Orthopedic Sports Medicine Board Review • Trey Remaley, DO • Assistant Professor • Department of Orthopedics and Sports Medicine • University of South Florida Conflicts • I have no conflicts of interest for this lecture or topic Content • Upper Extremity • Lower Extremity • Sports Physician Topics SHOULDER Upper Extremity • Shoulder • Instability • SLAP/Labral tears • Thrower’s shoulder Shoulder Anatomy • Glenohumeral complex • Humeral head retroverted 30o • Greater tuberosity • Lesser tuberosity • Posterior humeral circumflex artery • Scapula • Glenoid 5o retroverted • Upward tilt 5o-10o • Pear shaped • Coarcoid tip • Clavicle is S-shaped • First to ossify last to calcify Shoulder • Static restraints to stability • Glenohumeral ligaments • Glenoid labrum • Articular congruity and version • Negative intraarticular pressure • Dynamic restraints • Rotator cuff musculature • Biceps • Periscapular muscles Shoulder Stabilizing Ligaments • SGHL: limits inferior translation in adduction • MGHL: limits anterior translation at 45o • IGHL • Anterior band: limits anterior translation at 90o • Posterior band: aids internal rotation Relate Age to Common injuries • Young • Shoulder instability • AC joint injuries • Distal clavicle osteolysis • Old • Rotator cuff tears • Glenohumeral arthritis • Proximal humerus fracture • Mechanism • Directs blow: AC joint • Arm in ABD/ER position: Instability • Night pain/Overhead pain: Rotator cuff tears Evaluation • Visual inspection • ROM • Palpation • Special tests • Impingement: Neer’s, Hawkins • Cuff: Empty can, ER strength, Hornblower’s • Subscap: Inc ER, Lift off, Belly press • Pec: Resisted Adduction • Anterior Instability: Apprehension/Relocation, Load and Shift • Posterior Instability: Jerk test, Load and Shift • MDI: Remember Beighton’s criteria, Sulcus sign • Bicep tendon: Crank, Speed’s, O’Brien Imaging of the Shoulder • Xrays – Always for initial evaluation • AP • True AP (Grashey) • Axillary – Never forget • Valpeau • Scap Y • CT Scan • Fracture characteristics • Glenoid version or bone loss • MRI • Rotator cuff • Labrum – needs to be an arthrogram Radiographs CT/MRI Shoulder Instability Shoulder Instability • TUBS • AMBRI • Traumatic • Atraumatic • Unilateral/Unidirectional • Multidirectional • Bankart • Bilateral • Surgical • Rehabilitation • Inferior capsular shift Shoulder • Multidirectional Instability • AMBRI • Generally seen in the 2nd to 3rd decade of life • Microtrauma or overuse • Baseball throwers, swimmers, volleyball, gymnasts • May have an underlying connective tissue disorder – Ehler’s Danlos • Generalized ligamentous laxity MDI • Patients present with pain and instability with easy activities • Shoulder comes out while sleeping • Clinically must have instability in two planes to be defined as MDI • Keep in mind that cuff impingement in <20 y/o may be a sign of MDI MDI • Ligamentous laxity • Beighton’s criteria (out of 9 points) • Palms to floor • Genu recurvatum • Elbow hyperextension • MCP hyperextension • Thumb to forearm MDI Workup • X-rays • Likely normal in MDI • MRI • Consider arthrogram to eval for enlarged capsule volume • +/- Bankart lesion • +/- Kim lesion • Patulous capsule MDI Workup • Positive load and shift • Anterior and Posterior • Apprehension and relocation • Sulcus sign MDI Treatment • Non-operative management • Non-operative management • Non-operative management • 3-6 months of conservative • Dynamic stabilization PT • Closed kinetic chain exercises to stimulate co-contraction of muscle groups MDI Treatment • Avoid voluntary dislocators • Capsular shift • Capsular plication • Rotator interval closure • Produces the biggest loss of motion in external rotation with the arm at the side • Make sure to address any labral pathology as well • Address any bony deficiency? MDI Treatment • Open treatment • Subscap Tenotomy (Neer) • Longitudinal tenotomy • Labral repair • Humeral based shift (anteroinferior) • More powerful – hyperlax individuals • Subscap split (Jobe) • Horizontal capsulotomy • Labral repair • Glenoid based shift • Tailored – overhead athletes Traumatic Shoulder Instability • Most common shoulder injury • 1.7% among the general population • High recurrence rate in younger population • 90% in patients under 20 years of age • Position of vulnerability – abducted and ER TUBS • Injury can range from soft tissue only to including bony lesions on glenoid, humerus, or both • Lesions • Bankart – anterior inferior lesion involving the anterior band of the IGHL • 80—90% of patients with TUBS • HAGL • Higher recurrence rate if missed/not diagnosed • You may not have seen it, but is has seen you • Open repair? • GLAD • Sheared cartilage with labral tear • ALPSA • Anterior labral tear periosteal sleeve avulsion • Labrum can heal along medial aspect of glenoid neck • Higher failure rate after arthroscopic repair • Rotator cuff tears • 30% of TUBS >40 years • 80% of TUBS >60 years TUBS • Bony injuries • Bony Bankart • Anterior inferior glenoid fracture • Present in up to 50% of recurrent cases • 20%-25% is known as critical bone loss* • Need to address bony stabilization • Hill-Sachs defect • Posterior humeral head impaction fracture • 80% of traumatic dislocations, 25% of subluxations • Engaging versus non-engaging • Greater tuberosity fracture • Lesser tuberosity fracture TUBS Treatment • Treatment of first time dislocators in controversial • Sling and rehab as initial treatment • Age <20 years • Male • Contact athletics • Hyperlaxity • Glenoid bone loss (critical bone loss) TUBS Operative Treatment • Arthroscopic Bankart repair • 1st time dislocators with Bankart lesion in athlete under 25 years of age • High demand athletes • +/- Remplissage with engaging Hill-Sachs lesion • Similar outcomes with open repair, less pain and greater restoration of motion • Minimum of three abchors • Remplissage • Engaging Hill-Sachs deficits • Off-track lesions • Posterior capsule and infraspinatus sutured into Hill-Sachs defect TUBS Operative Treatment • Bony loss 20%-25%* • Latarjet (Triple effect) • Bony – coracoid bone restores glenoid loss • Sling – conjoined tendon across subscap • Capsule reconstruction– coracoacromial ligament • Autograft/allograft • Iliac crest tricortical graft • Tibial allograft TUBS Recurrence/Complications • Soft tissue only procedures with critical bony loss 25%* • Increased risk with young patients, contact athletes, male patients, unrecognized bony or soft tissue lesions (HAGL, off-track lesions, etc.) • Seizure disorder – exhaust all medical management prior to surgical intervention • Shoulder pain • Nerve injury • Musculocutaneous* • Axillary • Stiffness – ER • Infection • Graft lysis • Hardware complications • Chondrolysis Thrower’s Shoulder • Large forces • GIRD • Increased ER, decreased IR – Same total ARC of motion • Tight posterior capsule, loose anterior capsule • Increased humeral and glenoid retroversion • Posteroinferior capsular tightness leads to posterosuperior humeral translation • Internal Impingement • Rest • Posterior capsular stretches Phases of Throwing • Wind up • Minimal forces • Cocking • Early – Deltoid • Late – elbow valgus stress is greatest • Supraspinatus, infraspinatus, teres minor • Acceleration • Triceps; Pec major, Latissimus dorsi, Serratus anterior • Deceleration • Most harmful phase of throwing • Eccentric contraction of all muscles • SLAP tear, biceps tendon injury, brachialis injury, teres minor injury • Follow Through • Body rebalances Phases of Throwing GIRD • Increased external rotation • Decreased internal rotation • Remember – The total ARC of motion is the same • Increased humeral retroversion • Treatment • Posterior capsular stretch • Pec minor stretch • Subscap strengthening • Posterior inferior capsular release versus anterior capsular imbrication Internal Impingement • Late cocking/early acceleration phase • Posterior superior capsule, labrum, and cuff get entrapped • SLAP tear – peel back lesion • Bennett lesion – glenoid exostosis • Partial articular sided cuff tear near junction of supraspinatus and infraspinatus Internal Impingement • Treatment • Rest, stop throwing • NSAID • Posteroinferior capsular stretch • Pec minor • SICK scapula • Injection • Ultrasound guided glenohumeral or subacromial Internal Impingement • Treatment • Failed non-op: 3-6 month minimum • Arthroscopy • Debridement • SLAP repair* • Posterior capsular release – uncommon • Anterior capsular repair – rare • Concomitant rotator cuff repair – avoid if possible Little Leaguer’s Shoulder • Salter Harris I epiphyseal injury • Males > females • 11-16 years of age • Number of pitches is biggest indicator, breaking pitches are an associated culprit • Hypertrophic zone of the growth plate • Treatment • Rest • NSAID’s • Return after progressive throwing program and evaluation of mechanics • PITCH COUNT* Pitch Count SLAP Tears • Mechanism • Traumatic • Attritional/aging • Internal impingement • Risk factors • GIRD • Internal impingement • Rotator cuff tears – usually articular sided • Shoulder instability • Scapular dyskinesis • Tight P-IGHL may cause increased shear force of superior labrum due to the shift of the glenohumeral contact point posterosuperiorly • SLAP lesion increases strain on the A-IGHL which results in shoulder instability SLAP Tears • Treatments have been controversial • Evolved over time • Used to fix every one of them • Now either treat non-op or tenodesis • General outcomes OK if indication is appropriate • RTP not as predictable, overhead throwers less predictable SLAP Tears • Classification SLAP Tears SLAP