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Athletic Shoulder Injuries
Sean F. Bak, MD
Sports Medicine and Shoulder Reconstruction
Novi, MI
Shoulder Injuries-Overview
1. Chronic Shoulder Pain
2. Acute Shoulder Injuries and Fractures
Chronic Shoulder Injuries
“My shoulder hurts. Must be that rotator
cuff…”
Anatomy
Anatomy
Causes of Chronic Shoulder Pain
1.
2.
3.
4.
5.
Rotator Cuff Tendonitis/Bursitis
AC arthritis
Labral tear
Shoulder arthritis
Rotator Cuff tear
Impingement/Bursitis
• Most common cause
of shoulder pain
• Usually temporary
• Generally does not
need surgery
• Age 20-70
Impingement/Bursitis
Impingement
• Rotator cuff
tendonitis
• Bursitis
• Spur thought to
be principal
cause
Impingement
Internal Impingement
Overhead athletes
Cuff between humeral
head and posterior
glenoid
Articular sided cuff
tension
Impingement
•
•
•
•
Stage 1: Bursitis
Stage 2: Tendonitis
Stage 3: Rotator cuff tear
Without treatment, stages
progress with age
Impingement
• Process can be
stopped!
• 70-80% resolve
without surgery
– Motrin, Aleve, etc.
– Physical therapy
– Injections
Impingement
• Surgery
– Arthroscopic
– Clean out
inflammation
– Remove spur
– Sling 3-5 days
Impingement
AC Joint Arthritis
AC Joint Arthritis
• Pain on top of
shoulder
• NOT the ball-socket
joint
• Male predominance
• Weightlifters
• Age 20-70
AC Joint Arthritis
• Rest, modify
activities
• Injection
• Surgery: Remove
the end of the
collarbone
– Scope or open
Labral Tears
Labral Tear
•
•
•
•
Deep shoulder pain
Pain with rotation
Throwing athletes
Shoulder
dislocations
Labral Tears
Pathoanatomy
• Glenoid labrum
– GHL attachment
• Depth and conformity
• Detachment
– Anteroinferior
– Superior-SLAP
Labral Tears
• Bankart Tear
– Traumatic
dislocation
– Anteroinferior
labrum
Labral Tears
• SLAP tears
– Superior labrum
– More chronic
– Overhead athletes
Labral Tear
• Physical Therapy
– Post capsule stretch
• Injection
• Arthroscopic
treatment
recommended for
younger patients
Labral Tear-Postop Rehab
• Sling 4-6 wks
• PT for 2-3 mos
• Normal activities 3
mos
• Return to sports 5
mos
Rotator Cuff Tear
Rotator Cuff Tear
• Pain with movement
• Night pain
• Not always associated with
weakness
• Develops with time, age
• Age 50-80
Rotator Cuff Tears
• Rotator cuff tears agerelated
• Rarely traumatic
• Years of gradual
degeneration
Rotator Cuff Tears
• Injury may aggravate a
previously
asymptomatic tear
• Tear enlarges with time
• Symptoms may not
match progression
Rotator Cuff Tears
• All full thickness
rotator cuff tears
enlarge with time
• Rate of progression
varies widely
Rotator Cuff Tears
• Physical therapy very
successful
– Bursitis
– Rotator cuff
tendonitis
– Rotator cuff tears
Rotator Cuff Tears
• Therapy alleviates
symptoms, does not
heal tear
• Not everyone requires
surgery
Rotator Cuff Repair
“The smaller the incision the quicker the
recovery”
Rotator Cuff Repair
• Open rotator cuff
repair 1930’s - 90’s
• Miniopen 1990’s
• Arthroscopic 2000’s
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
Rotator Cuff Repair
• Success rate of
arthroscopic repair
only recently has
equaled traditional
methods
• Less pain
• Less complications
Rotator Cuff Repair-Recovery
• Initial arthroscopic results
substandard
– Better techniques today
• Patients removed slings
– Strict adherence to therapy
Rotator Cuff Repair-Recovery
No change in time to
healing of rotator cuff
Open: Sling for 6 wks
Arthroscopic: Sling for 6
wks
Full Recovery: 6-12 mos
NO CHANGE IN RECOVERY WITH
ARTHROSCOPY!
Shoulder Trauma-Acute Shoulder Injuries
Clavicle Fracture
• Trauma to lateral
shoulder with arm
adducted
• Pain, clavicle
deformity
• +/- neurovascular
injury
Clavicle Fracture
• Nonoperative
treatment
– Sling for 2 wks
followed by ROM
– Return to normal
activities 6-8 wks
– Traditional treatment
Shoulder Trauma
Clavicle Fractures
• Most clavicle fx heal
• Most pts have no
disability
• Most patients have a
“bump”
“All clavicles heal well”
• More recent studies
have shown a 1525% nonunion rate
“All clavicles heal well”??
• Union does not
equate with good
result
• 46% did not consider
themselves fully
recovered by 10
years post-injury
Clavicle Fracture-Surgery??
• Operative
Treatment
– Nonunion
– Open fractures
– Markedly
displaced/No cortical
contact
– > 2 cm shortening
– ? Better Function
Clavicle Fracture
• Operative
Treatment-Plates
– Direct compression
– Anatomic reduction
Con’s
– Plate irritation
– Large dissection
Clavicle Fracture
• Rehab
– Sling for 2 weeks
– Weeks 2-6: Begin
motion
– Weeks 6-12: Full
motion, strength
AC Separation
AC Separation
• Fall onto lateral
shoulder with arm
adducted
• Pain directly at AC joint
• Prominent distal
clavicle in higher
grades
AC Separation
Classification
Progressive Injury
• Type I-VI increasing severity
AC Separation
Treatment Recommendations
Nonoperative
Management
• Type I/II Separation
– Analgesia
– Sling for comfort
– Early ROM
AC Separation
Treatment Recommendations
Acute Surgical
Management
• Type IV/V/VI
AC Separation
Treatment Recommendations
• Type III AC
Separation
– No clear benefit of
acute surgery
– Consider surgery for:
• High demand
patients
• Chronic pain after
separation
AC Separation
Primary AC Joint Fixation
Complications
• Intraarticular injury
• Hardware
Complications
– Breakage
– Migration
AC Separation
Primary AC Joint Fixation
Clavicular Hook Plate
Plate Fixation
• Maintains AC Joint
• Soft Tissue Repair
• Require Plate Removal
AC Separation
Secondary Stabilization
Coracoclavicular
Reconstruction
• Tibialis allograft
around base of
coracoid thru bone
tunnels on clavicle
• Recreate anatomy
AC Separation
• Rehab (Operative)
– Sling for 6 weeks
– Pendulums/Wall walk
at 4 wks
– Active ROM 6 wks
– Strengthening 12 wks
Proximal Humerus Fractures
Neer Classification-Fracture Parts
Articular segment
Greater Tuberosity
Lesser Tuberosity
Humeral shaft
Proximal Humerus Fractures
Non-displaced
Displaced
80%
20%
Proximal Humerus Fractures
• Neuro Injury
• Not uncommon
• Axillary nerve
• Cannot test for
months
• Upper trunk
plexopathy
• PAIN
Proximal Humerus Fractures
• Sling, swathe
• Early ROM (7-10
days)
• Stable fracture
pattern
• Frequent xrays and
exam
Proximal Humerus Fracture
• Operative Options
– Percutaneous
pinning
– ORIF
• Suture vs Plate/screw
fixation
– ReplacementHemiarthroplasty
• Glenoid replacement
contraindicated
Proximal Humerus Fractures
•
•
•
•
Wires
Sutures
Plates/screws
IM Nails
Proximal Humerus Fracture
• Operative Options
–
–
–
–
Age
Bone quality
Fx pattern
Have various options
available and
consented for
Minimally Invasive Surgery
• Percutaneous reduction
• Percutaneous fixation
• Indications
– Specific fx patterns
– Compliance!
PH Fx
45 y.o. RHD female
PH Fx
Reduction
PH Fx
Provisional Fixation
PH Fx
Articular Surface-Shaft Fixation
PH Fx
2nd Pin Fixation
PH Fx
Final Reconstruction
PH Fx
Management
• Outpatient
• Interscalene
anesthesia
• F/U POD #4
• Check x-rays
PH Fx
Perc Pinning – Rehab?
 No rehab while pins
in
 Pin removal in OR at
4 weeks
 Begin PT