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Rotator Cuff and Impingement Injuries
Among athletic patients, overhead athletes are perhaps the most susceptible to rotator cuff injuries. They exhibit a high incidence of age-adjusted partial and small complete rotator cuff tears. The persistently high demands on the rotator cuff may predispose them to recurrent episodes of anterior, rotator cuff-related shoulder pain. Successful management of these patients requires a thorough knowledge of the relevant pathoanatomy, as well as an accurate and complete diagnosis.
Pathophysiology
Rotator cuff injuries in overhead athletes are rarely the result of a single etiologic factor. The complex interaction among the rotator cuff, the static capsular restraints, and the scapular stabilizers can be disrupted by abnormalities of any of these component structures. Potential contributing factors to rotator cuff injuries in the athlete include tensile failure of the rotator cuff tendon fibers, poor scapular mechanics, rotator cuff imbalance, anterior capsular laxity, posterior capsular contracture, and traditional supraspinatus outlet narrowing. Rotator cuff and impingement injuries are usually the result of a number of these etiologic factors acting concurrently.
History
Most overhead athletes with rotator cuff injuries do not report a single, isolated traumatic event. More often, the onset of shoulder pain is gradual and progressive. Overhead athletes who do report a single traumatic episode usually convey the presence of pre-existing shoulder pain of variable duration. Moreover, they may also recall previous episodes of shoulder pain that have resolved.
Magnetic Resonance Imaging
Rotator cuff imaging is a useful adjunct to history, physical examination, and radiographic evaluation in the athlete with suspected rotator cuff injury. Ultrasonography, arthrography, and magnetic resonance imaging (MRI) are all valid methods of rotator cuff imaging. However, MRI is especially useful in the athlete with suspected rotator cuff injury because of its ability to provide complementary information regarding the glenoid labrum.
NON-OPERATIVE MANAGEMENT
Phases of Shoulder Rehabilitation
Phase 1
Rest from painful activity.
Anti-inflammatory therapy
Passive range-of-motion and active-assisted range-of-motion exercises
Joint mobilization
Strengthening
Scapulothoracic strengthening
Aerobic conditioning
Phase 2
Progress range of motion and flexibility
Strengthening (manual, elastic band, and isotonic; multiangle isometrics; short-arc to full-arc excursion)
Aggressive scapulothoracic strengthening and integration
Aerobic conditioning
Phase 3
Prophylactic stretching
Strengthening and endurance (to full range and emphasize eccentrics, then progress to sport-specific positions); variable or free weight resistance, or both; isokinetics; plyometrics
Phase 4
Return to sport
SURGICAL MANAGEMENT
The athlete’s high activity level places significant demands on the post-operative shoulder and may influence the patient’s impression of the quality of the post-op result. This is particularly true of overhead athletes. Arthroscopy is better tolerated in the early post-op period because there is less potential for deltoid morbidity. The goal of arthroscopy is to smooth the undersurface of the anterior acromion. Arthroscopic surgery offers the advantage of decreased scarring and less deltoid morbidity, both of which may influence an athlete’s ability to return to competition after surgery.
Complete Rotator Cuff Tear
Complete rotator cuff tears, particularly in overhead athletes, often require operative repair in order to allow a return to competition. However, a 6- 12 week trial of rehabilitation and activity modification may be warranted. Most complete rotator cuff tears in overhead athletes are small (1 – 2 cm or 1 tendon) and minimally retracted. These are frequently amenable to arthroscopic repair. In larger tears (more than 2 cm or 1 tendon), open repair is preferred.
Williams, G.R.; Kelley, M.
Rotator Cuff and Impingement Injuries
Among athletic patients, overhead athletes are perhaps the most susceptible to rotator cuff injuries. They exhibit a high incidence of age-adjusted partial and small complete rotator cuff tears. The persistently high demands on the rotator cuff may predispose them to recurrent episodes of anterior, rotator cuff-related shoulder pain. Successful management of these patients requires a thorough knowledge of the relevant pathoanatomy, as well as an accurate and complete diagnosis.
Pathophysiology
Rotator cuff injuries in overhead athletes are rarely the result of a single etiologic factor. The complex interaction among the rotator cuff, the static capsular restraints, and the scapular stabilizers can be disrupted by abnormalities of any of these component structures. Potential contributing factors to rotator cuff injuries in the athlete include tensile failure of the rotator cuff tendon fibers, poor scapular mechanics, rotator cuff imbalance, anterior capsular laxity, posterior capsular contracture, and traditional supraspinatus outlet narrowing. Rotator cuff and impingement injuries are usually the result of a number of these etiologic factors acting concurrently.
History
Most overhead athletes with rotator cuff injuries do not report a single, isolated traumatic event. More often, the onset of shoulder pain is gradual and progressive. Overhead athletes who do report a single traumatic episode usually convey the presence of pre-existing shoulder pain of variable duration. Moreover, they may also recall previous episodes of shoulder pain that have resolved.
Magnetic Resonance Imaging
Rotator cuff imaging is a useful adjunct to history, physical examination, and radiographic evaluation in the athlete with suspected rotator cuff injury. Ultrasonography, arthrography, and magnetic resonance imaging (MRI) are all valid methods of rotator cuff imaging. However, MRI is especially useful in the athlete with suspected rotator cuff injury because of its ability to provide complementary information regarding the glenoid labrum.
NON-OPERATIVE MANAGEMENT
Phases of Shoulder Rehabilitation
Phase 1
Rest from painful activity.
Anti-inflammatory therapy
Passive range-of-motion and active-assisted range-of-motion exercises
Joint mobilization
Strengthening
Scapulothoracic strengthening
Aerobic conditioning
Phase 2
Progress range of motion and flexibility
Strengthening (manual, elastic band, and isotonic; multiangle isometrics; short-arc to full-arc excursion)
Aggressive scapulothoracic strengthening and integration
Aerobic conditioning
Phase 3
Prophylactic stretching
Strengthening and endurance (to full range and emphasize eccentrics, then progress to sport-specific positions); variable or free weight resistance, or both; isokinetics; plyometrics
Phase 4
Return to sport
SURGICAL MANAGEMENT
The athlete’s high activity level places significant demands on the post-operative shoulder and may influence the patient’s impression of the quality of the post-op result. This is particularly true of overhead athletes. Arthroscopy is better tolerated in the early post-op period because there is less potential for deltoid morbidity. The goal of arthroscopy is to smooth the undersurface of the anterior acromion. Arthroscopic surgery offers the advantage of decreased scarring and less deltoid morbidity, both of which may influence an athlete’s ability to return to competition after surgery.
Complete Rotator Cuff Tear
Complete rotator cuff tears, particularly in overhead athletes, often require operative repair in order to allow a return to competition. However, a 6- 12 week trial of rehabilitation and activity modification may be warranted. Most complete rotator cuff tears in overhead athletes are small (1 – 2 cm or 1 tendon) and minimally retracted. These are frequently amenable to arthroscopic repair. In larger tears (more than 2 cm or 1 tendon), open repair is preferred.
Williams, G.R.; Kelley, M.
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