1	THE OVERHEAD ATHLETE’S SHOULDER: WHERE WE ARE IN 2009 PRESTON M. WOLIN, M.D. DIRECTOR SPORTSMEDICINE NEUROLOGIC AND OTHOPAEDIC INSTITUTE OF CHICAGO and MEDICAL DIRECTOR CENTER FOR ATHLETIC MEDICINE CHICAGO
2	SHOULDER FUNCTION PLACES THE UPPER EXTREMITY IN SPACE, ENABLING “PREHENSILITY” NORMAL SHOULDER FUNCTION REQUIRES SYNCHRONY OF GLENOHUMERAL JOINT ACROMIOCLAVICULAR JOINT SCAPULOTHORACIC ARTICULATION
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4	THIS REQUIRES THE COMPLEX INTERACTION OF BONES MUSCLES LIGAMENTS NERVES
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9	SHOULDER LIGAMENTS
10	SHOULDER CAPSULOLABRAL ANATOMY
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12	BIOMECHANICS OF THROWING, OVERHEAD SHOTS, SPIKING/SERVING ALL SIMILAR
13	ALL REQUIRE TRANSFER OF ENERGY FROM GROUND UP: CORE STRENGTH SCAPULAR STABILITY: PARASCAPULAR STRENGTH ABILITY TO OFFSET DECELERATION FORCES: POSTERIOR CUFF MUSCLE STRENGTH
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18	CORE STRENGTH AND INJURY CLINE, WOLIN, LABELLA 2002 159 HIGH SCHOOL BASEBALL PLAYERS EXAMINED PRESEASON FOR CORE WEAKNESS WITH TRENDELENBERG, CORKSCREW, ETC TRAINERS KEPT WEEKLY LOGS OF INJURY
19	CORE STRENGTH AND INJURY RIGHT HANDED PITCHES WITH POSITIVE RIGHT TRENDELENBERG (PUSH OFF LEG) 3 TIMES ELBOW INJURY RATE THAN NORMAL
20	BEFORE WE DISCUSS INJURY TREATMENT, CAN WE PREVENT INJURY? CORRECT MECHANICS LIMIT EXPOSURE LIMIT CERTAIN TECHNIQUES CORRECT INFLEXIBILITY
21	A SOBERING STATISTIC 27 SHOULDER SURGERIES IN ONE PRO CLUB. 18 LABRAL REPAIRS 7 RETURNED TO SAME LEVEL 26% 1/10 AT AA OR ABOVE RETURNED TO SAME LEVEL
22	ANOTHER ONE MAZOUE AND ANDREWS. AJSM 2005 16 PRO PLAYERS WITH OPEN CUFF REPAIR. 12 PITCHERS 1/12 8% PITCHERS ABLE TO RETURN TO HIGH COMPETITIVE LEVEL WITHOUT SIGNIFICANT SHOULDER DYSFUNCTION 1/2 50% POSITION PLAYERS
23	CORRECTING MECHANICS NOT EASY REQUIRES TEAM APPROACH: ATHLETE, COACH, ATC, PT, MD/DO, PARENTS
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25	LIMITING EXPOSURE INNINGS—THE PROBLEM : HOW MANY PITCHES PER INNING PITCH COUNT—THE PROBLEM: HOW MANY TEAMS? HOW MANY FULL EFFORT THROWING SESSIONS? THE ONLY TRUE LIMITTING FACTOR IS A RESPONSIBLE ADULT. TOO MANY TIMES THERE ISN’T ONE.
26	EVIDENCE FOR LIMITING EXPOSURE LYMAN, FLEISIG, ET AL. AJSM 2002 476 PITCHERS AGES 9-14 FOLLOWED FOR ONE YEAR 50% SHOULDER OR ELBOW PAIN MARKED INCREASE SHOULDER PAIN OVER 75 PITCHES PER GAME AND 600 PER SEASON
27	EVIDENCE FOR RESTRICTING BREAKING PITCHES CURVEBALL 52% INCREASE IN SHOULDER PAIN. SLIDER 86% ELBOW CHANGE UP 29% DECREASE IN SHOULDER PAIN. 12% DECREASE IN ELBOW PAIN
28	USA BASEBALL RECOMMENDATIONS 75 PITCHES PER GAME 600 PER SEASON NO BREAKING BALLS BEFORE AGE 14 NOTE THESE REFER TO FULL EFFORT THROWING SESSIONS. BEWARE THE ‘SHOWCASE’
29	THE BREAKING BALL CONTROVERSY REVISITED DUN, LOFTICE, FLEISIG, ANDREWS. AJSM 2007 29 YOUTH PLAYERS 12.5-17 DATA ANALYSED FOR FASTBALL, CURVE, CHANGE UP AT MAX EFFORT ELBOW VARUS, SHOULDER IR TORQUE, ELBOW PROXIMAL FORCE, AND SHOULDER PROXIMAL FORCE FASTBALL>CURVEBALL>CHANGE UP
30	CONCLUSION OF AUTHORS ‘CURVEBALL MAY NOT BE MORE POTENTIALLY HARMFUL THAN THE FASTBALL FOR YOUR PITCHERS…(A)MOUNT OF PITCHING IS A STRONGER RISK THAN TYPE OF PITCH’
31	CHANGE UP: THROWN JUST LIKE A FASTBALL
32	CURVEBALL
33	CURVE BALL: DRAWING THE WINDOW SHADE DOWN
34	SLIDER: TURNING THE DOOR KNOB
35	MY PHILOSOPHY LIMITTING EXPOSURE AT LEAST AT THE YOUTH LEVEL WORKS TEACH ALL YOUR PITCHERS THE CHANGEUP A CURVEBALL IS NOT A SLIDER
36	INFLEXIBILITY THE SLAP CASCADE: CURRENTLY IN VOGUE AS THE CAUSE OF INJURY IN PITCHERS ESP THE SUPERIOR LABRAL TEAR CAN WE PREVENT IT AND WILL IT PREVENT INJURY
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39	HOW WE GOT HERE IN THE 80’S ARTHROSCOPY ALLOWED COMPLETE VIEW OF THE SHOULDER INCREASED RECOGNITION OF THE SLAP LESION AS A CAUSE OF PAIN IN THROWERS CLINICAL AND BIOMECHANICAL STUDIES TO TRY TO EXPLAIN THE PATHOLOGY
40	ETIOLOGY OF SLAP LESIONS IN THROWERS: THEORIES Deceleration forces at biceps anchor Abnormal laxity Altered center of motion due to posterior capsular contracture “Internal impingement”: the final common pathway
41	DECELERATION THEORY Force load at biceps anchor is considerable Can disrupt anchor and/or labrum, resulting in tear Andrews Arthroscopy 1985
42	ANTERIOR LAXITY THEORY Overhead athletes show glenohumeral laxity with excessive external rotation This can result in anterior laxity The superior labrum is injured as a result Levitz, Dugas, Andrews
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45	INTERNAL IMPINGEMENT: THE FINAL COMMON PATHWAY Compression of the articular surface of the rotator cuff vs. the superior labrum Concurrence of articular surface cuff and SLAP tears Types: Posterior superior Anterior superior Anterior
46	INTERNAL IMPINGMENT
47	UNDERSTANDING POSTERIOR CAPSULAR CONTRACTION IT IS A DECREASE IN THE TOTAL ROTATIONAL ARC OF MOTION THAT IS MOST IMPORTANT, NOT JUST JUST A DECREASE IN INTERNAL ROTATION: GLENOHUMERAL INTERNAL ROTATION DEFICITY (GIRD)
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51	INCREASED ER AND DECREASED IR IS NL IN PITCHERS CROCKETT, GROSS, WILK ET AL. AJSM2003 THROWERS VS. NONTHROWERS THROWERS INCREASED ER AND DECREASED IR VS NONTHROWERS HUMERAL RETROVERSION INCREASED IN THROWERS
52	GIRD AND RELATIONSHIP TO INJURY WILK ET AL AOSSM 2008 162 PRO PITCHERS COMPARED GIRD VS. NO GIRD GIRD STATISTICALLY ASSOCIATED WITH INCREASE OF BOTH DL AND SURGERY SIGNIFICANT LOSS 18.7 NOT 20 BUT >7 DEG LOSS OF ER+IR 3X CHANCE OF INJURY
53	OK WE KNOW THE RELATIONSHIP BETWEEN GIRD AND INJURY BUT CAN WE PREVENT IT WITH STRETCHING?
54	POSTERIOR CAPSULAR STRETCHING NOW ACCEPTED AS A STANDARD THROUGHOUT BASEBALL BUT TO DATE ONLY ONE UNPUBLISHED STUDY SHOWED A RELATIONSHIP BETWEEN STRETCHING AND DECREASED INJURY RATE IN BASEBALL IN TENNIS, THERE APPEARS TO BE A ROLE AS WELL
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61	WHAT IS EFFECTIVE STRETCHING FOR THE POSTERIOR CAPSULE? IZUMI, ET AL. AJSM. 2008 ANALYZED POSTERIOR CAPSULAR STRAINS WITH VARIOUS STRETCHING POSITIONS USING CADAVERS RESULTS 1. FOR MID AND LOWER CAPSULE. 30 DEG ELEVATION IN SCAP PLANE WITH IR. 2. FOR UPPER AND LOWER CAPSULE 30 DEG. EXTENSION AND INTERNAL ROTATION
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63	CONCLUSIONS RE: CAPSULAR CONTRACTURE IN THROWERS ALWAYS MEASURE ROM WHEN ASSESSING THROWERS THE CONCEPT OF STRETCHING SEEMS REASONABLE, BUT IT HAS NOT BEEN PROVEN THERE ARE A GROUP OF NONRESPONDERS TO STRETCHING IF THERE IS NO RESPONSE AFTER 10 DAYS, CONSIDER ALTERNATE TREATMENT
64	19 YO COLLEGIATE PITCHER REFERRED TO ME FOR SLAP REPAIR
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67	TREATMENT AVOID THROWING CAPSULAR STRETCHING PARASCAPULAR STRENGTHENING CORE STRENGTHENING CUFF STRENGTHENING RETURNED TO PLAY IN 3 MOS. NO FURTHER PROBLEMS.
68	WHAT ABOUT ‘OUTLET IMPINGEMENT’ IN THE THROWER IN 2008
69	IMPINGEMENT SIGN
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71	BEWARE ‘IMPINGEMENT’ IMPINGMENT SIGNS CAN ‘TRAP’ THE TORN LABRUM PRODUCING PAIN INTERNAL VS. OUTLET IMPINGEMENT CONSIDER MECHANISM AND AGE
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76	DOES ‘OUTLET IMPINGEMENT’ HAPPEN IN THE THE OVRHEAD ATHLETE LARGE NUMBER OF ASYMPTOMATIC OVERHEAD ATHLETES WITH ‘HOOKED ACROMIONS’ IF AGE IS LESS THAN 40-45, PROBABLY NOT THE CAUSE OF PROBLEMS IT MAY BE PRESENT IN THE OLDER ATHLETE, BUT RESULTS OF CUFF REPAIR WITH AND WITHOUT ACROMIOPLASTY ARE = IN ALL COMERS. ? VALUE IN OVERHEAD ATHLETES.
77	EVALUATING THE OVERHEAD ATHLETE AGE MECHANISM: NOT ALL ARE MICROTRAUMATIC DURATION COMPLETE PHYSICAL EXAM CORRECT IMAGING IF NEEDED. KEY IS A MUSCULOSKELETAL RADIOLOGIST.
78	IMAGING: MRI ARTHROGRAM MOST SENSITIVE
79	INITIAL MRI (OPEN): NO CUFF TEAR
80	SUBSEQUENT MRI ARTHROGRAM:>50% PARTIAL THICKNESS TEAR
81	SPECIFIC INJURIES RELATED TO INTERNAL IMPINGEMENT SLAP TEAR SLAP TEAR + UNDERSURFACE CUFF TEAR SLAP TEAR+BICIPITAL TENDINOPATHY
82	SLAP REPAIRS CANNOT BE SEEN OPEN NEEDS TO BE DONE TO ALLOW EARLY ROM THE BIGGEST COMPLICATION IS STIFFNESS NOT FAILURE
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85	THE SLAP TEAR WITH THE UNDERSURFACE CUFF TEAR AN INCREASING PART OF MY PRACTICE OPTIONS: DEBRIDEMENT VS. REPAIR RESULTS WORSE WITH DEBRIDEMENT IF THE TEAR IS > 40% OF THICKNESS
86	16 YO BASEBALL PLAYER
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90	SLAP TEAR WITH BICIPITAL TENDINITIS BEWARE THE ‘ISOLATED SLAP TEAR’ OVER AGE 35 REPAIR ONLY CAN LEAD TO STIFFNESS WITHOUT RESOLUTION OF SYMPTOMS ALWAYS CHECK PREOP FOR BICEPS SIGNS: SPEED, YERGASON
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92	47 YO SP SLAP REPAIR. REPAIR HEALED. BUT LIMITED ROM AND PAIN AT 6 MOS. POST OP
93	REQUIRED PARACAPSULAR RELEASE SUBPECTORAL BICEPS TENODESIS ALLOWED IMMEDIATE UNRESTRICTED ROM
94	POSTOPERTIVE TREATMENT Allow for early motion worst complication for a throwing athlete is stiffness Scapular stabilization immediately Progressive, phased strengthening Progressive, phased return to throwing Return to sport
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99	POSTOP SLAP REPAIR 5 MOS.
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101	NO MATTER HOW GOOD THE SURGERY/SURGEON THE PROCEDURE IS ONLY AN INTERLUDE BETWEEN INJURY AND RECOVERY NEED A STRONG TEAM: MD, PT, ATC, COACH THEY ALL NEED TO WORK WITH EACH OTHER
102	REHABILITATION IS THE KEY TO SUCCESS SPECIAL THANKS TO PROF. CAROL HUMBLE WHO TAUGHT ME THAT 2 DECADES AGO.