Surgical Management of Capsulolabral and Rotator Cuff Injuries in Throwing Athletes

Introduction

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Surgical management of the throwing shoulder has unique challenges specific to the high demands of the overhead throwing motion.
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Repetitive throwing places the shoulder in extreme positions under tremendous stress that rival some of the fastest movements in competitive sport.
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There exists a delicate balance separating physiologic adaptation (i.e., capsular laxity, increased humeral external rotation) during normal throwing motion and pathophysiologic changes (i.e., anterior instability, posterior capsular contracture, decreased humeral internal rotation) that may occur in the injured throwing shoulder.
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There are consistent injury patterns that occur in the throwing shoulder, including anteroinferior labral tears, posterosuperior labral tears and biceps tendon pathology, posteroinferior capsular contracture, and partial-thickness articular rotator cuff tears.
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In throwers with chronic insidious pain or instability, surgery is only indicated after failure of conservative management (i.e., optimizing the “kinetic chain,” improvement of scapular dyskinesia, and correction of pathologic humeral rotational deficits).
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Acute traumatic injuries in throwers may require earlier operative management. However, the vast majority are similarly treated with an initial course of conservative management and close observation before surgical intervention is offered.
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Preoperative planning includes detailed history and physical examination, review of imaging studies, and confirmation of the correct diagnosis during examination under anesthesia and diagnostic arthroscopy.
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The goal of surgical management is to recognize and treat pathologic structures while maintaining native joint laxity and range of motion (ROM), which are critical for return to throwing.
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Successful return to competitive throwing after shoulder surgery requires a combination of thoughtful preoperative planning, meticulous surgical technique, and a comprehensive goal-oriented postsurgical rehabilitation program.

Surgical Considerations

Preoperative Planning

Successful surgical management of the throwing shoulder must begin in the clinic setting. Carefully performed history, physical examination, and review of imaging studies gives the surgeon a working diagnosis before operative intervention. This may aid in selection of surgical approach (i.e., arthroscopic vs open) and arthroscopic surgical position (i.e., beach chair vs lateral decubitus) and allows for anticipation of procedure length and any special equipment needs before surgery. In general, the vast majority of surgical interventions in the throwing shoulder can be successfully performed using arthroscopic intervention. This includes capsulolabral and rotator cuff debridement or repair, removal of loose bodies, and synovectomy. Rarely, other procedures may be indicated, including subacromial decompression, distal clavicle excision, decompression of paralabral cysts, suprascapular nerve decompression, or debridement of small capsular exostosis (i.e., Bennett lesion). Open or mini-open approaches are considered for the management of humeral avulsion of the glenohumeral ligament (HAGL) lesions, for complex type IV tears or failed prior repair of the SLAP (superior labrum anterior and posterior) lesion when the surgeon selects to perform subpectoral biceps tenodesis, or for the rare case of complete subscapularis tears with retraction. Open approaches commonly performed in the athletic population are rarely performed in throwers but rather in the setting of complex shoulder instability, particularly when performing open Bankart and capsular shift procedures for contact or collision throwing athletes (i.e., football quarterback) with increased Injury Severity Index (ISI) scores or for athletes with substantial glenoid or humeral bone loss requiring reconstructive procedures.

Anesthesia and Surgical Position

Shoulder surgery in throwing athletes is typically performed under general anesthesia with an interscalene nerve block. Open procedures are performed in the beach-chair or modified beach-chair position. Arthroscopic procedures may be performed in either the beach-chair or lateral decubitus position, based mainly on surgeon experience and preference ( ). With either approach, careful attention is placed on protective padding for critical structures (i.e., axillary roll for lateral decubitus, pillows under knees, and peroneal padding for beach chair). Cerebral perfusion is improved with the lateral decubitus position, and there is less risk of hypotension or bradycardia during the procedure ( ). For arthroscopic management of the majority of conditions of the throwing shoulder, the authors prefer the lateral decubitus position ( ). Advantages of this setup include the use of traction, providing excellent 360-degree access to the glenohumeral joint, including easier access to the inferior labrum and the 6 o’clock position. A relative disadvantage is that repeat dynamic examination under anesthesia (EUA) is more cumbersome, requiring removal and replacement of the traction setup ( ). Additionally, if open surgery is required, the patient may need to be repositioned. However, the majority of the time, this requires only minor readjustment of the torso without repeat preparation and draping. The beach-chair position provides anatomic orientation and easier access for repetitive dynamic EUA ( ). This position may be favored for work limited to the anterior or superior quadrants, rotator cuff, biceps tendon, and Acromioclavicular (AC) joint. However, access to the posterior and inferior quadrants for labral repair or debridement requires substantial technical expertise to gain adequate exposure for appropriate treatment ( ).

Examination Under Anesthesia

Examination under anesthesia is a critical component of the workup and management of the throwing athlete. This should be performed after the induction of general anesthesia and before sterile preparation and draping so that both limbs may be examined. It is important to examine the normal nonoperative extremity to gain better appreciation for the athlete’s native joint laxity and physiologic parameters for ROM ( ). Understanding baseline nonpathologic degrees of humeral internal and external rotation will assist in detecting abnormalities in the throwing shoulder, including residual glenoid internal rotation contracture (GIRD) secondary to posterior capsular contracture ( ). Laxity testing on the noninvolved extremity includes assessment for sulcus sign and multidirectional load and shift of the humeral head ( ). Comparison with the operative extremity allows the surgeon to detect pathologic instability patterns (anterior, posterior, inferior, combined instability) that require surgical attention versus symmetric global hyperlaxity where surgical stabilization may be contraindicated ( ).

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