Shoulder Injuries
instability
If the ligaments in the shoulder are loose, the shoulder is
said to be “lax”. If this laxity can not be controlled by the rotator cuff, then
shoulder becomes “unstable”. In collision sports like football, instability most
often is the result of a trauma or blow to the shoulder and the athlete feels
like the shoulder comes part way or completely out of joint. In throwers,
however, instability is much more subtle. It develops gradually over time from
the thousands of throws year after year stretching the ligaments creating
increased laxity. If this laxity is too much for the rotator cuff to control,
then the shoulder will slip slightly off-center during the throwing motion,
causing pain. This can result from increasing laxity or from rotator cuff
weakness. The symptoms are pain and loss of velocity, rather than a sensation of
“slipping out of place”.
If the cause of this instability is from
rotator cuff weakness, strengthening the cuff through rehabilitation will
usually solve the problem. If the cause is too much laxity, increasing rotator
cuff strength may suffice, but has less of chance of doing so. Because there is
no way to tell if the rehabilitation will work beforehand, and surgery to
tighten the shoulder has a lengthy recovery, I always try rehabilitation first.
The odds are in your favor that it will work, and work quicker than surgery plus
rehabilitation would. However, if physical therapy does not succeed, surgery to
tighten the ligaments and capsule may be necessary. This can be
done arthroscopically as an outpatient.
instability
surgery:
Lately the trend has been to using sutures to "plicate" the
capsule by taking pleats in the tissue.
For years, open surgery was the only alternative to tighten
the shoulder. This was often unsuccessful in throwers due to the scar tissue and
stiffness that would develop. The shoulder would be stable, but often too stiff
to allow the external rotation needed to pitch competitively. As arthroscopic
techniques developed, the success rate improved. During the 1990’s, thermal
shrinkage was popular. Using a laser or heat probe, the ligaments could be
shrunk like a cotton shirt put in the dryer for the first time. The problem was
that the amount of shrinkage was difficult to control. While many shoulders
improved dramatically, some shoulders became very tight and some stretched out
soon after the surgery. Lately the trend has been to using sutures to “plicate”
the capsule by taking pleats in the tissue. This can be done arthroscopically
and the results are more predictable. I place sutures in the ligaments and
labrum, and then inspect the shoulder while putting the joint through motions
similar to throwing. The sutures can be changed to get the right amount of
tension. Of course, it is impossible to see what happens inside the shoulder
during an actual throw, but this is as close as we can get!
If the labrum is detached, this needs to be repaired also.
This is common in throwers, and involves using suture anchors to attach suture
to the bone (glenoid socket), then passing the sutures through the labrum and
tying the labrum down to the bone.
After the sutures are tied, the repair needs a chance to
heal. The sutures are not strong enough to keep the ligaments permanently tight
by themselves, so we depend on the body to heal the repair with living tissue.
It takes about six weeks for this tissue to be strong enough for everyday
activities, so you would wear a sling for about six weeks after surgery. It
takes about three months for the repair to be strong enough for light throwing,
so you could begin throwing three months after the surgery at the earliest.
Remember, the rotator cuff also controls the shoulder, so the cuff must be
strong enough to do its job before you can start throwing after surgery. That is
what the physical therapy is for!
Insert shoulder immobilizer pix
VIDEOS:
Diagnostic Shoulder
arthroscopy
Diagnostic shoulder
Arthroscopy - Slap Repair
slap suture anchors
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