The shoulder is the most commonly injured joint, and school-age athletes not only are at particular risk but have special treatment considerations due to the immaturity of their skeletal system. Illustrating this talk for primary care providers with case examples, pediatric orthopedic surgeon Micheal Chau, MD, PhD, delineates variables that raise risk for kids; gives a refresher on shoulder anatomy; offers keys to diagnosis and management, including notes on ensuring a thorough physical (with appropriate tests for specific injuries), and delivers guidance on imaging as well as when to refer.
Well, good afternoon, everyone. Uh, as Maria said, my name is Michael Chow. I'm one of the pediatric orthopedic surgeons specializing in sports medicine here at Benioff Children's Hospital. Thank you for the invitation to speak at this webinar. I'll be using this time to discuss shoulder injuries and skeletally immature athletes, and specifically, I want to focus on concepts that I think are relevant and or practical uh in the primary care setting. And I'm more than happy to take questions or comments um at the end of this talk. See advance. There we go. Um, I have no conflicts of interest to disclose for this presentation. Uh, our learning objectives, uh, for this webinar are as follows, to be able to identify and diagnose common shoulder injuries in skeletally immature athletes. To be able to perform a basic shoulder exam within the limited time allowed for a primary care visit. Uh, which is usually around 15 minutes or so. Uh, to be able to interpret basic shorter radiographs and MRI. And to have a game plan for managing young athletes with shoulder injuries in the primary care setting. As well as to know when to refer for a surgical consultation. So let us start with some epidemiology. Youth sports participation is rapidly growing throughout our country. Intensive training is increasingly starting at younger ages and taking longer taking place for longer durations throughout the year. There's also this issue of single sports specialization as our children strive for things like accolades and scholarships. Thus, many young athletes these days are pressured to perform at higher and higher standards. Thereby placing them at increased risk of injury. It has been estimated that nearly 2 million high school sports injuries occur annually in the US, and of these, up to 30% involve the upper extremity. Shoulder injuries in young athletes are often the result of overuse as opposed to traumatic mechanisms. Repetitive stress can lead to conditions that negatively affect growth and development. And furthermore, Longer term adaptive changes in bone and soft tissue can predispose children to injury. We all know the adage, children are not just simply small adults. Skeletal growth on average continues until 14 years of age for girls and 16 years of age for boys. Growth plates and hypophyses are the weakest structure in joints compared to bone, tendon, and ligament. Uh, and are therefore prone to injury. This in turn can lead to growth disturbances. Children are also at higher risk of injury due to having lower stamina, less refined neuromuscular coordination, and more variability in body size and strength when comparing peer to peer, which becomes relevant in contact sports. Let's review some basic anatomy. So, the shoulder is a ball and socket joint comprised of three bones, humerus, scapula, and clavicle, and two articulations, glenohumeral and acromioclavicular. The most basic function of the shoulder is to position the hand in space such that we can reach for and pick up items or throw objects such as balls. It is in fact the most mobile joint in the body. Uh, it is also the most commonly dislocated joint in the body. And due to this fine tenuous balance between motion and stability, the shoulder is often compared to a golf ball on a tee. Unlike other joints in the body, the muscles around the shoulder are the main stabilizers during activity. When the shoulder muscles become fatigued, The shoulder is at increased risk of injury and may become unstable. And therefore, it is important for our young athletes to get enough rest and sleep to prevent injury. There are 17 muscles that attach onto the scapula. And 10 muscles that cross the shoulder joint, including the 4 rotator cuff muscles, supraspinatus, infraspinatus, teres minor, and subscapularis. It's also a deltoid and the long head of the biceps. Hence, the scapula plays a pivotal role in overall shoulder stability. In fact, scapular dyskinesis is a very common A condition in patients with a disabled throwing shoulder. Static stabilizers of the shoulder include the glonohumeral ligaments, the superior, middle, and inferior. The joint capsule and the labrum. The labrum increases the depth of the glenoid socket and serves to anchor the glenohumeral ligaments. A clinical correlate is that shoulder dislocation resulting in labral tears and disruption of the gunnohumeral ligaments is one of the most common indications for surgery in young athletes, particularly upper extremity throwing athletes. A little more on static stabilizers is that the position of the shoulder determines the dominant static restraint. So for instance, in arm abduction, The superior glonohumeral ligament and the middle glonohumeral ligament are taut. As the arm is brought into the apprehension position of abduction. And external rotation. The anterior band of the inferior gonohumeral ligament is pulled up. To span the mid portion of the glenohumeral joint and thus providing anterior stability. This anatomy explains the apprehension tests that we regularly perform in clinic in the setting of an anterior inferior labral tear, also known as a Bankart lesion. And before moving on from the topic of status stabilizers, I think it is worth mentioning that connective tissue and collagen disorders should be considered in pediatric patients with shoulder instability. Conditions such as Erlosdomlos and generalized ligamentous laxity. Among various sports, Baseball inflicts some of the most significant forces across the shoulder joint. And results in some of the most common shoulder injuries we see in young athletes. The majority of these injuries are Overuse And therefore, topics such as pitch counts, types of pitches, And overtraining are important to consider and to address when it comes to injury prevention. So let's talk a little bit more about shoulder biomechanics. Which can be understood by closely scrutinizing the phases of throwing in baseball. So this may be a familiar diagram that depicts the mechanism of throwing broken down into phases. We have windup Early cocking, late cocking, acceleration. And deceleration And then follow through The maximum torque is generated during two actions of the phases of throwing. The first is maximal external rotation during the late cocking phase. And the second is just after ball release during the deceleration phase. The clinical correlate of the phase of throwing is as follows. The labrum is predominantly stressed during late cocking and therefore the late cocking phase is associated with conditions such as slap tears and internal impingement. On the other hand, the rotator cuff, particularly the posterior aspect of the supraspinatus and the anterior aspect of the infraspinatus, is predominantly stressed during the deceleration phase. And therefore, that's the acceleration phase is associated with tensile strain of the rotator cuff. Interestingly Over time Most throwers develop an obvious motion disparity where shoulder external rotation becomes excessive. And internal rotation is lost. This adaptive change actually allows throwers to achieve a more optimal arm slot position to generate a whip-like motion in order to maximize their projectile velocity. Anatomically, this is due to anterior capsular stretch. And posterior capsular tightening. As well as bony retroversion of the humeral head and glenoid socket. As patients gain external rotation. The total motion of the throwing arm remains constant, and this concept is known as Total emotion Which remains constant. Studies have reported in adolescent baseball players that the greatest change in shoulder Range of motion occurs between the ages of 12 and 13 years when growth plates are open. OK, so let us move on to history gathering in the clinic. Patients can often present to clinic with a very general chief complaint such as shoulder injury. It is important to discern what their exact symptoms are. So if it is pain, then it is helpful to know the location. The quality, whether or not it radiates down the arm. If their complaint is instability. Sometimes patients can actually recall whether it is anterior or posterior instability. And then distinguishing between acute and chronic onset. is helpful for narrowing diagnoses. Knowing mechanism of injury is helpful. For instance, a direct blow to the shoulder can be responsible for AC joint separations. Whereas instability, can occur with injury to the Abducted externally rotated arm. Aggravating and relieving factors, as well as knowing treatment measures previously attempted, are also helpful for developing a treatment plan. A thorough physical examination of the shoulder in clinic. will include inspection. Palpation Range of motion Neurovascular And provocative testing. Personally, I prefer to progress from being hands-on and least painful. To gradually being a little bit more hands-on, more painful, and perhaps more apprehensive. The contralateral shoulder should also be examined for comparison. The neck should be assessed to rule out confounding diagnoses such as cervical radiculopathy. Or muscle spasm A Bay score Should be documented. For joint hypermobility, which can be associated with conditions such as multidirectional shoulder instability. Breaking down the physical exam a little bit further. So on inspection, Bony contours. Um, and skin inspection is helpful, and the patient should be appropriately gowned. For this part of the exam. Visible visible deformity can suggest things like joint dislocation. Such as acromioclavicular or sternoclavicular. Or fractures such as clavicle or proximal humerus. Scapular dyskinesis and winging, as shown in the image below, can either be subtle or quite striking. And atrophy such as that of the deltoid muscle can reveal conditions such as nerve denervation in addition to deconditioning. Palpation should be systematic and bilateral, including the sternoclavicular joint, the clavicle, chromoclavicular joint, both the anterior and posterior aspects of the glenoid, and the bicipital groove. The purpose of our patient is to feel for crepitus and to elicit discomfort in order to localize pathology. Range of motion should be active and test all degrees of freedom of the shoulder, including flexion, extension. Abduction, cross-body abduction. External rotation with the elbow at the side. As well as with the shoulder abduct in 90 degrees. And internal rotation. Range of motion can be tested bilaterally at the same time for comparison. And then neurovascular, the neuro neuro exam can follow dermatomes or myotomes, but more commonly it follows peripheral nerve distributions. The vascular exam is to rule out rare diagnoses such as thoracic outlet syndrome. Provocative stability exams can be performed either with the patient's supine or seated. Personally, I find that positioning the patient in supine stabilizes the scapula on the exam table, and this makes maneuvers easier to perform, and I find that patients are usually more comfortable this way. Be careful though not to actually dislocate the patient's shoulder in clinic as there will be bad form. Provocative special tests that go by eponyms. can sometimes be hard to remember, especially for those who do not perform them regularly. Just remember that each test attempts to isolate a specific anatomical structure. So for instance, the Jobs test isolates supraspinatus. The O'Brien's test isolates the superior labrum. The Jurgensen's test isolates the biceps. And Nares and Hawkins tests. Try to elicit subacromial impingement. With practice, these tests can be performed relatively quickly. And inefficient. A thorough physical exam of the shoulder should take approximately 3 minutes to perform out of the 15-minute clinical visit. Moving on to imaging Shoulder X-rays are typically the first line in working up trauma and instability. It should be composed of orthogonal views, and these are the four views I typically order the AP, Grauchy, scapular Y, and axillary. The AP view demonstrates the glenohumeral joint. In its natural position where the humeral head it's slightly superimposing on the glenoid. The AP view typically shows a perfect profile of the AC joints shown here in green. The acromial humeral distance. Normally about 9 to 10 millimeters. As well as Beloney's line, which is shaped like a Gothic arch. And both be used to indicate that the gunnarcumbral joint is well reduced. The Grauchy, scapular Y, and axillary views are all orthogonal to one another. The Grashy view shows a perfect profile of the glenohumbula joint here shown in green. And the scapular Y view as well as the axillary view demonstrate anterior and posterior translation of the humeral head with respect to the glenoid. So the scapular Y and axillary views are good for assessing. Shorter instability. The scapular Y view can further show the morphology of the acromion. As either a straight, curved, or hooked morphology. The axillary view can further show the overhead projection of the AC joint to look for anterior or posterior suppluxation dislocation. If there's further concern for the shoulder that is not seen on X-ray, the indications for advanced imaging will be Concern for intra-articular derangement or soft tissue injury such as labral tear, cartilage disruption, Rotator cuff Tears Advanced imaging is usually performed with a non-contrast MRI. And the images are obtained in the axial, sagittal oblique, and chronal oblique planes. The sagittal and coronal oblique planes are perpendicular and parallel to the suprasmus tendon, respectively, in order to optimize evaluation of the rotator cuff. MRI can reveal either a bony contusion resulting from shoulder dislocation, which highlights lesions such as the Bankart and the Hillsacks lesions. It can also assess the integrity of the labrum and glonohumeral ligaments here shown in green. And they can identify rotator cuff tears. Shown here in red, which are actually pretty uncommon in the pediatric population. It can also show the status of the biceps tendon within the bicipital groove as highlighted in orange. So let us move on to discuss some of the most common shoulder injuries in skeletally immature athletes. For simplification, I usually like to categorize these injuries as either overuse or traumatic injuries. And due to our time constraints for this webinar, I've selected the following to review. And they include Little League Shorter. Glorihumeral internal rotation deficit or GERD. Gonohumeral joint instability, either anterior posterior or multidirectional. Sternal clavicular joint injuries. As well as fractures including clavicle and proximal humerus. So to go over common injuries, I have some cases. This is a nine year old right-hand dominant male baseball pitcher who presented with chronic and progressive right shoulder pain. Occurring with throwing. He also complained of decreased pitch velocity inaccuracy. And on exam, He was tender to palpation over the lateral aspect of the proximal humerus. He also exhibited pain at terminal ends of motion. So Little Leaguer's shoulder. is to find As An overuse injury caused by repetitive micro trauma to the skeletally immature proximal humeral growth plate. It is also called proxim humeral epiphysial lysis, which means separation of the epiphysis or humeral head from the metaphysis. Closer to the humeral neck. It is caused by overuse injury most commonly seen in overhead athletes due to the high torque that's generated during the late cocking phase of throwing. And it is a result of high volume of pitches. And maximal throwing efforts, as well as poor throwing mechanics, off-speed pitches. Like changeups and curveballs. And inadequate rest and sleep. The peak incidence of Little League shoulder is usually between 11 and 16 years of age. It is a clinical diagnosis, but radiographs. And we should obtain bilateral radiographs for comparison and reveal either a fal widening or irregularity at the level of the growth plate. The treatment of Little League shoulder is almost always non-operative. Rest usually for at least 3 months, after which most patients are able to return to sport. Physical therapy after all pain has subsided to work on strengthening. Flexibility and scapular stabilization to prevent further aggravation of the shoulder. Non-steroidal anti-inflammatories can be taken as needed. And patients should be taught proper pitching. Biomechanics Return to play is only allowed when there is no pain. And the patient has gone through a throwing program. Next, this is an 11 year old right-hand dominant male baseball pitcher. He presented with chronic and progressive right shoulder pain occurring with throwing. He complains of decreased performance. As well as difficulty reaching behind his back, as well as across his body. On exam He has side to side motion. Rotational differences. Of approximately 30 degrees as shown in this photo. So this is Characteristic of glenohumeral internal rotation deficit or GIRD. And it is defined as Decreased internal rotation. By at least 25 degrees. Compared to the contralateral shoulder. It can also be characterized by a side to side total motion arc difference. Signifying actual stiffness and not just a total arc change. In terms of patho anatomy, The adaptive changes Leading to tightness. And contracture of the posterior capsule occur from repeated microtrauma to the anterior capsule during the cocking phase of throwing. GERD is very common in overhead athletes. Who gain external rotation adaptively in order to increase their throwing velocity. GERD is a clinical diagnosis. In treatment is most of the time non-operative, focusing on physical therapy, working on stretching of the posterior capsule. The sleeper stretch is the most commonly described. It's performed at 60, 90, and 100 degrees of abduction as shown in the upper photo. The passive crossbody stretch has also been shown to be very effective, shown in in the bottom photo. Regular posterior capsule stretching. May in fact reduce shoulder injuries in overhead athletes and should be recommended for all overhead athletes. And finally, if non-operative management is not successful, Surgery can be offered and consists of posterior inferior capsular release. In order to improve internal rotation. Next we have a 13 year old right-hand dominant female swimmer as well as volleyball player. She presented to my clinic with right shoulder dislocation twice, first from jumping into a pool, and second from swimming in the ocean. Both times she had spontaneously relocation. But persistent pain and instability. That is recalcitrant to 6 weeks of physical therapy of strengthening. And shoulder biomechanics. On exam, she has a positive anterior apprehension and relocation tests. But negative posterior and inferior apprehension. And no signs of a sulcus gap. Her Bain score is 5 out of 9, and her MRI is shown on the right. Which shows a labral tear in the inferior. Anterior aspect of the glenoid. So this patient has glonohumeral joint instability. Which can either be traumatic versus a traumatic. She had the a traumatic version. Traumatic dislocations are often associated with structural damage to the labrum. So-called soft tissue bank heart lesions. And or glenoid rim, so-called Ossie Bankar lesions. As well as posterior humeral head defects called Hill sacks. There are also different variations of labral tears, including the Perthes lesion, which is the anterior inferior labral tear lifting from the glenoid but is still attached. Via the periosteum to the bony socket. GLAD lesion stands for glenal labral articular disruption. As you can see from the image on the right, there's a disruption at the labral chondral junction. And then ALPSA stands for anterior labral periosteal sleeve abulsion. As you can see, there is a labral tear. But the periosteal sleeve is still attached. To the anterior glenoid. And then the picture on the bottom. Demonstrates a Hillsacks lesion, which is a posterior defect of the humeral head. That is created when it engages with the anterior lip of the glenoid. During dislocation And relocation Gonohumeral joint instability occurs in 3 patterns. Anterior dislocation is the most common. It occurs. 95% of the time. Posterior dislocation is uncommon but can be associated with things like seizures and electrocution. In sports, it can be associated with batters or linemen who have posterior directed force placed on their shoulder. And the least common instability pattern is multidirectional. Which is common in patients with Connective tissue disorders. Glenohumeral joint instability is a clinical diagnosis. But imaging is helpful to confirm either a labral cartilage or glonoid rim. Effect The treatment of glenohumeral joint instability is initially urgent closed reduction, and there are various traction countertraction techniques to disengage the humeral head from the glenoid socket and then to relocate the joint. Usually patients do better with premedication and it decreases the risk of hydrogenic fracture during the reduction maneuver. After the Shoulder is relocated. The first line treatment for traumatic interior instability is either non-operative or operative and is still controversial in the literature and in practice. Traditionally, non-operative management with sling immobilization for 6 weeks. Followed by physical therapy. was the treatment of choice. But more recently, studies have shown that the rates of recurrent dislocation and instability after a first time dislocation, particularly a traumatic dislocation in patients younger than 20 years of age, Is high, high rate of recurrence with non-operative management up to 56 to 90% depending on the study that you reference. Thus there is a trend. To surgical management for younger patients or our population. The absolute surgical indications for surgery include open injuries, irreducible. Gohumeral joint dislocations as well as fracture dislocations with significant displacement. The mainstay for multidirectional instability is conservative treatment, focusing on periscapular. And rotator cuff strengthening in order to optimize dynamic stabilization. So for our patient, 13 year old female swimmer and volleyball player, She elected to undergo arthroscopic label repair and capsulorphy after failure of physical therapy. The image on the left shows the soft tissue bank car lesion. Born at the Inferior anterior aspect of the glenoid. Second image shows placement of suture anchors. And then 3rd and 4th images show a repaired bank heart lesion, restoring the Labral bumper or the gum humeral joint. Next is a 12 year old right-hand dominant female ice hockey player. Presented to the emergency department with right chest pain after she was hit in the chest while playing ice hockey. On exam, she had right sternoclavicular joint pain. As well as asymmetry. A specifically a depression compared to the contralateral side as you can kind of see in the images above. She did not have any difficulty breathing or swallowing. And her X-rays, initial X-rays are shown at the bottom. So this patient sustained a sternal clavicular joint injury, particularly a Posterior dislocation. So external clavicular joint injuries can either be traumatic, as in our case, or a traumatic. It can either be anterior or posterior. And the imaging or working up ternal varicular joint injury is usually with plain radiograph, specifically the serendipity view, which is the orthogonal view to the AP plane of the clavicle. A CT scan should be obtained to assess for impingement of any adjacent soft tissue structures, particularly the great vessels. For posterior dislocations. Treatment can either be observation if The mechanism is a traumatic or if the patient has had chronic dislocations, it goes in and out. Surgery is reserved for the acute anterior and posterior dislocations. That either fail close reduction. Or significantly impinge on soft tissue structures. So this is the imaging for our patient. The serendipity view again is orthogonal to the AP view shot at approximately 45 degrees. And shows a posterior dislocation of the medial aspect of the clavicle. The CT scan on the right shows that the displacement. Abuts against the Um, the greater vessels, uh, of the subclavian greater vessels. So this patient underwent open reduction and internal fixation. Using suture fixation and the Resultant reduction in taxation is shown on the fluoroscopy image on the right. Next we have an 11 year old. Right-hand dominant non-athlete who presented to The ED with a right shoulder deformity and pain after falling onto his right side. On exam, he had a visible shoulder deformity as well as skin tenting. But the skin was mobile without blanching. So this patient had a lateral 3rd. Clavicle fracture And he was treated non-operatively. With a simple sling. Or Several weeks Followed by a gradual range of motion as tolerated. Three months later, His fracture healed and demonstrated Substantial remodeling To find out the deformity, uh, clinically. So treatment of clavicular fractures in the adolescent. There are, there are many studies showing that the majority of clavicle fractures in children and adolescents can and should be treated non-operatively. In the past, recently, There was a slight rise in the surgical fixation of these injuries. Particularly those in adolescence because Studies were in uh were referenced from the adult literature. However, we have found that the remodeling potential of clavicles through adolescent and early childhood. Greatly exceeds that of the adult population. In fact, the medial aspect of the clavicle doesn't stop, doesn't fuse. Uh, until About 25 years of age. But when warranted, Surgery with open reduction internal fixation using plates and screws. Just like in the adult population has consistently shown good outcomes, with the most common complication being that of implant irritation requiring a second surgery for hardware removal. This is another patient 13 year old right-hand dominant soccer player who fell onto his right shoulder while running on the soccer field. He presented to the ED. In the evening with right shoulder deformity, skin tinting. As well as a poke hole wound with bleeding over the fracture site. So this patient had an open clavicle fracture, which is rare and an absolute indication for surgical management. So this patient underwent Open irrigation agreement followed by reduction and fixation using plate and screws. And after 3 months, Of rehabilitation, the patient has now painless range of motion. And really minimal um irritation of the plate. But will likely elect to have hardware removal. At about one year. And next This is a 15 year old right-hand dominant football player. Who had a fall uh during the game onto his left upper extremity, resulting in this injury. He presented with shoulder deformity. And substantial pain and Um Muscle spasms. On exam, his motor and sensory were intact and all peripheral nerve distributions. And the extremity was warm and well profused, but there was an obvious deformity of the proximal humerus. So proximal humerus fractures are those that involve the proximal humeral physis as well as metaphysis. And we should know that proximal humeral physis contributes. About 80% of the growth of the humerus itself and therefore there is significant remodeling potential of the proximal humerus in skeletally immature patients. Treatment of these injuries are based on age and expected remodeling potential. So the younger the patient, the more remodeling potential they have and the more Indication for them to be treated non-operatively. So pre-adolescent patients, the majority of them should be treated non-operatively. For older patients who are closer to skeletal maturity, surgical treatment can then be considered and offered in order to improve. Fracture alignment, as well as to reduce the risk of non-union. So for our 15 year old football player, Due to significant pain. Displacement As well as his Chronological and skeletal age, open reduction and flexible nail fixation. was performed. At 8 months, you can see still significant remodeling despite some translation. The patient is asymptomatic. Painless with full range of motion and has returned to sports. So in the primary care setting, I think shoulder injuries can be approached in a stepwise fashion, starting with a focused history. In physical exam And then obtaining appropriate imaging. Followed by decision to either treat in the primary care setting or if there is concern for A surgical problem, then refer for either then refer for a surgical consultation. I think knowing the basic shoulder anatomy will help one be more effective at performing the physical exam maneuvers. As well as interpreting The exams as well as the imaging of the shoulder. And also having various differential diagnoses in mind based on the most common shoulder injuries and skeletally mature athletes will help one decide. Help the patient decide the best management to to pursue. So in summary, pediatric and adolescent athletes are at risk for both overuse and traumatic injuries of the shoulder. Most young overhead athletes will sustain overuse injuries as opposed to traumatic injuries. And most overuse injuries can be treated with rest, rehabilitation, and gradual return to sports. Only those with recurrent anterior shoulder dislocation and labral tears may require surgical stabilization. Or other procedures Treatment of fractures as well as sternoclavicular and acromioclavicular joint. Uh, Barry And shoulder injuries. Overall, and skeletally mature patients may, I think, may be appropriately treated within the primary care setting. So that is all I have prepared. Um, thank you for your time and attention, and I welcome any questions or comments.
