FEATURE
(continued from page 17)
from impingement against the glenoid. The anterior capsule and
anterior inferior labrum can stretch and eventually avulse, leading
to anterior instability. Meanwhile, the follow through puts stress
on the posterior inferior capsule, creating scarring and tightening,
leading to loss of internal rotation. This creates further stress on the
anterior capsule and bicep anchor, leading to increased injury risk.
The athlete with a throwing or swimming injury complains of
pain in the shoulder with activity. Pain is particularly reproduced in
the abducted externally rotated position. With progression to tissue
injury, this includes night pain and elevation of arm to shoulder
level. Often athletes complain of feeling grinding with motion from
thickened inflamed tissue. With anterior capsule and labrum injury,
they will feel instability or dead arm symptoms. Popping on follow
through with throwing and the catch in swimming can be caused
by posterior instability.
Physical examination of the injured athlete’s shoulder often shows
winging of the scapula and loss of internal rotation and total arc
of motion. Tenderness may be anterior at the rotator cuff/bicep or
posterior at the joint line.
Pain is typically reproduced in the abducted externally rotated
position and relieved by posterior directed force in this position
(Jobe test). In this position, pain reproduced posteriorly denotes a
posterior superior labrum tear. Anterior pain can come from bicep
or rotator cuff injury. Apprehension or unstable feeling suggests
anterior inferior labrum tear. A position of flexion with internal
rotation can demonstrate posterior instability. Other physical signs
include weakness of the rotator cuff muscles against resistance.
Speeds test will be positive with bicep irritation.
Even in the face of significant labrum tears, rehabilitation can
be successful in restoring the athlete to sport up to 50 percent of
the time. Surgery is not routinely successful even in Major League
pitchers, with a rate of return to play of 48 percent. 10
The initial approach to the injured shoulder athlete is to rest
from provocative activity, restore motion through rehabilitation and
stretching, and to decrease pain through modalities and analgesics.
After these goals have been obtained, the athlete begins a strength-
ening program for the scapular stabilizers, core and lower extrem-
ities. The next focus is rotator cuff strengthening and stabilization,
followed by plyometrics and sport-specific motion patterns. This
process is given at least six to 12 weeks to gauge progress. Injections
can be utilized for pain control.
If the athlete fails to respond to rehabilitation, surgery for repair
of the injured labrum and rotator cuff is warranted. Recovery typi-
cally requires eight to 12 months to achieve a level of return to sport.
Prevention of overuse injuries requires diligence in resting the
18
LOUISVILLE MEDICINE
athlete when showing signs of fatigue and decreased performance.
Athletes in throwing and upper extremity propulsion sports should
stretch the shoulder capsule daily and maintain scapular and rotator
cuff strength. Watching pitch count is particularly important in
throwing athletes.
Dr. Smith practices orthopaedic surgery for Ellis & Bodenhausen Or-
thopaedics.
Endnotes
1 Pappas AM, Zawacki RM, Sullivan TJ; Biomechanics of baseball pitching: A
preliminary report. Am J Sports Med 1985; 13(4): 216-222.
2 Mihata T, Mcgarry MH, Neom, Ohue M, Lee TQ: Effect of anterior capsular
laxity on horizontal abduction and forceful internal impingement in a cadaveric
model of the throwing shoulder. Am J Sports Med 2015; 43(7): 1758-1763.
3 Walch G, Boileau P, Noel E, Donnell ST: Impingement of the deep surface of
the supraspinatus tendon on the posterior superior glenoid rim: An arthroscopic
study. J Shoulder and Elbow Surgery 1992; 1(5): 238-245.
4 Jobe CM: Posterior Superior Glenoid Impingement: Expanded Spectrum.
Arthroscopy 1995; 11(5): 530-536.
5 Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spec-
trum of pathology. Part 1: Pathoanatomy and biomechanics. Arthroscopy 2003;
19(4): 404-420.
6 Werner SL, Gill TJ, Murray TA, Cook TD, Hawkins RJ; Relationships between
throwing mechanics and shoulder distraction in professional baseball pitchers.
Am J Sports Med 2001; 29(3): 354-358.
7 Millstein ES, Snyder SJ: Arthroscopic management of partial, full thickness,
and complex rotator cuff tears: Indications, techniques and complications.
Arthroscopy 2003: 19 (suppl): 189-199.
8 Wilk KE, Macrina LC, Fleisig GS, et al: Deficits in glenohumeral passive range
of motion increase risk of shoulder injury in professional baseball pitchers: A
prospective study. Am J Sports Med 2015; 43(10): 2379-2385.
9 Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE Jr., Noonan TJ:
Preseason shoulder strength measurements in professional baseball pitchers;
Identifying players at risk for injury. Am J Sports Med 2010; 38(7): 1375-1382.
10 Fedoiw WW, Ramkummar P, McCulloch PC, Lintner DM: Return to play
after treatment of superior labral tears in professional baseball players. Am J
Sports Med 2014; 42(5): 1155-1160.