Sports Medicine: Just the Facts

of pathology. Eighty percent of MDI diagnosed patients

respond favorably to nonoperative treatment (Burkhead

and Rockwood, Jr, 1992).

REHABILITATION

• Rehabilitation for instability involves activation of the
  dynamic stabilizers of the shoulder to aide in the over-
  all stabilization. There are three main components—
  range of motion(ROM), strengthening, and brace wear.


• ROM:Full external, internal, abduction, and forward
  elevation should be established. This is obtained by
  passive, active assisted, and finally active range of
  motion. A trained therapist is critical for accuracy of
  movement, safety, and motivation.


• Strengthening:This begins with isometric contrac-
  tions within a range of motion that is comfortable for
  the patient. Once this is established, theraband exer-
  cises can begin. Finally isokinetic and isotonic
  strengthening with a complete arc of motion complete
  the program. Strengthening of the rotator cuff and
  scapular stabilizers is critical.


• Brace:Braces are used to limit the “at risk” position
  for return to sports.
  
  
  • SSI brace: (Boston Brace International) Limits
    motion and protects against blows.
  
  
  • The SAWA Shoulder Orthosis: Brace International
    provides anterior support and ads a check rein.
  
  
  • The Duke–wire harness–Lace up corset
  
  
  • The SSI brace was the most effective in limiting
    anterior shoulder subluxation while the SAWA was
    considered to be the most comfortable (DeCarlo et al,
    1996).
  
  
  
  

OPERATIVE TREATMENT OPTIONS

• Recurrent traumatic anterior: Recurrence rates in
  the young athletic population after nonoperative treat-
  ment are unpredictable (65–95%). Surgical stabiliza-
  tion should be considered in a young athlete who
  desires return to sport. Arthroscopic surgery has the
  advantage of creating less morbidity and allowing a
  more detailed examination of the shoulder. Although
  controversial acute stabilization arthroscopically in
  the high demand patient has been very successful and
  should be considered in the correct setting (Arciero
  et al, 1994; Kirkley, Griffin, and Richards, 1999).
  1.Arthroscopic results:Arthroscopic techniques
  have evolved over the last 35 years. The literature is
  replete with methods involving staples, transglenoid
  sutures, cannulated implants, and suture anchors. In
  the last 3–5 years arthroscopic techniques have

evolved to the level where they mimic the open tech-

nique. This involves plication of redundant inferior

capsule, reattachment of the anterior inferior labrum

directly to bone with suture anchors and closure of

the rotator interval. Recent reports place the recur-

rent dislocation event after surgery at 5 to 15%

(Bacilla, Field, and Savoie, 1997). In high demand

patients a recurrent subluxation event was 15%

(2/13 patients) with one requiring surgery

(Mazzocca et al, 2004).

2.Open results:Historically many procedures have

been described for glenohumeral instability. Many

of these did not repair the labral lesion and high

rates of instability were still found.

a.Magnuson-stack-muscle transposition of the

subscapularis

b.Putti-Platt-shortening of the subscapularis and

capsule

c. Bristow-transfer of the coracoid process

d. Weber-osteotomy of the proximal humerus

e. Meyer-Burgdorff-osteotomy of glenoid

f. Gallie-reconstruction with fascia lata

g. Nicola-biceps tendon through humeral head

h. Du Toit-staple repair of labrum

i. Bankart-suture repair of labrum

• Bankart lesions (tears of the anterior inferior labrum)
  were found in 84% of patients with continued insta-
  bility after surgery. Stability was restored in 92% with
  repair of labrum. Uncorrected capsular redundancy
  was also a reason for failure in over 80% of patients
  (Rowe, Zarins, and Ciullo, 1984).
  3.Bone reconstruction:There are instances where
  the anterior inferior glenoid has a large fracture or
  is deficient secondary to impaction or chronic
  instability. In these instances soft tissue procedures
  are not adequate and bone graft may be required.
  a.Glenoid deficiency: A 21% glenoid defect
  caused instability and limited range of motion
  after Bankart repair (Itoi et al, 2000). For large
  defects two procedures exist:
  1.Laterjet/Bristow: Coracoid bone graft
  placed to the glenoid (Burkhart and De Beer,
  2000).
  2.Extracapsular iliac crest:Iliac crest auto-
  graft placed extracapsular with 3.5 mm
  screws 20/21 excellent results after chronic
  instability (Churchill et al, 2001).
  b.Hill sachs lesion:If the humeral head lesion is
  large (greater than 33%) or engages the glenoid
  in a functional range of motion then various
  procedures can be considered (Burkhart and De
  Beer, 2000).
  
  
  1. Humeral head allograft
  
  
  2. Open capsular shift
  
  
  
  

266 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE