Jonathan D. Gelber, MD, MS; Lonnie Soloff, DPT, PT, ATC; Mark S. Schickendantz, MD

Disclosures

J Am Acad Orthop Surg. 2018;26(6):204-213. 

In This Article

Nonsurgical Management

Overhead athletes require coordination of the kinetic chain to deliver energy from the legs and the core through the arm to a ball, racket, or other object. A break anywhere along the chain can predispose an athlete to injury. It is important to identify players at risk for injury, especially in the off-season, preseason, or at baseball spring training. During the entrance or preseason physical examination, the total arc of motion should be measured on both sides and compared. A major loss of motion from GIRD found on physical examination should be documented, and the thrower should begin a posterior capsular stretching program.

Ninety percent of throwers respond to a nonsurgical stretching program, such as the sleeper stretch exercise.[7] Wilk et al[36] observed that pitchers with insufficient external rotation in the throwing shoulder (ie, <5° greater external rotation on the throwing side) were 2.2 times more likely to be placed on the disabled list because of a shoulder injury and 4.0 times more likely to require shoulder surgery than pitchers who exhibited increased external rotation on the throwing side. A specific subset of overhead athletes may develop the SICK scapula syndrome (ie, scapular malposition, inferior medial border prominence, coracoid pain, and dyskinesia of scapular movement).[41] These patients will present with an asymmetric "dropped scapula" on physical examination, which not only can lead to fatigue of the scapular musculature but also can decrease shoulder internal rotation.

In addition to maintaining range of motion and avoiding excessive stretching of the anterior capsule, overhead athletes need to maintain balanced rotator cuff strength and scapular control. Professional baseball pitchers tend to have greater internal rotation strength than external rotation strength in the dominant arms. Wilk et al[42] analyzed the isokinetic muscular performance characteristics of the external/internal rotator muscles of professional baseball pitchers and noted that torque testing showed approximately 5.5% less external rotation strength at lower speeds (180 deg/sec) for the throwing shoulder, but this side-to-side muscular imbalance appears to even out at higher speeds (300 deg/sec). This same study suggested that for appropriate glenohumeral muscle balance in asymptomatic throwing shoulders, external rotation should be ≥65% of the strength of internal rotation.[42] In a separate study, preseason weakness of external rotation and supraspinatus strength was associated with in-season throwing-related injuries requiring surgical intervention.[43] Throwers should also have increased shoulder adductor strength, which is important in the late-cocking and acceleration stages.[44]

A level IV case series showed that 10 of 15 overhead-throwing athletes treated with a nonsurgical regimen for a type II SLAP tear returned to play at the same or higher level of performance than before the injury. The patients required a mean of 18 physical therapy sessions (range, 4 to 40 visits) before returning to sport.[45]

A retrospective review of a single Major League Baseball organization by Fedoriw et al[46] evaluated surgical versus nonsurgical treatment of type II or type II posterior-variant SLAP tears. Twenty-one pitchers with these tears completed a nonsurgical algorithm focusing on the correction of scapular dyskinesia, posterior capsular contracture with glenohumeral internal rotation deficit, and concomitant lapses in the overall kinetic chain. Two rounds of physical therapy were attempted: the first with the team trainer in the player's respective city and the second after having visited the study authors. This was then followed by a graduated return to a 6-week pain-free throwing program. The RTP rate was 40%, and the return to prior performance (RPP) rate was 22%.

Fedoriw et al[46] noted that Thus, it appears that for pitchers, nonsurgical treatment of type II SLAP tears may have a more successful outcome than surgical intervention.

"the RTP rate for 27 pitchers who underwent surgical procedures was similar at 48%, and the RPP rate was lower at 7%. For 10 position players treated nonsurgically, the RTP rate was 39% and the RPP rate was 26%. The RTP rate for 13 position players who underwent 15 procedures was higher at 85%, with a higher RPP rate of 54%."

Thus, it appears that for pitchers, nonsurgical treatment of type II SLAP tears may have a more successful outcome than surgical intervention.

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