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  • Thispresentationistheintellectualpropertyoftheauthor.ContactthematDUTTAA@UTHSCSA.EDUforpermissiontoreprintand/ordistribute.

    SLAPLESIONS,ROTATORCUFFTEARS,ANDINTERNAL

    IMPINGEMENTINATHLETES

    AnilDutta,MD

    AssociateProfessorUTHSCSAOrthopaedics

    UT SPORTS MEDICINE SYMPOSIUM 2013

    FinancialDisclosure Dr.AnilK.Duttahasnorelevantfinancialrelationshipswithcommercialintereststodisclose.

    IHATETHISTOPIC!

    SLAPANDRCTINATHLETES LEARNINGOBJECTIVES: UnderstandtheacutetraumaticandrepetitiveoverusecausesforSLAPandRCTinathletes

    Reviewanatomy,diagnosticexam,andimaging UnderstandtheconceptofInternalImpingement UnderstandhowInternalImpingementrelatestoSLAPtearsandpartialrotatorcufftearsinathletes

    Understandthesportspecificissuesfortreatmentandprognosis

    Discusscurrentstateoftreatment(nonsurgicalandsurgical)forbothconditions.

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    RotatorCuffFunction DynamicStabilizeroftheShoulder ForceCoupler

    AcromionMorphology TypeI:Flat TypeII:Curved TypeIII:Hooked 70%ofShoulderswithtearshadahookedacromion

    CLASSICALEXTERNALIMPINGEMENT(NEER):

    Stages

    NEERdividedrotatorcuffdiseaseinto3classicalstagesrelatedtolifecycle:

    StageI:subacromialedemaandhemorrhage(40)

    Causes:ExternalImpingment

    CALigament SubacromialSpurs ACJointOsteophytes

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    SubacromialDecompression

    ROTATORCUFFREPAIR OPEN

    MINIOPEN

    ALLARTHROSCOPIC

    INTERNALIMPINGEMENT Overheadsports(LateCocking),EarlyAcceleration

    Baseball Volleyball Swimming WaterPolo Javelin Tennis

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    INTERNALIMPINGEMENT

    Microinstability

    Microtrauma Hyperangulation Abd(coronal)/MaxER Strainanteriorcapsule Anteriorsubluxation Lossofmax.congruence Internalimpingement SLAPtear peelback

    Walch JSES 92

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    INTERNALIMPINGEMENT Posterosuperiorpain

    Followthrough Latecocking Deadarm(heavinessw/oneurologic)

    AsynchronousROM(ERvs.IR) Posteriorcapsulartightness

    Obligatoryanteriortranslation PItethercausingPSrollingofhumeralhead GIRD:GlenohumeralInternalRotationDeficit

    TheUsualSuspects INTERNALIMPINGEMENT SLAPTEARS(PEELBACKLESION)

    BICEPSDISEASE ANTERIORMICROINSTABILITY

    POSTERIORCAPSULARTIGHTNESS

    (GIRD) TENSILEFAILUREOFTHEROTATORCUFF(PTRCT)

    SCAPULARDYSKINESIA(SICKSCAPULASYNDROME)

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    SLAPTEAR:TypeII

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    SLAPTEARS CLASSIFICATION TYPEI:Fraying:debride TYPEII:Detached:repair TYPEIII:BucketHandleTear:debride TYPEIV:BucketHandlewithinvolvementofbiceps:bicepstenodesis

    CLASSIFICATION TYPEI:Fraying:debride

    TYPEII:Detached:repair

    CLASSIFICATION TYPEIII:BucketHandleTear:debride

    TYPEIV:BucketHandlewithinvolvementofbiceps:bicepstenodesis

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    Variations:Maffet (AJSM95) TYPEV:BankarttoSLAP TYPEVI:Unstableflapwithdetachmentofbiceps

    TYPEVII:Bicepsanchorseparationwithextensionanteriorlyintomiddleglenohumeralligament

    SLAPIISubtypes:MorganandBurkhart

    TYPEIISLAP

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    SLAPwithGlobalLabralTear

    SLAP REPAIR

    Posterior

    AnteriorTokish JBJS 09, Mazzocca AJSM 01

    ROTATORCUFFTEARSINATHLETES:Keyissues

    ClassicalSubacromial Impingementvs InternalImpingement?

    AcuteTraumavs ChronicRepetitiveTrauma? Throwervs OtherOverheadAthletevs NonOverhead?

    Instabilitypresentorabsent? Labral tearpresentandwhatkind? Posteriortightness?

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    Shoulder Impingement Syndrome in AthletesTreated by an Anterior AcromioplastyJAMESE . TIBONEM, .D., FRANKW . JOBE,M .D., ROBERTK . KERLAN, M.D.,VINCENTS . CARTERM, .D., CLARENCEL . SHIELDSM, .D., STEPHENJ . LOMBARDOM, .D.,AND LEWIS A. YOCUM, M.D.

    CORR 1985

    89%Bettersubjectivelybutonly43%returntopreinjurylevelofplay

    WhatcausestheTear?Sources

    Degenerationwithage/use:InmanycasesitisWEAR andnotTEAR. Thetendonisdegeneratingandithastobestimulatedtoregenerate(areaofresearch)

    AcuteTrauma(Shoulderdislocationsordirectblows)

    ScapulothoracicDysfunction InflammatoryDisease:UnderlyingsystemicdiseaselikeRheumatoidArthritis.

    UnderlyingInstability

    ATHLETES

    Inathletesitcanbeanyofthesefactorsoracombination.Inathletesspecialfocusison INSTABILITY(INTERNALIMPINGEMENT)

    ACUTETRAUMA

    WhatcausestheTear:BloodSupplyDeficiency

    BloodSupply

    Anteriorcircumflexhumeral

    Posteriorcircumflexhumeral

    Suprascapularartery Thoracromialarch

    3vascularsources:Muscular,osseous,directtendinous

    Watershedzone(1cmproximaltocuffinsertion)(Codman)

    Hypervascularity?

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    CLINICALEVALUATION:Keys ElicithistoryofAcuteTrauma(Notalwaysrecalled)

    Recordtimeframe,modifyingfactors,treatments

    LookforInstabilityonexam LookforAsymmetry(strengthandROM) RememberScapulardysfunction

    CLINICALEVALUATION:SLAPANDRCTINATHLETES

    History

    Anterolateralshoulderpainwithradiation

    Weakness Worsewithuseoverhead

    Nightpain/dependency DeadArmssymptoms/parasthesias

    Lossofcontrol/velocity

    Exam

    StrengthandROM(GIRD) ImpingementSign/Test Hawkins,Jobe OBriens,Speeds,Yergason

    Apprehension/Relocation/Jerk

    AnteriorandPosteriorShiftandLoad

    Sulcus/ScapulaWinging

    IMAGING:MRIARTHROGRAM

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    MRI:FullthicknessRCtear

    Tuite M J et al. Radiology 2000;215:841-845

    2000 by Radiological Society of North America

    TYPE2SLAP

    Type2SLAPandRCT

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    MANAGEMENT:NonoperativeTreatment

    Nonoperativemanagement:teamapproach

    Coaches,trainers,therapists,parents,patient

    Rehabilitationprogram Expectationsdefinedearly

    RehabilitationNonOperative 1ImproveMechanics 2ImproveGIRD(posteriorstretching) 3Shoulderstabilization:emphasisonSubscapularisandInfraspinatusstrengthening

    4Scapularsymmetryandcorrectdyskinesia 5Rest(limitplayandpractice) 6NSAIDSprn(avoidexcessiveorprolongedusage) 7Injections(verylimitedrolebutforendofseasonorcriticalpointinseasonaconsideration

    RotatorCuffTreatmentinThrowers TiboneJBJS86:FullThicknessRepair50%RTPatPIlevelin45athletes

    TiboneCORR85:SAD43%RTPand4/18pitcherstoPIstatus

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    RotatorCuffTreatmentinThrowers

    Reynolds,AndrewsCORR08:Debridements 76%RTP(atprofessionallevel),but55%atsameorhigherlevel

    Payneetal(HSS)AJSM97:Debridements :2groupsTraumaandinsidiousonset:TraumaGroup86%and64%RTPbutGroup266%satand45%RTP

    RepairofPASTA

    Conway Op Tech Sports Med 92

    PASTARepair

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    RotatorCuffTreatmentinThrowers:Repair Mazoue,Andrew8%AJSM06(1/12pitchers)RTP,3/4positionplayersRTP

    VanKleunen,Savoie(AJSM12):6/17ptsreturntothrowing.ThesepatientshadSLAPrepair,posteriorrelease,ISrepair

    RotatorCuffTreatmentinThrowers:Repair Mazoue,Andrew8%AJSM06(1/12pitchers)RTP,3/4positionplayersRTP

    VanKleunen,Savoie(AJSM12):6/17ptsreturntothrowing.ThesepatientshadSLAPrepair,posteriorrelease,ISrepair

    Habermeyer21/21AJSM08RTPOverheadathletes(European)evenwith25%retearrate.

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    RotatorCuffTreatmentinThrowers:Repair Mazoue,Andrew8%AJSM06(1/12pitchers)RTP,3/4positionplayersRTP

    VanKleunen,Savoie(AJSM12):6/17ptsreturntothrowing.ThesepatientshadSLAPrepair,posteriorrelease,ISrepair

    Habermeyer21/21AJSM08RTPOverheadathletes(European)evenwith25%retearrate.

    AnteriorStabilizationinThrowers JobeAJSM:18/25returntocompetitioininthrowersusingopenACLR

    AnteriorCapsulolabralReconstruction thecapsuleisplicated

    Shifttheinferiorcapsuleflapproximally

    Shiftthesuperiorcapsuleflapdistally

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    Jobe ACLRJobe AJSM91

    ThermalCapsulorrapy Levitz(Andrews)Arthroscopy2001:Heatprobe90%returntocompetetioncomparedto70%withoutheatprobe(HP)

    Multiplereportsofchondrolysis Poorresultsinmanyseriesforinstability Riskforcompletecapsularnecrosis

    SLAPRepairinThrowers Brockmeier(HSS)JSES09:74%returntocompetitioninthrowers,(92%inathleteswit

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