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Sport FRCS > Shoulder injuries in throwing athlete > Flashcards

Shoulder injuries in throwing athlete Flashcards

SLAP lesion Internal impingment glenohumeral internal rotation deficit little league shoulder posterior labral tear

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1
Q

What is a SLAP lesion?

A
  • **A tear of Superior labrum from Anterior to Posterior **
  • Occur in isolation or assoc with
    • ​internal impingement
    • RC tears
    • Instability
  • ​Mechanism
    • Reptitive overhead activities​
    • Foosh w tensed biceps
    • traciton on arm
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2
Q

Describe the pathophysiology of SLAP lesion?

A
  • In throwers maybe tightness of the posterior IGHL which shifts the glenhumeral contact point posteriosuperiorly and increases the shear force on the superior labrum
  • SLAP lesion increases the strain on the anterior band of the IGHL and so comprise the stability of the shoulder
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3
Q

Describe the function and anatomy of the glenoid labrum?

A
  • Function
    • chock block to subluxation
  • composed of fibrocartilagenous tissue
  • blood supply
    • anterior-superior labrum has poorest blod supply
    • from suprascapular, circumflex scapular, post humeral circumflex arteries
    • from capsule and periosteal vessels not form underlying bone
  • Stability
    • superior labrum- anchors biceps tendon ( weak link->SLAP)
    • most common pattern of boceps tendon attachment to sup labrum is posterior to 12o’clock position ( posterior or posterior dominant)- 70% pts
  • Anatomical variants
    • sublabral recess- can be confused with tear on MRI
    • meniscoid appearance 1%
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4
Q

What is the classification of SLAP lesions?

A

Snyder classification I-IV, Maffet adds V-VII

  • type 1- labral & biceps fraying, bicpes anchor intact
  • type 2- labral fraying with detached biceps tendon anchor
  • 3- bucket handle tear, intact biceps tendon & anchor
  • 4- bucket handle tear with detached biceps anchor
  • 5- SLAP with anterior labral tear ( Bankhart lesion)
  • 6- Superior flap tear
  • 7- SLAP lesion with capsular injury
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5
Q

Describe the presentation of SLAP lesion?

A
  • Vague deep shoulder pain
  • mechanical symptoms- popping/clicking
  • weakness, easy fatigue

O/E

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6
Q

What is seen on imaging?

A
  • Normal xrays
  • MRI
    • t2 linear signal intensity between superior labrum and glenoid rim
    • may assoc with prelabral ganglion cyst
      • usually seen in spinoglenoid notch
  • Arthroscopy
    • dx
    • peel back test - peel back of labrum at 90o external rotation
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7
Q

Describe the tx of SLAP tear?

A

Non operative

  • Physio/ NSAIDS
    • first line
    • address scapular dyskinesia, RC
    • incidental finding of SLAP tear in pt >45 years not b necessary need to repair as may lead to stiffness if tis is repaired.

Operative

  • Athroscopic debridement and stabilisation of labrum and biceps tendon
  • type 1 debride,
  • type 2, treattach labrum
  • type 3- debride flaps
  • type 4 - if tendon <1/3 then excise bucket, if tendon >1/3 same and preform biceps tenodesis/tenotomy
  • Rehab
    • 1-4 wks sling with passive forward elevation. aboid extreme abduction/external rotation
    • passive and active assisted flexion
    • wks 4-6 progressive to active rom, isometric
    • wks 6-12 functional exercise, light strengthening
    • wks 12+ adv strength , rom, sport activity
    • return sports 6 months
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8
Q

What is internal shoulder impingement?

A
  • refers to the impingement within the glenohumeral joint which occurs as the posterosuperior glenoid labrum makes contact with the greater tuberosity, causing impingement on the posterior rotator cuff.
  • refers to pathology on undersurface of rotator cuff cf to subacromial/ external impingment which occurs on bursal side of RC
  • includes
    • fraying of post rotator cuff
    • post and superior labral lesions
    • hypertrophy and scarring of post capsule glenoid ( Bennet lesion)
    • Cartilage damage at posterior glenoid
  • Major cause of pain in throwing athletes
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9
Q

What is the pathology of internal shoulder impingement?

A
  • Impingement of posterior under-surface of supraspinatus tendon on the posteriosuperior gleboid rim
  • impingement occurs during max arm abduction and external rotation during the late cocking and early acceleration phases of throwing
  • -> peelback phenomenon of posteriosuperior labrum
  • thought to be due to
    • tightness of posterior band of IGHL
    • anterio micro instability
  • Assoc with glenohumeral internal rotation deficit GIRD
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10
Q

Describe the presentation of internal shoulder impingement?

A
  • Diffuse pain in post shoulder along the post deltoid
    • shoulder pain worse with throwing
    • esp during late cocking early acceleration

O/E

  • Increased external rotation
  • Decreased internal rotation
    • loss of >20o of IR at 90o
    • must stabilise scapular to access GH rotation
    • often RC weakness
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11
Q

What is seen on imaging of internal shoulder impingement?

A
  • Xrays
    • usually unreamarkable
    • Ap may show Bennett lesion - posterioinferior glenoid extostosis
  • MRI​
    • may show assoc RC tear/ larbal pathology
    • signal at greater tuberosity and posteriosuperior labrum
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12
Q

What is the tx of internal shoulder impingement?

A

Non operative

  • Posterior capsule stretching physio for 6 months
    • most tx consx
    • post capsular stretches with sleeper stretches
    • RC stretching and strengthening

Operative

  • Arthroscopic debridement and repair of RC tear/labrum
    • failed consx, Partial thickness RC tears ( PASTA) compromise integrity of RC >50%, bennete lesion
  • Posterior capsule release vs anterior stabilisation
    • failed consx, shoulder instability
    • contraversial for each
    • complx- inferior suprascapular n ( infraspinatus) is at greatest risk during posterior release
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13
Q

What is glenohumeral internal rotation deficit ?

A
  • A condition resulting in loss of IR of the GH joint as compared to contraleral side
  • occurs in overhead athletes, baseball pitchers
  • Aet= repetitive throwing thought to occur in late cocking and early acceleration phase
  • GH mechanics shift by posteriosuperior shift in humeral head so posterior capsule becomes tightened and anterior capsule stretched
  • Assoc conditions
    • GH instability
    • internal impingment
    • SLAP lesions
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14
Q

What is the presentation of a pt with glenohumeral internal rotation deficit ?

A
  • Vague shoulder pain
  • sometimes painless

O/E

  • Excessive ER is present at expense of decreased IR
  • IR is usually > than 25 degrees difference as cf non throwing shoulder
  • must stabilise scapula to get true measure of GH rotation.
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15
Q

Descrube the tx of glenohumeral internal rotation deficit ?

A

Non operative

  • Rest from throwing for 6/12 with physio
    • post capsule strecthing ( sleeper stretch)
      • performed w IR at 90o abduction with scapular stabilised
    • Pectoralis minor stretching
    • subsacpularis and serratus ant strengthening

Operative

  • Post capsule release vs anterior stabilisation
    • only if physio fail
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16
Q

What is little league’s shoulder?

A
  • A salter harris type 1 physeal injury to proximal humerus
  • seen in adolescent pitches, tennis players
  • arm overuse -> microtrauma at physis from
    • high loads of tourque
    • breaking pitches are implicated
  • Hypertrophic zone implicated due to weakest portion of growth plate
  • PC
    • arm and shoulder pain whilst throwing worse in late cocking or decleration phase
    • point tenderness over humerus
17
Q

What is seen on imaging of little league shoulder?

A
  • Xray
    • Widening of proximal humerus physis
    • metaphyseal bone changes
  • MRI
    • Oedema around physis
18
Q

Describe the tx of little league shoulder?

A
  • Non operative
    • Physio, rest, ice , progressive throwing programme
    • refrain pitches 2-3 months
    • Physio strengthen RC, posterior shoulder capsule stretches, core strengthening and stretching
19
Q

What are the complications of little league shoulder’s?

A
  • Premature growth arrest of proximal humeral epiphysis
    • cause growth arrest
    • angular deformity
20
Q

What is a posterior labral tear?

A
  • AkA Reverse Bankart lesion
  • may occur athletes due to trauma
    • football lineman
    • weightlifters
  • Mechanism
    • usually from a posterior directed force with arm flexed , adducted and internally rotated
  • Assoc injuries
    • Kim lesion = incomplete and sometimes concealed avulsion of posterior labrum
21
Q

Describe the function and anatomy of posterior labrum?

A
  • Function
    • Helps create a cavity- compression and creates 50% of the glenoid socket depth
    • Provides Posterior stability
  • Anatomy
    • composed of fibrocartilagneous tissue
    • anchors posterior inferior glenohumeral ligament (PIGHL)
22
Q

What is the presentation of a pt posterior labral tear?

A
  • Shoulder pain
  • sense of instability
  • mechanical symptoms- clicking/popping with rom

O/E

  • Posterior joint line tenderness
  • provocation tests
    • Posterior load & shift
    • Jerk test- subluxation with post applied force while arm is flexed and internal rotation
    • Kim test- subluxation with post applied force as arm is dynamically adducted by examiner
23
Q

What is seen on imaging of posterior labral tears?

A
  • Xrays- often normal
  • MRI
    • dx
    • intra-articular contrast
24
Q

What is the tx of posterior labral tear?

A

Non operative

  • Nsaids, Physio
    • 1st line of tx
    • RC strengthening and periscapular stabilisation

Operative

  • Posterior labral repair w capsulorrhaphy
    • if non op fails
    • both open vs arthroscopic used
    • probing of post labrum to rule out Kim lesion
25
Q

What are the risks of posterior labral repair and capsulorrhaphy?

A
  • axillary n palsy
    • post branch of axillary n is at risk during arthroscopic stabilisation
    • travels within 1mm of the inferior shoulder capsule and glenoid rim
    • at risk during suture passage at posterior inferior glenoid
    • lead to numbness regimental badge ( sup-lateral brachial subcutaneous nerve) and weakness to teres minor ( external rotation) - n to teres minor from posterior branch
  • Overtightening of post capsule
    • can lead to anterior subluxation or coracoid impingement

Sport FRCS (26 decks)

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