Thrower’s Shoulder; Causes, Symptoms , Diagnosis Treatment

Thrower’s Shoulder; Causes, Symptoms , Diagnosis Treatment

Thrower’s shoulder has long been a topic of debate among shoulder specialists. The tremendous forces produced during the throwing motion coupled with the compilation of the pathology encountered in the thrower’s shoulder have generated a complex treatment algorithm. Simplifying management options has been challenging and recommendations continue to evolve. Treatment of injuries to the thrower’s shoulder most commonly involves addressing partial articular-sided rotator cuff tears. These can be isolated or more commonly associated with tearing of the posterior superior labrum. The understanding of the dramatic difference between the surgical treatment of shoulder injuries in overhead athletes and nonoverhead athletes is paramount to positive outcomes after surgery.

The throwing athlete’s shoulder is a unique, complex entity with challenges in diagnosis and management. The shoulders in these athletes possess unique biomechanics and pathologic conditions. Unfortunately, return to play outcomes are often poor when specifically evaluating overhead athletes, especially with regard to a SLAP repair. It is imperative for the surgeon to be cautious when indicating these athletes for surgery because although they may demonstrate improvements in pain and general function, subtle changes in accuracy or velocity as a result of surgery can significantly affect the success of an overhead throwing athlete at the competitive level.

  • runs from the superior aspect of the glenoid and coracoid process to the fovea capitis just superior to the lesser tuberosity of the humerus
  • initially anterior then anteroinferior to the long head of the biceps tendon; stabilizes the biceps brachii tendon 3
  • runs from the anterosuperior glenoid, arising just inferior to the superior GHL, to the anterior aspect of the anatomic neck of the humerus
  • sometimes referred to as the inferior glenohumeral ligament complex
  • runs from the inferior two-thirds of the glenoid labrum and/or neck to the lateral humerus
  • composed of three parts
    • anterior band
    • posterior band
    • axillary pouch: laxity between anterior and posterior bands
  • most important of the three GHLs as it prevents dislocation at the extreme range of motion and is the main stabilizer of the abducted shoulder 
  • also referred to as fasciculus obliquus 
  • runs from the infraglenoid tubercle and triceps tendon to the lesser tubercle of the humerus where it shares an insertion with the subscapularis tendon
  • not well-known, but consistently demonstrated on both anatomic dissection and MR arthrography
  • superior GHL is almost always present (97%) but has a variable origin, arises with biceps brachii tendon, arises with middle GHL
  • middle GHL is variable in size and appearance 1 and absent in 30% forms part of the Buford complex.

Pathophysiology

The extrinsic compressive theory of SIS supports the inciting factors leading to SIS to be anatomic and/or mechanical in nature. These structures result in increased pressures and pathologic contact, leading to a susceptible and tendinopathic cuff.  Extrinsic mechanisms include:

  • SIS
  • Internal impingement

The intrinsic theory of SIS cites the predisposition for a weakened cuff which degenerates over time. Age, hand-dominance, vascular changes, and repetitive eccentric forces cause the cuff to weaken over time, compromising the dynamic stability of the shoulder. Consequently, the humeral head migrates proximally and decreases the acromiohumeral interval, predisposing the cuff to further injury and degeneration.  Intrinsic mechanisms include:

Tendon vascularity (the anterior critical zone of the supraspinatus tendon)

  • Tendon biology
  • Tendon mechanical properties
  • Tendon morphology
  • Genetic predisposition

Causes of Thrower’s Shoulder

Buford complex is a congenital glenoid labrum variant where the anterosuperior labrum is absent in the 1-3 o’clock position and the middle glenohumeral ligament is thickened (cord-like) and originates directly from the superior labrum at the base of the biceps tendon and crosses the subscapularis tendon to insert on the humerus. It is present in approximately 1.5% of individuals.

Of the five phases that make up the pitching motion, the late cocking and follow-through phases place the greatest forces on the shoulder.

  • Late-cocking phase – in order to generate maximum pitch speed, the thrower must bring the arm and hand up and behind the body during the late cocking phase. This arm position of extreme external rotation helps the thrower put speed on the ball, however, it also forces the head of the humerus forward which places significant stress on the ligaments in the front of the shoulder. Over time, the ligaments loosen, resulting in greater external rotation and greater pitching speed, but less shoulder stability.
  • Follow-through phase-  During acceleration, the arm rapidly rotates internally. Once the ball is released, follow-through begins and the ligaments and rotator cuff tendons at the back of the shoulder must handle significant stresses to decelerate the arm and control the humeral head.
  • Rotator cuff (RC) tendonitis/tendinosis acute or chronic tendinopathic conditions that result from a vulnerable environment for the RC secondary to repetitive eccentric forces and predisposing anatomical/mechanical risk factors. Acute injuries and chronic overuse can result in focally weakened cuff regions. These vulnerable areas evolve into PTTs or FTTs, depending on the type of eccentric forces experienced by the RC.[rx]
  • Shoulder impingement  a clinical term often used nonspecifically to describe patients experiencing pain/symptoms with overhead activity.
  • Internal impingement[rx] –  common in overhead-throwing athletes such as baseball pitchers and javelin throwers. Impingement occurs at the posterior/lateral articular side of the cuff as it abuts the posterior/superior glenoid rim and labrum when the shoulder is in maximum abduction and external rotation (i.e., the “late cocking” phase of throwing) The term, “thrower’s shoulder” refers to a common set of anatomic adaptive changes that occur over time in this subset of athletes. These adaptive changes include but are not limited to increased humeral retroversion and posterior capsular tightness. Glenohumeral internal rotation deficit (GIRD) is a condition resulting from these anatomic adaptations, and GIRD is known to predispose the thrower’s shoulder to internal impingement.
  • External impingement –  a term used synonymously with SIS. External impingement (EI) encompasses etiologies of external compressive sources (i.e. the acromion) leading to subacromial bursitis and bursal-sided injuries to the RC.[rx][rx][rx]
  • Mechanism of injury – The two described mechanisms for acute tears of the triceps are direct contact trauma, such as a fall or hitting fixed resistance with the posterior elbow[,,,]. Weightlifting[,,,,] was the most common sport associated with acute tears and was often associated with a history of steroid use[,,]. American football[,] and general sports injuries[], as well as direct lacerations[] have all also been reported as a mechanism
  • Trauma – Injuries to the triceps, such as a muscle tear from placing too much force on the muscle, can lead to pain.
  • Repetitive stress – Repeating the same shoulder motions, again and again, can stress your triceps muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse of tears, as well.
  • Lack of blood supply – As we get older, the blood supply in our triceps brachiilessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
  • Bone spurs – As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the triceps brachii muscle. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of injury.
  • Sports injuries – Many Injury occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline
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Symptoms Of Thrower’s Shoulder

Depending on the cause of your shoulder pain you may experience

  • Pain deep in the shoulder joint, in the back or the front of the shoulder and the upper part of the arm. Sometimes the pain in the shoulder can be described as a ‘catching pain’. The location and type of pain is likely to relate to the structure causing the pain
  • Reduced movement, and pain when moving your shoulder.
  • The weakness of the shoulder/upper arm. Depending on the condition, there may be a sensation of the joint slipping out and back into the joint socket, or the shoulder can become completely dislodged (dislocated)
  • Sensations of pins and needles (tingling) and burning pain. This is more likely to be associated with nerves from the neck than the shoulder joint itself.
  • Lack of movement after a shoulder dislocation. This is usually due to pain. Complete rotator cuff tears and injury to the axillary nerve both cause weakness in moving the arm away from the body. These problems require close clinical examination.

Symptoms Of 

  • Pain in the muscle after impact.
  • Pain and difficulty when lifting the arm to the side.
  • Tender to touch the muscle.
  • Bruising appears.
  • There may be some swelling

Diagnosis of Thrower’s Shoulder

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Definitions for common terminology used in the diagnosis and treatment of GIRD

Term Definition
GIRD (glenohumeral internal rotation deficit) Loss of internal rotation (IR) of ≥20° or greater compared to the contralateral shoulder
TRM (total rotational shoulder motion) Summation of internal and external rotation (ER) measured at 90° of shoulder abduction; should not exceed 187°
Internal impingement Contact between the greater tuberosity of the humerus and the posterior superior glenoid rim leading to impingement of the posterosuperior labrum and articular side of the rotator cuff
External impingement Contact between and greater tuberosity of the humerus and the acromion leading to impingement on the bursal side of rotator cuff
SLAP (superior labrum, anterior to posterior) Tear of the superior labrum from anterior to posterior
ABER (abduction and ER) Position of the shoulder in the cocking phase of throwing where shoulder abduction is ≥90° and ER can achieve up to 160°
IGHL (inferior glenohumeral ligament) Capsular thickening that provides restraint to the translation of the humeral head; anterior band prevents posterior translation in ABER and posterior band prevents anterior translation
PASTA (partial articular-sided supraspinatus tear) Articular-sided partial-thickness tear of the posterior supraspinatus tendon caused by internal impingement of the greater tuberosity on the posterior labrum

Thorough pitching history and shoulder pain history.

Pitching History Pain History
Age patient first began pitching Description of pain: location, character, duration, radiation
Total years throwing The phase of throwing cycle in which pain occurs
Number of outings per year Point of the season when the pain began (is thrower exceeding the number of innings he or she is accustomed to throwing)
The approximate number of pitches/outing The point in outing pain begins (early innings vs late innings)
Were pitch-count limits enforced Changes in velocity
Amount of rest between outings Changes inability to locate the ball
Amount of complete rest from throwing/year Changes in endurance (ability to go into late innings)
Types of pitches thrown Changes in ability to “get loose” prior to the outing
Age at which different pitches were first thrown
The ratio of fastballs to breaking balls thrown
History of injury/treatment to throwing a shoulder
History of missed outings due to pain or injury

The clinician can assess motor strength grading for C5 to T1 nerve roots in addition to specific RC muscle strength testing. Specifically, RC strength and/or pathology can be assessed via the following examinations

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Supraspinatus

  • Jobe’s test – the positive test is pain/weakness with resisted downward pressure while the patient’s shoulder is at 90 degrees of forwarding flexion and abduction in the scapular plane with the thumb pointing toward the floor.
  • Drop arm test –  the patient’s shoulder is brought into a position of 90 degrees of shoulder abduction in the scapular plane. The examiner initially supports the limb and then instructs the patient to slowly adduct the arm to the side of the body. A positive test includes the patient’s inability to maintain the abducted position of the shoulder and/or an inability to adduct the arm to the side of the trunk in a controlled manner.

Infraspinatus (IS)

  • Strength testing is performed while the shoulder is positioned against the side of the trunk, the elbow is flexed to 90 degrees, and the patient is asked to externally rotate (ER) the arm while the examiner resists this movement.
  • External rotation lag sign: the examiner positions the patient’s shoulder in the same position, and while holding the wrist, the arm is brought into maximum ER. The test is positive if the patient’s shoulder drifts into internal rotation (IR) once the examiner removes the supportive ER force at the wrist.

Teres Minor (TM)

  • Strength testing – is performed while the shoulder positioned at 90 degrees of abduction and the elbow is also flexed to 90 degrees. Teres minor (TM) is best isolated for strength testing in this position while ER is resisted by the examiner.
  • Hornblower’s sign –the examiner positions the shoulder in the same position and maximally ERs the shoulder under support. A positive test occurs when the patient is unable to hold this position and the arm drifts into IR once the examiner removes the supportive ER force.
  • IR lag sign –  the examiner passively brings the patient’s shoulder behind the trunk (about 20 degrees of extension) with the elbow flexed to 90 degrees. The examiner passively IRs the shoulder by lifting the dorsum of the handoff of the patient’s back while supporting the elbow and wrist. A positive test occurs when the patient is unable to maintain this position once the examiner releases support at the wrist (i.e., the arm is not maintained in IR, and the dorsum of the hand drifts toward the back)
  • Passive ER ROM – a partial or complete tear of the subscapularis (SubSc) can manifest as an increase in passive ER compared to the contralateral shoulder.
  • Liftoff test – more sensitive/specific for lower SubSc pathology. In the same position as the IR lag sign position, the examiner places the patient’s dorsum of the hand against the lower back and then resists the patient’s ability to lift the dorsum of the hand away from the lower back.
  • Belly press –  more sensitive/specific for upper subscapularis pathology. The examiner has the patient’s arm at 90 degrees of elbow flexion, and IR testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The elbow is initially supported by the examiner, and a positive test occurs if the elbow is not maintained in this position upon the examiner removing the supportive force.

External impingement/SIS

  • Neer impingement sign – positive if the patient reports pain with passive shoulder forward flexion beyond 90 degrees.
  • Neer impingement test – positive test occurs after a subacromial injection is given by the examiner and the patient reports improved symptoms upon repeating the forced passive forward flexion beyond 90 degrees.
  • Hawkins test – positive test occurs with the examiner passively positioning the shoulder and elbow at 90 degrees of flexion in front of the body. The patient will report pain when the examiner passively IR’s shoulder.

Internal impingement

  • Internal impingement test – the patient is placed in a supine position, and the shoulder is brought into terminal abduction and external rotation. A positive test reproduces the patient’s pain.

Jerk test

  • The jerk test (posterior stress test) has been considered to be highly sensitive for posterior instability. This test is performed by stabilizing the scapula with one hand, while the other hand holds the elbow with the arm in 90° of abduction and internal rotation. A firm axial compression force is applied to the glenohumeral joint. The arm is horizontally adducted while maintaining the firm axial load.

Kim test

  • A further test for posterior instability is the so-called Kim test, which is a modification of the jerk test []. The test is performed with the patient in a sitting position and their arm in 90° of abduction. The examiner holds the elbow and lateral aspect of the proximal arm and applies a strong axial load in line with the scapula. While maintaining the axial load, the arm of the patient is elevated 45° diagonally upward and a posterior force is applied to the proximal arm. The test is positive if the patient complains of pain during this maneuver.
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Pertinent findings

The most common radiographic changes associated with EI/SIS and RCS include:

  • RCA – Proximal humeral migration and decreases in the acromiohumeral interval to < 7 mm
  • Degenerative findings:
    • osteophytes on the acromion, proximal humerus and/or glenoid are often seen in cases of advanced disease
    • calcification of the CAL and/or coracohumeral ligament (CHL)
    • greater tuberosity cystic degeneration
    • AC joint arthritis
  • Hooked” acromion- best appreciated on the supraspinatus outlet view
  • Os acromiale- best seen on an axillary lateral radiograph

Imaging Tests

Your doctor may order tests to confirm your diagnosis and identify any associated problems.

  • X-rays – This imaging test creates clear pictures of dense structures, like bone. X-rays will show any problems within the bones of your shoulder, such as arthritis or fractures.
  • Magnetic resonance imaging (MRI) – This imaging study shows better images of soft tissues. It may help your doctor identify injuries to the labrum, ligaments, and tendons surrounding your shoulder joint.
  • Computed tomography (CT) scan – This test combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.-
  • Ultrasound – Real-time images of muscles, tendons, ligaments, joints, and soft tissues can be produced using ultrasound. This test is typically used to diagnose rotator cuff tears in individuals who are not able to have MRI scans.

Ultrasound

  • Ultrasound (US) is an often-underutilized imaging modality to detect RC tendon and muscle belly integrity. In 2011, a meta-analysis of over 6,000 shoulders revealed a sensitivity of 0.96 and specificity of 0.93 in assessing shoulders for partial- or full-thickness cuff tears. Another study highlighted the potential inability to differentiate between partial- and full-thickness cuff tears (PTT versus FTT) measuring about 1 cm in size.

Magnetic Resonance Imaging

  • Magnetic Resonance Imaging (MRI) is useful in evaluating the overall degree of RC pathology. MRI can be helpful in providing more accurate cuff tear details, including partial- versus full-thickness tears, the extent and size of the tear(s), location, and the degree of retraction. In cases of chronic RC pathology, the cuff can be assessed for fatty degenerative changes on the T1-weighted sagittal sequence series.[rx]

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Differential diagnosis of pain in the throwing shoulder.

Extrinsic Intrinsic Neurovascular
Rotator cuff Bone Thoracic outlet syndrome
Tendinitis Bony Bankart Neurogenic, arterial, venous
Tear OCD Axillary artery
Subacromial impingement Posttraumatic/osteoarthritis Thrombosis, aneurysm
Scapular dysfunction Bennett’s lesion Effort thrombosis
Scapular dyskinesis Biceps tendon Quadrilateral space syndrome
SICK scapula Tendinitis/tendinopathy Long thoracic nerve palsy
Snapping scapula Soft tissue Suprascapular nerve palsy
Scapulothoracic bursitis SLAP Brachial neuritis
Scapular winging Bankart/anterior instability
Posterior labral tear/posterior instability
HAGL
MDI
GIRD
OCD, osteochondritis dissecans; SICK, Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement; SLAP, superior labrum anterior and posterior; HAGL, humeral avulsion of the glenohumeral ligament; MDI, multidirectional instability; GIRD, glenohumeral internal rotation deficit.

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Treatment of Thrower’s Shoulder

Nonsurgical Treatment

In many cases, the initial treatment for a throwing injury in the shoulder is nonsurgical. Treatment options may include:

  • Activity modification – Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.
  • Ice –  Applying icepacks to the shoulder can reduce any swelling.
  • Anti-inflammatory medication – Drugs like ibuprofen and naproxen can relieve pain and inflammation. They can also be provided in the prescription-strength form.
  • Physical therapy – In order to improve the range of motion in your shoulder and strengthen the muscles that support the joint, your doctor may recommend specific exercises. Physical therapy can focus on muscles and ligament tightness in the back of the shoulder and help to strengthen the structures in the front of the shoulder. This can relieve some stress on any injured structures, such as the labrum or rotator cuff tendon.
  • Change of position – Throwing mechanics can be evaluated in order to correct body positioning that puts excessive stress on injured shoulder structures. Although a change of position or even a change in sport can eliminate repetitive stresses on the shoulder and provide lasting relief, this is often undesirable, especially in high-level athletes.
  • Cortisone injection— If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine. Injecting it into the bursa beneath the acromion can provide long-term pain relief for tears or other structural damage.

Throwers

  • Special attention to preoperative internal rotation deficit and scapular dyskinesis
  • Consider internal impingement as a cause of pain
  • Special attention to the posterior aspect of the supraspinatus and anterior infraspinatus
  • Special attention to the posterior superior labrum
  • Consider debridement of partial rotator cuff tears and posterior superior labral tears
  • Postoperative accelerated thrower’s rehabilitation.

Nonthrowers

  • Special attention to preoperative strength and night pain
  • Consider external impingement as a cause of pain
  • Special attention to the anterior aspect of the supraspinatus
  • Special attention to the acromial morphology or acromioclavicular joint arthritis
  • Consider completion and repair of the partial rotator cuff tear with acromioplasty and distal clavicle excision
  • Postoperative immobilization and physical therapy

Treatment guidelines for the overhead athlete. given the complex nature of rotator cuff syndrome (RCS), we recommend the treatment and management be broken down into the following categories:

Group 1: Partial-Thickness (PTTs) or Full-Thickness RC Tears (FTTs), Asymptomatic Patient

  • Patients presenting with MRI-evidence of PTTs or FTTs often present without any symptoms. The most recent American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) summary reported the growing awareness of incidental RC pathology revealed via shoulder MRIs in asymptomatic patient populations. Although there is evidence of the increasing prevalence of RC disease in the aging population, there is no reliable evidence that surgical intervention prevents tear propagation or the development of clinical symptoms.  Thus, the committee recommended symptomatic management via nonoperative modalities alone.[rx]

Group 2: Partial-Thickness (PTTs), Symptomatic Patients

  • Patients presenting with symptoms of EI/SIS in the absence of FTTs are first managed with nonoperative treatment modalities. There is no agreed-upon time interval that is most appropriate to proceed with surgical intervention in this particular group of patients. The literature ranges from 3 months to 18 months. Surgical intervention should be individually tailored based on the patient’s symptoms, improvement with nonoperative modalities, and overall goals.[rx][rx]

Group 3: Chronic RC Tears, Symptomatic Patients

  • The AAOS CPG reported a “weak” recommendation grade secondary to limited available evidence in the literature comparing rotator cuff repair (RCR) to continued nonoperative treatment modalities in this subset of patients. Certainly, the overall clinical picture must be considered, and the treatment tailored to the individual patient in each scenario.

Nonoperative RCS Treatment Modalities[rx][rx]

Physical therapy (PT)

  • Physical therapy (PT) remains the mainstay of first-line treatment for RCS. PTTs can often be managed with PT alone, including an aggressive RC and periscapular stabilizer strengthening programs, as well as ROM exercises.

Anti-inflammatory medications

  • First-line nonoperative management also includes the use of non-steroidal anti-inflammatory (NSAIDs) medications in conjunction with PT modalities.
  • Although the AAOS CPG reported inconclusive evidence for the use of NSAIDs, iontophoresis, transcutaneous electrical nerve stimulations (TENS), and other similar therapy modalities in the presence of FTTs, the committee reported a “moderate” recommendation grade for exercises and/or NSAIDs in the presence of RCS symptoms in the absence of FTTs.

Cortisone injections

  • For EI/SIS, the most utilized injection includes one into the subacromial space. Patients can experience symptomatic relief almost instantaneously after the injection is given, ideally allowing them to participate in subsequent PT therapy sessions.

Rest/Activity modifications

  • Patients benefit from an initial period of rest from the exacerbating activity (occupation or sport), especially repetitive overhead activity and heavy lifting

Surgical management

RCS surgical techniques range from debridement, subacromial decompression (SAD), and/or acromioplasty to RC debridement and, when indicated, RC bursal- or articular-sided tear completion with RCR. The latter will not be discussed in this review. Assuming no RC FTTs are present, the extent of surgical management for external impingement/SIS alone includes [rx]3rx][rx][rx][rx]:

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Subacromial decompression

  • Extensive debridement of the subacromial space is beneficial in patients with persistent symptoms of EI/SIS after at least 4 to 6 months of failed nonoperative modalities
  • Comprehensive bursectomy allows for the thorough and more accurate evaluation of the bursal side of the cuff itself
  • CAL debridement is recommended in the setting of substantial CAL fraying and/or calcification as this is considered an additional source of impingement.
  • A meta-analysis of nine studies comparing open versus arthroscopic procedures yielded equivalent surgical times, outcomes, and complication rates at 1-year follow-up; the arthroscopic cohort returned to work quicker compared to the open cohort.

Acromioplasty

  • Shaving the undersurface of the acromion, especially in the setting of significant spurring, improves the environment surrounding the cuff and allows additional clearance distance between the acromion and cuff itself throughout mid-arc and terminal ROM and impingement positions.
  • With hooked acromion morphologies, care is taken to debride this area with a shaver, burr, or rasp to flatten the undersurface.
  • The anterior extent of the acromioplasty is demarcated by the anterior deltoid origin. This area should be respected in the debridement process. The anteroinferior region of the acromion is a common site of spurring and causes impingement symptoms in these patients.

Os acromiale

  • With persistent symptoms, a two-stage procedure is often utilized. First, the os acromiale is fused using bone grafting-techniques, followed by a formal acromioplasty after healing is achieved.


Medication

In Severe Condition of the Proximal Biceps Tendon Rupture

Physiotherapy Treatment and Rehabilitation

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Phase 1: Acute Phase
Goals
  • Diminish pain and inflammation

  • Improve posterior flexibility

  • Reestablish posterior strength and dynamic stability (muscular balance)

  • Control functional stresses/strains

Treatment Abstain from throwing until pain-free full ROM and full-strength—specific time determined by a physician
Modalities
  • Iontophoresis (disposable patch highly preferred)

  • Phonophoresis

  • Electrical stimulation and cryotherapy as needed

Flexibility
  • Improve IR ROM at 90° abduction to normal total motion values

  • Enhance horizontal adduction flexibility

  • Gradually stretch into ER and flexion—do not force into painful ER

Exercises
  • Rotator cuff strengthening (especially ER) with light-moderate weight

    • Tubing ER/IR

    • Side ER

  • Scapular strengthening exercises

    • Retractors

    • Depressors

    • Protractors

  • Manual strengthening exercises

    • Side ER

    • Supine ER at 45° of abduction

    • Prone row

    • Side flexion in the scapular plane

  • Dynamic rhythmic stabilization exercises

  • Proprioception training

  • Electrical stimulation to posterior cuff as needed during exercises

  • Closed kinetic chain exercises

  • Maintain core, lower body, and conditioning throughout

  • Maintain elbow, wrist, and forearm strength

Criteria to progress to phase 2
  • Minimal pain or inflammation

  • Normalized IR and horizontal adduction ROM

  • Baseline muscular strength without fatigue

Phase 2: Intermediate Phase
Goals
  • Progress strengthening exercises

  • Restore muscular balance (ER/IR)

  • Enhance dynamic stability

  • Maintain flexibility and mobility

  • Improve core stabilization and lower body strength

Flexibility
  • Control stretches and flexibility exercises

    • Especially for IR and horizontal adduction

    • Gradually restore full ER

Exercises
  • Progress strengthening exercises

  • Full rotator cuff and scapula shoulder isotonic program—begin to advance weight

  • Initiate a dynamic stabilization program

    • Side ER with RS

    • ER tubing with end range RS

    • Wall stabilization onto the ball

    • Push-ups onto ball with stabilization

  • May initiate 2-hand plyometric throws

    • Chest pass

    • Side to side

    • Overhead soccer throws

Criteria to progress to phase 3
  • Full, pain-free ROM

  • Full 5/5 strength with no fatigue

Phase 3: Advanced Strengthening Phase
Goals
  • Aggressive strengthening program

  • Progress neuromuscular control

  • Improve strength, power, and endurance

  • Initiate light throwing activities

Exercises
  • Stretch prior to an exercise program—continue to normalize total motion

  • Continue strengthening program above

  • Reinitiate upper-body program

  • Dynamic stabilization drills

    • ER tubing with end-range RS at 90° abduction

    • Wall stabs in 90° of abduction and 90° of ER

    • Wall dribble with RS in 90° of abduction and 90° of ER

  • Plyometrics

    • Two-hand drills

    • One-hand drills (90/90 throws, deceleration throws, throw into bounce-back)

    • Stretch postexercise

Criteria to progress to phase 4
  • Full ROM and strength

  • Adequate dynamic stability

  • Appropriate rehabilitation progression to this point

Phase 4: Return-to-Activity Phase
Goals
  • Progress to throwing program

  • Continue strengthening and flexibility exercises

  • Return to competitive throwing

Exercises
  • Stretching and flexibility drills

  • Shoulder program

  • Plyometric program

  • Dynamic stabilization drills

  • Progress to interval throwing program

  • Gradually progress to competitive throwing as tolerated

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Complications

Complications associated with rotator cuff syndrome (RCS) are best broken down into nonoperative- versus operative-related complications:

Nonoperative management:

  • Persistent pain/recurrent symptoms
  • In the setting of PTTs, there is at least a theoretical risk of tear propagation, lack of healing, fatty infiltration, atrophy, and retraction.
  • Overall a controversial topic, a 2017 study analyzed independent risk factors for symptomatic RC tear progression over a 19-month period of nonoperatively managed shoulders; risk factors for tear progression included:
    • The initial presence of an FTT
    • Medium-sized cuff tears (1 to 3 cm)
    • Smoking
    • While PTTs were included in the study, the presence of a PTT was not a risk factor for cuff tear progression
  • In the setting of chronic/atrophic tears, especially with RC tear propagation, degenerative joint disease and RCA ensue


References

Myobloc (RimabotulinumtoxinB or botulinum toxin type B)


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