Sports Medicine: Just the Facts

b.Repair is considered in those lesions greater

than 50% of tendon thickness (normal 12–

16 mm).

c. Debridement is in lower grade lesions and in

those with normal preoperative strength.

d. Consider acromioplasty and/or coracoacromial

ligament release.

IMPINGEMENT

PRIMARY

• Rare as an isolated entity.


• High incidence of intra-articular pathology.


• Arthroscopy indicated in all patients to assess for
  additional pathology.


• Conservative resection.
  a. Do not resect type I acromion.
  b. Release of coracoacromial ligament (no resection).

SECONDARY

• Most often missed and inappropriately treated as pri-
  mary problem:
  
  
  • Requires treatment of the primary problem either
    with rehabilitation or surgical intervention.
  
  
  
  


• Arthroscopy helps assess for primary intra-articular
  pathology.


• The employment of subacromial decompression in
  isolation has been shown to be unpredictable with
  respect to return to prior activity level.
  a. In one study, only 43% of patients with surgical
  decompression returned to preinjury level of com-
  petition (Tibone et al, 1985).
  b. Return is perhaps more indicative of improvement
  in their muscular imbalance through thoughtful
  rehabilitation than as a result of the surgical proce-
  dure.

REHABILITATION ISSUES

SCAPULOTHORACICARTICULATION

• Often the cause of secondary impingement.


• Scapula has five specific functions that have implica-
  tions in throwers (Kibler, 1998).
  a. Stable part of the glenohumeral articulation, where
  rotation of the glenohumeral joint allows maximal
  concavity and compression.
  b. The scapula retracts and protracts the shoulder
  complex along the thoracic wall.
  c. Acromial elevation to avoid impingement with arm
  elevation.
  d. Base for muscular attachments.
  e. Energy transfer from the legs, back, and trunk.

SCAPULOTHORACICDYSKINESIA

• Abnormal set of motions and positions affecting the
  relative position of the scapula and the proximal
  humerus.
  a. Etiologies include nerve or muscle injury, muscle
  inhibition, and glenohumeral stiffness or laxity.
  b. Mechanical dysfunction may result in impinge-
  ment as well as insufficient translation of energy
  from the lower body.
  
  
  1. Excessive stress results in overuse injuries.
  
  
  2. Clinical picture is confusing as a result of sec-
     ondary impingement and capsular changes that
     may occur as a result of the adaptations to
     scapular malalignment.
  
  
  
  

PROPRIOCEPTION(LEPHART ANDHENRY, 2000)

• Excessive joint laxity associated with capsuloliga-
  mentous injury and resulting microtrauma cause
  damage to the neural receptors and lead to deaf-
  ferentation.


• Neuromuscular deficits impair reflexive muscular sta-
  bilization, predisposing shoulder to episodes of func-
  tional instability.
  a. Diminished joint position sense, kinesthetic aware-
  ness, and abnormal humeroscapular firing patterns
  (Lephart et al, 1996).
  b. Abnormal firing patterns documented on EMG
  studies in throwers with glenohumeral instability
  (Glousman et al, 1988).
  c. Following surgical reconstruction, joint position
  sense, and reproduction of passive positioning
  improve to baseline levels (Lephart et al, 1996).


• Restoration of functional stability.
  a. Traditional strengthening exercises do not address
  neuromuscular deficits.
  b. Four elements necessary to restore functional sta-
  bility (Lephart et al, 1996):
  
  
  1. Peripheral somatosensory, including visual and
     vestibular
  
  
  2. Spinal reflexes:
     
     
     • Sudden alteration in joint position that
       requires reflex muscular stabilization.
     
     
     
     
  
  
  3. Cognitive programming:
     
     
     • Appreciation of joint position.
     
     
     
     
  
  
  4. Brain stem.
     c. All four elements need to be addressed in order
     to fulfill the objective of stimulating all sub-
     systems:
  
  
  5. Dynamic stabilization:
     a. Promotes coactivation of force couples
     b. Centers humeral head
  
  
  6. Joint position sensibility:
     
     
     • Restore through conscious and unconscious
       pathways.
     
     
     
     
  
  
  
  

290 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE