Rotator cuff injuries in adolescent athletes

Postoperative Rehabilitation Following Subscapularis Repair and Biceps Tenodesis in an Adolescent Overhead Athlete: A Resident's Case Report

Background

The incidence of rotator cuff pathology in adolescent athletes is incredibly rare, consisting of only 1% of upper extremity injuries in those under the age of 20. Most rotator cuff injuries in this population are of the supraspinatus with few being of the subscapularis. The subscapularis aids with internal rotation and stabilization of the glenohumeral joint. Surgical management of these injuries in an adolescent athlete presents unique challenges due to periods of rapid growth in adolescence. Additional challenges exist in guiding post-operative physical therapy due to limited information on this injury. The purpose of this case report is to describe the surgical management and postoperative physical therapy of an adolescent, overhead athlete with a full thickness subscapularis tendon tear with concomitant long head of biceps tendon tear.

Case Description

A 13-year-old, male overhead athlete with a complete subscapularis tendon tear and partial-thickness tendon tear of the long head of the biceps was treated surgically with open subscapularis tendon repair and bicep tenodesis. The subject completed 22 physical therapy sessions over 30 weeks including completion of a return-to-throwing program.

Outcomes

By the end of the course of treatment, the subject was able to return to sport and displayed clinically meaningful improvements in in range of motion and strength as well as patient reported outcome measures including the Pennsylvania Shoulder Score (PSS) and the QuickDASH.

Discussion

This case report emphasizes the uniqueness of an injury to the subscapularis tendon and long head of the biceps tendon tear in an adolescent overhead athlete along with the rarity of surgical intervention in this population. This case further outlines the success of surgical management following the use of a multi-phased rehabilitation program, allowing the athlete to safely return to sport.

Level of Evidence

Level 5.

Traumatic avulsion of the subscapularis tendon in adolescents: Return to sport after surgical repair

INTRODUCTION

Traumatic complete rotator cuff tears are rare in the pediatric population. These injuries might be a result of shoulder dislocation or direct trauma experienced during contact sports (i.e., rugby, judo). The purpose of this study was to identify the epidemiologic and clinical characteristics of these injuries and assess the medium- and long-term outcomes following surgery, with return to sport as the primary endpoint.

MATERIALS AND METHODS

An electronic questionnaire was sent to all surgeons who were members of the French Shoulder and Elbow Society (SOFEC) and/or the French Society of Arthroscopy (SFA), asking if they ever had to surgically treat a traumatic complete tear of 1 or more rotator cuff tendons in a child or adolescent. Ninety (38.6%) of the 233 surgeons members of the SOFEC and/or the SFA responded to our questionnaire. We then contacted the 15 surgeons who answered affirmatively to collect the complete medical records of their patient(s).

RESULTS

We reviewed the records of 17 children and adolescents who underwent surgery for a traumatic complete rotator cuff tear. The mean age at surgery was 15.2 years (range, 12-17). Glenohumeral dislocation during contact sports (n=7/17) was a frequent mechanism of injury (41%). All of these cases involved at least the subscapularis muscle with an avulsed bony insertion. The injury involved other rotator cuff tendons in 29% of cases (5/17). The bone and tendon repair was either performed as open surgery (n=5/17) or arthroscopically (n=12/17). At a median follow-up of 24 months and a mean follow-up of 50 months, 82.4% of patients had returned to sport at their preinjury level. Three patients presented neurologic complications resulting from the traumatic event, but only 1 of them required nerve grafting with a favorable outcome. We also reported 3 cases of nonunion of the lesser tuberosity that required revision surgery with good outcomes. Only 1 patient out of all those with at least 1 episode of dislocation presented a recurrent anterior shoulder instability that required a bone block-type procedure 7 years after the initial surgery.

CONCLUSION

Traumatic complete rotator cuff tears are rare in children and adolescents. They often occur during contact sports. These types of injuries are diagnosed by clinical examination and confirmed by cross-sectional imaging, ideally magnetic resonance imaging. Tendon injuries mainly involve the subscapularis but can also affect other cuff tendons. Return to preinjury activity levels after surgical management was possible in more than 80% of cases.

LEVEL OF EVIDENCE

IV.

Achieving tendon enthesis regeneration across length scales

Surgical reattachment of tendon to bone is a clinical challenge, with unacceptably high retear rates in the early period after repair. A primary reason for these repeated tears is that the multiscale toughening mechanisms found at the healthy tendon enthesis are not regenerated during tendon-to-bone healing. The need for technologies to improve these outcomes is pressing, and the tissue engineering community has responded with many advances that hold promise for eventually regenerating the multiscale tissue interface that transfers loads between the two dissimilar materials, tendon, and bone. This review provides an assessment of the state of these approaches, with the aim of identifying a critical agenda for future progress.

Rotator Cuff Injuries in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Center

BACKGROUND

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making.

HYPOTHESIS

To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts.

RESULTS

A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01).

CONCLUSION

The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients.

CLINICAL RELEVANCE

This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

The Effects of Pre-existing Mood Disorders on Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the effect of pre-existing mood disorders on patient-reported outcomes after arthroscopic rotator cuff repair (ARCR).

METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, Cochrane Library, and Scopus databases. Only studies which grouped as either having a pre-existing mood disorder (namely anxiety and/or depression) or not and evaluated patient-reported outcomes following ARCR procedures were considered for inclusion. Meta-analysis was performed on outcomes using RevMan, with a p-value <0.05 being deemed statistically significant.

RESULTS

Our search found 8 studies including 1,166 shoulders (58.9% males), with an average age of 57.7 ± 3.2 years (21-81) and mean follow-up of 20.8 ± 16.7 months (3-77) which met our inclusion criteria. There were a total of 262 patients (22.5%; mean age 59.9 ± 1.4 years) with pre-existing anxiety and/or depression and 904 patients (77.5%; mean age 59.7 ± 1.7 years) in the control group who underwent ARCR, respectively. Meta-analysis found significantly lower American Shoulder and Elbow Surgeons scores as well as Simple Shoulder Test scores in patients with pre-existing anxiety and/or depression when compared with a control (mean difference [MD] -7.92 [-9.45, -6.40], p < 0.0001, I2 = 0%; MD -1.56 [-2.54, -0.59], p = 0.002, I2 = 80%, respectively) In addition, meta-analysis demonstrated significantly higher Visual Analog Scale scores for pain in patients with pre-existing anxiety and/or depression when compared with a control (MD 0.70 [0.02, 1.38], p = 0.04, I2 = 71%). Furthermore, meta-analysis performed found that ARCR resulted in significant changes in the rates of reported anxiety and/or depression in patients with pre-existing anxiety and/or depression (MD 4.06[-2.47, 6.68], p < 0.0001, I2 = 0%).

CONCLUSION

Our review found that patients with pre-existing mood disorders were significantly more likely to report higher rates of postoperative pain and poorer functional outcomes following ARCR procedures, when compared with controls without mood disorders. Therefore, the presence of pre-existing anxiety and/or depression warrants consideration in the management paradigm for patients with rotator cuff tears. More optimistically, however, ARCR resulted in significant improvements in anxiety and/or depressive symptoms postoperatively.

LEVEL OF EVIDENCE

Level III; systematic review of retrospective comparative studies. See Instructions for Authors for a complete description of levels of evidence.

Rotator Cuff Repair in Pediatric and Adolescent Athletes: Indications and Outcomes

Rotator cuff (RC) tears in pediatric and adolescent athletes are rare events. In these patients, RC tears are more likely to be traumatic or related to overuse among overhead. Repeated movements of abduction and external rotation are frequent mechanisms of injury. The supraspinatus is the most commonly involved tendon and the articular-sided tears are more common than the bursal side. Magnetic resonance imaging is considered the gold standard for diagnosing RC tears. Conservative treatment, arthroscopic, and open repair are all effective treatment methods depending on the type of injury. The risk of growth plate injury in these patients should be always considered when planning surgical interventions. Return to sport for competitive-level throwing athletes represents the greatest challenge in the treatment of these injuries.

Rotator cuff injury in the pediatric population: a systematic review of patient characteristics, treatment, and outcomes

Rotator cuff injuries (RCIs), traditionally thought to be an adult-type pathology, have been reported in the pediatric population, but there remains limited evidence regarding this injury pattern in pediatric patients. The purpose of this study was to systematically review the literature to characterize the epidemiology, injury patterns, treatment modalities, and outcomes for pediatric patients with RCIs. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, reviewing Pubmed, Embase, Cochrane, and CINAHL databases. Studies reporting imaging confirmed RCIs, and treatment outcomes in patients less than 18 years of age were included. Patient demographics, mechanism, injury type, and injury location were recorded. Treatment type and patient outcomes were abstracted when available and summarized with descriptive statistics. Our search identified 28 studies published from 1994 to 2020, which included 215 total tendons injured in 185 patients. Twenty-six studies were classified as level IV evidence, whereas only two were level III. When described, the most injured tendon ( n = 184) was the supraspinatus, whereas the most described injury type ( n = 215) was a partial tear. Surgical intervention was pursued in 75.8% of injuries, with arthroscopy being more common than open repair (79.4% vs. 20.6%). Nonoperative treatment was primarily utilized for partial tears. Among the 24 studies reporting on return to sports, nonoperatively managed patients returned later than those treated operatively (mean: 10.7 vs. 7 months). Only eight studies included patient reported outcome measures (PROMs), and just five had pre- and posttreatment scores. Three complications were noted, all in operative patients. RCIs in pediatric patients have been reported in the literature with increasing frequency over the last decade, but the quality of evidence remains poor with inconsistent injury descriptions and outcome reporting. Excellent results were seen for all injury types and locations with both operative and nonoperative treatments. The literature for pediatric RCIs remains limited in guiding management decisions indicating a need for more high-quality studies to compare outcomes across injury and treatment type. Level of evidence: level III.

Scaffold-based tissue engineering strategies for soft-hard interface regeneration

Repairing injured tendon or ligament attachments to bones (enthesis) remains costly and challenging. Despite superb surgical management, the disorganized enthesis newly formed after surgery accounts for high recurrence rates after operations. Tissue engineering offers efficient alternatives to promote healing and regeneration of the specialized enthesis tissue. Load-transmitting functions thus can be restored with appropriate biomaterials and engineering strategies. Interestingly, recent studies have focused more on microstructure especially the arrangement of fibers since Rossetti successfully demonstrated the variability of fiber underspecific external force. In this review, we provide an important update on the current strategies for scaffold-based tissue engineering of enthesis when natural structure and properties are equally emphasized. We firstly described compositions, structures and features of natural enthesis with their special mechanical properties highlighted. Stimuli for growth, development and healing of enthesis widely used in popular strategies are systematically summarized. We discuss the fabrication of engineering scaffolds from the aspects of biomaterials, techniques and design strategies and comprehensively evaluate the advantages and disadvantages of each strategy. At last, this review pinpoints the remaining challenges and research directions to make breakthroughs in further studies.

Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review

Purpose

To systematically review the literature to determine the injury mechanisms, presentation, and timing of diagnosis for pediatric patients with intratendinous rotator cuff tears and to determine the efficacy of surgical intervention for affected patients.

Methods

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were searched. Studies were included if they involved only pediatric patients, soft-tissue rotator cuff injuries managed surgically, and reported outcomes. Patient characteristics, injury mechanisms, physical examination and imaging findings, time to diagnosis, surgical technique, and treatment outcomes were extracted. Findings were descriptively analyzed with weighted means and proportions.

Results

Twenty-one studies comprising 78 patients were included. The age range was 8 to 17 years and 57 were male. The supraspinatus (n = 56) was the most injured tendon. American football was the most reported sport played at the time of injury. Most patients were diagnosed within 6 months of injury via magnetic resonance imaging. Arthroscopic management was undertaken in 68 patients. Forty-six of 51 patients for whom data were available returned to sports at a range of 2.5 to 12 months postoperatively. Repair failure occurred in three patients.

Conclusions

The extant literature regarding rotator cuff tears in pediatric patients is limited to reports of low methodological quality. Qualitative synthesis of this low-level literature reveals that rotator cuff tears are mostly reported in male collision sport athletes but may also occur in female athletes and/or throwing athletes. These injuries are often successfully managed via arthroscopic repair, and patients and their families can be reassured that the majority of patients return to sports following surgery.

Level of Evidence

Level IV, systematic review of level IV studies.

Toughening mechanisms for the attachment of architectured materials: The mechanics of the tendon enthesis

Architectured materials offer tailored mechanical properties but are limited in engineering applications due to challenges in maintaining toughness across their attachments. The enthesis connects tendon and bone, two vastly different architectured materials, and exhibits toughness across a wide range of loadings. Understanding the mechanisms by which this is achieved could inform the development of engineered attachments. Integrating experiments, simulations, and previously unexplored imaging that enabled simultaneous observation of mineralized and unmineralized tissues, we identified putative mechanisms of enthesis toughening in a mouse model and then manipulated these mechanisms via in vivo control of mineralization and architecture. Imaging uncovered a fibrous architecture within the enthesis that controls trade-offs between strength and toughness. In vivo models of pathology revealed architectural adaptations that optimize these trade-offs through cross-scale mechanisms including nanoscale protein denaturation, milliscale load-sharing, and macroscale energy absorption. Results suggest strategies for optimizing architecture for tough bimaterial attachments in medicine and engineering.

What are the patient-reported outcomes, functional limitations, and complications after lesser tuberosity fractures? a systematic review of 172 patients

BACKGROUND

Lesser tuberosity fractures are relatively rare, with an incidence of 0.46 per 100,000 persons per year. This systematic review was performed to address patient-reported outcomes (PROMs), shoulder function, and complications after lesser tuberosity fractures in pediatric and adult patients, as well as patients with an associated posterior shoulder dislocation. Within these groups, identical outcomes were evaluated for nonoperative, surgical, acute and delayed treatment.

METHOD

A comprehensive search was carried out in multiple databases. Articles were included if patients sustained a lesser tuberosity fracture without a concomitant proximal humerus fracture. There were no restrictions on age, type of treatment, fragment displacement, time to presentation, or associated injuries.

RESULTS

One thousand six hundred forty-four records were screened for eligibility of which 71 studies were included (n = 172). Surgical treatment was provided to 50 of 62 (81%) pediatric patients, 49 of 66 (74%) adults, and 34 of 44 (77%) patients with an associated posterior shoulder dislocation. In the pediatric group, the mean of PROMs was 94 (range 70-100) and among adults 89 (range 85-100). In the posterior shoulder dislocation group, 89% did not regain full range of motion and the complication rate was 17%. In pediatric patients, surgery was associated with fewer complications (P = .021) compared to nonoperative treatment.

CONCLUSION

Pediatric patients have excellent outcomes after lesser tuberosity fractures and respond well to surgical treatment. Adults have acceptable outcomes but patients with an associated posterior shoulder dislocation have impaired range of shoulder movement and are more likely to develop complications.

Excellent Clinical Outcomes and Rates of Return to Play After Arthroscopic Rotator Cuff Repair for Traumatic Tears in Athletes Aged 30 Years or Less

Purpose

To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma.

Methods

We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned.

Results

Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level.

Conclusions

After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure.

Level of Evidence

Level IV, therapeutic case series.

Maturation-dependent findings in the shoulders of pediatric baseball players on magnetic resonance imaging

PURPOSE

To compare the prevalence and characteristics of shoulder osseous and soft tissue findings on magnetic resonance imaging (MRI) with respect to skeletal maturation in symptomatic pediatric baseball players without a history of acute trauma.

METHODS

The IRB-approved, HIPAA-compliant retrospective study analyzed 87 consecutive pediatric baseball players (86 boys and 1 girl; mean age, 15.4 ± 2.1 years) with shoulder MRI performed between March 1, 2012 and September 30, 2017. In consensus, two radiologists assessed the MRI studies for findings involving the humerus, the glenoid, the labrum, the rotator cuff, and the acromioclavicular joint. Exact Cochran-Armitage trend and Mantel-Haenszel Chi-square tests were used to investigate the association between these findings and skeletal maturation.

RESULTS

The mean ages between players who are skeletally immature (37 shoulders), maturing (26 shoulders), and matured (24 shoulders) were significantly different (p < 0.001). Bone marrow edema (p < 0.001) and sclerosis (p < 0.001) within the proximal humeral metaphysis decreased with skeletal maturation. Glenoid remodeling (p = 0.038) was more severe in the skeletally immature players and the prevalence of Bennett lesions (p = 0.048) increased with skeletal maturation. The prevalence of labral tears, rotator cuff tendinosis, and acromioclavicular joint separation did not significantly change with skeletal maturation.

CONCLUSIONS

The change in the prevalence of findings within the proximal humerus and glenoid with skeletal maturation suggest differences in the distribution of stress within the shoulders of pediatric baseball players during development.

Rotator Cuff Repair in Adolescent Athletes

BACKGROUND

Rotator cuff tears are rare injuries in adolescents but cause significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with few data to guide treatment.

HYPOTHESIS

Adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair but would have some difficulty with returning to overhead sports.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

A retrospective search of the practice's billing records identified all patients participating in at least 1 sport who underwent rotator cuff repair between 2006 and 2014 with an age <18 years at the time of surgery and a minimum follow-up of 2 years. Clinical records were evaluated for demographic information, and telephone follow-up was obtained regarding return to play, performance, other surgery and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index.

RESULTS

Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range, 13.2-17.9 years) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event, and 27 of these patients (93%) had no symptoms before the trauma. The most common single tendon injury was to the supraspinatus (21 patients, 66%), of which 2 were complete tendon tears, 1 was a bony avulsion of the tendon, and 18 were high-grade partial tears. Fourteen patients (56%) underwent single-row repair of their rotator cuff tear, and 11 (44%) underwent double-row repair. All subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically. Twenty-seven patients (84%) completed the outcome questionnaires at a mean 6.2 years after surgery (range, 2-10 years). The mean ASES score was 93 (range, 65-100; SD = 9); mean Western Ontario Rotator Cuff Index, 89% (range, 60%-100%; SD = 13%); and mean numeric pain rating, 0.3 (range, 0-3; SD = 0.8). Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) were forced to change positions. There were no surgical complications, but 2 patients did undergo a subsequent operation.

CONCLUSION

Surgical repair of high-grade partial-thickness and complete rotator cuff tears yielded successful outcomes among adolescents, with excellent functional outcomes at midterm follow-up. However, overhead athletes may have difficulty playing the same position after surgery.

Transosseous Physeal-Sparing Rotator Cuff Repair in an Adolescent Football Player

Rotator cuff injuries in the pediatric and adolescent population are rare. These injuries are normally caused by an acute event or by repeated microtrauma as a result of poor mechanics during overhead sporting activities. Overall, these injuries account for fewer than 1% of all rotator cuff tears. Physeal injuries, tuberosity avulsions ("rotator cuff equivalents"), and proximal humeral fractures commonly occur in the pediatric population. Traumatic full-thickness rotator cuff ruptures that occur in this age group during contact sports are an extremely uncommon cause of shoulder pain. The rarity of this type of injury in the pediatric and adolescent population may be the result of the excellent tensile properties of rotator tendons in childhood that often resist mechanical forces better than the growth plate or the apophyses. This report describes a full-thickness rotator cuff tear and a posterior labral tear in a 12-year-old boy who had a direct injury to the shoulder while playing football. The authors' goal in reporting this case is to increase orthopedic surgeons' awareness of this type of injury. Early use of magnetic resonance imaging for persistent shoulder pain after direct injury during contact sports may avoid undue delay in diagnosis. This report also describes the mini-open transosseous extraphyseal technique of cuff repair and reviews the literature on this infrequent injury. Overall, excellent clinical outcomes and return to sports can be expected after surgical repair of torn and often retracted tendons.

Rupture of the Long Head of the Biceps Tendon in a Pediatric Athlete: A Case Report

CASE

We report a case of an adolescent athlete who sustained an isolated rupture of the long head of the biceps tendon and was subsequently treated with subpectoral biceps tenodesis.

CONCLUSION

Provided that there is no damage to the rotator cuff, an open biceps tenodesis may be performed in this young patient population with good short-term outcomes and return to full activity.

Common sports-related musculoskeletal injuries presenting to the emergency department

Young athletes are specialising in sports at a younger age, placing the developing musculoskeletal system under considerable stress. Overuse injuries such as apophysitis are chronic in nature and account for a large proportion of musculoskeletal injuries suffered by young athletes; however, with an increased emphasis on success in sport, tendinopathy and fatigue fractures are now being reported with increasing frequency, in the adolescent population. Correct diagnosis and early protection, rest, ice, compression and elevation therapy is critical, along with supervised rehabilitation an expert in paediatric and adolescent sports medicine. Acute traumatic knee injury and ankle sprain account for most acute injuries. Although most are soft tissue in nature, radiography may be useful in specific situations before early initiation of protection, rest, ice, compression and elevation therapy. These injuries will also require follow-up by an expert in paediatric and adolescent sports medicine to confirm the diagnosis and instigate ongoing rehabilitation and/or orthopaedic referral. Many of these injuries are preventable and due consideration should be given to simple prevention strategies.

Traumatic Supraspinatus Tears in Patients Younger Than 25 Years

Traumatic rotator cuff tears in patients younger than 25 years are rare events, with few reports in the literature. When compared with the more mature shoulder, the young, healthy supraspinatus tendon is a robust tendon that is able to absorb a significant amount of energy before tendon failure. Therefore, the diagnosis of a rotator cuff tear can be often overlooked in this population due to the patient's age. This is a report of traumatic supraspinatus repairs in patients younger than 25 years. Nine patients younger than 25 years were identified with a posttraumatic supraspinatus tear as visualized during routine diagnostic shoulder arthroscopy. These 9 patients represented 0.33% of all rotator cuff repairs during a 9-year period. Average patient age was 19.1 years (±3.7 years; range, 13 to 25 years). Magnetic resonance imaging failed to diagnose a rotator cuff tear in 50% of the patients. Mean delay from injury to surgery was 6.6 months. All tears were arthroscopically repaired. Concomitant anterior instability pathology was demonstrated among 66.7% of the patients. No complications were reported. At latest follow-up, all patients reported minimal to no shoulder pain and were tolerating strenuous work, activities, and sports without significant complaints. Even with advanced imaging, the diagnosis of a rotator cuff tear can often be missed in this patient population. Although clinical outcomes can be good, care must be taken to broaden the diagnostic differential in young patients with posttraumatic shoulder pain.

Subscapularis tears and lesser tuberosity avulsion fractures in the pediatric patient

Background:

Pediatric subscapularis tears are known to be rare injuries. They are often associated with an avulsion fragment of the lesser tuberosity leading to dual description in the literature of either subscapularis tear or lesser tuberosity avulsion. Historically, they were managed nonoperatively; however, outcomes have improved with operative management. Nonoperative management often led to bony overgrowth at the lesser tuberosity that limited motion. The literature is limited to case reports and a few small case series, often not restricted to pediatric patients.

Study Design:

Case series.

Level of Evidence:

Level 5.

Methods:

Radiographic and operative databases were retrospectively reviewed to identify pediatric patients with subscapularis tears or lesser tuberosity avulsions in the past 10 years.

Results:

Five cases of pediatric subscapularis tears were identified that underwent operative management. Of the 5 cases, 4 had delayed presentation. In 1 case, the lesser tuberosity fragment was initially missed on radiographic imaging. All patients underwent operative management.

Conclusion:

These cases add to the body of knowledge of a rare pediatric injury that is commonly missed or diagnosis delayed. The importance of suspicion in the adolescent male patient without instability and unrelenting shoulder pain is stressed. Additionally, the importance of early magnetic resonance imaging with suspicion as well as an axillary view of the shoulder is demonstrated. As with all rare entities, it is important to disseminate information on natural history and interventions for this injury.