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. As Maria said, my name is Michael Tr. 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 sculpturally 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, advance, there we go. Um I have no conflicts of interest disclose for this presentation. Uh Our learning objectives uh for this webinar are as follows to be able to identify and diagnose common shorter injuries and skeletally immature athletes to be able to perform a basic shorter exam within the limited time allotted 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 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 um longer, taking place for longer durations throughout the year. There is also this issue of single sports specialization as our Children strive for things like accolades and scholarships. Thus many young athletes um 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 and 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 hypotheses 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 grow disturbances. Children are also at higher risk of injury due to having lower stamina, less refined neuromuscular co ordination and more variability in body size and strength when comparing peer to peer which becomes rel relevant in contact sports. Let's review some basic Katy. So the shoulder is a ball and socket joint comprised of three bones, humerus, scapula and clavicle and two articulations glenohumeral and a chrom clavicular. 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 shorter 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 four 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 shorter 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 glan humeral 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 critic correlate is that shoulder dislocation resulting in laboral tears and disruption of the gun or humeral 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 Gloor humeral ligament and the middle Gloor humeral ligament are taught as the arm is brought into the apprehension position of abduction and external rotation. The anterior band of the inferior goner humeral ligament is pulled up to span the mid portion of the glo heal joint, thus providing anterior stability. This anatomy explains the apprehension tests that we regularly perform in clinic in the setting of an anterior inferior labor tear, also known as a bank car 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 Earl's do los and generalized ligaments, 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 shorter 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 wind up 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 face 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, a 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 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 an interior capsular stretch and posterior capsular tightening as well as bony retro version 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 motion which remains constant. Studies have report have reported in adolescent baseball players that the greatest change in shorter 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 below to the shoulder can be responsible for ac joint separations. Whereas instability can occur with injury to the abducted, externally rotated, harm, aggravating and relieving factors as well as knowing treatment measures previously attempted are also helpful with 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 B score should be documented for joint hypermobility which can be associated with conditions such as multidirectional border 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 sternal clavicular or fractures such as clavicle or proxy, humerus, scapular dyskinesis and winging as shown in the image below can either be subtle or quite striking. An 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 sternal clavicular joint, the clavicle chromo clavicular joint, both the anterior and posterior aspects of the glenoid and the bicipital group. The purpose of how 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, crossbody abduction, external rotation with the elbow at the side as well as with the shoulder abduct at 90 degrees and internal rotation major motion can be tested bilaterally at the same time for comparison. And then neurovascular, the neuro neuro exam can follow derma toes 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 patients 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 it would be bad form. Provocative special tests that go by eponym 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'briens test isolates the superior labrum. The Jorgensen's test isolates the biceps and Nares and Hawkins tests try to elicit sub coral impingement with practice. These tests can be performed relatively quickly and inefficient. A thorough physical exam of the shoulder should take approximately three 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 A P grouchy scapular Y in axillary. The A P view demonstrates the glenohumeral joint in its natural position where the humoral head is slightly super imposing on the glenoid. The A P view typically shows a perfect profile of the ac joint shown here in green. The acromial humeral distance normally about 9 to 10 millimeters as well as Maloney's line, which is shaped like a gothic arch can both be used to indicate that the gunner Kimbrough joint is well reduced. The grouchy scapular Y and Axo views are all orthogonal to one another. The grouchy view shows a perfect profile of the glenner humble 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 act views are good for assessing shorter instability. The scapular y view can further show the morphology of the chromium 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 subluxation dislocation. If there is further concern for the shoulder that is not seen on X ray, the indications for advanced imaging will be concern for intra-articular derangements or soft tissue injury such as laboral tear, Carlos, disruption, rotator cuff tears, advanced imaging is usually performed with a noncontrast MRI and the images are obtained in the axial sagittal oblique and chrono oblique planes. The sagittal and chrono bleed planes are perpendicular and parallel to the super smit tendon respectively. In order to optimize evaluation of the rotator cuff MRI can reveal either bony contusion resulting from shoulder dislocation, which highlights lesions such as the B card and the hill sacks lesions. It can also assess the integrity of the labrum and Gloor ligaments here shown in green and they can identify rotator cup 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 bicycle 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 shoulder GC, internal rotation deficit occurred humeral of joint instability, either an interior poster 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 and accuracy and on exam, he was tender to palpation over the latter aspect of the proximal humerus. He also exhibited pain at terminal ends of motion. So little eager shoulder is defined as an overuse injury caused by repetitive micro trauma to the skeletally immature proximo, humeral growth plate. It is also called proxim humeral epiphysis, 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 um efforts as well as poor throwing mechanics off speed, pitches like changeups and curveballs and an adequate rest and sleep. The peak incidence of Little Lake Shoulder is usually between 11 and 16 years of age. It is a clinical diagnosis of radiographs and we should obtain bilateral radiographs for comparison and reveal either a pal 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 three 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 a 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 Sam. He has side to side motion rotational differences of approximately 30 degrees as shown in this photo. So this is characteristic of Glenn humeral internal rotation deficit or GD 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 Papal Anatomy. The adapter changes leading to tightness and contraction of the posterior capsule occur from repeated micro trauma to the anterior capsule during the cocking phase of throwing GD is very common in overhead athletes who gain external rotation adaptively in order to increase their throwing velocity. GD is a clinical diagnosis and 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 90 100 degrees of abduction as shown in the upper photo. The passive cross body stretch has also been shown to be very effective shown in in the bottom photo, regular posterior capsule stretching may in fact in reduce shoulder in injuries in overhead athletes and should be recommended for all overhead athletes. And finally, if non offer 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 the concentrate to six weeks of physical therapy of strengthening and shorter 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 main score is five out of nine and her MRI is shown on the right which shows a laboral tear in the inferior ante aspect of the glenoid. So this patient has g humor joint instability which can either be traumatic versus a traumatic. She had a the a traumatic version, traumatic dislocations are often associated with structural damage to the labrum, so called soft tissue bank heart lesions and or gleno rim so called Aussie bank car lesions as well as posterior humor had defects called hill sacks. There are also different variations of laboral tears including the earthy lesion, which is the anterior inferior laboral tear lifting from the glenoid but is still attached via the periosteum to the bony socket. Glad lesion stands for glen laboral articular disruption. As you can see from the image on the right, there is disruption at the laboral chondral junction and then ALSA stands for anterior laboral periosteal sleeve evolution. As you can see, there is a laboral tear but the periosteal sleeve is still attached to the anterior glenoid. And then the picture on the bottom demonstrates a hill sack 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, glenohumeral joint instability occurs in three 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. Humor, joint instability is a clinical diagnosis but imaging is helpful to confirm either a laboral cartilage or clon rim. The effect. The treatment of gunner humeral joint instability is initially urgent closed reduction. And there are various traction counter traction techniques to disengage the humeral head from the glynos socket and then to relocate the joint. Usually patients do better with premedication and it decreases the risk of hydrogen 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 mobilization for six 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 or surgical management for younger patients or our population. The absolute surgical indications for surgery include open injuries, irreducible humeral 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 labor repair and caps morphy after failure of physical therapy. The image on the left shows the soft tissue b heart lesion born at the inferior anterior aspect of the glenoid. Second, image shows placement of future anchors and then 3rd and 4th images show a repaired bank heart lesion, restoring the labor bumper or the hero 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 sternal caviar joint pain as well as a symmetry. 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 external joint injury is usually with plain radiograph. Specifically the serendipity view, which is the orthogonal view to the A P plane of the clavicle AC T scan should be obtained to assess or 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 and 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 A P 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 but against the um the greater vessels uh sub of the subclan 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 third clavicle fracture and he was treated non operatively with a simple sling for several weeks, followed by a gradual range of motion as tolerated. Three months later, his fracture healed and demonstrated substantial remodeling to flat out the deformity uh clinically. So, treatment of clavicular fractures in the adolescent. There are, there are many studies um showing that the majority of clavicle fractures in Children Allison 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 menial 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 plate 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 tenting, as well as a poke hole wound with bleeding over the fracture site. So this patient had an open logical fracture, which is rare and a absolute indication for surgical management. So this patient underwent open irrigation and agreement followed by reduction and fixation using the plate and screws. And after three 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 harder 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 der distributions and the extremity was warm and well perfused, but there was an obvious deformity of the proximal humerus. So, proximal humerus fractures are those that involve the proximal humeral phys as well as metaphysis. And we should know that prox humor phys contributes about 80% of the growth of the humerus itself. And therefore, there is significant remodeling potential of the proxy humerus and 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, preadolescent patients, the majority of them should be treated. No oerly for older patients who are closer to skull of maturity, surgical treatment can then be considered and offered in order to improve fracture alignment as well as to reduce the risk of nonunion. So for our 15 year old football player, due to significant pain displacement, as well as his chronological and cult age open reduction and flexible nail fixation was performed at eight 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 step wise 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 PURs 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 location and laboral tears may require surgical stabilization or other procedures, treatment of fractures as well as sternal clavicular and a chromic 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.
