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Medial: Ulnar Collateral Ligament Injury

Epidemiology, Anatomy, Mechanism of Injury, History, Physical Examination, and Imaging Christopher S. Ahmad, MD Justin L. Hodgins, MD Abstract Injury to the medial ulnar collateral ligament (MUCL) of the elbow is a debilitating condition primarily affecting overhead throwing athletes. Overuse injuries to the ligament are very common, because throwing places tremendous valgus torque across the elbow and MUCL. The injury is most common in baseball as it can…

Throwing Programs and Return to Sport

Return to a throwing sport after elbow or shoulder injury can be a daunting task. Return to play rates after ulnar collateral ligament reconstruction have been favorable but lower than once thought ( ). Many studies show a high return rate to major league baseball, but return to similar performance and workload is not as high ( ). Return to throwing after surgical treatment for superior…

Surgical Management of Capsulolabral and Rotator Cuff Injuries in Throwing Athletes

Introduction ▪ Surgical management of the throwing shoulder has unique challenges specific to the high demands of the overhead throwing motion. ▪ Repetitive throwing places the shoulder in extreme positions under tremendous stress that rival some of the fastest movements in competitive sport. ▪ There exists a delicate balance separating physiologic adaptation (i.e., capsular laxity, increased humeral external rotation) during normal throwing motion and pathophysiologic changes…

Epidemiology, Mechanism of Injury, History and Physical Examination, Imaging, Workup, and Indications for Surgery

Introduction The overhead throwing motion is an intricate, highly coordinated musculoskeletal sequence placing multidirectional and supraphysiologic forces on the shoulder. In fact, the angular velocity during pitching represents the fastest human movement recorded ( ). This repetitive and highly demanding action results in adaptive structural changes permitting the shoulder to effectively perform overhead athletic motions but potentially at the expense of normal kinematics at the glenohumeral…

Treatment

Introduction The pectoralis major (PM) muscle functions as a potent flexor, adductor, and internal rotator of the shoulder, as well as a dynamic stabilizer of the glenohumeral joint ( ). Although the PM is not required for activities of daily living ( ), rupture of the tendon or muscle–tendinous junction leads to significant functional deficits and limitations of athletic performance or labor-intensive activities ( ). Nonoperative…

Overview

Introduction ▪ Injuries to the pectoralis major (PM) occur infrequently, typically in young male athletes ( ). ▪ This injury most often develops during high loads, with the arm extended, abducted, and externally rotated, while transitioning from eccentric to concentric contractions of the PM ( ). ▪ Although some of these injuries can be successfully treated nonoperatively, rupture of the tendon can result in significant functional…

Treatment

Labral Repair Dustin L. Richter, MD Jourdan Cancienne, MD Stephen F. Brockmeier, MD Abstract Superior labrum anterior and posterior (SLAP) tears are commonly a result of a traction injury and are often seen in overhead athletes. Type II SLAP tears, characterized by a detached biceps tendon anchor, are the most common type of SLAP tear to require surgical repair. Indications for arthroscopic repair of SLAP lesions continue to evolve.…

Overview

Important Points ▪ There is a shift away from SLAP (superior labrum anterior and posterior) repair toward biceps tenodesis. ▪ The biceps–labrum complex (BLC) can be divided into three anatomic locations: inside (the superior labrum and biceps anchor), junction (the intraarticular segment of the long head of the biceps tendon and the biceps pulley), and bicipital tunnel (the extraarticular segment of the biceps tendon and its…

Treatment

Indications for Surgery Sternoclavicular joint injuries are rare, and indications for their surgery are also rare. Fractures of the medial end of the clavicle are usually not sports related, are the result of vehicular trauma, and rarely need surgery ( ). Generally, surgery is avoided in atraumatic subluxations of the sternoclavicular joint, because this disorder is generally found in patients with generalized ligamentous laxity and failures…

Overview

Anatomy, Epidemiology, and Etiology Although injuries to the sternoclavicular joint are relatively rare in athletes, team physicians must be vigilant for such injuries because they represent one of the few potentially life-threatening injuries in sports. The sternoclavicular joint is a saddle-shaped, diarthrodial joint, with minimal osseous constraint and inherent stability in the joint. Motion at this joint is important for shoulder function. With forward elevation of…

Treatment Options: Distal Clavicle Fractures

Background ▪ Distal fractures of the clavicle (DCFs) are defined as fractures of the lateral third of the clavicle and are classified by their relationship to the acromioclavicular (AC) and coracoclavicular (CC) ligaments. ▪ DCFs account for approximately 15% to 35% of all clavicle fractures. ▪ High-energy trauma and a direct fall onto the shoulder are among the most common causes of DCFs. ▪ In general,…

Surgical Treatment Options: Mid-Shaft Fracture

Percutaneous Pinning Connor G. Ziegler, MD Robert A. Arciero, MD Abstract Midshaft clavicle fractures which require reduction and internal fixation can be managed using two primary approaches. Open reduction and internal fixation with one or more plates is one approach and intramedullary (IM) fixation is another option. IM fixation may be performed percutaneously or through a limited open approach. This chapter reviews the indications, techniques and potential complications…

Overview

Introduction ▪ Clavicle fractures are common and potentially devastating injuries in athletes that may result in complete loss of the competitive season. ▪ Approximately 20% to 45% of all clavicle fractures are attributed to sport-related activity with cycling and contact sports being the most common. ▪ A systematic approach is required when examining injured athletes. Isolated clavicle injuries can be diagnosed with standard radiographic views of…

Surgical Treatment

Surgical Treatment: Arthroscopic Erik M. Fritz, MD Brooke M. DelVecchio, PT, DPT, OCS Jonas Pogorzelski, MD, MHBA, Peter J. Millett, MD, MSc Abstract Acromioclavicular joint injuries that require surgery may be managed using arthroscopic and open techniques. This chapter reviews the indications, techniques, complications and post-operative rehabilitation of arthroscopic surgical treatment. Keywords: Acromioclavicular joint, AC joint arthroscopy, AC joint, AC joint reconstruction, Shoulder Separation Introduction ▪ Injuries to the acromioclavicular…

Acromioclavicular Joint Anatomy

Introduction ▪ The most widely used classification is , which is based on severity of injury. ▪ Clinical evaluation is especially important in assessing posterior dislocations and scapulothoracic dyskinesia. ▪ Imaging should always include standard shoulder views, including an axillary view in addition to bilateral Zanca views. ▪ Nonoperative treatment is the best approach for most acromioclavicular (AC) injuries and should include short-term immobilization and active…

Rotator Cuff Physical Therapy, Rehabilitation and Return to Sport

Postoperative Physical Therapy and Rehabilitation Brooke M. Delvecchio, PT, DPT, OCS Paul E. Westgard, PT, DPT, OCS, SCS, CSCS Helen Bradley, PT, MSc, SCS, CSCS Abstract This Chapter reviews the factors, biologic healing, early and delayed range of motion, and guidelines of rotator cuff post-operative physical therapy and rehabilitation. The guidelines discuss in detail the four phases of rehabilitation including maximal protection, muscular endurance, muscular strength and muscular power.…

Revision Repair

Posterior Cuff Kyle R. Duchman, MD Brian R. Wolf, MD, MS Abstract It is very common for patients to experience loss of structural integrity following a primary rotator cuff repair. Causes of failure after the primary repair can include biologic failure, technical error, traumatic failure, or a complication stemming from the primary injury. When evaluating a failed repair, it is critical to evaluate range of motion and obtain…

Isolated Subscapularis Tendon Tear

Physical Examination and Imaging David Bernholt, MD Robert H. Brophy, MD Abstract Isolated tears of the subscapularis can occur through forced external rotation or by anterior shoulder dislocation. Tears can be full or partial and are associated with weakness of internal rotation of the shoulder. A variety of examination maneuvers have been described to evaluate for subscapularis injury, including the lift-off test, internal rotation lag sign, belly press…

Full Thickness Posterior Rotator Cuff Tear

Arthroscopic Posterosuperior Rotator Cuff Repair for Full-Thickness Tears Matthew P. Noyes, MD Patrick J. Denard, MD Stephen S. Burkhart, MA, MD Abstract This chapter provides a thorough review of the advancements in tear recognition that have facilitated the improved techniques which have resulted in anatomic repair and better outcomes following rotator cuff repair. The indications and descriptions for multiple techniques are discussed in detail. Keywords: double row, full thickness…