持續醫學進修專訊

Throwers’ Shoulder:
January 2007
A Critical Review of Its Problems
二零零七年一月
and Current Management – Part II
Dr. KONG Kam Fu James
Specialist in Orthopaedics & Traumatology
M.B.,B.S.(HK), M.Sc. (Ex & Sports Med) (Bath), F.C.S.H.K., F.R.C.S.Ed, F.R.C.S.Ed(Orth),
F.H.K.C.O.S., F.H.K.A.M.(Orth)

Diagnosis A systematic approach of

inspection, palpation,
To treat successfully the painful shoulder in
range of motion, and
throwers, the doctor needs to take a detailed
neuromuscular testing
history, perform a thorough physical examination
should be performed. On
and use special studies prudently.4
inspection, throwers often
posture with their
The interview should begin with the documentation
shoulder forward and down in comparison with
of the chief complaint. Pain is the most common
their nonthrowing side. Muscular hypertrophy is
reason for presentation. The physician should,
usually noted and best seen along the deltoid and
during the interview, try to establish the onset,
infraspinatus fossa. Atrophy in the area is important
location and duration of the pain. It is also useful
in rotator cuff disease or it may be related to
to ask the thrower to demonstrate at what phase
suprascapular nerve innervation.
he experiences the pain. Further questioning of
other injuries is also important. Faulty biomechanics
The position of scapular on the thorax with the
of low back and extremity injuries may affect the
serratus anterior or trapezius is important. Winging
shoulder.4, 43
of the scapular can indicate problems with the
serratus anterior or trapezius, its major stabilizers.
Throwers often experience stiffness, catching,
A wall push up test can be used to assess scapula
clicking or radicular symptoms. These are often
muscle control. The parascapular muscles can be
secondary complaints but can be the reason for
palpated during the concentric and eccentric
referral. Stiffness is often noted when a sore
contraction.58
shoulder is present. Again, the stiffness may be
associated with fatigue. Catching and clicking is
Palpation of the shoulder should be done in
often located within the subacromial bursae or
regions. Pressure along the clavicle is helpful in
within the joint. When it is associated with pain,
establishing the presence of pain in the
true pathology exists. A painful click can be found
sternoclavicular and acromioclavicular joints. The
when torn labrum, loose bodies, or thickening of
biceps, rotator cuff and larger muscles should be
bursae exists.14, 22
approached systemically and palpated. These
muscles may be tested against resistance. The
Radicular symptoms are common with shoulder
bicipital groove is palpated at the same time
injuries. Pain is often referred to the deltoid
during contraction and relaxation. The examiner
insertion and posterolateral aspect of the shoulder.
should be aware of the additive effects of
The “dead arm syndrome” is a common form of
glenohumeral and scapulothoracic motion during
radiculopathy associated with anterior subluxation.
these maneuvers. The extremes of motion are
In the cocking and accelerated position, the arm
performed actively by the patient and then with
feels as if it is going numb, often with soreness
added assistance, further motion is recorded.
that lingers on.13, 14
Passive motion is noteworthy, especially if painful.
Forward elevation, abduction, external rotation,
A complete shoulder examination is mandatory
and internal rotation are noted.48, 68
before any special tests to pinpoint the diagnosis.

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 Throwers’ Shoulder: A Critical Review of Its Problems
and Current Management – Part II

Rotation measurements are made with the elbow at the

side and at 90 degrees of abduction. Most examiners have
adaptive changes including increases in external rotation
and loss of internal rotation in the dominant extremity.
The acceleration phase of throwing often permits gradual
stretch of the anterior structures that increase the ability
to externally rotate. Loss of external rotation may thus
signify an underlying problem of apprehension or injury to
the anterior capsular ligaments.

Internal rotation should include a cross chest adduction

stretch and an underhand back scratch as described by
the American Shoulder and Elbow Surgeons. Loss of
internal rotation is common in throwers, especially in
those with posterior capsular tightness. Posterior capsular
changes can result in increased impingement symptoms.
Functional Strength Testing
Weakness is an important finding in a thrower’s shoulder.
Pain can aggravate weakness and should be taken into
account. By positioning the arms at the side and placing
the arms in a moderate degree of external rotation, the
examiner gradually overpowers the strength to externally
rotate. This test isolates the external rotators and the
integrity of the rotator cuff. Supraspinatus strength
testing is performed with the arms abducted, pushed
against resistance.1
Fig 9B: Forced internal rotation of Shoulder
Neer and Welsh documented that the finding of pain relief
after a subacromial injection of lignocaine with return of
strength is also useful. Anterior instability was classically
tested with the apprehension sign. With the arm in
abduction, external rotation and extension, the patient
indicates verbally or visually that there is an impending
dislocation. However, in mild form of subluxation in
throwers, it may not be present. Such individuals will have
pain instead when being stressed in external rotation and
abduction. Pain seems to be a more common event in
experienced throwers with anterior instability.49

Impingement and Instability Testing

Two tests which aggravate impingement are (1) forced
passive stretching in full elevation and (2) forced internal
rotation of forward flexed position. (Fig 9) Rotator cuff
tendinitis may produce the hallmark findings of the
impingement syndrome. The painful provocation tests
mentioned previously, with absence of instability testing
may suggest primary impingement.28, 34, 48, 49

Fig 9A: Impingement Test Fig 10: Relocation test

P. 2 HKMA CME BULLETIN • JANUARY 2007

 Throwers’ Shoulder: A Critical Review of Its Problems
The relocation test is performed with improved results on
testing occult anterior instability. The patient has pain and
reduced external rotation in the abducted, external rotated
position. Augmentation with anterior pulling increases the
pain. By placing anterior pressure on the front part of the
humeral head, the arm can be stressed with greater
degrees of external rotation with less pain. (Fig 10) This
test suggests that the painful shoulder is a result of the
head pressing anterior on the static stabilizers often found
in subluxation.
Glenohumeral translation testing is helpful in determining
the presence of instability. Reproduction of symptoms is
useful to distinguish the instability from adaptive translation
in the thrower’s shoulder. It is found that important
isolated glenohumeral involvement with the scapular
stabilized can occur in throwers compared to controls in
exact quantity of translation.70
Historically, Hawkins el al has developed the load and shift
test to quantitate translation. In a supine individual, a
gentle load is applied to the humeral head to ensure
concentric reduction within the glenoid fossa. (Fig 11) The
head is gently stressed anteriorly, posteriorly, and inferiorly.
The degree of translation can be appreciated as the head
is driven in tested directions. Grade I is noted when the
head rides up onto the labrum. Grade II is when the joint
seal is broken and the head rides over the labrum and
occasionally remains dislocated. Grade III is where the
humeral head can be shifted completely across the glenoid
rim and remain dislocated. This test should initially be
performed supine and repeated in a sitting relaxed
patient. Testing is done with minimal abduction and is
repeated in the 90-degree abducted posture.28
Fig 11: “Load & Shift Test” described by Hawkins
and Current Management – Part II
Common findings in throwers include excessive external
rotation in abduction, limitation of internal rotation in the
cross-chest or behind the back position, weakness of
shoulder external rotators, increased posterior translation
in neutral rotation, and subtle scapula winging.
Radiographic Studies
Radiographic evaluation of the shoulder should be used to
confirm the clinical examination. Three perpendicular view,
including anteroposterior, lateral transcapular and axillary
views should be done. Plain films are useful to identify
chronic changes and loose bodies. Further imaging is
often necessary when the diagnosis remains obscure.
Currently, MRI has replaced almost entirely the role of
imaging in shoulder pathologies, except in cases of
fractures. MRI with gadolinium (contrast) arthrogram best
illustrates labral pathology. The arthrogram may also
demonstrate a full thickness cuff tear and occasionally a
partial undersurface tear. It will not illustrate bursal
pathology unless there is a completer cuff tear.61, 62, 80
Electromyography and Muscle Testing
Neurological examination should be included in every
workup. Cervical symptoms are often present to the
medial border of the scapular and down the arm below
the elbow. To further clarify shoulder weakness with an
intact cuff, EMG should be done. Two forms of
suprascapular nerve problems are best identified: total
nerve, involving both the supraspinatus and infraspinatus
or infraspinatus paresis alone.1
Nonoperative Treatment
Most shoulder problems in throwers respond to a well-
managed conservative treatment program. Inflammation is
reduced with rest, non-steroidal anti-inflammatory
medications and possibly a bursal dexamethasone injection.
In fact, rest is a relative term. Activity modification is
probably a more appropriate term. Physical therapy
modalities, including ultrasongraphy and electrical
stimulation, can be helpful. Stretching is quickly initiated
to mobilize the inflamed shoulder. The program should be
performed carefully and monitored to avoid further
damage. In the initial stages, aggressive stretching should
be avoided to prevent extension of the injury. Strengthening
can be instituted as the range of motion improves. Mild
resistive exercises are helpful to improve the circulation,
decrease spasm and reduce pain.82
HKMA CME BULLETIN • JANUARY 2007 P. 3
 Throwers’ Shoulder: A Critical Review of Its Problems
and Current Management – Part II
A general exercise program is reviewed here but should be
modified based on the diagnosis, severity of injury, and
eventual expectations. The stretching program is performed
in four directions. “North” is forward elevation and can be
performed supine to stabilize the scapular or in an upright
pose. The other arm can be used for assistance if needed.
“East” is external rotation, initially performed with the
elbow at the hip opposite arm to assist. Drawing the arm
across the chest to the “west” will gently stretch the
posterior capsule. “South” is behind the back as the arm
is drawn up the back by either the other hand or a towel
draped from above as in the “drying off” motion. The
goals of stretching are to reduce stretching is essential.
Stretching in external rotation and abduction should be
avoided in throwers suspected of having subtle anterior
instability.32, 37, 82
The individual pathology will direct the specific stretching
program. Because posterior capsular contractions are
common, throwers should emphasize internal rotation
stretching. The cross chest adduction press with the
forearm under the chin and the back scratch position
stretch the posterior capsule. Isokinetic exercises can be
introduced at the faster speeds i.e. 240 degrees per
sound. Shoulder flexion and extension and rotational
strengthening should be used within limits. If anterior
structures have been injured, external rotation should be
limited to 45 degrees. If impingement is the primary
diagnosis, flexion should be blocked at 90 degrees and
abduction at 60 degrees.
The last but important phase is the interval throwing
program. The emphasis of this program is sport-specific
action of the shoulder. A gentle toss of short distance is
gradually progressed in distance and velocity. Emphasis on
proper mechanics is critical here. The shoulder should have
achieved the majority of rehabilitation goals before this is
attempted. Both the confidence of the thrower and staff
can graduate as this phase progresses. If the program has
failed, reassessment is indicated.32, 37
Diagnostic Arthroscopy
Arthroscopy can help to diagnose internal derangement in
the thrower.16 When combined with an accurate history
and physical examination, it can provide valuable
information not revealed by other radiographic techniques.
It helps to allow examination under anaesthesia.
Visualization and palpation are performed within the joint.
P. 4 HKMA CME BULLETIN • JANUARY 2007
The undersurface of the rotator cuff, the biceps labral
complex and the capsular-labral and glenoid restraints are
examined. Labral changes can be inspected around the
entire circumference of the joint. By reversing the scope
portals, additional information regarding the anterior
labrum and capsular ligaments and posterior capsule can
be obtained. Palpation of structures and lifting the
humeral head for better access across the joint are helpful
as well.12, 31
Instability found within the joint during arthroscopy may
include labral tears, capsule tears and redundancy, humeral
head abrasions or impaction fractures and glenoid injuries.
In most throwers, the head appears to sit anteriorly on the
labrum and inferior glenohumeral ligament while traction
is in place. Reduction of traction and deflation of the joint
permit the head to rock back into a more concentric
position.65
The subacromial arthroscopic examination follows the
interarticular study. (Fig 12) The bursae can be inspected
carefully before proceeding. The relationship of the exterior
of the rotator cuff and the undersurface of the subacromial
arch is seen. Bursal changes of impingement are best seen
with this view. Impingement findings include thickened
diseased bursae that are often poorly visualized. Abraded
changes on the exterior cuff, thickening of the
coracoacromial ligament, and hypertrophy of the acromion
and undersurface of the acromioclavicular joints can be
illustrated in patients in whom the impingement is
present. Anterior inferior acromial irritation may suggest
impingement.64, 75
Fig 12: Arthroscopic View of Subacromial Space
Experience is required to understand the combined aspects
of the interarticular and extra-articular views of the joint.
The examination is not completed until all portions of the
anatomy are examined and the findings combined with
those of the clinical examination.
 Throwers’ Shoulder: A Critical Review of Its Problems
Arthroscopic Treatment of
Specific Lesions
Primary Compressive Cuff Disease
Primary compressive cuff disease may be a primary cause
of cuff disease when it is associated with a type III hooked
acromion, degenerative spurs, os acromiale and occasionally
a congenitally thick coracoacromial ligament. It may also
be caused by a prominence of a degenerated
acromioclavicular joint. Compressive cuff disease results in
an outside-in type of rotator cuff tear.78
Throwing and serving motions that require use of the arm
in a 90 – degree or greater horizontally abducted position
with rotation into internal and horizontal adduction may
produce impingement symptoms. This is reproducible on
physical examination by forceful forward flexion (positive
impingement sign). By injecting 1% lignocaine into the
subacromial space helps to confirm the diagnosis. Most
patients respond to a conservative program of active rest,
non-steroidal anti-inflammatory medication and progressive
rotator cuff strengthening and stretching exercises.12
Surgical intervention may be warranted if the symptoms
are not relieved by nonoperative measures. Arthroscopy of
the subacromial space may reveal bursitis that can be
derided easily with a motorized resector. A lateral portal is
necessary for the introduction of operative instruments.
The portal is established under direct visualization with an
18-gauge needle. The spinal needle is introduced
approximately 4 cm midlateral to the lateral tip of the
acromion. The following procedures are performed. Firstly,
the soft tissue on the undersurface of the acromion is
removed using a full-radius resector. An acromioplasty is
performed using a motorized burr, removing approximately
8 mm of the anterior acromion extending medially to the
acomioclavicular joint and beveled posteriorly for about 2
cm. This is technically demanding procedure. Care should
be taken to control bleeding. Hypotensive anesthesia of
below 100 mm Hg may be used to decrease the bleeding.
Pump pressure is kept at approximately 50 to 60 mm Hg,
thus giving less than a 50-mm Hg gradient. Electrocautery
is also used to control the bleeding, as well as to release
and resect the coracoracromial ligament, because of the
tendency of the acromial branch of the thoraco-acromial
artery to bleed. The electrode on the elctrocautery is
shielded except at the tip; therefore, it can be used in
saline solution. Normally epinephrine is not required in the
infusion to control the bleeding.75
and Current Management – Part II
If partial tearing of the superior surface of the rotator cuff
is present, it is debrided to healthy, bleeding tissue. The
humeral head is rotated to assess the adequacy of the
amount of space available between the acromion and the
rotator cuff.
Debridement of partial rotator cuff tears appears to
reduce pain in the athlete’s shoulder sufficiently to enable
him or her to engage in a program of progressive
strengthening exercises and a gradual return to competitive
throwing, which usually takes 6 months or more.8, 31, 48, 77
Biceps-labral complex tears are thought to occur during
the deceleration and follow-through phase of throwing.
Large forces are placed on the proximal attachment of the
biceps tendon at or near 90 degrees of abduction, at the
humerus internally rotate at the same time as deceleration
of elbow extension is occurring. There also may be some
type of concurrent entrapment of the biceps-labral complex
associated with glenohumeral laxity.
At arthroscopy, a tear of the labrum in the anterosuperior
quadrant at the insertion of the long head of the biceps is
evident. A partial tear of the biceps tendon nears its origin
may also be evident. Andrews et al suggested a mechanism
for the anterorsuperior glenoid labral tear. It was noted
83% of all shoulder arthroscopies had glenoid labral
tearing at the biceps-labral complex anterosuperiorly. (Fig
13) Electrical stimulation of the biceps in five patients at
arthroscopy produced tension in the biceps tendon and
lifting up of the superior labrum off the glenoid. Andrews
et al hypothesized that this eccentric contraction may
cause tearing of the anterosuperior labrum.3,
Fig 13: SLAP lesion
Treatment for this lesion involves arthroscopic debridement
and repair with sutures if surgically feasible followed by
rehabilitation. Arthroscopic decompression of the
subacromial space is associated with minimal morbidity
because the insertion of the deltoid id not violated. It also
permits early rehabilitation, which permits an earlier return
of the athlete to competition.3, 25, 76
HKMA CME BULLETIN • JANUARY 2007 P. 5
 Throwers’ Shoulder: A Critical Review of Its Problems
and Current Management – Part II

Secondary Compressive Cuff Disease impingement may be present with further tearing of the
outer surface of the rotator cuff. In these patients,
Impingement may be secondary to another underlying
subacromial decompression with an aacromioplasty should
problem, such as glenohumeral instability. To make a
be performed. In a review by Royce et al of 2 to 7 years
correct diagnosis is mandatory because treatment includes
follow up, subacromial decompression of such patients
alleviating the primary problem. The patient may present
generally yield satisfactory results.64
only with a complaint of pain; therefore, a thorough
history and physical examination must be performed.
Andrew el al reported on 34 athletes with partial tears
Generalized ligamentous laxity should be noted.
who underwent arthroscopic debridement.3 76% of the
patients had an excellent result, 9 percent had a good
If anterior laxity is evident, the compressive cuff disease
result and all were able to return to their previous athletic
may be secondary to anterior shoulder laxity. If only mild
activities. 15% of the patients had poor results and were
instability is present, treatment options include rehabilitation
not able to return to competitive throwing.
with an emphasis on dynamic stabilization by muscular
strengthening. If this fails, arthroscopic or open stabilization
Glenohumeral Laxity
may be warranted. Primary rotator cuff failure from tensile
overload may also cause secondary impingement.8 This The diagnosis of shoulder laxity can usually be made on
failure occurs because of repetitive tensile overloading of the bass of the history and physical findings. The athlete
the cuff, such as that seen in the deceleration phase of may have a documented history of anterior dislocation
throwing. These forces encountered in athletic activity with subsequent redislocations or may only present with
may ultimately exceed the ability of both the dynamic complaints of pain, clicking, or so-called dead arm
stabilizers of the rotator cuff and the anterior static syndrome. In this syndrome, the athlete feels as deep
stabilizers to compensate, which may lead to a secondary sharp or paralyzing pain when the shoulder is forcibly
impingement phenomenon of the rotator cuff. Again, externally rotated in the abducted overhead position.
rehabilitation is the first line of treatment; if this fails Apprehension test is used to confirm the diagnosis, in
arthroscopic stabilization and/or decompression of the which the abducted arm is rotated externally while
subacromial space or both, as necessary.64 forward pressure is exerted on the humeral head. The
pushes the humeral head forward against the anterior
Tensile Lesions capsule. If the patient experiences pain and apprehension,
anterior instability is suggested.43
The tensile lesions usually seen in an athlete’s shoulder
occur as undersurface rotator cuff tears or biceps-labral
Approximately one-half of the patients with shoulder
complex tears. The mechanism of injury in a primary
subluxation are unwire of its presence. Therefore, physical
tensile rotator cuff tear is deceleration of the rotator cuff
examination, radiography and arthroscopy become
as it resists horizontal adduction, internal rotation, and
important in diagnosis.
anterior translation and distraction forces seen during the
deceleration phase of throwing. This results in eccentric
At arthroscopy, a detachment of the inferior glenohumeral
tensile overload failure. Partial tears usually ensue secondary
ligament/labral complex from the lower half of the glenoid
to repetitive microtrauma. These are found in the region
margin is usually associated with anterior instability. 44
of the undersurface of the supraspinatus tendon and may
Under direct visualization using the arthroscopy, the
extend posterior to the area of the infraspinatus tendon.
humeral head is pushed anterior, posterior and inferior
These tears may also be found isolated to the infraspinatus
and the amount of translation or subluxation is noted.
muscle tendon and the posterior cuff capsule.8, 29
This is helpful to decide the major direction of instability,
although it may be difficult to measure humeral head
If there is no improvement over a period of 2 to 3 months
subluxation with arthroscopy. If the labrum is torn, it can
of conservative treatment, arthroscopy may be performed,
be repaired by suture anchors and sutures developed
which will reveal a partial tearing of the undersurface of
technically recently.
the rotator cuff at or near its insertion into the humeral
head. Arthroscopic debridement with a motorized shaver
The arthroscopy set-up is the same as that previously
is performed to healthy bleeding tissue. The arthroscopy
described. (Fig 14) The arthroscope is brought in through
should e switched to the anterior portal so that the
the posterior portal, the anterior portal being the
posterior cuff can be visualized in its entirety and any
“operative” portal. The detached labrum-ligament complex
tearing derided with the shaver in the posterior portal.
is evaluated, and the excess scar o hypertrophied synovium
Inspection of the subacromial space is then performed.
is debrided using a motorized full-radius resector. A
Frequently, there are no signs of impingement
motorized burr is then used to abrade the anterior glenoid
intraoperatively, but in chronic situations; secondary

P. 6 HKMA CME BULLETIN • JANUARY 2007

 Throwers’ Shoulder: A Critical Review of Its Problems
neck to facilitate healing of the soft-tissue repair to the
raw surface of the bone. A 70 degree arthroscope inserted
either in the posterior or anterior portal may be used to
visualize the anterior glenoid better.75
Fig 14: Set-up of Shoulder Arthroscopy
Depending on the surgeon’ preference, either techniques
developed by Snyder 33 or Burkart may be inserted. The
principle remains similar. A suture anchor, which may be
bioabsorable or metallic in nature, is inserted at the
glenoid-cartilage complex.34, 65 There are 1 -2 sutures in
each suture anchor. The sutures are then grasped out of
the arthroscope. A soft tissue passer (suture lasso) or
thread passing device (developed by Synder et al) is used
to pass through and grasp the soft tissue of the glenoid.
The sutures are then passed by either the suture lasso or
thread passing device. A surgical knot is then tightened
arthroscopically. There are two types of surgical knots
available in shoulder arthroscopy: the sliding and non-
sliding knots. Many sliding slots have been developed for
shoulder arthroscopy for example SMC (Samsung Medical
Centre) knot. (Fig 15) The idea of a sliding knot is to allow
the knot to slide to the tissue and tightens gradually. This
is further reinforced by non-sliding knots to prevent
slipping. An example of non-sliding knot is ‘Revo knot’.
and Current Management – Part II
Fig 15: SamSung Medical Knot
Under direct visualization, the labrum-ligamentous complex
is then observed as tension is applied to the sutures,
making sure the tissue is pulled against the glenoid neck.
Stability of the shoulder should be checked at this time.
Postoperatively, the shoulder is immobilized in the adducted
and internally rotated position in a shoulder immobilizer
for 4 weeks to ensure soft-tissue healing.
Glenoid Labral Tears
A tear of the upper half of the labrum may occur with
throwing and racquet sports or with some other type of
deceleration injury. The mechanism of labral tearing can
be due to repetitive overhead activity, such as that in
throwing, tennis or swimming. It may also be due to
forceful entrapment associated with an avulsion sprain of
the biceps-labrum complex between the humeral head
and the glenoid rim, such s that occurring when a player
dives to catch a baseball on the outstretched arm. A
significant percentage of labral tears in the throwing
athlete involve the anterosuperior portion near the insertion
of the long head of the biceps tendon and are not
associated with instability. Papps et al noted a functional
instability form the torn hypermobile labrum in one
patient. 51 There was no increase in glenohumeral
translation: Pappas et al that there was clicking, catching
or locking in the joint secondary to the intermittent
interposition of a partially attached fragment or bucket
handle tear between the glenoid and humeral head.
Arthroscopy is indicated in the athlete with shoulder pain
who has symptoms of catching, who on physical
examination may demonstrate a positive clunk test.
Arthroscopy is performed routinely as described.
Debridement of labral pathology, when needed is performed
with motorized shavers and resector via routine anterior
and posterior portals. Debridement should be carried out
to a stable rim.
Andrews et al reported on the results of arthroscopic
debridement in 73 athletes with labral tears, 83% of who
were found to have anterosuperior tears.3 After arthroscopic
debridement, 88% had good-to-excellent results at 13.5
months follow up. Glasgow et al also reported good
results with labral tears that underwent arthroscopic
resection in 29 patients.22
HKMA CME BULLETIN • JANUARY 2007 P. 7
 Throwers’ Shoulder: A Critical Review of Its Problems
and Current Management – Part II
Throwers’ Exostosis
It was firstly described by Bennett in 1941 who studied a
group of throwers with shoulder pain. The exostosis is
located at approximately the eight o’clock position on a
right glenoid and is probably a secondary reaction
associated with repeated microtrauma and tearing of the
posterior and inferior capsule off of its glenoid insertion.
For many tears it was thought that the exostosis was
calcification in the long head of the triceps tendon
insertion. The exostosis is visualized arthroscopically from
the anterior portal using a 70-degree arthroscope. Resection
is accomplished using a synovial resector from the
posterior portal to reflect the posterior and inferior
capsular insertion and a motorized burr is then used to
resect the exostosis.1
Acromioclavicular Joint
Athletes who lift weights as part of their training program
and weight-lifters are prone to acromioclavicular joint
injuries. These include osteolysis of the distal clavicle
secondary to longitudinal shear or compressive forces
across the joint and partial or complete acromioclavicular
separations secondary to post-traumatic injury to the joint.
The athlete usually complains of a dull ache or pain over
the joint. Conservative treatment is tried initially, consisting
of non-steroidal anti-inflammatory medication, physical
therapy, modification of physical activity and finally steroid
injection into the joint. If this fails, arthroscopic debridement
of the joint may be performed with decompression on
both the acromion and clavicular side of the joint.1
Alternatively, the acromioclavicular joint can be debrided
from the subacromial space at the time of acromioplasty, if
warranted. An 18-gauge spinal needle is inserted in the
joint from above to help delineate it. The arthroscope can
be inserted in the joint from above to help delineate it.
The arthroscope can be inserted in either the anterior or
posterior portal site, and the motorized instruments can
be placed in the opposite portal. Complete debridement
or resection or both is then carried out from below. A 70-
degree arthroscope may be used to help facilitate
visualization of the entire acromioclavicular joint from
below.75
Open Surgical Techniques
While the recent trend is towards arthroscopic and
minimal invasive surgery, open surgery still plays a role in
shoulder surgeries for a variety of reasons such as lack of
instruments and technical expertise. Open surgical
approaches deals with common problems, such as rotator
cuff pathology, primary impingement, and instability. In
addition, some uncommon syndromes that occur about
the athlete’s shoulder are also necessary so that proper
recognition and management can be achieved.
P. 8 HKMA CME BULLETIN • JANUARY 2007
Rotator Cuff Tears
Surgical procedures to achieve decompression of the
subacromial space include coracoacromial ligament
resection, anterior acromioplasty (open or arthroscopic),
distal clavicle resection and acromioclavicular joint inferior
entophyte resection.
Patient is put into beach-chair position. A longitudinal
incision in Langer’s line is made over 5 cm on the
acromion. The coracoacromial ligament is identified as it
inserts onto the anterior acromion and is then resected
using sharp dissection. The rotator cuff is identified and
protected. A thin sharp 1.5 inch osteotome is then
directed from an anterior to posterior direction, resecting a
wedge approximately 0.9 cm thick anteriorly and 2 cm
long. A motorized burr may be used to smooth out the
undersurface of the acromion. In small tears without
retraction, only a small amount of mobilization may be
necessary. With large tears, more extensive mobilization
on the joint and bursal side of the cuff may be necessary
and often resection of the coracohumeral ligament is
required to gain enough mobility of the torn rotator cuff.
Most cuff repairs are best performed to a trough at the
bone. After the operation, careful reattachment of the
deltoid to the acromion is necessary and preferably
through the bone of the acromion.56, 78
Shoulder Instability
Perhaps the most concise and simplest method of
classification has been proposed by Matsen, who has
suggested that patients may have instability that is
Traumatic, Unidirectional, often associated with a Bankart
lesion and usually requires Surgery (TUBS). Alternatively,
some patients have an Atraumatic etiology to the instability,
which is usually Multidirectional and often Bilateral and
will often respond to Rehabilitation so that surgical
therapy is not usually necessary, but if it is, an Inferior
capsular shift should be performed (AMBRI).56
Anterior Instability
The Bankart operation is familiar to most orthopaedic
surgeons. A longitudinal deltopectoral approach is utilized
and the insertion of subscapularis on the lesser tuberosity
is exposed after retracting the conjoined tendon. (Fig 16)
The subscapularis is detached and reflected medially with
attached capsule approximately 1.5 cm medial to the
insertion on the lesser tuberosity. After the glenoid is
exposed, sutures are passed through the anterior glenoid
after drill holes are fashioned at 1 o’clock, 3 o’clock and 5
o’clock positions. The sutures are then passed through the
anterior capsule and labrum, with an attempt being made
to avoid excessive tightening of the shoulder, which limits
external rotation.34
 Throwers’ Shoulder: A Critical Review of Its Problems
Fig 16: Bankart Operation
Posterior Instability
The patient is positioned in the lateral decubitus position
and the posterior shoulder is approached through a
posterior incision which extends from the posterolateral
tip of the acromion toward the glenohumeral joint in
Langer’s lines for a distance of 8 to 10 cm. The deltoid is
exposed, and the fibrous interval between the middle and
posterior one third of the deltoid is developed. The
posterior capsule can be exposed by one of two methods.
Hawkins performs a longitudinal incision through the
tendinous portion of the infraspinatus and utilizes the
infraspinatus tendon attachment to reinforce the posterior
capsular repair. Alternatively, the capsule can be exposed
via a split through the interval between the infraspinatus
and teres minor muscles or through a slit in the infraspinatus
muscle itself.56 Postoperatively the patients are immobilized
for a period of 6 weeks before stretching and strengthening
exercises are begun.
Uncommon Surgical Problems
in The Athlete’s Shoulder
Suprascapular Neuropathy
The entity is most often confused with tearing of the
rotator cuff and therefore shoulders arthrography, as well
as EMG and nerve conduction studies are usually necessary
to differentiate the two entities.1 CT or MRI may become
necessary to identify areas of nerve compression. However,
if patients do not respond or if a soft tissue or bony lesion
is identified as the cause of compression and subsequent
neuropathy, surgical therapy should be considered.
Two surgical approaches to the suprascapular nerve are
possible, depending on the location of the pathology,
namely anterior and posterior Supraspinous
approaches.
and Current Management – Part II
Posterior Infraspinous Approach. For lesions in the
infraspinous fossa, such as ganglia, a posterior shoulder
approach similar to the standard posterior procedures is
preferable. The infraspinatus muscle and its tendon are
isolated and the tendon is then divided perpendicular to
its fibers at approximately 1 cm from its insertion into the
greater tuberosity. The infraspinatus is gently reflected
medially with blunt dissection to elevate it from the
posterior shoulder capsule. Medial retraction permits
identification of the suprascapular nerve, which courses
beside the circumflex scapular artery coursing around
lateral border of the scapular spine and innervating the
infraspinatus muscle from its undersurface.
Conclusion
Throwing itself involves a series of biomechanical stress
particular on the shoulder. Impingement, which may be
either primary or secondary and instability remain the
most common problems of throwers’ shoulders. They may
manifest in a number of ways, from a spectrum of disease
from rotator tendinitis, rotator cuff tears, impingement
syndrome, dead arm syndrome and glenoid labral tears.
Diagnosis requires a meticulous history taking, physical
examination, special provocation tests and sometimes
investigations such as X rays and MRI with or without
contrast. Treatment of these depends on its pathology
which is usually conservative first and if it fails, operative
treatment; either arthroscopic or open surgeries may be
required, depends on the expertise of the surgeons.
A comprehensive integral rehabilitation program is also
important. Currently a multi-phases program is commonly
used. Phase I is to reduce the inflammation with rest and
anti-inflammatory medications with ice. Phase II is to
regain the range of motion of the respective joint. Phase III
is strengthening and proprioceptive training exercises.
Phase IV is pre-game training in order to prepare the
athlete to return to his own sports.
After extensive and critical review of the available literature,
however there are gaps which need to be filled in for
future studies. For example, the role and the relative
positions of the scapular during the pitching; the underlying
electrophysiological basis of scapular dyskinesis, as described
by Burkhart et al 13. As the old saying always quote,
“Prevention is better than cure”. Hopefully with a better
understanding of the biomechanics of the shoulder, as
viewed as a unity of interaction of biceps tendon, rotator
cuff muscles, glenohumeral joint and acromion during
overhead sporting activities, the two major problems of
instability and impingement may be completely prevented
and treated.
HKMA CME BULLETIN • JANUARY 2007 P. 9
 Throwers’ Shoulder: A Critical Review of Its Problems
and Current Management – Part II
Self-Assessment Questions
(Please indicate true or false to the following questions.)
1. The ‘dead-arm syndrome’ is associated with posterior
subluxation of shoulder.
2. Adaptive changes of throwers’ shoulder include
increase in external rotation and loss of internal
rotation.
3. Relocation test is a test of occult anterior instability.
4. Hawkins described the ‘load & shift test’.
5. Suprascapular nerve supplies both the supraspinatus
and infraspinatus muscles.
6. Posterior capsular contractions are not common in
throwers.
7 Samsung Medical Snot is a non-sliding knot.
8. Repair of rotator cuff muscles also requires
subacromial decompression.
9. Throwers’ exostosis is located along the glenoid
region.
10. Open Bankart operation is to repair the glenoid
labrum of the shoulder.
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