Sports Medicine: Just the Facts

CHAPTER 48 • THE THROWING SHOULDER 289

• Analysis of rotator cuff contact in throwing and non-
  throwing extremities, however, has revealed contact in
  both arms when in ABER position, lending credence
  to the theory of physiologic impingement which
  develops problems as a result of repetitive trauma
  (Halbrecht, Tirman, and Atkin, 1999).

BONY CHANGES

• Bennett’s lesion: Bony reactive changes at the poste-
  rior glenoid margin (Bennett, 1959)
  
  
  • Symptom complex includes pain in posterior deltoid
    in follow-through phase
    
    
    1. Exostosis typically at the posterior, inferior gle-
       noid margin.
    
    
    2. Size of lesion not correlated with symptoms.
    
    
    3. Symptoms may occur gradually or acutely.
    
    
    
    
  
  
  • Not always clinically symptomatic.
  
  
  • Symptomatic exostoses usually respond to rest and
    occasional steroid injections.
  
  
  • Excision is performed through either an arthro-
    scopic or posterior open approach (Lombardo et al,
    1977; Meister et al, 1999).
  
  
  
  

MANAGEMENT OF SPECIFIC INJURIES

SLAP LESIONS

•Variable amounts of detachment encountered. The
established classification system defines the clinically
unstable lesions as those that involve the biceps
anchor (Snyder et al, 1990).

• Conservative management in an established SLAP
  lesion does not fare well.


• Attempts at rehabilitation center around increasing
  rotator cuff strength and management of secondary
  scapulothoracic dyskinesia.


• Surgical management is arthroscopic stabilization
  with the use of suture anchors. The use of solid,
  arthroscopically delivered tacks is contraindicated in
  throwing athletes and is reserved for less active
  patients (Morgan et al, 1998).

CAPSULAR LAXITY (MICROINSTABILITY)

• Most commonly present with impingement (second-
  ary).


• Initial treatment is focused on decreasing pain and
  inflammation, followed by a cuff strengthening pro-
  gram emphasizing flexibility, strength, power, and
  endurance of the rotator cuff.

•Surgery is indicated with failure to progress within 3

to 6 months.

• Surgical intervention has been shown to be successful
  with either open (capsulolabral reconstruction)
  (Rubenstein et al, 1992) or arthroscopic capsular imbri-
  cation.


• Thermal capsulorrhaphy alone may be indicated in
  those cases where labral pathology is nonexistent and
  the patient has excessive external rotation with a total
  arc of motion greater than 30°as compared to the con-
  tralateral side (D’Alessandro et al, 1998).
  •Surgical intervention with the goal of limiting motion,
  especially external rotation, should be undertaken fol-
  lowing a thorough rehabilitation course and careful
  discussion with the patient.
  
  
  • All of these procedures, to some extent, limit motion.
  
  
  • Rate of return is not always 100%.
  
  
  
  

INTERNAL IMPINGEMENT

•Overlap with laxity has made treatment difficult.

• In cases where no obvious instability is present,
  debridement may be an option with approximately
  65% return to prior activity level (Walch et al, 1992).


• Capsular imbrication:
  
  
  • May be performed with any method available,
    including open capsulolabral reconstruction, arthro-
    scopic plication or heat capsulorrhaphy (Levitz,
    Andrews, and Dugas, 2000).
    •Variable results with no long-term series are available.
  
  
  
  


• Derotation:
  
  
  • This is a highly invasive surgical procedure.
  
  
  • This may be used in extreme cases following failure
    of debridement and/or capsulorrhaphy with a desire
    to return to high level throwing.
  
  
  
  

ROTATOR CUFF TEARS

•Partial thickness tearing is most common. Partial tears

result from the excessive tension developed within

fibers.

• Intra-articular partial tears are most common.


• Diagnosis is done via MRI with intra-articular gado-
  linium.
  a. Assess arm in ABER position
  b.Highly suspicious of diagnosis in high level throw-
  ers
  •Surgical indications
  a. Arthroscopic evaluation of joint is important as a
  result of high incidence of labral lesions and par-
  tial cuff tears.