Sports Medicine

Shoulder Injuries of Overhand Athletes

Bursitis

The bursa is a small fluid-filled sac that helps to reduce friction around the tendons and bones. It allows for the tendons to move smoothly. Inflammation and irritation of the bursa is a condition called bursitis and can be caused by both overuse and trauma. Rest and icing of the shoulder, anti-inflammatory medications, and physical therapy are conservative options to treat bursitis. However, if bursitis is not responsive to conservative treatment, a cortisone injection can help reduce inflammation in the shoulder. As a final option, arthroscopic shoulder surgery can be performed to remove the inflamed bursa that is causing pain.

Impingement Syndrome

A painful condition where the rotator cuff tendons and the fluid filled sac (bursa), which allows the shoulder to glide smoothly, rub against the acromion, a bony projection (bone spur) of the shoulder blade. Arthroscopy can be performed to shave the underside of the acromion to increase the amount of space between the acromion and the rotator cuff, thus reducing pain and inflammation and allowing for improved range of motion. Arthroscopy can also be performed to clean out inflamed and damaged tissue.

Internal Impingement

Internal Impingement most commonly affects overhead athletes (baseball players, tennis players). It refers to the condition in the shoulder joint where the rotator cuff tendons are pinched between the head of the arm bone (humerus) and the socket (glenoid). It results in injury or tearing of the rotator cuff and labrum including the superior labrum (SLAP tears). It may result in instability of the shoulder as well. Typically internal impingement occurs during the cocking phase of the throwing motion. While it often responds well to conservative treatment, there are times when the pathology is significant enough to warrant surgery.

Labral Tears

The labrum is a rim of soft tissue that adds depth to the shoulder socket (glenoid) to make the socket more like a cup. It goes around the socket like a bumper around a pool table. The labrum helps the socket hold the humeral head in place. Trauma to the shoulder, such as falling with the arm outstretched, or overuse can injure the labrum, resulting in a tear. Repetitive motion of the shoulder with an injured labrum can exacerbate the injury. Labral tears often lead to shoulder instability, in which the humeral head does not stay tightly in the socket. Pitchers in baseball are particularly susceptible to labral tears. Patients with a torn labrum may feel popping or catching during shoulder movements, aches, and pain. Labral tears are diagnosed through physical exam and MRI imaging. Conservative treatment is usually attempted first to treat labral tears and includes rest, anti-inflammatory medications, and cortisone injection. Physical therapy and stretching exercises are then recommended for anywhere from six weeks to 3 months. If a labral tear is nonresponsive to conservative treatment, surgery can be performed to reattach the torn labrum back to bone. Labral repairs are performed arthroscopically, in which the surgeon uses an arthroscope and instruments through small incisions in the patient’s shoulder. While conservative treatment is usually adequate for older patients who do not partake in high-level activity, surgery may be necessary for young athletes, such as baseball players, to return to their sport. Athletes, particularly pitchers and other overhead athletes, may require six months to one year to make a full recovery back to their sport.

Rotator Cuff Tears

A rotator cuff tear is a condition in which one or more of the rotator cuff tendons tears from its attachment on the proximal humerus. This can occur from a traumatic event, such as a fall, or, more commonly, from overuse. Many rotator cuff tears often begin as fraying and increase in size. Cuff tears can range from partial to full thickness tears. In complete rotator cuff tears, the rotator cuff is longer attached to the arm bone (humerus). Rotator cuff tears are common among baseball players as overuse injuries, especially pitchers. Patients with rotator cuffs will likely feel pain and weakness in the shoulder. Baseball players may complain of dead arm symptoms. Rotator cuff tears are diagnosed by examination and MRI or ultrasound. Pain and function can be improved conservatively with rest, medication, physical therapy and strengthening exercises, injection, and lifestyle changes. If pain and function do not respond to conservative treatment, surgery can be performed. Surgery is performed arthroscopically and involves re-attaching the torn tendon back to the head of the upper arm bone using anchors and sutures. A physical therapy program is prescribed, with several months typically required for recovery.

Rotator Cuff Tendonitis

The rotator cuff is a group of 4 muscles surrounding the shoulder that mainly help the arm rotate and help keep the ball centered on the socket to allow the deltoid and other large muscles to move the arm and shoulder. The muscles attach to the humerus via tendons. Rotator cuff tendonitis describes the condition in which one or more of these tendons becomes inflamed. Rotator cuff tendonitis can develop from overuse of the shoulder and is accompanied by shoulder pain in the upper arm, particularly during overhead movement. A physical exam and/or diagnostic imaging, such as X-ray and MRI, can be used to diagnose shoulder tendonitis. Usually, rest and strengthening exercises are recommended as treatment for rotator cuff tendonitis and anti-inflammatory medications may be used to help reduce pain and inflammation in the shoulder. A cortisone injection can also help reduce inflammation and pain for patients suffering from rotator cuff tendonitis as well.

Shoulder Instability

Shoulder instability is a condition where the ball (head) of the upper arm bone (humerus) pops out of the socket (glenoid) of the shoulder. It can partially slide out of place (subluxate) of the socket or completely come out of place (dislocate). Shoulder instability is caused when one or more of the following happens: connective tissue (labrum, ligaments and joint capsule) surrounding the shoulder joint tears, the rotator tears, bone from the sockets breaks. In overhead sports, overuse of the shoulder in repetitive throwing or overhead motion can cause stretching in the shoulder joint capsule and ligaments, loosening the joint. Proper overhead biomechanics and throwing technique are important to prevent instability. Patients with instability may experience pain, clicking and popping, weakness, and a sensation of the shoulder joint shifting out of place during movement. Your physician can perform tests during examination to diagnose instability. Patients can be tested for apprehension, which is the sensation that the shoulder does not feel stable and is about to either subluxate or dislocate. Diagnostic imaging, such as X-ray and MRI, can also be used to assist diagnosis. Depending on the cause of the instability combined with the patient’s age and activity level, shoulder instability may be treated conservatively with physical therapy, rest, and rehabilitation. In baseball players, adequate rest is extremely important in treating instability. If abnormal throwing or overhead biomechanics are determined to be a cause of instability, the player’s technique should be corrected or modified. An exercise program will likely be prescribed to improve outcomes and players suffering from shoulder instability should gradually return to baseball under the supervision of their physician and/or physical therapist. If conservative treatment fails, surgical intervention may be necessary and can be performed either arthroscopically or as an open procedure, depending on the specific pathology encountered. During surgery, torn ligaments are reattached or plicated to tighten the torn or stretched tissue.

Elbow Injuries of Overhand Athletes

Golfer’s Elbow (Medial Epicondylitis)

Golfer’s elbow (medial epicondylitis) is a common condition that is characterized by pain over the inner aspect of the elbow that can also radiate down the palm side of wrist. Medial epicondylitis is caused by damage to the tendons that bend the wrist toward your palm. This damage is due to repetitive overuse and is common among pitchers, who bend the wrist forward with excessive force while pitching. Your physician can diagnose medial epicondylitis through examination of your arm and with the help of diagnostic imaging. Most cases of medial epicondylitis are resolved with conservative treatment, including resting and a structured physical therapy program that focuses on stretching and strengthening of the elbow and forearm muscles. Cortisone injections can help alleviate immediate pain, but also present possible long-term negative side effects. Platelet rich plasma (PRP) injections can help alleviate symptoms without the risks associated with cortisone injection. Lastly, surgery can be performed to remove degenerative or torn tissue and repair healthy tendon back to bone.

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Tennis Elbow (Lateral Epicondylitis)

Tennis elbow (lateral epicondylitis) is a common condition that is characterized by pain over the outer aspect of the elbow and the muscles that control wrist extension, in which the wrist is bent upwards. Like medial epicondylitis, lateral epicondylitis is usually caused by repetitive overuse. Lateral epicondylitis is common amongst athletes who need to grip often, especially using the thumb and index and middle fingers. Despite the name “tennis elbow”, lateral epicondylitis is common, not only in tennis players, but baseball players and other athletes as well. Less than 5% of lateral epicondylitis diagnoses are in tennis players. Lateral epicondylitis is diagnosed through physical examination by a physician and usually successfully treated using conservative treatment, such as rest, physical therapy, and adjustment of any improper mechanics. As in medial epicondylitis, cortisone injections can help alleviate immediate pain in patients suffering from lateral epicondylitis, but also present possible long-term negative side effects. Platelet rich plasma (PRP) injections can be used to treat lateral epicondylitis without the risks associated with cortisone injection. As a final resort, surgery can be performed to remove degenerative or torn tissue and repairing healthy tendon back to bone.

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Torn Ulnar Collateral Ligament (UCL)

~ Tommy John Surgery

The ulnar collateral ligament (UCL) connects the upper arm bone (humerus) to the ulna, a bone in the forearm. This ligament is especially susceptible to tearing amongst throwing athletes, due to high stress and forces caused by the throwing motion. Constant overuse, such as when pitchers throwing high pitch counts and/or fail to rest sufficiently between competitions or practice, can lead to microscopic tears that eventually progress to larger tears. Although a tear in the UCL may not affect the daily activities of most normal people, athletes, such as baseball players, may experience pain or looseness in the elbow and decreased throwing ability. A torn UCL can be diagnosed by physical examination and with the help of MRI and X-rays. Conservative treatment for a torn UCL includes cessation of the offending sport, anti-inflammatory medications, a structured physical therapy and possibly a PRP injection. However, if the condition is nonresponsive to conservative treatment, surgery can be performed to replace the injured UCL with a tendon from elsewhere in the patient’s own body, such as the hamstring or wrist. This replacement tendon is called an autograft.. Throwing can resume four months after surgery, while pitching off a mound usually starts about 7 months after. Return to competitive play usually takes at least nine to twelve months.

Click to read more in-depth regarding Tommy John Surgery.

Overhand Injury Prevention

In order to prevent the aforementioned common overhand injuries, it is imperative to perform light stretching and warm up exercises prior to throwing and baseball activities. A throwing warm-up session is particularly important for pitchers, who should also adhere to league and age-recommended pitch count limits. Young athletes, in particular, should err on the conservative side of any league pitch count restrictions, as their bodies are still developing. Swimmers and volleyball and tennis players should also warm up their overhead motion prior to competitive play. It is also vital that athletes exhibit proper overhead biomechanics, especially pitchers who throw repeatedly at high speeds and with great force using the shoulder and elbow joints. If necessary, throwing or overhead mechanics and techniques may need to be adjusted to help prevent shoulder or elbow injuries. Adequate rest between substantial throwing sessions or sport competition is necessary for the body to recover and repair muscle tissue. Muscle strengthening, through proper weight and resistance training, can also be considered to prevent injury.