THE PARTIAL TEAR IN A THROWING ATHLETE: LEAVE IT ALONE! Felix H. - - PowerPoint PPT Presentation

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Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA

THE PARTIAL TEAR IN A THROWING ATHLETE: LEAVE IT ALONE!

COI

• Royalties: none
• Consultant: Smith &

Nephew, Mitek, Biomet Sports, Exactech, Rotation Medical

• Board of Directors:

AANAEF, OLC

• Research support:

Mitek, Smith & Nephew

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DISABLED THROWING SHOULDER

• Increased laxity =

instability?

• Scapular dyskinesis, core

and hip issues?

• Internal impingement

with peelback SLAP or PASTA lesion: normal adaptation or too much?

• Posterior band tightness:

GIRD vs Tarm?

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LOOSE, TIGHT, OR BOTH?

• In order to throw the

shoulder has to have increased laxity

• When does laxity

become instability?

• Are the changes really

pathology that needs repair or normal for the activity? (Walch, D Lintner)

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EXPERT OPINION

• Yes, instability does occur but it is “micro”-
• instability. Jobe, Andrews etc.
• No, it is actually too tight, not loose and

there is “pseudolaxity”, Morgan, Burkhart

• It is both, depending on the position of the

scapula? Kibler

• Of course but it is normal adaptation to the

activity, therefore not “instability” Lintner, Wilk, Payne etc.

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JOBE / ANDREWS

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#1 Anterior

Capsular

Stretching Scapular dyskinesis

Labral tears Tight posterior capsule RCT

MORGAN/BURKHART

#1 Tightened PIGHL or loose SLAP RCT Shift center Post-sup labral tear

• f rotation

Anterior “pseudolaxity”

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KIBLER

#1 Scapular Dyskinesis Anterior Instability/ RCT

AS Labral Tear

Tight Posterior Capsule

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CURRENT CONCEPTS (WILK)

• Laxity is necessary to

throw and should be greater in the throwing arm

• There are congenital
• r adaptive bony

changes that must be present to throw well

• Throwing shoulder is a

perfect example of muscle balance

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• Total arc of motion

(T-arm) may be most important concept

• GIRD changes daily

–often within the same game

• Muscular balance
• f the kinetic chain

essential to avoid injury

CORE STRENGTH

• Trunk strength and

stability

• Allows lower extremity

power to transmit to the arm ( Kibler’s kinetic chain)

• Often not well

developed in children and adolescents, leading to increased injury ( one leg squat to 90)

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THROWING SHOULDER

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• Scapular position=key
• Core exercises maintain

scapular retraction

• Scapular retraction allows

maximum RC function- the partial tear is an adaptation

• Proper mechanics/posture

protects elbow

KIBLER

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• Scapula position

is key indicator of core strength

• Easy to see

visually and on physical exam

THROWING SHOULDER PHYSICAL EXAM

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• Scapular position: @ rest

and then manually retracted

• Check and compare side

to side motion

• “Whipple” test with and

without retraction to test rotator cuff balance

• Dynamic Labral Shear test

for instability

THROWING SHOULDER: IMAGING

• Regular MRI will

almost always show pathology: usually SLAP tears and cuff “irregularity”

• MRA more accurate
• ABER position

during the scan is a necessity in throwers

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THROWING SHOULDER: PATHOLOGY

• Throwing shoulder has reset itself to adapt to the

demands of the desired activity

– Bone changes occur early and are normal – Increased laxity a necessity – Labral and infraspinatus degeneration are an adaptive response to internal impingement When/how do we address the painful throwing shoulder? focus should be on non-operative treatment, and with surgery “less is more”

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WHAT ABOUT THE INFRASPINATUS TEARS?

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• Debride the flaps
• Do not repair to bone

(Van Kleunan: AJSM)

• ? Stabilize with PDS?

–cannot risk shortening tendon : better to debride rather than repair in most cases

• Conway/Andrews had

very poor results with repair

MY EXPERIENCE

• Non-operative

treatment is the key to all ages

– Works about 70% of time

• Surgery reserved for a

failure of adequate physiotherapy

• Pathology is age

dependent and so should be treatment

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ALTCHEK/DINES HSS

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ANDREWS

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SHAFFER

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MIHATA- THAI LEE: KJOC

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WHAT TO DO?

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• 16 year old pitcher
• Non op rx 15month-continued to

play

• Surgery peelback slap repair and

PRP to Paint lesion

• Post op course: immobilized 3

weeks-scapular/core POD 1; Shoulder rehab 4 wks Plyometrics and integrated rehab 8 wks – Throwing program 12 weeks – Released to play 18 weeks – Level of play increased

ELITE ATHLETES

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• Subluxation

“normal”

• Rest/rehab may be

best option

• Internal

impingement also normal? Walch – IS tear – Peel back lesion – Posterior tightness

28 yo MLB Pitcher

SUMMARY

• Pathology of the throwing shoulder varies

widely by age

• Rehabilitation of the entire kinetic change

usually the preferred method of Rx

• Surgery should be minimalistic-all of them are

unstable, so try to fix only what “tipped them

• ver the edge” for best results
• In throwers best to leave the rotator cuff alone

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THANK YOU

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