations in scapular orientation are thought to predispose to shoulder injuries in throwing athletes, the biomechanical mechanism underlying shoulder injuries in throwing athletes with an altered scapular orientation remains unclear. METHODS Seven fresh-frozen cadaveric shoulders were evaluated at 90° of abduction, with the humerus externally rotated from 90° to the maximum angle, to simulate the late cocking phase of the throwing motion. Loads were applied to the deltoid, pectoralis major, latissimus dorsi, teres major, and all rotator cuff muscles. Contact pressure in the glenohumeral joint was measured with use of a pressure sensor. The area of internal impingement was calculated on the basis of three-dimensional position data. Glenohumeral contact pressure and the area of impingement were compared between 20°, 30°, and 40° of internal scapular rotation; between 20°, 30°, and 40° of upward scapular rotation; and between 0° and 10° of anterior scapular tilt. Data were analyzed with use of repeated-measures analysis of variance with the Tukey post hoc test. RESULTS Contact pressure was at its maximum in the posterior aspect of the glenohumeral joint. The glenohumeral contact pressure and internal impingement area increased with increasing internal scapular rotation. The glenohumeral contact pressure at 40° of internal scapular rotation was significantly (43.4%) greater than that at 20° of internal scapular rotation (p < 0.01), and the impingement area at 40° of internal scapular rotation was significantly (43.1%) greater than that at 20° of internal scapular rotation (p < 0.05). Decreasing upward scapular rotation resulted in an increase in internal impingement area. The internal impingement area at 40° of upward motion was 38.1% less than that at 20° of upward rotation (p < 0.001) and 28.9% less than that at 30° of upward rotation (p < 0.01). CONCLUSIONS Increasing internal scapular rotation and decreasing upward scapular rotation significantly increase glenohumeral contact pressure and the area of impingement of the rotator cuff tendon between the greater tuberosity and glenoid during simulated throwing motion.
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Affiliation(s)
- Teruhisa Mihata
- Department of Orthopedic Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
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20
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Jones KJ, Kahlenberg CA, Dodson CC, Nam D, Williams RJ, Altchek DW. Arthroscopic capsular plication for microtraumatic anterior shoulder instability in overhead athletes. Am J Sports Med 2012; 40:2009-14. [PMID: 22869628 DOI: 10.1177/0363546512453299] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extreme loading conditions at the glenohumeral joint during overhead athletic activities can result in both soft tissue and osseous adaptative changes at the shoulder. Subtle alterations in the stabilizing structures may lead to anterior instability and debilitating shoulder pain with subsequent inability to participate in athletics. There is currently a paucity of data documenting clinical outcomes after arthroscopic capsular plication in overhead athletes who demonstrate objective findings of pain and anterior instability on physical examination. PURPOSE To evaluate outcomes after arthroscopic capsular plication for anterior instability in overhead athletes with an emphasis on postoperative range of motion, postoperative shoulder function, and return to sport. STUDY DESIGN Case series; Level of evidence, 4. METHODS The authors identified 20 overhead athletes with debilitating shoulder pain and a failed trial of nonoperative management who underwent arthroscopic capsular plication (12 suture plication, 8 suture anchor plication) for anterior instability related to isolated capsular redundancy. Patients were evaluated with the Single Assessment Numerical Evaluation (SANE) and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, and they were interviewed to determine the rate of return to athletic activity. Failures of treatment included patients who demonstrated debilitating pain that precluded return to sport. RESULTS At a mean follow-up of 3.6 years (range, 2.0-5.5 years), 18 (90%) patients returned to overhead sports, with 17 (85%) at their preinjury level. The mean (SD) SANE score was 86 (17.5%; range, 30%-100%), and the mean (SD) KJOC score was 82 (18.2; range, 28-100). When compared with the contralateral extremity, there were no significant differences in glenohumeral range of motion. Two patients with associated rotator cuff injury experienced persistent pain with overhead activity and were unable to return to sport, representing a 10% failure rate. CONCLUSION Arthroscopic capsular plication for anterior instability related to isolated capsular redundancy is an effective procedure that yields a high rate of patient satisfaction and return to overhead athletic activity with an acceptably low failure rate. Patients with associated rotator cuff injury may be at higher risk for treatment failure.
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Affiliation(s)
- Kristofer J Jones
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA.
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Dewan AK, Garzon-Muvdi J, Petersen SA, Jia X, McFarland EG. Intraarticular abnormalities in overhead athletes are variable. Clin Orthop Relat Res 2012; 470:1552-7. [PMID: 22095131 PMCID: PMC3348313 DOI: 10.1007/s11999-011-2183-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The cause of shoulder pain and dysfunction in the overhead athlete can be variable. Several studies illustrate the wide variety of lesions seen at the time of arthroscopy in overhead athletes who require surgery but it is unclear whether these differ by sport. QUESTIONS/PURPOSES We examined overhead athletes with shoulder dysfunction to determine (1) the range of arthroscopically visualized shoulder abnormalities with specific attention to the posterosuperior glenohumeral joint and the rotator cuff; and (2) the relationship of sport type to these abnormalities. METHODS We reviewed our institution's database for professional and collegiate athletes in overhead sports who, from 1996 through 2010, had diagnostic shoulder arthroscopy for insidious, nontraumatic, persistent pain and inability to participate in their sport. A descriptive analysis of the arthroscopic findings from 51 consecutive patients (33 males, 18 females; mean age, 25 years; range, 15-59 years) was done. We analyzed the arthroscopic findings with respect to sport using analysis of variance and Fisher's exact test. RESULTS There was a wide range of superior labrum, posterosuperior glenoid, and rotator cuff abnormalities. Overall, the most frequent abnormalities were posterosuperior glenohumeral joint changes. Swimmers had fewer intraarticular abnormalities than baseball players. CONCLUSIONS We found a wide spectrum of intraarticular abnormalities in the shoulder of overhead athletes with shoulder pain requiring surgery. Additional study is needed to determine whether these abnormalities or combinations relate to specific athletic movements. LEVEL OF EVIDENCE Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ashvin K. Dewan
- Division of Shoulder Surgery and the Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
| | - Juan Garzon-Muvdi
- Division of Shoulder Surgery and the Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
| | - Steve A. Petersen
- Division of Shoulder Surgery and the Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
| | - Xiaofeng Jia
- Division of Shoulder Surgery and the Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
| | - Edward G. McFarland
- Division of Shoulder Surgery and the Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
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22
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Toth AP, Warren RF, Petrigliano FA, Doward DA, Cordasco FA, Altchek DW, O’Brien SJ. Thermal shrinkage for shoulder instability. HSS J 2011; 7:108-14. [PMID: 22754408 PMCID: PMC3145864 DOI: 10.1007/s11420-010-9187-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Accepted: 10/05/2010] [Indexed: 02/07/2023]
Abstract
UNLABELLED Thermal capsular shrinkage was popular for the treatment of shoulder instability, despite a paucity of outcomes data in the literature defining the indications for this procedure or supporting its long-term efficacy. The purpose of this study was to perform a clinical evaluation of radiofrequency thermal capsular shrinkage for the treatment of shoulder instability, with a minimum 2-year follow-up. From 1999 to 2001, 101 consecutive patients with mild to moderate shoulder instability underwent shoulder stabilization surgery with thermal capsular shrinkage using a monopolar radiofrequency device. Follow-up included a subjective outcome questionnaire, discussion of pain, instability, and activity level. Mean follow-up was 3.3 years (range 2.0-4.7 years). The thermal capsular shrinkage procedure failed due to instability and/or pain in 31% of shoulders at a mean time of 39 months. In patients with unidirectional anterior instability and those with concomitant labral repair, the procedure proved effective. Patients with multidirectional instability had moderate success. In contrast, four of five patients with isolated posterior instability failed. Thermal capsular shrinkage has been advocated for the treatment of shoulder instability, particularly mild to moderate capsular laxity. The ease of the procedure makes it attractive. However, our retrospective review revealed an overall failure rate of 31% in 80 patients with 2-year minimum follow-up. This mid- to long-term cohort study adds to the literature lacking support for thermal capsulorrhaphy in general, particularly posterior instability. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (doi:10.1007/s11420-010-9187-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alison P. Toth
- Duke Sports Medicine Center, 317 Finch Yeager Building, Durham, NC 27710 USA
| | - Russell F. Warren
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Frank A. Petrigliano
- David Geffen School of Medicine, University of California at Los Angeles, 757 Westwood Blvd., Los Angeles, CA 90095 USA
| | - David A. Doward
- Jacksonville Orthopaedic Institute, 1325 San Marco Blvd., Suite 102, Jacksonville, FL 32258 USA
| | - Frank A. Cordasco
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - David W. Altchek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Stephen J. O’Brien
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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23
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Virk SS, Kocher MS. Adoption of new technology in sports medicine: case studies of the Gore-Tex prosthetic ligament and of thermal capsulorrhaphy. Arthroscopy 2011; 27:113-21. [PMID: 20974526 DOI: 10.1016/j.arthro.2010.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/01/2010] [Accepted: 06/02/2010] [Indexed: 02/02/2023]
Abstract
Evaluation of new technology in sports medicine is supposed to promote improvements in the care of patients. It is also supposed to prohibit technology that can harm patients. This evaluation process is not perfect and at times can promote technology that not only does not help patients but may harm them. Two examples of new sports medicine technology that were widely adopted but eventually abandoned are thermal capsulorrhaphy for treatment of shoulder instability and the Gore-Tex prosthetic ligament (W. L. Gore & Associates, Flagstaff, AZ) for patients with anterior cruciate ligament deficiency. On analysis of the quick adoption of these 2 failed procedures, certain recommendations are apparent for improvement of the evaluation process. There must be a sound rationale behind any new technology, basic science research into the theory of the medical technology, and demonstrated improvements in animal models and clinical studies that are prospective cohort studies or randomized controlled trials, and finally, there must be careful follow-up and postmarket surveillance.
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24
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25
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Abstract
Repetitive throwing or other overhead activity places great stress on the shoulder. As a result, the shoulder is a common site of injury in athletes. Addressing throwing-related injuries requires an understanding of throwing biomechanics and pathology. Nonoperative treatment is directed at restoring strength, flexibility, and neuromuscular control to the entire kinetic chain. Surgery is indicated when nonoperative treatment fails, and is directed at correcting labral, capsular, and rotator cuff pathology.
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26
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Behrens SB, Compas J, Deren ME, Drakos M. Internal impingement: a review on a common cause of shoulder pain in throwers. PHYSICIAN SPORTSMED 2010; 38:11-8. [PMID: 20631459 DOI: 10.3810/psm.2010.06.1778] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Internal impingement is a term used to describe the pathologic contact of the undersurface of the rotator cuff with the glenoid. It typically occurs in overhead athletes, particularly throwers. In these athletes, the bones and soft tissues adapt to allow these athletes to have a supraphysiologic range of motion. In many athletes, these changes may lead to symptoms of internal impingement. This article discusses the background, biomechanics, pathophysiology, clinical and radiographic assessment, treatments, and outcomes of this disorder.
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Affiliation(s)
- Steve B Behrens
- Department of Orthopaedics, Brown University, Warren Alpert Medical Schoo, Providence, RI
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27
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Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health 2010; 2:101-15. [PMID: 23015928 PMCID: PMC3445082 DOI: 10.1177/1941738110362518] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses imposed on the athlete's shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of the overhead athlete and the demands endured during the act of throwing. These principles are described and incorporated in a multiphase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both nonoperatively and postoperatively.
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Affiliation(s)
- Michael M. Reinold
- Boston Red Sox Baseball Club, Boston, Massachusetts
- Division of Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J. Gill
- Boston Red Sox Baseball Club, Boston, Massachusetts
- Division of Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - James R. Andrews
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama
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28
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Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW. Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am 2009; 91:2719-28. [PMID: 19884449 DOI: 10.2106/jbjs.i.00409] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Internal impingement of the shoulder refers to a constellation of pathologic conditions, including, but not limited to, articular-sided rotator cuff tears, labral tears, biceps tendinitis, anterior instability, internal rotation deficit, and scapular dysfunction. Physiologic adaptations to throwing include increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all of which may predispose an individual to internal impingement. Nonoperative treatment should always be attempted first, with a focus on increasing the range of motion and improving scapular function. When an operative intervention is chosen, it is important to address microinstability in order to have a good outcome and prevent failure.
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Affiliation(s)
- Mark C Drakos
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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29
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Abstract
Internal impingement of the shoulder is a pathologic condition characterized by excessive or repetitive contact of the greater tuberosity of the humeral head with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated. This arm positioning leads to rotator cuff and glenoid labrum impingement by the bony structures of the glenohumeral joint. Although some degree of contact between these structures occurs under normal conditions, to date most of the orthopaedic literature has focused on internal impingement as a disease state that affects overhead athletes and is characterized by the development of articular-sided rotator cuff tears and posterosuperior labral lesions. The precise cause of these impingement lesions remains unclear. However, it is believed that varying degrees of glenohumeral instability, posterior capsular contracture, and scapular dyskinesis may play a role in the development of symptomatic internal impingement. The purpose of this article is to review the pathomechanics, clinical complaints, physical examination findings, and imaging findings that are associated with internal impingement. The results of treatment will be reviewed, and a diagnostic and therapeutic algorithm for the management of internal impingement is presented.
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Affiliation(s)
- Benton E Heyworth
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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30
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Abstract
Pathologic conditions in the shoulder of a throwing athlete frequently represent a breakdown of multiple elements of the shoulder restraint system, both static and dynamic, and also a breakdown in the kinetic chain. Physical therapy and rehabilitation should be, with only a few exceptions, the primary treatment for throwing athletes before operative treatment is considered. Articular-sided partial rotator cuff tears and superior labral tears are common in throwing athletes. Operative treatment can be successful when nonoperative measures have failed. Throwing athletes who have a glenohumeral internal rotation deficit have a good response, in most cases, to stretching of the posteroinferior aspect of the capsule.
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Affiliation(s)
- Sepp Braun
- Steadman Hawkins Research Foundation, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, USA
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31
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Abstract
UNLABELLED The overhead throwing motion is an extremely skillful and intricate movement. When pitching, the overhead throwing athlete places extraordinary demands on the shoulder complex subsequent to the tremendous forces that are generated. The thrower's shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower's paradox." This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Rehabilitation follows a structured, multiphase approach, with emphasis on controlling inflammation, restoring muscles' balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses occurring during overhead throwing. Treatment should include the restoration of these adaptations. LEVEL OF EVIDENCE Level 5.
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32
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Lu Y, Markel MD, Kalscheur V, Ciullo JR, Ciullo JV. Histologic evaluation of thermal capsulorrhaphy of human shoulder joint capsule with monopolar radiofrequency energy during short- to long-term follow-up. Arthroscopy 2008; 24:203-9. [PMID: 18237705 DOI: 10.1016/j.arthro.2007.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 08/02/2007] [Accepted: 08/02/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the histologic morphology of human shoulder joint capsule after thermal capsulorrhaphy with monopolar radiofrequency energy (mRFE) during short- to long-term follow-up. METHODS This study comprised 27 patients who received an arthroscopic mRFE thermal capsulorrhaphy and 10 patients without mRFE treatment serving as the control group. Biopsy samples from 3 locations (anterior-superior, anterior-inferior, and posterior-medial) of the shoulder joint capsule were harvested from both the mRFE-treated patients and the control patients. The follow-up time for the mRFE treatment ranged from 3.5 to 62 months, which was divided into 3 groups: short, 3.5 to 12 months; medium, 14 to 25 months; and long, 31 to 62 months. The biopsy samples were analyzed via a histologic scoring system, evaluating an intact synovial layer, subsynovial edema, collagen morphology, cellularity, vascularity, and inflammatory cells. Histologic scores among each follow-up group were compared with each other and with those in the control group. RESULTS There were no significant differences in the histologic categories of intact synovial layer, subsynovial edema, collagen morphology, and inflammatory cells among the control and mid- and long-term mRFE groups. The short-term mRFE group had greater increased cellularity and vascularity compared with the mid- and long-term groups, which progressively improved toward the appearance in the normal control group with time. CONCLUSIONS After mRFE capsulorrhaphy, histologic analysis revealed that the mRFE-treated shoulder joint capsule had almost returned to normal, except for persistent cellularity and increased vascularity, which were present at up to 5 years after this procedure. LEVEL OF EVIDENCE Level III, therapeutic case-control study.
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Affiliation(s)
- Yan Lu
- Comparative Orthopaedic Research Laboratory, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin 53706-1102, USA.
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33
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Complications of Thermal Capsulorrhaphy of the Shoulder. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2007. [DOI: 10.1097/bte.0b013e318060d36d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Siskosky MJ, ElAttrache NS. Management of Internal Impingement and Partial Rotator Cuff Tears in the Throwing Athlete. OPER TECHN SPORT MED 2007. [DOI: 10.1053/j.otsm.2007.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Thermal capsulorrhaphy has been used to treat many different types of shoulder instability, including multidirectional instability, unidirectional instability, and microinstability in overhead-throwing athletes. A device that delivers laser energy or radiofrequency energy to the capsule tissue causes the collagen to denature and the capsule to shrink. The optimal temperature to achieve the most shrinkage without causing necrosis of the tissue is between 65 degrees and 75 degrees centigrade. This treatment causes a significant decrease in mechanical stiffness for the first 2 weeks, and then, after the tissue undergoes active cellular repair from the surrounding uninjured tissue, the mechanical properties return to near normal by 12 weeks. If the thermal energy is applied in a grid pattern, then the tissue heals with more stiffness by 6 weeks. Clinical studies on thermal capsulorrhaphy for the treatment of multidirectional instability have shown a high rate of recurrent instability (12%-64%). The clinical studies on unidirectional instability showed much better recurrence rates (4%-25%), but because most of the patients also underwent concomitant Bankart repairs and superior labral anterior posterior lesion repairs, the efficacy of the thermal treatment cannot be ascertained. A randomized controlled trial would be needed to assess whether instability with Bankart lesions requires augmentation with thermal capsulorrhaphy. For the patients with microinstability who are overhead-throwing athletes, thermal capsulorrhaphy has shown varying results from a 97% rate of return to sports to a 62% rate of return to sports. Complications of this technique include temporary nerve injuries that usually involve the sensory branch of the axillary nerve and thermal necrosis of the capsule, which is rare.
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Affiliation(s)
- Anthony Miniaci
- Director of Sports Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, A41, Cleveland, OH 44195, USA.
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Brushøj C, Bak K, Johannsen HV, Faunø P. Swimmers' painful shoulder arthroscopic findings and return rate to sports. Scand J Med Sci Sports 2006; 17:373-7. [PMID: 16805785 DOI: 10.1111/j.1600-0838.2006.00571.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Shoulder pain is the most common musculo-skeletal complaint in competitive swimmers. It remains one of the shoulder pain syndromes in overhead athletes where no golden standard of treatment exists. Eighteen competitive swimmers who all had undergone shoulder arthroscopy for therapy-resistant shoulder pain were retrospectively evaluated with respect to operative findings and ability to return to their sport after the operation. The most common finding at arthroscopy was labral pathology in 11 (61%) and subacromial impingement in five shoulders (28%). Operative procedures included debridement in 11 swimmers, partial release of the coraco-acromial ligament in four, and bursectomy in four. Sixteen (89%) responded to the follow-up evaluation. Nine swimmers (56%) were able to compete at preinjury level after 4 (2-9) months. Findings at arthroscopy suggest that the term "Swimmer's shoulder" covers a variety of pathologies including labral wearing and subacromial impingement. Arthroscopic debridement of labral tears or bursectomy in swimmers with shoulder pain has a low success rate with regard to return to sport. Further understanding and investigation of this syndromes complex pathophysiology is needed.
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Affiliation(s)
- C Brushøj
- Division of Sports Orthopaedics, Department of Orthopaedic Surgery, Amager Hospital, Copenhagen, Denmark.
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Abstract
Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. Increased anterosuperior translation of the humeral head occurs with forward flexion and can mimic the pain reported with impingement syndrome; however, the patient with impingement syndrome presents with normal range of motion. Initial management of posterior capsular contracture should be nonsurgical, emphasizing range-of-motion stretching with the goal of restoring normal motion. For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. Management involves regaining internal rotation such that the loss of internal rotation is not greater than the increase in external rotation. In the athlete who fails nonsurgical management, a selective posteroinferior capsulotomy can improve motion, reduce pain, and prevent further shoulder injury.
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Affiliation(s)
- H Gregory Bach
- Department of Orthopaedic Surgery, University of Illinois-Chicago, 60612, USA
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Abstract
PURPOSE This study examined whether radiofrequency electrothermal shrinkage has a role in the treatment of patients with symptomatic dynamic and predynamic scapholunate (SL) instability without advanced degenerative changes. METHODS From January 1999 to July 2001, 19 wrists with laxity of the SL ligament, but with symptomatic instability, were treated with arthroscopic electrothermal shrinkage of the SL ligament using a monopolar radiofrequency probe. Before surgery, all patients underwent wrist arthroscopy to confirm the diagnosis and exclude arthritis. The sample included 16 men and 3 women with an average age of 23.3 years (range, 18 to 27 years). The average time from injury to operation was 17.2 months (range, 14 to 28 months). All patients underwent follow-up at our clinic regularly for an average of 28.1 months (range, 24 to 34 months). RESULTS All 19 patients had attenuation or laxity of the continuity SL ligament in the radiocarpal joint. Modified Mayo wrist scores revealed the following functionality: the total arc of wrist motion in the flexion-extension plane loss averaged 5.1 degrees (P > .01). Grip force improved significantly, with 14.7% improvement of that on the normal side (P < .01). The Wilcoxon signed-rank test was used to compare the results: the postoperative scores were significantly better than the preoperative scores (P < .01). Fifteen patients (79%) were fully satisfied with the results and returned to their preinjury activity. Four patients (21%) had recurrent laxity of the SL joint. CONCLUSIONS Electrothermal shrinkage of the SL ligament in patients with symptomatic, predynamic and dynamic SL instability had a 79% success rate at a minimum of 2 years' follow-up. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Jui-Tien Shih
- Department of Orthopaedic Surgery, Armed Forces Taoyuan General Hospital, Long-Tan, Taoyuan, Taiwan.
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Abstract
BACKGROUND Despite the relative frequency of partial-thickness rotator cuff tears seen in baseball players, full-thickness rotator cuff tears in baseball players are uncommon. HYPOTHESIS Return to competitive baseball is difficult after surgical treatment of a full-thickness rotator cuff tear. STUDY DESIGN Case series; Level of evidence, 4. METHODS We evaluated the results of 16 professional baseball players after a mini-open repair of a full-thickness rotator cuff tear. Twelve patients were pitchers with injury to their dominant shoulders. Four patients were position players; 2 had injuries involving their dominant shoulders, and 2 had injuries to their nondominant shoulders. RESULTS At a mean follow-up of 66.6 months for the pitchers, only 1 player (8%) was able to return to a high competitive level of baseball with no significant shoulder dysfunction after mini-open repair of a full-thickness rotator cuff tear. Of the 2 position players with mini-open repairs of the full-thickness rotator cuff tear of their dominant shoulders, 1 was able to return to professional baseball. Of the 2 position players with mini-open repairs of the full-thickness rotator cuff tear of their nondominant shoulders, both were able to return to professional baseball at the same or higher level. CONCLUSION It is very difficult for a professional baseball pitcher to return to a competitive level of pitching after a full-thickness rotator cuff repair with a mini-open approach.
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Affiliation(s)
- Christopher G Mazoué
- Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, 29203, USA.
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Thermal Energy for Shoulder Instability. Sports Med Arthrosc Rev 2005. [DOI: 10.1097/01.jsa.0000189964.92909.cb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Terry GC, Miskovsky SN, Kelly RL. The Role of Thermal Energy in Shoulder Instability Surgery. Sports Med Arthrosc Rev 2005. [DOI: 10.1097/01.jsa.0000189963.54791.0c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. The purpose of this study was to evaluate the ability of MRI to show the findings of internal impingement of the shoulder. CONCLUSION As opposed to our six patients with clinically and surgically diagnosed internal impingement, the control patients had isolated pathology in the rotator cuff, labrum, or humeral head. We found that the constellation of findings of undersurface tears of the supraspinatus or infraspinatus tendon and cystic changes in the posterior aspect of the humeral head associated with posterosuperior labral pathology is a consistent finding diagnostic of internal impingement.
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Affiliation(s)
- Eddie L Giaroli
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
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Abstract
BACKGROUND With the failure of thermal capsulorrhaphy for shoulder instability, there have been concerns with capsular thinning and capsular necrosis affecting revision surgery. PURPOSE To report the findings at revision surgery for failed thermal capsulorrhaphy and to evaluate the technical effects on subsequent revision capsular plication. STUDY DESIGN Case series; Level of evidence, 4. METHODS Fourteen patients underwent arthroscopic evaluation and open reconstruction for a failed thermal capsulorrhaphy. The cause of the failure, the quality of the capsule, and the ability to suture the capsule were recorded. The patients were evaluated at follow-up for failure, which was defined as recurrent subluxations or dislocations. RESULTS The origin of the instability was traumatic (n = 6) or atraumatic (n = 8). At revision surgery in the traumatic group, 4 patients sustained failure of the Bankart repair with capsular laxity, and the others experienced capsular laxity alone. In the atraumatic group, all patients experienced capsular laxity as the cause of failure. Of the 14 patients, the capsule quality was judged to be thin in 5 patients and ablated in 1 patient. A glenoid-based capsular shift could be accomplished in all 14 patients. At follow-up (mean, 35.4 months; range, 22 to 48 months), 1 patient underwent revision surgery and 1 patient had a subluxation, resulting in a failure rate of 14%. CONCLUSIONS Recurrent capsular laxity after failed thermal capsular shrinkage is common and frequently associated with capsular thinning. In most instances, the capsule quality does not appear to technically affect the revision procedure.
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Affiliation(s)
- Hyung Bin Park
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue #A672, Baltimore, MD 21224-2780, USA
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Maiotti M, Massoni C, Tarantino U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy 2005; 21:751-7. [PMID: 15944635 DOI: 10.1016/j.arthro.2005.03.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate the preliminary results of arthroscopic thermal capsular shrinkage performed for chronic lateral ankle instability in soccer players. TYPE OF STUDY Case series. METHODS We reviewed 22 male soccer players (average age, 18 years) with chronic lateral ankle instability who underwent arthroscopic thermal shrinkage between 1997 and 1998. The only exclusion criterion for this study was the failure of previous surgery. Before surgery, all patients had participated in a physical rehabilitation program consisting of peroneal strengthening exercises and proprioceptive training for several months, without any relief of their symptoms. All patients were characterized by repeated episodes of giving way, a positive anterior drawer sign, and positive stress radiographs. The stress radiographs consisted of a sagittal stress and talar tilt by the TELOS device (Fallston, MD). The Karlsson and Peterson ankle function scoring scale was used to assess these patients for their current activity level as well as activity before surgery. RESULTS Patients were reviewed at a mean of 42 months (range, 32 to 56 months); 19 patients (86.3%) reported a good or excellent functional outcome as assessed by the Karlsson and Peterson ankle function scoring scale. Eighteen of the 22 patients presented no evidence of ankle instability on physical examination or on stress radiographs. Only 1 patient was not able to return to his previous level of sports activity and complained of ankle instability when walking on uneven ground. CONCLUSIONS This study suggests that arthroscopic thermal capsular shrinkage is a valid and safe procedure for treatment of chronic lateral ankle instability. Longer follow-up is needed, however, to see how these results may change with time in high-demand athletes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Marco Maiotti
- Sports Medicine Center, San Giovanni-Addolorata-Calvary Hospital, Rome, Italy.
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Lu Y, Bogdanske J, Lopez M, Cole BJ, Markel MD. Effect of simulated shoulder thermal capsulorrhaphy using radiofrequency energy on glenohumeral fluid temperature. Arthroscopy 2005; 21:592-6. [PMID: 15891727 DOI: 10.1016/j.arthro.2005.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine joint fluid temperatures at different time intervals during treatment with radiofrequency energy (RFE) applied in intermittent and continuous treatment manners under flow or no-flow conditions using a simulated shoulder joint model. TYPE OF STUDY In vitro measurement of simulated joint fluid temperature during RFE treatment. METHODS A custom-built jig with a chamber (volume size, 25 mL) was used to mimic the adult human shoulder. Three RFE systems: Vulcan EAS plus TAC-S probe (Smith & Nephew Endoscopy, Andover, MA); VAPR II plus End-Effect Electrode (Mitek, Westwood, MA); and ArthroCare 2000 plus TurboVac 90 degrees probe (ArthroCare, Sunnyvale, CA) were tested in the chamber with saline solution initially set at 23 degrees C. Each RFE probe was applied in a paintbrush pattern on the capsular tissue in the chamber and a fluoroptic thermometry probe was placed 1 cm above the RFE treatment probe to record the fluid temperature. Both intermittent and the continuous treatment manners were tested under flow and no-flow conditions. For each probe/manner/flow combination, 6 bovine capsular tissue specimens were tested (n = 6). All data were recorded using a HyperTerminal software program (Hilgraeve Inc, Monroe, MI) into a personal computer. RESULTS When using intermittent and continuous treatment manners with flow, all recorded chamber fluid temperatures for all tested RFE probes at each time interval were below 40 degrees C. Under no-flow conditions, with intermittent treatment, the ArthroCare probe caused joint fluid temperatures to exceed 50 degrees C after 70 seconds of RFE treatment. With the continuous treatment, the ArthroCare caused chamber fluid temperatures to exceed 65 degrees C after 2 minutes of treatment. The highest mean recorded chamber fluid temperature was caused by ArthroCare probe, which reached 80 degrees C at 3 minutes. For all probes, continuous treatment caused significantly higher chamber fluid temperatures than intermittent treatment. CONCLUSIONS The results of this study indicate that using flow during thermal capsulorrhaphy could lower joint fluid temperature to prevent heated joint fluid from killing chondrocytes of articular cartilage, and the intermittent treatment manner caused lower fluid temperature compared with continuous treatment within the RFE-treated shoulder joint. CLINICAL RELEVANCE Articular cartilage of the humeral head may suffer potential thermal injury from heating of joint fluid during RFE thermal capsulorrhaphy.
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Affiliation(s)
- Yan Lu
- Comparative Orthopaedic Research Laboratory, Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, Wisconsin 53706-11102, USA
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Abstract
The initial wave of enthusiasm for thermal capsulorrhaphy has subsided. Long-term clinical data were lacking until D'Alessandro et al's prospective study indicated the results were not as promising as the previously reported short-term studies. Complications including obliteration or attenuation of capsular tissue, axillary nerve injury, and chondrolysis have all been reported in recent years further raising concern about the widespread use of this procedure. The inexact nature of how much "shrinkage" is being performed has led surgeons to further develop surgical technique in capsular plication, shift, or advancement. Although it remains to be seen if these techniques will lead to good clinical outcomes, it appears that they more closely resemble the original operative procedure-anterior capsular shift.
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Affiliation(s)
- William N Levine
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
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Abstract
Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.
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Affiliation(s)
- Eric C McCarty
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of Colorado, 1745 South High Street, Denver, CO 80210, USA.
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Labbé MR, Field LD. The Role of Thermal Surgery in the Throwing Athlete. Sports Med Arthrosc Rev 2004. [DOI: 10.1097/01.jsa.0000105262.26165.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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