RETURN TO PLAY (RTP) SHOULDER AND ELBOW

July 29, 2016

Mark Sytsma, MD Bronson Sports Medicine Specialists

Disclosure

• I have no conflicts of interest of relevant financial relationships relating to this talk. Return to Play (RTP)

• Background • Shoulder injuries – Fracture, dislocations, stinger, AC injuries, Clavicle fractures • Elbow injuries – Dislocation, fracture, ligament injuries • Youth and overuse injuries Why We Cover Sports

• Most injuries do not have serious consequences…but some do! • Hours of preparation, observation and training for a few critical moments. • ALWAYS be prepared!

4 Why We Cover Sports

• OUR PRIMARY GOAL – The health and wellbeing of our athletes

5 Goals of Sideline Management

• Assess the athlete quickly and diagnose the problem • Is this an injury that will allow the player to return? – Finger dislocation vs ankle fracture Return to Play (RTP)

• Depends on the sport – Contact vs non-contact – Specific position • Depends on the body part injured – Example: Non-dominant hand in a soccer player • Depends on the level of sport – Higher levels may absorb more risk

Above All Else

• Protect the athlete – More important than the desires of the athlete, coach, parent, etc…

8 Shoulder Injuries

• Stinger/Burner (Dr. Jensen) – Dead arm, numbness and tingling from shoulder to hand – Caused by direct contact and stretch to the brachial plexus (nerves exiting neck)

9 Stinger/Burner

• Always evaluate for pain in the shoulder joint – May indicate shoulder instability event • Return to play? – Sensation returns – Normal shoulder strength (Rotator cuff test)

10 Shoulder Dislocation

• Most common major joint dislocation • 90+% anterior • Mechanism – Force or fall on Abducted, ER arm: anterior dx – Force or fall on Adducted, IR arm: posterior dx

11 Shoulder Dislocation

• Many spontaneously reduce. Pain – “shift” or “slip” • Locked dislocation – Reduce – Transfer to hospital if not reducible • RTP?

Shoulder Dislocation

• Return to play? – Sport, body part, level – Consider surgery after first dislocation (new evidence) • Often 3-6+ weeks • Shoulder brace?

Shoulder Dislocation

• Younger Athletes (<25) – High risk for recurrent dislocations/instability • Mature athletes (>40) – Must evaluate for acute rotator cuff tears

AC Separation

• Most common shoulder injury in contact sports – Tenderness (+/-swelling/deformity) directly at AC joint • Continuum of severity

15 AC Separation

• Mechanism: direct hit to or fall on shoulder • If lower grade (Type 1,2), may RTP if shoulder strength and motion are normal

AC Separation

• Most have weakness within shoulder due to pain on day of injury – No return on day of injury • RTP: 1-4 weeks • For persistent pain without weakness – Low grade injury (Type 1 or 2) – Local anesthetic injections can be useful • Do not inject with steroids • Surgery: out of contact for 5+ months

Sternoclavicular Dislocation

• Much less common than AC injuries • Mechanism: usually a direct blow to chest • Anterior dislocation (more common) – Deformity • Posterior dislocation (more consequences) – Difficulty breathing or swallowing

Sternoclavicular Dislocation

• May be a fracture through growth plate – Fuses at age 20-25 • No return to play – Seek medical care – DO NOT reduce Clavicle Fracture

• 35% of shoulder fractures involve the clavicle • Mechanism: direct contact or fall on shoulder • Most commonly involve the middle 1/3 Clavicle Fracture

• Clavicle fractures – Diagnosis • Deformity? • Tenderness to palpation directly over the clavicle – Unable to return to play • Strength will be decreased • If minimally displaced, still at significant risk for displacement – Sling and X-ray evaluation

Clavicle Fracture

• If non-displaced or minimally displaced – Nonoperative – RTP?

• Midshaft, displaced, shortened – Operative, RTP?

Clavicle Fracture

• Clavicle Fractures – Distal fractures may mimic AC injuries

– If significantly displaced, usually managed operatively Elbow Ligament Injuries

• Ulnar collateral ligament (Tommy John Ligament) Elbow Ligament Injuries

• Throwing athletes – Pop or acute pain along inside of elbow – Remove from play immediately • Medical evaluation – RTP? • Direct contact – May brace (depending on sport) – RTP?

Elbow Dislocation

• Second most common major joint dislocation – 80% posterolateral • Mechanism: – Fall or direct blow • Simple dislocation (50-60%) – Ligament injury only • Complex dislocation – Fracture + ligament injury Elbow Dislocation

• NO immediate return to play – Usually 2+ months before return to contact sports if it is a simple dislocation Elbow Fractures

• Mechanism: Fall or direct contact

Pediatric Elbow Fractures

• Usually involve growth plates

• Ligaments usually don’t tear, growth plates separate/fracture Elbow Fractures

• Exam – Deformity, swelling, or loss of motion – Pain with direct palpation over the bone • Remove from play – Splint – Obtain X-rays or appropriate studies Elbow Fractures RTP

• Never return a young athlete immediately to play if they have bone or joint tenderness • Need full motion and strength • RTP 6+ weeks – Longer for contact sports and articular fractures – Sport, location, level Overuse Injuries

• Primarily with overhead sports – Baseball, volleyball, Tennis, Etc… • You can NOT play through pain – Remove from competition – Medical evaluation http://www.stopsportsinjuries.org/

Questions?

Thank you! bronsonhealth.com