Sports Conditions

SLAP Tears

Aetiology

  • Overhead sports, especially throwing
  • Repetitive or chronic
  • Often in association with other conditions

Clinical Diagnosis

History

  • Pain with overhead activity
  • Deep anterior pain
  • Clicking

Clinical Tests

  • Crank test
  • O’Brien’s test
    • More pain with arm internally rotated than externally rotated
    • Replicates compression of humeral head against SLAP lesion
    • False positive with ACJ arthritis
    • High sensitivity, low specificity

MRI Arthrogram

  • Usually diagnostic

Diagnostic Arthroscopy

  • Gold standard

Outcomes

  • Good with appropriate diagnosis, treatment, and rehab
  • Fixation prone to causing stiffness; only perform if history, examination, and arthroscopic findings fit
  • Stiffness is especially problematic with concurrent cuff repair

Classification

Type Description Management
Type 1 Fraying of superior labrum, intact anchor Debride
Type 2 Unstable Biceps Anchor Re-attach
Type 3 Bucket handle detachment of superior labrum from intact biceps anchor Debride
Type 4 Bucket handle detachment of whole biceps anchor with propagation into LHB tendon Re-attach +/- LHB tenotomy

Additional Types:
- Type 5 – SLAP with Labral tear – reattach both
- Type 6 – Superior flap tear – debride
- Type 7 – SLAP with capsular tear – fix and reattach

Spinoglenoid Notch Cyst

Aetiology

  • In association with a SLAP tear
  • Synovial fluid leaks out via SLAP to form a cyst in the spinoglenoid notch
  • Causes compression of suprascapular nerve at spinoglenoid notch
  • Suprascapular nerve has already given off branch to supraspinatus, only infraspinatus is affected

Clinical Features

  • Weakness out of proportion to pain
  • Infraspinatus fossa wasting
  • External rotation lag sign positive

Imaging

  • MRI
    • High signal on T2
    • SLAP lesion

Management

  • Surgical if:
    • Nerve compression
    • Symptomatic SLAP lesion
  • Surgery:
    • Decompress cyst
    • Repair SLAP (often repair alone suffices as cyst will resorb)

Complications

  • Recurrence – rare if SLAP repaired
  • Suprascapular nerve injury

Internal Impingement

Aetiology

  • Posterior RTC is impinged against posterior superior aspect of glenoid
  • Due to:
    1. Throwing sports – stretch anterior & tighten posterior capsule
    2. Micro anterior instability
    3. Posterior capsular tightness

Clinical Findings

  • Pain during the activity at the late cock back phase
  • Pain on abduction & external rotation of the arm

XR Features

  • May see extra-articular calcification behind posterior superior glenoid (Bennett Lesion)

MR Features

  • Articular surface RCT fraying

Arthroscopy

  1. Hypertrophy of posterior labrum
  2. Peel back of labrum
  3. Chondral damage
  4. Articular side cuff tear

Management

  • Mainstay is non-operative
    • Sleeper stretches for posterior capsule
    • RTC strengthening to minimize anterior stability
  • Surgical – if non-operative fails
    • Debride and repair any structures at posterior-superior glenoid
    • Address cuff tear:
      • Debride if <50% thickness

      • 50% perform transtendinous in situ repair without takedown

Biceps Tendon Pathology

Tendinitis/Tendinosis

  • Almost never in isolation
  • Usually in association with RTC tear or bicipital groove stenosis
    • Subscapularis
    • Leading edge supraspinatus
  • Likely degenerative pathology

Diagnosis

  • Pain over anterior shoulder
  • Activity related
  • Tests:
    • Speed’s
    • Yergason’s
  • MRI:
    • Fluid in bicipital groove

Management

Non-Operative

  • Activity modification, analgesia, physiotherapy
  • Injection into LHB sheath

Operative

  • Debridement of tendon and tendon sheath
  • Surgical decompression of stenotic sheath
  • Tenodesis

Proximal Biceps Rupture

  • Usually preceded by shoulder symptoms
  • Snap/pop
  • Extensive bruising
  • Popeye sign
  • Rarely needs any treatment at all

Biceps Tendon Subluxation

Aetiology

  • Strongly associated with subscapularis tear
  • May also be due to CHL tear or transverse humeral ligament tear
  • Subluxates into intra-articular space normally
  • May occur secondary to GT or LT fracture

Clinical Features

  • Popping sound & sensation on external rotation, abduction of arm
  • Patient points to area and can relocate tendon with rotation
  • Painful – tendon inflammation
  • Weakness of subscapularis

Imaging

  • MRI or Dynamic USS
    • Demonstrate LHB outside its groove
    • Subscapularis tear
    • Fluid in sheath

Management

Non-Operative

  • If possible

Operative

  • Subscapularis repair
  • Relocation of tendon
  • Debridement of tendinotic portion and sheath
  • Tenodesis
    • Detach from glenoid and fold back and sew to soft tissues or proximal humerus

Acromioclavicular Joint Arthritis

Aetiology

  • Common in middle-aged and older people
  • Associated with:
    • Heavy labor, pneumatic tools
    • Post-traumatic ACJ injury
    • Idiopathic

Clinical Features

  • Specific pain over ACJ
  • Impingement secondary to bone spurs
  • Tests:
    • Cross arm abduction test
    • Paxino’s compression test (AP compression of ACJ)

Diagnostic/Therapeutic LA/Steroid Injection

  • 2ml syringe & blue needle into ACJ following plane of joint from XR

Imaging

  • XR
    • Often shows ACJ pathology (not always symptomatic, beware of other shoulder conditions)
  • MRI
    • If doubt over diagnosis
    • Screens rest of shoulder for other pathology
    • Shows high signal in ACJ – more likely to be a pain source

Management

Non-Operative

  • Activity modification, analgesia
  • Injection – diagnostic and therapeutic

Surgical

  • Arthroscopic:
    • Anterior working portal opposite ACJ
    • Lateral viewing portal
    • Excise bone on either side of joint (more from clavicle than acromion)
    • Leave superior capsule intact – main stabilizer
    • Ensure removal of all impinging bone posteriorly (main cause of procedure failure)
  • Open:
    • Useful if angle of ACJ difficult to resect arthroscopically
    • Results equal if not better than arthroscopic
    • Slightly longer recovery
    • Can be painful for several weeks
    • Raise full-thickness capsular flaps to allow good repair
    • Excise distal clavicle mainly
    • Ensure posterior impinging bone all removed

Distal Clavicle Osteolysis

Aetiology

  • Weight lifters
  • Overhead throwers
  • Post-traumatic distal clavicle fracture or ACJ injury

Clinical Presentation

  • Pain with overhead activities
  • Positive signs as for ACJ OA

Management

  • Distal clavicle resection
  • Stabilize distal clavicle if elevated:
    • Weaver Dunn
    • Surgilig fixation
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