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Nerve Entrapment

Nerve Entrapment in the Shoulder The incidence of entrapment neuropathies involving the shoulder is largely unknown, but as our understanding of the anatomy and pathology of these conditions grows, earlier and more accurate recognition of these conditions has led to higher rates of treatment. Symptom presentation is most often subtle and insidious in onset, necessitating diagnostic acumen on behalf of the treating physician. Injuries resulting from…

Scapulothoracic Disorders

The scapula connects the upper extremity to the thorax and allows for complex movements about the shoulder. Although there are minimal bony connections to the axial skeleton, the scapula plays an integral role in the function of the upper extremity and especially in the throwing mechanism. In total there are 17 muscles that have their origin or insertion on the scapula ( Table 53.1 and Fig.…

Glenohumeral Arthritis in the Athlete

Arthritis or degenerative joint disease (DJD) of the shoulder in young athletes is a disabling condition that often limits sports participation and is extremely challenging to treat. Shoulder arthritis, defined as a degeneration of the articular cartilage of either the humeral head or glenoid, is caused by multiple etiologies, including primary osteoarthritis and secondary causes such as trauma, iatrogenic disease, and rheumatoid disease. Although each subtype…

Stiff Shoulder

The structural anatomy of the glenohumeral articulation affords considerable range of motion (ROM) to the shoulder. The osseous and soft tissue structures provide limited yet sufficient static and dynamic restraints to allow significant motion not only for activities of daily living but also for high-level athletic endeavors. At one end of the motion spectrum is shoulder instability, a pathologic and symptomatic condition in which the humeral…

Other Muscle Injuries

Muscle injuries about the shoulder are increasingly common in active individuals, with the prevalence of upper extremity muscle sprains, strains, and ruptures rising as more athletes join gyms and engage in recreational and professional strength training and weight lifting. However, these injuries remain inadequately described and defined despite their ability to cause significant functional disability, pain, and time lost from sport. Pectoralis Major Injuries to the…

Revision Rotator Cuff Repair

Primary rotator cuff repair frequently leads to successful subjective results with decreased pain and increased function, but incomplete healing or retearing is known to commonly occur. Retear rates following repair of small to medium tears have been reported as high as 40%, and up to 94% following massive, chronic cuff tears. Despite retear, many patients can maintain pain relief and improved functional outcome. However, patients who…

Subscapularis Injury

The subscapularis represents the anterior portion of the rotator cuff and is an important stabilizer and internal rotator for the glenohumeral joint. The first reported case documenting a subscapularis tendon tear was by Smith in 1834, with the first reported repair described by Hauser in 1954. Despite these reports, operative management of subscapularis pathology remained relatively neglected until Gerber et al. described their management of 16 patients…

Rotator Cuff and Impingement Lesions

Historical Perspective A description of rotator cuff pathology is found in the earliest surgical text, the Edwin Smith Papyrus (c.1500 bce ). Subsequently, throughout ancient and modern history, multiple authors have written about the rotator cuff, its disease, and its nonoperative and operative treatment. Monro penned the first modern case report and illustration of a rotator cuff tear in 1788 in his treatise, A Description of…

Proximal Biceps Tendon Pathology

Introduction Pathology to the proximal aspect of the long head of the biceps tendon (LHBT) has long been recognized as a source of shoulder pain and dysfunction. Referred by some as the biceps-labral complex, the proximal biceps tendon includes its origin on the superior labrum, the intra-articular tendon, and the tendon as it courses its way through its stabilizing pulley down the bicipital tunnel to the…

The Thrower’s Shoulder

The thrower's shoulder is a unique and challenging subset of sports medicine given the extreme demands placed on the glenohumeral joint and surrounding soft tissue structures. For purposes of discussion, we will mainly focus on medical issues as they relate to baseball players; however, we certainly acknowledge that many other sports (volleyball, tennis, handball) and positions (quarterbacks) have overlapping demands and injury patterns and will draw…

Superior Labrum Anterior to Posterior Tears

Superior labrum anterior to posterior (SLAP) lesions have been recognized as a cause of shoulder pain since the mid-1980s. Controversy regarding normal variant labral anatomy versus truly pathologic lesions causing consistent clinical symptoms surfaced almost immediately thereafter. Snyder and colleagues described the pathologic anatomy of four types of SLAP lesions and the implications for treatment ( Figs. 44.1 and 44.2 ). Other authors have described additional…

Revision Shoulder Instability

The recurrence of anterior glenohumeral instability is not uncommon following primary surgical repair with reported rates of 15% to 30%. Optimal management for recurrent shoulder instability remains controversial; as many acceptable surgical options exist, and the decision-making process is heavily case dependent. Numerous level one studies have looked at risk factors for recurrent instability, consistently reporting a young age and arm position at the time of…

Multidirectional Instability of the Shoulder

The shoulder is unique in that it is the most mobile joint in the human body. It serves primarily to position the hand in space and thus requires a delicate balance of stability and flexibility to accomplish its function. The inherent complexity of the glenohumeral joint requires contributions from both dynamic and static stabilizers to achieve this balance. Further, whereas some activities, such as swimming, place…

Posterior Shoulder Instability

Posterior shoulder instability is a unique condition that not only represents a spectrum of instability, but can also be difficult to diagnose and technically challenging to treat. Although less common than anterior shoulder instability, accounting for only 2% to 10% of cases, this condition is becoming increasingly recognized in the athletic population. Mclaughlin et al. first recognized the wide clinical spectrum of posterior shoulder instability ranging from…

Anterior Shoulder Instability

Anterior shoulder instability is the most common type of shoulder instability. It is typically the result of a traumatic event with dislocation of the glenohumeral joint. However, instability also may present as subluxation, a condition in which the joint symptomatically translates but does not completely dislocate. The estimated incidence of shoulder dislocations in the United States in 23.9 per 100,000. Patients of any age may sustain…

Shoulder Arthroscopy

Background Shoulder arthroscopy was first described in the 1930s by Burman, who learned how to perform arthroscopy on cadaveric joints. Remarkably, shoulder arthroscopy has been used regularly only for the past 30 years. The use of shoulder arthroscopy has continued to grow, and today it is one of the most commonly performed orthopedic procedures. It is the second most common procedure performed by persons taking Part…

Glenohumeral Joint Imaging

Conventional Radiography Conventional radiography is and should be the initial imaging examination performed for a patient presenting with shoulder pain. Although radiographs provide limited evaluation of the rotator cuff and glenoid labrum, they can offer important information about the source of the patient's symptoms. Radiographs depict an assortment of osseous abnormalities, including fracture, arthritis, soft tissue calcifications, postsurgical changes, and tumor, and they are frequently complementary…

Shoulder Diagnosis and Decision-Making

Perhaps more than any other joint in the body, the shoulder can present a complex diagnostic challenge to the examining physician. There are a variety of anatomic and clinical reasons for this challenge. First, the “shoulder” is actually a functional complex of four distinct and separate articulations: the sternoclavicular joint, acromioclavicular joint, glenohumeral joint, and scapulothoracic joint. These joints all function together to allow a strong,…

Shoulder Anatomy and Biomechanics

The shoulder can really be considered a complex ( Fig. 36.1 ), consisting of four joints or articulations (all with important stabilizing ligaments), two spaces, and more than 30 muscles and their respective tendons. The shoulder complex is an intricate structure that requires synchronized/orchestral-type motions/movements to function properly. A thorough understanding of the anatomy and complex biomechanics of the shoulder is helpful to clinicians in diagnosing…

Return to Activity and Sport After Injury

With sports participation comes an inherent risk of injury. In 2017, a summary report on the National High School Sports-Related Injury Surveillance Study for the school year of 2016–17 estimated that 7.9 million students participated in high school sports, with approximately 1.16 million injuries across the United States. Based on this report, the overall injury rate in all high school sports combined was 2.09 injuries per…