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2/7/2017

1

www.prismsports.org

PRiSM Presents:

Management of Adolescent

Shoulder Instability

7 February 2017

VuMedi Webinar

Moderator:

Matthew R. Schmitz, M.D.

Pediatric Sports Medicine and

Young Adult Hip Preservation

San Antonio Military Medical Center

www.prismsports.org

Carlin Senter, MD, FACP

•Associate Professor

•Primary Care Sports Medicine

•University of California San

Francisco

•Co-Director UCSF Sports

Concussion Program

•Head Team Physician SF

Deltas

www.prismsports.org

Dele Kammen, MD

•Pediatric Radiologist

•UCSF Benioff Children’s

Oakland

•Harvard Medical School

•UPenn Radiology Resiency

•UCSF Peds Radiology

Fellowship

2/7/2017

2

www.prismsports.org

Michelle Cappello, PT, MSPT, SCS

•Masters in PT from Boston

University

•Board Certified Sports

Clinical Specialist

•American Physical Therapy

Association

•Soccer player, coach, mom

www.prismsports.org

Dr Nirav K. Pandya

•Assistant Professor,

Orthopaedic Surgery, UCSF

•Director of Pediatric Sports

Medicine, UCSF Benioff

Childrens’ Hospitals

•Undergrad: Univ of Chicago

•Med School: Univ of Chicago

•Residency: Penn

•Fellowship: Rady Children’s

San Diego

www.prismsports.org

Brett Burton –Bio

•Education:

–University of Nebraska-Lincoln

(Athletic Training)

–University of Nebraska Medical Center

(Physical Therapy)

–St. Luke’s Sports Medicine

(Physical Therapy Residency)

•Experience:

–Worked closely with the University of

Nebraska Baseball Team

–Trained at the Andrews Institute, Athletes’

Performance (currently EXOS), and the

Mayo Clinic

–Currently serves as physical therapist at

Northwest Nazarene University and treats

several adolescent patients in outpatient

clinical setting at St. Luke’s Rehab in Idaho

2/7/2017

3

PRiSM is a multidisciplinary society

focused on research in pediatric

sports medicine.

Features of PRiSM membership:

•Guiding new research by joining

a Research Interest Group

•Leadership development

through board and committee

participation

•Registration discounts to the

Annual Meeting

•Access to Clinical Orthopaedics

and Related Research, PRiSM's

official journal

2/7/2017

1

www.prismsports.org

Adolescent Shoulder Instability:

Patient Presentation

Carlin Senter, MD

Associate Professor

Primary Care Sports Medicine

UCSF Medicine and Orthopaedics

February 7, 2017

www.prismsports.org

Epidemiology

•Shoulder is most commonly dislocated joint in

the body

–1-2% of the population

•90-95% of shoulder dislocations are anterior

•20% of shoulder dislocations occur in patients

under 20 years of age.

•Mechanism = fall on outstretched arm or

collision, especially when arm is abducted and

externally rotated

www.prismsports.org

Shoulder anatomy:

Bony stability

2/7/2017

2

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Injured structures

•Anterior dislocation

–Failure of anterior inferior glenohumeral ligaments

–+/- axillary nerve injury

https://posna.org/Physician-Education/Study-Guide/Shoulder-Dislocation-Instability.

Accessed January 29, 2017.

www.prismsports.org

Traumatic Instability

•T –Traumatic

•U –Unidirectional

•B –Bankart Lesion

•S –Surgical

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Multidirectional Instability

•A –Atraumatic

•M –Multidirectional

•B –Bilateral

•R - Rehab, rehab, rehab

•I –Inferior Capsular

Shift

2/7/2017

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Shoulder dislocation:

History

•Trauma vs atraumatic

•Past history of dislocation or subluxation

•Age at time of first dislocation

www.prismsports.org

Anterior shoulder

dislocation: Acute exam

•Athlete will use other arm

to hold affected arm

•Flat appearance of deltoid

•Humeral head palpable

anteriorly, below coracoid

•Neurovascular status

–Axillary nerve in particular

•Sensation lateral shoulder

•Contraction deltoid muscle

www.prismsports.org

Anterior shoulder

dislocation: Full exam

•Inspection

•Palpation

•Range of Motion

•Neurovascular

2/7/2017

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Anterior shoulder

dislocation: Special tests

•Load and shift

–Patient supine

–Shoulder abducted 45

degrees in plane of

scapula, 30 degrees of

flexion, neutral rotation

–Axial force with examining

hand centering humeral

head in glenoid fossa

–Other hand applies

anterior force to check

translation

www.prismsports.org

Anterior shoulder

dislocation: Special tests

•Apprehension test

–Patient is supine

–Affected arm in abduction,

extension and external

rotation

–Apply gentle anterior

translation on proximal

humerus apprehension

•Relocation test

–Apply posteriorly directed

force instability is

relieved

www.prismsports.org Instability: Sulcus Sign

•Inferior instability

•Arm relaxed in

neutral position

•Arm pulled

downward at elbow

•Positive test is a

visible sulcus at

infra-acromial area

–Compare to

contralateral side

2/7/2017

5

www.prismsports.org

Anterior shoulder

dislocation, recurrent

•Beighton score for joint hypermobility

–Passively dorsiflex 5th MCP joint by at least 90°

–Oppose thumb to the volar aspect of the ipsilateral

forearm

–Hyperextend elbow by at least 10°

–Hyperextend kne by at least 10°

–Place hands flat on floor without bending knees

•1 point for each maneauver (R and L side)

•4 or more points generalized joint

hypermobility

www.prismsports.org

Thank you!

1

1

Imaging of Glenohumeral Instability in

the Adolescent Patient

Dele Kammen MD

bkammen@mail.cho.org

Department of Diagnostic Imaging

2/7/17

2

Disclosure

Advisory Board on Hypophosphatasia

Alexion Pharmaceuticals, Inc.

3

Goals

Imaging acute traumatic shoulder dislocation

Imaging chronic instability with repeated dislocation

Diagnostic Imaging

Characterize extent of structural damage

Show osseous and soft tissue abnormalities

Guide surgical planning

Choice of stabilization procedure

2

4

Imaging Modalities

Radiographs

MRI

MR arthrography

•Direct

•Indirect

CT

5

Radiographs

Obtained following acute dislocation

Routine series

•AP internal and external rotation

•Scapular Y view

•Axillary view

Post-reduction films

•Evaluate for fractures

•Residual malalignment

6

Radiographs

Hills-Sachs Bankart

External Rotation Internal Rotation Y-view External Rotation Y-view

Patient 1 Patient 2

3

7

MRI

Acute setting

•Joint effusion or hemarthrosis

•MR arthrogram not necessary

•Mechanism evident by edema pattern

s

Conventional MRI

Axial T2 FS

8

Standard MRI Technique

3T

Axial

T2 FS

PD

Sagittal

T2 FS

T2

Coronal

T2 FS

T1

TE/TR

T2 60/3000

PD 30/3000

T1 15/600

9

Axial T2 FS Axial PD

14 year old football player with 5 repeated traumatic dislocations

4

10

Sagittal T2 FS Sagittal T2

14 year old football player with 5 repeated traumatic dislocations

11

Coronal T2 FS Coronal PD

Osseous Bankart

SLAP tear

Rotator cuff tendinosis

14 year old football player with 5 repeated traumatic dislocations

12

Glenohumeral Joint Anatomy

Like a golf ball on a tee

The greatest range of motion of any joint

Vulnerable to instability

Dynamic and static stabilizers

5

13

Stabilizers of the Glenohumeral Joint

Infraspinatus

MGHL

Supraspinatus

Subscapularis

Teres minor

Biceps tendon

SGHL

IGHL

Glenoid and

Labrum

14

Inferior labroligamentous Injuries

•Tear

•Sprain

•Floating

AIGHL

•HAGL

•BHAGL

•Bankart

•Perthes

•ALPSA

•GLAD Glenoid

Failure

75%

Humeral

Failure

15%

Capsular

Failure

Humeral

and

Glenoid

Failure

15

Patient with prior anterior shoulder dislocation

Courtesy of Dr. Diego Jaramillo, Miami Children’s Hospital

MR Arthrogram T1 FS

Humeral Avulsion Glenohumeral Ligament HAGL

6

16

Capsulo-Labral Lesions

Lesion Normal Soft Tissue

Bankart Osseous Bankart Perthes

A

nterior

L

abroligamentous

P

eriosteal

S

leeve

A

vulsion

ALPSA

G

leno-

L

abral

A

rticular

D

isruption

GLAD

Periosteum Normal Stripped and

Torn Torn Stripped Stripped Mildly Stripped

Labrum Normal Displaced Displaced Nondisplaced Medially

Displaced Nondisplaced

17

•Axial T2 FS •Axial T2

17 year old female with 5 episodes of anterior shoulder dislocation

18

•Axial T2 FS •Axial T2

Anterior Labroligamentous Periosteal Sleeve Avulsion ALPSA

17 year old female with 5 episodes of anterior shoulder dislocation

7

19

17 year old football player s/p several traumatic dislocations

Axial T2 FS

20

Axial T2 FS

21

Axial T2 FS

GlenoLabral Articular Disruption GLAD

8

22

MR Arthrogram

Direct Indirect

Arthrogram with dilute gadolinium solution IV injection of gadolinium

Joint Distension Does not distend joint

ABduction External Rotation (ABER)

Provocative positioning maneuvers

23

Abduction External Rotation (ABER)

Place anterior band of

IGHL under tension

Labral tear at

attachment site of IGHL

Outlines undersurface of

Infraspinatus tendon

24

Pre-operative Planning

MDCT or MRI with volume rendering

•Quantify Glenoid deficiency

•Measure Hills-Sachs

9

25

Axial T2 FS Sagittal T2 FS Coronal T2 FS

16 year old girl with shoulder instability and multiple dislocations

26

The American Journal of Sports Medicine, Vol. 39, No. 11, 2011 DOI: 10.1177/0363546511398644

Engaging Hills-Sachs vs nonengaging

•More horizontally oriented to shaft

26˚vs 14˚

•Engaging lesions -larger width

and depth

27

No gold standard for quantification of Hill-Sachs defects

Classifications based on size, depth, location

No correlation between various classifications

No treatment algorithm based on classifications

10

28

16 year old who experienced his first shoulder dislocation 1 year

prior while playing football and has had multiple dislocations since.

Courtesy of Dr. Mimi Lin, Washington Radiologist Medical Group

29

Critical Area for Glenoid Deficiency is 25%

Defect greater than 25% glenoid width would

need bone grafting (Burkhart, De Beer)

Burkhart SS, Debeer JF, Tehrany AM, et al (2002) Quantifying glenoid bone loss arthroscopically in shoulder instability.

Arthroscopy 18:488-491.

Normal

Glenoid Significant

Bone Loss

30

Contact area of humerus on glenoid = glenoid track for critical ROM

Width of track is 84% glenoid width

Bankart lesions decreases width of tract

If medial margin of Hills-Sachs defect is more medial than glenoid

tract, standard stabilization are unlikely to stabilize the shoulder

11

31

Good agreement between 4 observers about % glenoid bone loss

Poor agreement assessing Hills-Sachs defect

Poor reliability of the glenoid track classification

Method

•71 patients with anterior

inferior shoulder instability

•4 Reviewers

Goal

Assess reproducibility of

characterizing bipolar bone

loss and treatment

32

Summary

In the acute setting radiographs

MRI and MR arthrography

•Osseous and soft tissue abnormalities

CT and MRI with 3D reformations

•Characterize and measure glenoid deficiency

and Hill-Sachs lesions for preoperative

planning

33

THANK YOU!!!

Imaging of Glenohumeral Instability in

the Adolescent Patient

2/7/2017

1

www.prismsports.org

Traumatic Anterior Shoulder Instability:

Rehabilitation Through Return to Play

Michelle Cappello, PT, MSPT, SCS

USCF Benioff Children’s Hospitals

Sports Medicine Center for Young Athletes

February 7th, 2017

www.prismsports.org Objectives

•Review conservative management for primary

TASI

•Review evidence based return to sport criteria

for traumatic anterior shoulder instability (TASI)

www.prismsports.org

Traumatic Anterior Shoulder

Instability (TASI)

•Treatment of first time traumatic GH dislocators will be

different from that of a patient with atraumatic

instability. Micro vs. Macro

•A gradual graded advancement of ROM and exercise

progression will be required, based on the degree of the

acute injury

•Goals remain the same; dynamically stabilize the

inherently unstable glenohumeral joint.

•Master the “Thrower’s Paradox”; Shoulder loose enough

to throw yet stable enough to prevent injury (Wilk AJSM

2002)

2/7/2017

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www.prismsports.org

Rehabilitation Overview

•Reduce acute pain & inflammation

•Restore motion and soft tissue mobility

•Emphasize strength balance

•Enhance dynamic humeral head control

•Integrate kinetic chain

•Return to Sports Specific Activity/PLF

www.prismsports.org

TASI Goals of Rehab

OUTCOME MEASURES

•Patient Reported

•Shoulder ROM

•Movement Segment Strength

•Functional Testing: Ybalance, SL squat,

CKCUET, OH Squat, Seated shot put

•Sports Specific training to competition

www.prismsports.org

Rehabilitation Timeline

8 weeks +4 weeks

Injury 2 weeks

Sling

Brace PT Day 3-4

Initiate Return

to Sport Testing

Acute

Phase Intermediate Phase Advanced Strengthening

Phase

Return to

Play

DX Specific Pain Management >> Functional Progression Athlete

Specific

2/7/2017

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www.prismsports.org

Acute Phase

Goals: Protect the injured, healing capsular & labral

structures

1. Abstain from Sport 2+ weeks (control stresses)

–Sling for comfort, no evidence on duration,

inconclusive ER vs. IR of shoulder position

2. Diminish pain & inflammation

3. Reestablish pain –free ROM, Do not push range

4. Delay muscle atrophy & reestablish voluntary

muscle activity

www.prismsports.org

Intermediate Phase

Goals:

1. Improve strength

1. Rotator cuff anterior and posterior

2. Scapular “stabilizers” – incl. serratus anterior

3. Core for energy transfer

2. Normalization of shoulder girdle motion and

arthorkinematics, manual therapy for tissue mobility

3. Enhancing dynamic stabilization of cuff and scapular

muscles & neuromuscular control with upper extremity

activities

–BALANCE net force ant/post/distraction of humoral head

–3-4% decrease in RTC strength results in loss of dynamic

stability (Reinhold, Sports Health 2010)

www.prismsports.org

The Adolescent Shoulder:

Linking development into the plan

of care

CORE:

•Group of muscles that form a cylinder around your waist

TA,RA, IO, EO

Paraspinals

Diaphragm

Pelvic Floor

Hip Muscles

Thoracolumbar Fascia

•Optimum production, transfer, and control of force delivered to the

terminal segment

•Core provides 65% force production, 85% force attenuation

•Glut Max 100% MVIC stride to late cocking phase, Glut Med 40%

•Poor Single leg squat associated with posterior chain weakness

which is underdeveloped in pre/adolescents (Wilk PMR 2016)

Oliver JSCR 2010 &

2015

2/7/2017

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www.prismsports.org

The Adolescent Shoulder:

Linking Core into the plan of care

www.prismsports.org

The Adolescent Shoulder: Linking UE & LE

www.prismsports.org

The Adolescent Shoulder: Exercises Examples

Linking UE & LE

2/7/2017

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www.prismsports.org

Advanced Strengthening

Phase

Goal: improve strength, power, endurance,

MOTOR CONTROL, enhance dynamic stabilizers

of the GH joint and Scapula.

www.prismsports.org

Stabilization

•Rapid torque control

progressing into 90/90

shoulder position

•Closed Kinetic chain for

proprioception training

www.prismsports.org

Return to Play Phase

Goal: Athletes need to be resilient, strong,

technically proficient to robustly maintain proper

motor skill competence within the demands of their

sport

OUTCOME MEASURES

•Patient Reported

•Shoulder ROM

•Movement Segment Strength

•Functional Testing

2/7/2017

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www.prismsports.org

Criteria for Return to Play

1. Patient Reported Outcome Measures

•Quick Dash

•developed by Amer. Society of Ortho

Surgeons

•11 questions, 4 additional with

sports activity module

•goal is < 5 Best possible score = 0

•Kerlan -Jobe Orthopedic Shoulder

and Elbow Score Alberta AJSM 2010

•KJOC > 90% (best possible =

100%)

www.prismsports.org Criteria for Return to Play

2. ROM Shoulder & Posture & Stability Testing

•Demonstrate pain free range of motion with Active shoulder total arc of motion

within 5 degrees of non-throwing side Wilk AJSM 2002. Manske & Ellenbecker IJSM 2005

•Passive shoulder flexion within 5 degrees of non-throwing side Wilk AJSM 2014

•Scapular anterior tilt symmetry within 10 degrees of non-dominant side to

decrease scapular dyskinesia. Kibler et al. JShouderElbow Surg 2002

•Active internal rotation deficit no greater than 20 degrees of non-throwing side

Meister , Keith, et al. AJSM 2005

•Thoracic Kyphosis –no real studies on posture, adult norms = 40°kyphosis

•Demonstrate negative results for shoulder stability with no pain for the

Glenohumeral anterior and posterior drawer with arm elevated to 90 degrees in

scapular plane Sportsfisio 2015 Kevin Wilk, “Return to Play Criteria for the Overhead Athlete.”

www.prismsports.org Criteria for Return to Play

3. Strength

•Dominant side 10% stronger

•Scapular dynamic stabilizers –Endurance test

•Gluteals included

•Isokinetic Strength Testing (to be performed before and after functional testing. Ratio

demands remain the same for both pre and post fatigue) Ratios for isokinetic strength

testing from Wilk et al: AJSM ’93, ‘95

•External Rotation/Internal Rotation ratio 70-76%

•External Rotation/Body Weight ratio 18-23%

•Internal Rotation/Body Weight ratio 26-32%

•Isometric scapular strength for mid trap and lower trapezius within 10% of non-

throwing / dominant side

•Gluteals: Limited studies out there talking about expected/normative strength for hip

musculature. In our practice, we set a goal of 1/3rd the body weight with HHD

2/7/2017

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www.prismsports.org Criteria for Return to Play

4. Functional Testing

These are the ones we use regularly.

•CKCUEST – Place tape 36” apart with arms in push up position

(hands/toes). Tap across each tape alternately many times as they can in

15 sec. Repeat 3 trials and take average them. >23 touches in 15 seconds

BMC musculoskeletal disorders 2014:

•LE Y balance: Composite score > 92% (Baseball Players Diagnosed With Ulnar

Collateral Ligament Tears Demonstrate Decreased Balance Compared to Healthy

Controls, J. Craig Garrison et al, JOSPT, Oct 2013)

www.prismsports.org Criteria for Return to Play

4. Functional Testing (cont.)

•Perform maximum effort 2 handed chest passes with 8 lb. medicine ball 2

x 20 Sportsfisio 2015 Kevin Wilk

•Perform maximum effort 1 handed “shot-put” throw with 4 lb. medicine

ball 2 x 20 (just need to complete without pain/instability)

•Prone Y endurance test for scapular stabilizers

•Tests fatigue in middle and lower traps.

•Testing performed with 3% of body weight. Metronome set to 60Hz.

•Task failure was defined as: 1. Unable to keep up with metronome, 2.

Demonstration of compensatory strategies, 3. Inability to go above

horizontal each time.

•Only norms available on Football players (26-28 repetitions).

•For OH athlete I would aim for 10% better on dominant side

Pontillo, Marisa, Bryan A. Spinelli, and Brian J. Sennett. "Prediction of in-season shoulder injury from

preseason testing in division I collegiate football players." Sports Health: A Multidisciplinary

Approach (2014): 1941738114523239

www.prismsports.org Criteria for Return to Play

5. Return to Sports

•Begin a specified return to throwing program for

throwing athletes

•Work with a sports specific skills coach

•Build intensity and volume, as well as impact

•Single sports specific task, then add complexities

and reactive drills

•Start with non-contact practice

•Full practice for 2 full weeks

•Competition

2/7/2017

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www.prismsports.org Summary

1. Return to sports after a shoulder dislocation involves many factors

2. There are ideal criteria that give some guidelines for when to return the athlete to

play, this will be athlete specific, more research need for proven battery of

outcome measures.

3. Timelines for return to play will be athlete specific, and only should occur after

attainment of full strength, motion, stability, and confidence.

4. Fatigue is above all the biggest injury risk, train for dynamic stability / postural

endurance then power/speed

5. Core/Legs provide >65% of power/torque to the UE – “Train the Chain”

2/3/2017

1

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Operative Management of

Adolescent Shoulder Instability:

Keys for Success

Dr. Nirav K. Pandya

Assistant Professor of Orthopaedic Surgery

Director of Pediatric Sports Medicine

University of California San Francisco

Nirav.Pandya@ucsf.edu

www.prismsports.org

Disclosures

Consultant - Orthopediatrics

www.prismsports.org

Common Scenario

“So I heard you are the person

who is going to make my

shoulder normal again?”

“Can I go back and play 6

weeks after surgery?”

“I will never dislocate out again

right?”

“Are you going to do the

surgery with a laser?”

2/3/2017

2

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Common Scenario

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Key Point

Studies cite up to a 30% re-dislocation rate

with arthroscopic treatment in this age group

PREPARE PATIENTS EARLY

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Key H and P

•Sport: collision vs. non-collision

•Sport: throwing / swimming

•Hand dominance

•Number of prior dislocations

•Force needed to dislocate and re-locate

•In-season vs. out-of-season

•Ligamentous laxity

•Expectations

2/3/2017

3

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Key H and P

Remember to differentiate atraumatic instability

from traumatic instability

www.prismsports.org What Can I Do?

Open

vs.

Arthroscopic

www.prismsports.org How Do I Decide?

It’s not just

about

throwing some

anchors in and

fixing the

labrum!

2/3/2017

4

www.prismsports.org How Do I Decide?

•I am searching for evidence that I need to

do more than just an arthroscopic labral

repair

•History = collision sports, number of

dislocations, compliance?

•Imaging!!!

www.prismsports.org What’s In My Tool Box?

•Arthroscopic labral repair

•Arthroscopic remplissage

•Open labral repair

•Open Latarjet

www.prismsports.org Pearl #1

Collision athlete /

extreme athlete =

consider open

repair

2/3/2017

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www.prismsports.org Pearl #2

On –Track

vs.

Off –Track

www.prismsports.org

Pearl #2

Engaging Hill

Sach’s

= >

Remplissage

www.prismsports.org Pearl #3

Glenoid Bone

Loss > 25%

=

Open Latarjet

2/3/2017

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www.prismsports.org What’s In My Tool Box?

•Arthroscopic labral repair

•Arthroscopic remplissage

•Engaging / off-track Hill-Sach’s

•Open labral repair

•Collision / extreme athlete

•Open Latarjet

•> 25% bone loss

www.prismsports.org Labral Repair Keys

•Beach chair vs. lateral

•Mobilize labrum!

• Knotless vs. standard (dealer’s choice)

•Get down low (5:30 – 6:00 o’clock)

•Grab capsule AND labrum AND advance tissue

• Don’t be an anchor animal (space out)

www.prismsports.org Remplissage Keys

•Engaging /

Off-Track

•Prepare bed

•Pass sutures

before

performing

anterior

stabilization

2/3/2017

7

www.prismsports.org Post-Op

•Not worried about stiffness

•Worried about compliance!!

www.prismsports.org What’s The Data??

•17 studies comprising 654 total shoulder instability events

•Patients grouped non-operative vs operative treatment

•Primary non-operative group was more likely to have recurrence compared to

the primary operative group (OR=13.41; 99% CI 3.60 to 49.93, p<0.001)

•The rate of recurrence in patients aged <14 years was high (44.44%)

•For RTP, there is evidence that RTP rates were higher for primary operative

patients (95.3%) versus primary non-operative (41.3%, Z=6.12, p<0.001) and

secondary operative patients (77.6%, Z=2.66, p=0.008).

www.prismsports.org What’s The Data??

•21% re-dislocation rate

•18.75% re-dislocation rate

2/3/2017

8

www.prismsports.org What’s The Data??

•25% re-dislocation rate

www.prismsports.org What’s The Data??

•6 studies, 167 patients

•5.4 % re-dislocation rate

•Low complication rate

•No significant loss of shoulder motion

www.prismsports.org Key Summary

•High repeat dislocation rate in this population

•Assess activity level and expectations

•Know your tools: arthroscopic, open, remplissage, Latarjet

•Engaging / off-track = remplissage; glenoid loss > 25% =

Latarjet

•Start low, shift capsule-labrum arthroscopically

•Be prepared to do a remplissage if necessary

•Post-op = compliance, compliance, compliance

2/3/2017

9

www.prismsports.org Thank You

2/7/2017

1

www.prismsports.org

Postoperative Management and

Return to Play for Adolescent

Shoulder Instability

Brett Burton, PT, DPT, SCS, ATC, CSCS

St. Luke’s Sports Medicine

burtonbr@slhs.org

February 7, 2017

www.prismsports.org

Disclosure

•There are no relevant financial relationships to disclose.

www.prismsports.org

Postoperative Management

•Guiding Principles1

–Communication with surgeon is imperative

–Understand the surgery

•Know all structures involved

–Understand structures to be protected, how they are

stressed, and healing rates

–Impart appropriate levels of stress to the tissue

•Absolute ROM, controlled submaximal loading, and dynamic stability

–Management of initial immobilization and understanding

rate of ROM progression

stressprotection

2/7/2017

2

www.prismsports.org

Postoperative Management

•Rehabilitation Overview - approximate timelines2

–Weeks 0-6: Immobilization in sling

–Weeks 2-4: PROM at graded intervals; isometric exercise

•Screen trunk and lower extremity (mobility, stability, and strength)

and address limitations3

–Weeks 4-8: Basic strengthening exercise

–Weeks 5-6: Begin AROM

–Weeks 8-12: Advanced

strengthening and plyometrics

–Week 16: Return to play

testing performed

–Week 24: Contact and

overhead sports begin

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Return to Play

–Pain free movement

–Range of motion established

•Minimize glenohumeral internal

rotational deficit (GIRD) and total

range of motion (TROM) deficits4,5

•Consider specific surgery

•Loss of motion does increase risk of

shoulder or elbow injury6,7

–Strong and pain free manual

muscle testing

•Test throwers in 90/90 position

•Weakness of supraspinatus is also

related to increased risk of injury8,9

Foundational

Criteria

Advanced

Criteria

Advanced

Criteria Under

Fatigue

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Return to Play

Trunk Stability Push Up10 Single Arm Seated Shot-Put11

•Assesses trunk stability in sagittal

plane while performing bilateral,

closed chained, upper extremity

movement

•Desired score: 2/3

•Utilizes a 6 lb. medicine ball to

assess unilateral, open chained,

upper extremity power

movement

•Desired score:

< 10% difference

between extremities

Foundational

Criteria

Advanced

Criteria

Advanced

Criteria Under

Fatigue

2/7/2017

3

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Return to Play

Closed Kinetic Chain Upper

Extremity Stability Test

(CKCUEST)12,13

Upper Quarter Y-Balance

Test (UQ-YBT)12

•Assesses power, speed, and

stability while performing

bilateral, closed chained, upper

extremity movement

•Desired score: minimum of 21

touches, see sport specific norms

•Assesses unilateral stability,

proprioception, and mobility of

thoracic spine, scapula, and upper

extremity

•Desired score: Composite score of

> 80% and < 4 cm reach

difference between extremities

Foundational

Criteria

Advanced

Criteria

Advanced

Criteria Under

Fatigue

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Return to Play

•Why re-test while fatigued?

–It’s a better simulation of upper extremity performance

during sport

–Fatigue impacts joint position and sensorimotor system14,15

–Fatigue should show symmetrical decrease in performance

–Asymmetrical decrease may indicate greater compensation

and increased injury risk during play

Foundational

Criteria

Advanced

Criteria

Advanced

Criteria Under

Fatigue

mobility

stability

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References

1. Gaunt BW, Shaffer MA, Sauers EL, Michener LA, McCluskey III, GM, Thigpen CA. The American Society of

Shoulder and Elbow Thearpists’ Consensus Rehabilitation Guideline for Arthroscopic Anterior Capsulolabral

Repair of the Shoulder. J Orthop Sports Phys Ther. 2010; 40: 155-168.

2. Milewski MD, Nissen CW. Pediatric and Adolescent Shoulder Instability. Clin Sports Med. 2013; 32: 761-779.

3. Laudner L, Wong R, Onuki T, Lynall R, Meister K. The relationship between clinically measured hip rotational

motion and shoulder biomechanics during the pitching motion. J Sci Med Sport. 2015; 18: 581-584.

4. Shanley E, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion

measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J

Sports Med. 2011; 39: 2997-2006.

5. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational

motion to shoulder injuries in professional baseball players. Am J Sports Med. 2013; 39(2):329-335.

6. Wilk KE, Lacrina LC, Fleisig GS, et al. Deficits in glenohumeral range of motion increase risk of elbow injury in

professional baseball pitchers: A prospective study. Am J Sports Med. 2014; 20: 1-7.

7. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of

shoulder injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2015; 43: 2379-2385.

8. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Noonan TJ. Preseason shoulder strength

measurements in professional baseball pitchers: Identifying players at risk for injury. Am J Sports Med. 2010;

38: 1375-1382.

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www.prismsports.org

References

9. Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ, McHugh MP. Risk factors for shoulder and elbow injuries in

high school baseball pitchers: The role of preseason strength and range of motion. Am J Sports Med. 2014;

42: 1993-1999.

10. Cook G, Burton L, Hoogenboom BJ, Voight M. Functional Movement Screening: The Use of Fundamental

Movements as an Assessment of Function –Part 2. Int J Sports Phys Therapy. 2014; 9: 549-563.

11. Negrete RJ, Hanney WJ, Kolber MJ, et al. Reliability, Minimal Detectable Change, and Normative Values for

Test of Upper Extremity Function and Power. J Strength and Cond Res. 2010; 24: 3318-3325.

12. Taylor JB, Wright AA, Smoliga JM, DePew T, Hegedus EJ. Upper extremity physical performance tests in

collegiate athletes. J Sport Rehabil. 2016; 25: 146-154.

13. Pontillo M, Spinelli BA, Sennett BJ. Prediction of In-Season Shoulder Injury From Preseason Testing in Division

I Collegiate Football Players. Sports Health. 2014; 6: 497-503.

14. Tripp BL, Yochem EM, Uhl TL. Functional Fatigue and Upper Extremity Sensorimotor System Acuity in

Baseball Athletes. J Athl Train. 2007; 42: 90-98.

15. Grantham WJ, Byram IR, Meadows MC, Ahmad CS. The Impact of Fatigue on the Kinematics of Collegiate

Baseball Pitchers. Orthop J of Sports Med. 2014; 2: 1-10.