Treating the Thrower's Shoulder
Treating the Thrower's Shoulder
Throwing athletes with a shoulder injury usually present with complaints of pain, particularly in the late cocking or early acceleration and deceleration phases of the throwing motion. These athletes may complain of a "dead arm" feeling, which is classified as being slow, stiff, and unable to throw the ball with the same velocity and accuracy. In addition, they may complain of an associated clicking or subluxation event during throwing. Night pain, weakness, and instability are nonspecific and may be caused by a variety of things including rotator cuff tears, labral tears, impingement, biceps tendinopathy, and the like.
It is helpful to ascertain if the athlete had an acute injury or the gradual development of pain and worsening performance. If possible, the phase of pitching that is most painful to the athlete should be gathered. The athlete should also be questioned regarding changes in throwing mechanics, increased pitching or training, or injury in other aspects of the kinetic chain, including the legs and trunk because these may be contributing to fatigue, overuse, or altered biomechanics during throwing. Finally, the clinician should also evaluate whether the patient has had any previous injuries or treatments, including surgery.
The physical examination is very important in the diagnosis of shoulder pain in a throwing athlete, and the entire kinetic chain should be evaluated for abnormalities. A careful inspection of the shoulder girdle should be performed and compared to the opposite side. Inspection may reveal scapular asymmetry or muscle atrophy. With palpation, the athlete may have shoulder pain, which can be localized or generalized in nature. Range of motion is then assessed and compared to the contralateral side to evaluate and abnormalities, including GIRD. Strength testing is performed to evaluate the rotator cuff and scapular stabilizers, as weakness or imbalance may lead to pain or decreased performance. Finally, special testing is utilized to evaluate for internal impingement, rotator cuff pain, biceps-labral complex injuries, instability, or subacromial impingement.
Many special tests have been developed to detect for specific injuries about the shoulder; however, sensitivity and specificity of these tests are variable. Therefore, the clinician must carefully evaluate testing and associate all findings in relation to the clinical history. Mostly unique to the throwing or overhead athlete, internal impingement must be assessed with the internal impingement sign (Figure 2). There are numerous tests evaluating biceps-labral complex injuries, including the active compression test (O'Brien), crank test (Andrews), biceps load test, resisted supination external rotation test (Andrews), and anterior slide test (Kibler); however, the specificity and sensitivity of these tests are extremely variable. Rotator cuff tests in the throwing athlete include manual muscle testing of the supraspinatus, infraspinatus, and subscapularis muscles. Most rotator cuff injuries in a thrower will be partial tears; however, concern for a more severe rotator cuff injury can be evaluated with the drop arm test (Jobe) for the supraspinatus, hornblower's test for the infraspinatus and teres minor, and the belly press and lift-off tests for the subscapularis. External subacromial impingement is assessed using the Hawkins and Neer impingement tests. Finally, instability testing is performed, and the clinician must pay special attention to signs of generalized laxity and multidirectional instability in these athletes because these findings are important to consider in any treatment plan. Instability testing includes load and shift testing for anterior and posterior instability, apprehension and relocation tests for anterior instability, jerk test and Kim test for posterior instability, and the sulcus sign and Gagey test for multidirectional laxity or instability.
(Enlarge Image)
Figure 2.
Internal impingement sign. (Copyright Daryl C. Osbahr, MD).
Shoulder radiographs should be obtained to rule out bony abnormalities. Specific to throwing athletes, the clinician should evaluate images for sclerosis and/or cyst formation in the greater tuberosity, a Bennett lesion, and glenoid osteochondral lesions. If the throwing athlete is skeletally immature, the proximal humeral epiphysis should additionally be evaluated for epiphysiolysis. MRI with or without arthrogram is helpful in evaluating the soft tissues and is the gold standard of diagnosis for most shoulder pathology. However, one must consider the implications of obtaining an MRI carefully, especially if operative treatment is not feasible for the athlete at this time. Due to the high sensitivity of MRI, a considerable number of athletes will have pathology on MRI, including rotator cuff tears and SLAP tears (Figure 3), although the clinical significance is not always correlated to these findings. In addition to normal MRI sequences, the clinician should consider obtaining the abduction external rotation (ABER) view in all throwing athletes to evaluate for signs of internal impingement, including PASTA and PAINT partial-thickness rotator cuff injuries (Figure 4).
(Enlarge Image)
Figure 3.
MRI showing superior labrum anterior posterior (SLAP) tear. (Copyright Daryl C. Osbahr, MD).
(Enlarge Image)
Figure 4.
MRI in abduction external rotation showing partial articular intratendinous type (PAINT) rotator cuff tear. (Copyright Daryl C. Osbahr, MD).
Clinical Evaluation of the Thrower's Shoulder
Clinical History
Throwing athletes with a shoulder injury usually present with complaints of pain, particularly in the late cocking or early acceleration and deceleration phases of the throwing motion. These athletes may complain of a "dead arm" feeling, which is classified as being slow, stiff, and unable to throw the ball with the same velocity and accuracy. In addition, they may complain of an associated clicking or subluxation event during throwing. Night pain, weakness, and instability are nonspecific and may be caused by a variety of things including rotator cuff tears, labral tears, impingement, biceps tendinopathy, and the like.
It is helpful to ascertain if the athlete had an acute injury or the gradual development of pain and worsening performance. If possible, the phase of pitching that is most painful to the athlete should be gathered. The athlete should also be questioned regarding changes in throwing mechanics, increased pitching or training, or injury in other aspects of the kinetic chain, including the legs and trunk because these may be contributing to fatigue, overuse, or altered biomechanics during throwing. Finally, the clinician should also evaluate whether the patient has had any previous injuries or treatments, including surgery.
Physical Examination
The physical examination is very important in the diagnosis of shoulder pain in a throwing athlete, and the entire kinetic chain should be evaluated for abnormalities. A careful inspection of the shoulder girdle should be performed and compared to the opposite side. Inspection may reveal scapular asymmetry or muscle atrophy. With palpation, the athlete may have shoulder pain, which can be localized or generalized in nature. Range of motion is then assessed and compared to the contralateral side to evaluate and abnormalities, including GIRD. Strength testing is performed to evaluate the rotator cuff and scapular stabilizers, as weakness or imbalance may lead to pain or decreased performance. Finally, special testing is utilized to evaluate for internal impingement, rotator cuff pain, biceps-labral complex injuries, instability, or subacromial impingement.
Many special tests have been developed to detect for specific injuries about the shoulder; however, sensitivity and specificity of these tests are variable. Therefore, the clinician must carefully evaluate testing and associate all findings in relation to the clinical history. Mostly unique to the throwing or overhead athlete, internal impingement must be assessed with the internal impingement sign (Figure 2). There are numerous tests evaluating biceps-labral complex injuries, including the active compression test (O'Brien), crank test (Andrews), biceps load test, resisted supination external rotation test (Andrews), and anterior slide test (Kibler); however, the specificity and sensitivity of these tests are extremely variable. Rotator cuff tests in the throwing athlete include manual muscle testing of the supraspinatus, infraspinatus, and subscapularis muscles. Most rotator cuff injuries in a thrower will be partial tears; however, concern for a more severe rotator cuff injury can be evaluated with the drop arm test (Jobe) for the supraspinatus, hornblower's test for the infraspinatus and teres minor, and the belly press and lift-off tests for the subscapularis. External subacromial impingement is assessed using the Hawkins and Neer impingement tests. Finally, instability testing is performed, and the clinician must pay special attention to signs of generalized laxity and multidirectional instability in these athletes because these findings are important to consider in any treatment plan. Instability testing includes load and shift testing for anterior and posterior instability, apprehension and relocation tests for anterior instability, jerk test and Kim test for posterior instability, and the sulcus sign and Gagey test for multidirectional laxity or instability.
(Enlarge Image)
Figure 2.
Internal impingement sign. (Copyright Daryl C. Osbahr, MD).
Imaging
Shoulder radiographs should be obtained to rule out bony abnormalities. Specific to throwing athletes, the clinician should evaluate images for sclerosis and/or cyst formation in the greater tuberosity, a Bennett lesion, and glenoid osteochondral lesions. If the throwing athlete is skeletally immature, the proximal humeral epiphysis should additionally be evaluated for epiphysiolysis. MRI with or without arthrogram is helpful in evaluating the soft tissues and is the gold standard of diagnosis for most shoulder pathology. However, one must consider the implications of obtaining an MRI carefully, especially if operative treatment is not feasible for the athlete at this time. Due to the high sensitivity of MRI, a considerable number of athletes will have pathology on MRI, including rotator cuff tears and SLAP tears (Figure 3), although the clinical significance is not always correlated to these findings. In addition to normal MRI sequences, the clinician should consider obtaining the abduction external rotation (ABER) view in all throwing athletes to evaluate for signs of internal impingement, including PASTA and PAINT partial-thickness rotator cuff injuries (Figure 4).
(Enlarge Image)
Figure 3.
MRI showing superior labrum anterior posterior (SLAP) tear. (Copyright Daryl C. Osbahr, MD).
(Enlarge Image)
Figure 4.
MRI in abduction external rotation showing partial articular intratendinous type (PAINT) rotator cuff tear. (Copyright Daryl C. Osbahr, MD).
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