Symptomatic Internal Impingement of the Shoulder in Overhead Athletes

The use of the Western Ontario Rotator Cuff Index to assess effectiveness of physical therapy on rotator cuff injuries: A systematic review

The Western Ontario Rotator Cuff Index (WORC) is a self-administered questionnaire designed to assess quality of life in patients with rotator cuff injuries. This systematic review aims to evaluate the effectiveness of exercise-based interventions using WORC as an outcome measure in patients with rotator cuff injuries. A comprehensive search was conducted in PubMed, Cochrane Library, EMBASE, Ovid MEDLINE, and PEDro from inception until August 2024. Out of 13 potentially eligible studies, five studies (218 patients) met the inclusion criteria and were included in the review. Various rehabilitation interventions, such as exercise therapy, neuromuscular training, kinesiotaping, and proprioceptive exercises, showed significant improvements in pain relief, shoulder function, and quality of life. These findings suggest that the WORC index is a reliable tool for assessing pain and quality of life in patients with rotator cuff injuries.

Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics

Overhead throwing athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions.

The Epidemiology of Shoulder Injuries in Water Polo Players: A Monocentric Descriptive Study on Clinical and Radiological Presentation

Water polo players' shoulders are exposed to repeated overhead and throwing motions as well as direct and indirect traumas. Shoulder injuries account for over half of all injuries sustained by water polo players. This is a monocentric descriptive epidemiological study on the clinical and radiological presentation of a consecutive series of water polo players from January 2002 to September 2022. All patients underwent clinical and physical examinations and an MRI arthrogram. A total of 92 water polo players were included in this study. Fifty-three patients (57.6%) reported at least one previous shoulder instability episode; 100% of patients in this group were diagnosed with a capsulolabral complex lesion, and 88.7% of these players complained of subjective symptoms of shoulder instability (RR: 4.4). A total of 39 out of 92 patients (42.4%) did not report previous shoulder dislocation episodes; the mean age at presentation in this group was significantly higher than the mean age of the patients who experienced previous instability episodes (p < 0.01), and the throwing arm was affected in 79.5% of patients (RR = 1.41).

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Arthroscopic Bennett Lesion Resection and Posterior Labral Repair Using All-Suture Anchors

The Bennett lesion is an extra-articular ossification at the posteroinferior glenoid rim that is common among overhead-throwing athletes. While the majority of these exostoses are asymptomatic, some may cause posterior shoulder pain during throwing motion and frequently have concomitant posterior labral tears. Multiple approaches to Bennett lesion resection have been described, and there is debate regarding the need for capsulotomy, posterior labral repair, and capsular repair. The purpose of this article is to describe our preferred surgical technique for arthroscopic Bennett lesion resection and posterior labral repair using knotless all-suture anchors.

Management Options for Shoulder Impingement Syndrome in Athletes: Insights and Future Directions

Athletes participating in overhead sports are at particularly high risk of shoulder impingement syndrome. Subcoracoid impingement is defined as impingement of the anterior soft tissues of the shoulder between the coracoid process and the lesser tuberosity. Subacromial impingement syndrome (SIS) occurs due to extrinsic compression of the rotator cuff between the humeral head and coracoacromial structures or intrinsic degeneration of the supraspinatus tendon and subsequent superior migration of the humerus. Internal impingement is a major cause of shoulder pain in overhead athletes, and it occurs due to repetitive impingement of the articular surface of the rotator cuff with the glenoid during maximum abduction and external rotation of the arm. When examining athletes with suspected impingement of the shoulder, it is important to discuss the sport-specific motion that regenerates the symptoms and perform a combination of physical examination tests to improve the diagnostic accuracy. Radiographic evaluation is recommended, and the extent of soft tissue abnormalities can be assessed on ultrasound or magnetic resonance imaging of the shoulder. Management of shoulder impingement syndrome can be conservative or operative, based on the severity and chronicity of symptoms and the associated structural abnormalities. This review provides an update on the management of SIS, subcoracoid impingement, and internal impingement in the athletic population.

Arthroscopic Resection of Symptomatic Bennett Lesions

Bennett lesions, also known as "thrower's exostosis" of the shoulder, involve ossification of the posteroinferior glenoid and are not uncommon in overhead throwing athletes. The literature surrounding the optimal operative management of the symptomatic Bennett lesion is limited. The purpose of this article is to describe the arthroscopic surgical technique for the visualization and excision of the symptomatic extra-articular pathologic ossification involving the posteroinferior glenoid. Because many surgeons may not be familiar with this problem or procedure, we present a straightforward method that allows for identification and excision of the exostosis through an arthroscopic posterior arthrotomy.

A Clinician's Guide to Analysis of the Pitching Motion

PURPOSE OF REVIEW

This review examines recent literature regarding analysis of the throwing motion in baseball players and how modern technology may be used to predict or prevent injury.

RECENT FINDINGS

Proper throwing technique is vitally important to prevent injury and it is easier to correct poor mechanics prior to foot strike. Recent findings suggest that the inverted-W position may not lead to an increased risk of injury, but incorrect trunk or pelvis rotation does. Three-dimensional motion analysis in a laboratory setting is most commonly used to evaluate the throwing motion, but it does not allow for assessment in real game scenarios. Wearable monitors allow for this and have proven to reliably assess pitching workload, kinematics, and kinetics. Injuries in youth baseball pitchers have increased along with the trend towards more single sport specialization. To prevent injury, assessment of a pitcher's throwing motion should be performed early to prevent development of poor mechanics. Classically, three-dimensional motion analysis has been used to evaluate throwing mechanics and is considered the gold standard. Newer technology, such as wearable monitors, may provide an alternative and allow for assessment during actual competition.

Evaluation of a Shoulder Injury Prevention Program in Wheelchair Basketball

Context:Previous literature has theorized that alterations in shoulder physical characteristics are present in wheelchair athletes and contribute to shoulder pain and injury. Limited empirical evidence is present that evaluates the effectiveness of a shoulder injury prevention program focusing on improving these altered characteristics.Objective:To evaluate the effectiveness of a 6-week intervention program at improving characteristics that increases the risk of developing pain or shoulder injury.Design:Pretest and posttest.Setting:Home-based and controlled laboratory.Participants:Seven college wheelchair athletes.Interventions:Shoulder range of motion (ROM) and scapular muscle strength were assessed, and a 5-minute injury prevention program was taught to participants. Participants completed the intervention 3 times per week for 6 weeks. Following completion of the program, a postintervention screening was performed.Main OutcomeMeasures:Internal rotation (IR)/external rotation (ER) ROM, retraction strength, and IR/ER strength.Results:Participants experienced a significant improvement in dominant limb shoulder IR ROM (t6 = 3.56,P = .01) with an average increase of 11.4° of IR ROM and a significant improvement in dominant limb shoulder ER ROM (t6 = 2.79,P = .03) with an average increase of 8.0° of ER ROM. There were no significant increases in shoulder IR or ER strength and scapular retraction strength (P > .05).Conclusions:Improvements in ROM have previously been linked to decreases in shoulder pain and injury in other upper-extremity dominant sports by improving scapular kinematics. These results provide evidence that a 6-week strengthening and stretching intervention program may decrease risk factors for shoulder injury in wheelchair basketball athletes.

Increased pitch velocity and workload are common risk factors for ulnar collateral ligament injury in baseball players: a systematic review

Importance

Ulnar collateral ligament (UCL) injuries commonly occur in baseball players. Strategies for injury prevention have long been accepted without clinical data informing which risk factors lead to serious injury.

Objective

The objective of this study was to systematically review the impact of various pitching-related risk factors for UCL injury in baseball players from all levels of play.

Evidence review

The electronic databases MEDLINE, EMBASE and PubMed were systematically searched until 4 March 2018, and pertinent data were abstracted by two independent reviewers. Search terms included ‘ulnar collateral ligament’, ‘medial ulnar collateral ligament’, ‘Tommy John’, ‘risk’ and ‘association’. Inclusion criteria were English-language studies, level of evidence I–IV and studies reporting risk factors for UCL injury of the elbow in baseball players. Study quality was assessed using the methodological index for non-randomised studies (MINORS) criteria. The results are presented in a narrative summary.

Findings

Pitching practices (workload and pitch characteristics) were reported in 9/15 studies. Specifically, three of four studies (n=1810) reported increased pitch workload as a risk factor for native UCL injury (p<0.001 to 0.02). The most common pitch characteristic reported was pitch velocity with four of five studies showing increased velocity being significantly associated with native UCL injury (p<0.01 to 0.02). Biomechanical risk factors reported were increased humeral retrotorsion (two studies; n=324), poor lower extremity and trunk balance (one study; n=42) and loss of total arc of shoulder motion (two studies; n=118), all significantly associated with UCL injury (p<0.0001 to 0.05). One of three studies assessing pitch workload as a risk factor for re-rupture of UCL reconstruction found a significant association (p<0.01).

Conclusions and relevance

Pitching practices, reflected by increased pitch workload and velocity, were most commonly associated with UCL injury; however, the definition of workload (number of pitches per game, inning or season) was inconsistently reported. Biomechanical risk factors were less commonly reported and lack sufficient evidence to recommend preventative strategies. More quality data is needed to refine the current recommendations for injury prevention in baseball players.

Level of evidence

III.

Glenohumeral internal rotation deficit in throwing athletes: current perspectives

Glenohumeral internal rotation deficit (GIRD) is an adaptive process in which the throwing shoulder experiences a loss of internal rotation (IR). GIRD has most commonly been defined by a loss of >20° of IR compared to the contralateral shoulder. Total rotational motion of the shoulder is the sum of internal and external rotation and may be more important than the absolute value of IR loss. Pathologic GIRD has been defined as a loss of IR combined with a loss of total rotational motion. The leading pathologic process in GIRD is posterior capsular and rotator-cuff tightness, due to the repetitive cocking that occurs with the overhead throwing motion. GIRD has been associated with numerous pathologic conditions, including posterior superior labral tears, partial articular-sided rotator-cuff tears, and superior labral anterior-to-posterior tears. The mainstay of treatment for patients with GIRD is posterior capsular stretching and strengthening to improve scapular mechanics. In patients who fail nonoperative therapy, shoulder arthroscopy can be performed. Arthroscopic surgery in the high-level throwing athlete should be to restore them to their functional baseline with the minimum amount of intervention possible.

Risk Factors for Tear Progression in Symptomatic Rotator Cuff Tears: A Prospective Study of 174 Shoulders

BACKGROUND

The risk factors for tear progression in symptomatic rotator cuff tears have not been clarified yet. It is important for orthopaedic surgeons to know the natural course of tear progression when nonoperative management is to be chosen.

HYPOTHESIS

Tears in younger patients, high-activity patients, or heavy laborers would progress in size more than those in older patients, low-activity patients, or light laborers.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Two hundred twenty-five consecutive patients with symptomatic rotator cuff tears visited our institute between 2009 and 2015. Of these, 174 shoulders of 171 patients (mean age, 66.9 years) who underwent at least 2 magnetic resonance imaging (MRI) examinations were prospectively enrolled. The mean follow-up was 19 months. Tear progression was defined as positive when the tear size increased by ≥2 mm. The demographic factors that were analyzed by multivariate analysis included age, sex, hand dominance, smoking, alcohol drinking, hypercholesterolemia, sports participation, job type, tear size, and tear type (full or partial thickness).

RESULTS

Of the 174 shoulders, 82 shoulders (47%) showed tear progression. The mean (±SD) tear length and width in the progression group on final MRI were 23.1 ± 12.5 mm and 17.3 ± 9.6 mm, respectively; the tear size progressed by a mean 5.8 ± 5.6 mm in length and 3.1 ± 5.2 mm in width. The mean propagation speed was 3.8 mm/y in length and 2.0 mm/y in width. The size of full-thickness tears significantly increased compared with that of articular-sided partial-thickness tears ( P = .0215). The size of medium tears significantly increased compared with that of other tears ( P < .0001). According to the logistic regression analysis, smoking was significantly correlated with tear progression ( P = .026). Subgroup analyses showed that male sex, hand dominance, and trauma were correlated with tear progression. Age, alcohol drinking, hypercholesterolemia, sports participation, and job type did not show any correlation with tear progression.

CONCLUSION

The tear size of symptomatic rotator cuff tears progressed in 47% of the shoulders during a mean of 19 months, and the speed of progression was 3.8 mm/y in length and 2.0 mm/y in width. The risk factors for tear progression were (1) a medium-sized tear, (2) a full-thickness tear, and (3) smoking.

Top 50 cited journal articles on overhead throwing athletes: a bibliographic analysis

Background

The frequency of citations for a journal article is a reflection of its academic impact. The purpose of this study was to identify and characterize the top 50 cited journal articles related to overhead throwing athletes in the published literature.

Methods

The Web of Science database was searched on January 18, 2016, using the terms "throwing athlete," "baseball," and "pitcher" to identify the top 50 cited articles related to overhead throwing athletes using the all-database function. The type of study, country of origin, publishing journal, and year published were reviewed for each article.

Results

The top 50 articles identified were cited between 95 and 471 times and were published in 13 journals between 1969 and 2011. Most of the articles were small case series or nonsystematic literature reviews. The shoulder was the most common body region studied in the top 50 articles (33 of 50 [66%]). Among original studies (n = 43), there was a good representation of surgical management of shoulder and elbow pathology in overhead athletes (9 of 43 [20.9%]); however, most of the articles reported on shoulder and elbow kinematics (19 of 43 [44.2%]) and pathoanatomy (15 of 43 [34.9%]).

Conclusion

The greater prevalence of nonsurgical articles may reflect a continued effort to better understand the different pathologies specific to overhead throwing athletes. An understanding of the variable content and quality of frequently cited articles on overhead throwing athletes may serve as a stepping stone for future studies to advance the diagnosis and management of complex elbow and shoulder injuries in these high functional individuals.

A novel flexible drill device enabling arthroscopic transosseous repair of Bankart lesions

We have developed a flexible drill device that makes arthroscopic transosseous repair possible, and report preliminary results. Twelve patients with post-traumatic anterior inferior glenohumeral instability were selected.

SURGICAL TECHNIQUE

the flexible drill device is inserted into the shoulder joint through the posterior portal and the guide pipe unit is placed 5mm posterior to the margin of the anterior glenoid rim. The flexible drill is driven through the glenoid with the power drill, creating a hole in the glenoid. A non-absorbable suture is passed through the hole and a sliding knot tying is performed over the capsule and labrum after completing stitches with the suture hook loaded. The same procedures are repeated in the 2, 3 and 4 o'clock positions of the glenoid. There was no recurrence of dislocation at the mean follow-up period of 52.3 months. The mean Rowe score was 89.5.

In vivo clinical and radiological effects of platelet-rich plasma on interstitial supraspinatus lesion: Case series

BACKGROUND

Rotator cuff tear (RCT) is a frequent condition of clinical relevance that can be managed with a symptomatic conservative treatment, but surgery is often needed. Biological components like leukocytes and platelet rich plasma (L-PRP) could represent an alternative curative method for interstitial RCT.

HYPOTHESES

It has been hypothesized that an ultrasound guided L-PRP injection in supraspinatus interstitial RCT could induce radiological healing.

MATERIAL AND METHODS

A prospective case series including 25 patients was performed in order to assess the effect of L-PRP infiltration into supraspinatus interstitial RCTs. Primary outcome was tear size change determined by magnetic resonance imaging arthrogram (MRA) before and 6 months after L-PRP infiltration. Secondary outcomes were Constant score, SANE score, and pain visual analog scale (VAS) after L-PRP infiltration.

RESULTS

Tear volume diminution was statistically significant (P=.007), and a >50% tear volume diminution was observed in 15 patients. A statistically significant improvement of Constant score (P<.001), SANE score (P=.001), and VAS (P<.001) was observed. In 21 patients, Constant score improvement reached the minimal clinical important difference of 10.4 points.

DISCUSSION

We observed a statistically significant and clinically relevant effect on RCT size and clinical parameters after L-PRP infiltration. Such an important improvement of supraspinatus interstitial RCT with conservative management is uncommon, therefore intratendinous L-PRP infiltrations could have been beneficial. This encouraging result could pave the way for future randomized studies in order to formally determinate whether L-PRP infiltrations are a possible alternative to surgical treatment of interstitial RCT.

LEVEL OF EVIDENCE

Prospective observational study; Level of evidence II.

Epidemiologic Comparison of Pitching Mechanics, Pitch Type, and Pitch Counts Among Healthy Pitchers at Various Levels of Youth Competition

PURPOSE

To determine differences among healthy pitchers at various levels of competition regarding pitching history, pitching mechanics, and prevalence of breaking pitches.

METHODS

Demographic, anthropometric, pitching history, and kinematic data were collected on healthy youth pitchers using dual orthogonal high-speed video analysis. Players were grouped by maturity level (9 to 12 [prepubescent], 13 to 15 [pubescent], 16 to 17 [mature], and 18 to 22 years [adult]). Groups were compared regarding pitch counts, pitching mechanics, and use of breaking pitches. Mechanics were assessed for favorable observational parameters (e.g., closed foot orientation at foot-strike) and measurable parameters at cocking, foot-strike, and ball release (e.g., knee flexion).

RESULTS

Two hundred ninety-five pitchers were included. Sixty-three were 9 to 12, 130 were 13 to 15, 78 were 16 to 17, and 24 were 18 to 22 years of age. Older pitchers threw more pitches per game (41, 52, 69, and 50 by age group; P < .001), per season (766, 975, 1,079, and 881; P = .017), and per year (901, 1,343, 2,064, and 1,302; P < .001). They were more likely to pitch for multiple teams, for more than 9 months, in showcases, and in violation of pitch count recommendations. Older pitchers were more likely to maintain their hand on top of the ball, maintain closed shoulders at foot-strike, achieve hip and shoulder separation, and lead with their hips. Older pitchers achieved greater relative stride-length, greater knee flexion at front-foot contact, and increased lead hip flexion at ball release. Pitchers began throwing curveballs and sliders at 12.6 and 13.5 years, respectively.

CONCLUSIONS

As pitchers age, they throw more pitches per game, per season, and per year and are more likely than younger pitchers to violate pitch count recommendations. Older pitchers tend to pitch with improved mechanics and velocity. The proportion of pitchers throwing breaking pitches increases with age, with the greatest increase occurring between ages 12 and 13.

LEVEL OF EVIDENCE

Level II, cross-sectional study.