WEBVTT

00:00:00.000 --> 00:00:02.759
Welcome to The Deep Dive, the show where we unpack

00:00:02.759 --> 00:00:04.980
complex topics and arm you with the essential

00:00:04.980 --> 00:00:07.559
insights you need to be truly well -informed.

00:00:08.320 --> 00:00:10.619
Today, we're plunging into a marvel of human

00:00:10.619 --> 00:00:13.080
engineering, a joint that really epitomizes both

00:00:13.080 --> 00:00:16.519
extraordinary power and, well, surprising fragility,

00:00:17.000 --> 00:00:19.589
the shoulder. It really is quite something, isn't

00:00:19.589 --> 00:00:22.010
it? It's an incredible feat of anatomy, capable

00:00:22.010 --> 00:00:24.910
of immense force and delicate precision, yet

00:00:24.910 --> 00:00:27.710
paradoxically, it's also one of the most inherently

00:00:27.710 --> 00:00:30.829
unstable joints in the human body. So how does

00:00:30.829 --> 00:00:33.030
this fundamental conflict play out, particularly

00:00:33.030 --> 00:00:35.710
in the demanding, high -stakes world of professional

00:00:35.710 --> 00:00:37.969
athletics, where every movement is pushed to

00:00:37.969 --> 00:00:40.189
its absolute limit? It's truly a fascinating

00:00:40.189 --> 00:00:42.530
paradox that incredible range of motion often

00:00:42.530 --> 00:00:45.030
comes at a cost, making the shoulder a frequent

00:00:45.030 --> 00:00:47.700
sight of injury in sports, as you know. Indeed.

00:00:48.100 --> 00:00:50.479
And that's precisely why we're taking an in -depth

00:00:50.479 --> 00:00:53.240
look today. This deep dive is an exploration

00:00:53.240 --> 00:00:55.939
into the intricate world of sports -related shoulder

00:00:55.939 --> 00:00:59.140
injuries. Our aim is to provide mid -senior medical

00:00:59.140 --> 00:01:01.560
professionals like you with practical, evidence

00:01:01.560 --> 00:01:04.260
-based insights that hopefully transcend basic

00:01:04.260 --> 00:01:06.459
understanding, giving you that critical edge

00:01:06.459 --> 00:01:09.030
in diagnosis and management. And joining me today

00:01:09.030 --> 00:01:11.489
to navigate this complex landscape is a truly

00:01:11.489 --> 00:01:13.510
distinguished expert in the field, Professor

00:01:13.510 --> 00:01:16.569
Mo Imam. He possesses an exceptional ability

00:01:16.569 --> 00:01:19.129
to synthesize complex orthopedic information,

00:01:19.510 --> 00:01:21.730
draw critical connections between nuanced details,

00:01:22.069 --> 00:01:24.469
and truly illuminate the broader clinical implications

00:01:24.469 --> 00:01:26.189
of these injuries. Thank you. It's a pleasure

00:01:26.189 --> 00:01:28.170
to be here and to delve into a topic that truly

00:01:28.170 --> 00:01:30.230
underpins so much of what we see in practice.

00:01:30.569 --> 00:01:33.069
Our mission today is clear. We're going to meticulously

00:01:33.069 --> 00:01:35.310
unpack the shoulder's fundamental anatomy and

00:01:35.310 --> 00:01:37.859
biomechanics, dissect common injury patterns

00:01:37.859 --> 00:01:41.340
unique to athletic demands and explore cutting

00:01:41.340 --> 00:01:43.939
-edge diagnostic approaches and evolving management

00:01:43.939 --> 00:01:47.140
strategies. Ultimately, we want to enhance your

00:01:47.140 --> 00:01:49.340
diagnostic precision and elevate the efficacy

00:01:49.340 --> 00:01:51.579
of your treatment plans, optimizing outcomes

00:01:51.579 --> 00:01:53.620
for your athletic patients. You know, when we

00:01:53.620 --> 00:01:55.579
talk about the shoulder, it's this incredible

00:01:55.579 --> 00:01:58.099
paradox capable of throwing a fastball at, what,

00:01:58.099 --> 00:02:01.299
100 mile of horror, yet seemingly prone to dislocation

00:02:01.299 --> 00:02:03.780
just from falling awkwardly. What is it about

00:02:03.780 --> 00:02:05.840
its fundamental architecture with its five joints,

00:02:06.019 --> 00:02:07.870
eight ligaments, and 30 muscles that creates

00:02:07.870 --> 00:02:10.430
this inherent conflict, offering unparalleled

00:02:10.430 --> 00:02:12.669
mobility at the cost of inherent instability.

00:02:12.990 --> 00:02:15.789
That really is the core paradox, isn't it? The

00:02:15.789 --> 00:02:18.550
shoulder achieves its status as the most movable

00:02:18.550 --> 00:02:21.770
joint in the human body, precisely because it

00:02:21.770 --> 00:02:25.330
sacrifices inherent stability. Its primary function

00:02:25.330 --> 00:02:28.550
is to facilitate incredibly precise hand positioning

00:02:28.550 --> 00:02:32.129
in space, allowing for complex multi -directional

00:02:32.129 --> 00:02:35.090
movements. But this comes at the expense of a

00:02:35.090 --> 00:02:37.879
deep bony socket, the kind that would provide

00:02:37.879 --> 00:02:40.120
intrinsic stability like you see in the hip,

00:02:40.120 --> 00:02:42.280
for instance. Why? So it's a trade -off. Exactly.

00:02:42.580 --> 00:02:44.259
And when we consider its movements, we're talking

00:02:44.259 --> 00:02:46.620
about a full spectrum, internal and external

00:02:46.620 --> 00:02:48.979
rotations, abduction and adduction in the frontal

00:02:48.979 --> 00:02:51.719
plane, and flexion and extension in the sagittal

00:02:51.719 --> 00:02:54.180
plane. The combination of these elementary movements

00:02:54.180 --> 00:02:56.639
generates circumduction, that complex circular

00:02:56.639 --> 00:02:59.039
trajectory we see, for example, in a picture's

00:02:59.039 --> 00:03:01.889
wind -up. Crucially, the glenohumeral joint also

00:03:01.889 --> 00:03:04.669
has significant translational capabilities anterior

00:03:04.669 --> 00:03:07.610
-posterior, superior -inferior, and medial -lateral.

00:03:08.289 --> 00:03:10.289
All of this extensive range of motion is critically

00:03:10.289 --> 00:03:12.509
dependent on a balanced and synchronized interplay

00:03:12.509 --> 00:03:15.030
between both its static or passive and active

00:03:15.030 --> 00:03:17.889
or dynamic stabilizers. Without that delicate

00:03:17.889 --> 00:03:20.889
balance, the entire system falters. OK, so passive

00:03:20.889 --> 00:03:23.909
and active stabilizers working together. 1 .2

00:03:23.909 --> 00:03:27.150
static stabilizers. the passive framework. So

00:03:27.150 --> 00:03:30.509
if extreme mobility is paramount, what precisely

00:03:30.509 --> 00:03:32.889
is holding it all together? Let's delve into

00:03:32.889 --> 00:03:35.090
the static stabilizers first, starting with the

00:03:35.090 --> 00:03:37.509
bony components. What's truly fascinating about

00:03:37.509 --> 00:03:40.129
the bone geometry that contributes to this delicate,

00:03:40.610 --> 00:03:43.069
often precarious balance? Well, the bony anatomy

00:03:43.069 --> 00:03:46.030
itself is a major contributor to the shoulder's

00:03:46.030 --> 00:03:48.569
inherent instability, actually. Take the humeral

00:03:48.569 --> 00:03:51.389
head, for instance. It exhibits significant variability

00:03:51.389 --> 00:03:54.069
in shape and size. And on average, it's retroverted

00:03:54.069 --> 00:03:56.099
by about 90%. degrees, though there's quite a

00:03:56.099 --> 00:03:59.280
range. This retroversion, along with the humeral

00:03:59.280 --> 00:04:02.080
head's curvature, plays a role in how it articulates

00:04:02.080 --> 00:04:03.800
with the glenoid. And the glenoid, that's the

00:04:03.800 --> 00:04:05.860
socket part, isn't it? Yes, and it's remarkably

00:04:05.860 --> 00:04:08.400
shallow. It's pear -shaped, with an average depth

00:04:08.400 --> 00:04:10.879
of just 2 .5 millimeters in the entero -posterior

00:04:10.879 --> 00:04:13.319
direction, and maybe 9 millimeters superior,

00:04:13.580 --> 00:04:16.399
inferiorly. This minimal bony containment, coupled

00:04:16.399 --> 00:04:19.079
with its slight retroversion and superior inclination,

00:04:19.660 --> 00:04:22.290
is a fundamental architectural compromise. It

00:04:22.290 --> 00:04:24.649
grants unparalleled mobility but forces the soft

00:04:24.649 --> 00:04:26.490
tissues to do the heavy lifting for stability.

00:04:26.709 --> 00:04:28.709
So the bones offer very little constraint on

00:04:28.709 --> 00:04:32.069
their own. Precisely. What's even more astounding

00:04:32.069 --> 00:04:34.829
is that only a maximum of 30 % of the humeral

00:04:34.829 --> 00:04:37.230
articular surface articulates with the glenoid

00:04:37.230 --> 00:04:40.470
at any given time. This starkly underscores the

00:04:40.470 --> 00:04:43.269
indispensable role of the soft tissue and dynamic

00:04:43.269 --> 00:04:45.720
restraints. When we consider how little bone

00:04:45.720 --> 00:04:48.180
-on -bone contact there is, it becomes clear

00:04:48.180 --> 00:04:51.279
why even subtle changes in bony anatomy can significantly

00:04:51.279 --> 00:04:53.839
influence stability. Which brings us to bony

00:04:53.839 --> 00:04:57.079
lesions after trauma. Exactly. Certain bony lesions

00:04:57.079 --> 00:04:59.680
often arise after traumatic events leading to

00:04:59.680 --> 00:05:02.339
instability. The bony bankart lesion, for example,

00:05:02.639 --> 00:05:05.120
located at the anterior inferior glenoid rim.

00:05:05.240 --> 00:05:07.660
It becomes clinically significant when it involves

00:05:07.660 --> 00:05:10.100
more than 20 % of the glenoid's length predisposing

00:05:10.100 --> 00:05:12.620
to recurrence. If it involves over 50 % of the

00:05:12.620 --> 00:05:14.699
glenoid, shoulder stability is reduced by more

00:05:14.699 --> 00:05:17.600
than 30%. And the classification for that? Bigliani

00:05:17.600 --> 00:05:22.720
et al. Classified it into type 1, 2, and 3 based

00:05:22.720 --> 00:05:25.600
on displacement and healing. Then you have the

00:05:25.600 --> 00:05:28.120
hill -sax lesion, a compression fracture at the

00:05:28.120 --> 00:05:30.459
post -relateral aspect of the humeral head that

00:05:30.459 --> 00:05:33.060
typically occurs following an anterior dislocation.

00:05:33.480 --> 00:05:35.860
And we also see reverse lesions, like the reverse

00:05:35.860 --> 00:05:38.300
bony bankart lesion or the reverse hill -sax,

00:05:38.319 --> 00:05:41.120
also called the McLaughlin lesion, on the anterior

00:05:41.120 --> 00:05:43.779
humeral head, which can become engaging during

00:05:43.779 --> 00:05:46.180
specific arm movements. Right, engaging, meaning

00:05:46.180 --> 00:05:49.180
it can catch on the glenoid rim. Exactly. Okay,

00:05:49.180 --> 00:05:51.480
beyond the intricate bony architecture, you mentioned

00:05:51.480 --> 00:05:54.439
the soft tissues play an equally crucial if not

00:05:54.439 --> 00:05:57.720
more critical, role. What are these unsung heroes

00:05:57.720 --> 00:06:00.339
and how do their complex interconnections contribute

00:06:00.339 --> 00:06:03.879
to stability and, well, instability when injured?

00:06:04.120 --> 00:06:05.720
You're right. The soft tissues are absolutely

00:06:05.720 --> 00:06:08.339
vital. A key concept here, especially for understanding

00:06:08.339 --> 00:06:11.199
instability, is the glenoid tract. Think of this

00:06:11.199 --> 00:06:13.660
as the contact area between the glenoid and humeral

00:06:13.660 --> 00:06:16.800
head. It shifts from the inframedial to the post

00:06:16.800 --> 00:06:18.959
-relateral portion of the humeral head's posterior

00:06:18.959 --> 00:06:21.779
articular surface during maximum external rotation,

00:06:22.180 --> 00:06:24.579
extension, and abduction. Okay, so the contact

00:06:24.579 --> 00:06:27.759
zone moves. Precisely. And the glenoid tract's

00:06:27.759 --> 00:06:31.079
width is about 84 % of the glenoid's width. This

00:06:31.079 --> 00:06:33.399
means that any glenoid articular surface loss,

00:06:33.699 --> 00:06:36.660
as we see in bony bankart lesions, significantly

00:06:36.660 --> 00:06:39.860
influences this crucial dimension. Why this matters

00:06:39.860 --> 00:06:42.579
clinically? It precisely influences the risk

00:06:42.579 --> 00:06:45.290
of Hill -Sachs lesion engagement. If the humeral

00:06:45.290 --> 00:06:47.509
head bony loss remains within the glenoid tract,

00:06:47.810 --> 00:06:49.949
it's considered on track. Meaning less risk.

00:06:50.230 --> 00:06:52.709
Exactly. No possibility of the hill sacs lesion

00:06:52.709 --> 00:06:55.410
overriding the glenoid rim. Conversely, if it

00:06:55.410 --> 00:06:57.370
extends over the medial margin of the glenoid

00:06:57.370 --> 00:06:59.790
tract, it's off track, and the risk of engagement

00:06:59.790 --> 00:07:02.550
rises significantly. This distinction is critical

00:07:02.550 --> 00:07:04.569
for surgical planning. That makes sense. So what

00:07:04.569 --> 00:07:06.829
are the main soft tissue players? Well, looking

00:07:06.829 --> 00:07:09.189
at the soft tissue stabilizers themselves, we

00:07:09.189 --> 00:07:12.009
have the glenoid labrum, the glenohumeral capsule,

00:07:12.189 --> 00:07:14.250
the glenohumeral ligaments, the rotator interval,

00:07:15.009 --> 00:07:17.810
negative intercapsular pressure, and the adhesion

00:07:17.810 --> 00:07:21.110
-cohesion mechanism. The glenoid labrum, that

00:07:21.110 --> 00:07:23.949
triangular fibrocartilaginous ring, is particularly

00:07:23.949 --> 00:07:27.110
prone to lesions. A bankard tear, affecting the

00:07:27.110 --> 00:07:29.730
anteroinferior labrum, has a high association

00:07:29.730 --> 00:07:32.050
with recurrent instability, potentially up to

00:07:32.050 --> 00:07:35.189
an 87 % recurrence after an arthroscopic bankard

00:07:35.189 --> 00:07:37.290
procedure under certain conditions. That's a

00:07:37.290 --> 00:07:39.829
huge recurrence rate. It is. We also see the

00:07:39.829 --> 00:07:43.509
ALPSA anterior labral ligamentus periosteal sleeve

00:07:43.509 --> 00:07:46.189
avulsion, where the complex rolls up, displaced

00:07:46.189 --> 00:07:48.850
medially and inferiorly. This potentially carries

00:07:48.850 --> 00:07:51.310
an even higher risk of re -dislocation than undisplaced

00:07:51.310 --> 00:07:53.569
bankard tears. And the capsule and ligaments?

00:07:53.870 --> 00:07:56.139
Also key. Capsular stretching is quite common

00:07:56.139 --> 00:07:58.699
in recurrent anterior instability found in up

00:07:58.699 --> 00:08:02.660
to 28 % of patients. Conversely, recurrent posterior

00:08:02.660 --> 00:08:05.319
subluxations lead to posterior capsular redundancy

00:08:05.319 --> 00:08:07.639
and increased joint volume causing posterior

00:08:07.639 --> 00:08:10.899
instability. This redundancy in various directions

00:08:10.899 --> 00:08:13.779
is a very common finding in atraumatic multidirectional

00:08:13.779 --> 00:08:16.779
instability. The glenohumeral ligament superior,

00:08:17.060 --> 00:08:20.649
SGHL, middle. MGHL, and especially the inferior

00:08:20.649 --> 00:08:24.149
glenohumeral ligament complex, IGHLC, primarily

00:08:24.149 --> 00:08:26.149
act at the extremes of range of motion when they

00:08:26.149 --> 00:08:28.610
are in tension. So, not so much in the midrange?

00:08:28.730 --> 00:08:30.750
Correct. In the middle ranges, the rotator cuff

00:08:30.750 --> 00:08:33.549
and long head of biceps take over more. The IGHLC

00:08:33.549 --> 00:08:35.970
forms a crucial sling -like structure that moves

00:08:35.970 --> 00:08:38.669
anteriorly during abduction, external rotation,

00:08:38.830 --> 00:08:40.889
and extension to restrain anterior humeral head

00:08:40.889 --> 00:08:43.789
translation. And AGHL lesion, humeral avulsion

00:08:43.789 --> 00:08:45.809
of the glenohumeral ligament, where the ligament

00:08:45.809 --> 00:08:47.990
pulls off the humerus, has an incidence as high

00:08:47.990 --> 00:08:50.649
as 10 % and can often be missed. So another potential

00:08:50.649 --> 00:08:53.529
hidden injury. Yes. Then there's the rotator

00:08:53.529 --> 00:08:55.970
interval, that triangular space bounded by the

00:08:55.970 --> 00:08:59.929
coracoid, biceps tendon, subscapularis, and supraspinatus.

00:09:00.429 --> 00:09:03.840
It's an important inferior stabilizer. Insufficiency

00:09:03.840 --> 00:09:05.919
here can be clinically appreciated, especially

00:09:05.919 --> 00:09:08.360
in athletes when muscles are contracted. And

00:09:08.360 --> 00:09:11.399
finally, almost imperceptibly, you have mechanisms

00:09:11.399 --> 00:09:14.399
like negative intracapsular pressure, a sort

00:09:14.399 --> 00:09:16.679
of suction effect, and the adhesion -cohesion

00:09:16.679 --> 00:09:19.299
effect. Like wet glass. Exactly like wet glass

00:09:19.299 --> 00:09:21.940
surfaces sticking together. The articular cartilage

00:09:21.940 --> 00:09:24.980
surfaces create a subtle but critical bond through

00:09:24.980 --> 00:09:27.879
fluid -mediated mechanisms. This highlights how

00:09:27.879 --> 00:09:30.600
vital a healthy, intact cartilage surface is

00:09:30.600 --> 00:09:33.039
for maintaining that foundational stability even

00:09:33.039 --> 00:09:36.620
before the muscles kick in. 1 .3 Dynamic Stabilizers

00:09:36.620 --> 00:09:39.840
The Active Control System Okay, so the static

00:09:39.840 --> 00:09:41.620
structures provide the foundational architecture,

00:09:41.700 --> 00:09:43.639
but the shoulder is anything but static. It's

00:09:43.639 --> 00:09:45.940
constantly in motion, performing incredible feats.

00:09:46.299 --> 00:09:47.840
That brings us to the Active Control System,

00:09:47.919 --> 00:09:50.000
doesn't it? How do the muscles and proprioception

00:09:50.000 --> 00:09:52.259
actively coordinate to keep the shoulder in check

00:09:52.259 --> 00:09:55.159
and enable its incredible mobility? Precisely.

00:09:55.259 --> 00:09:58.539
The dynamic stabilizers are the real -time guardians,

00:09:59.080 --> 00:10:02.039
constantly adjusting, and their combined and

00:10:02.039 --> 00:10:04.700
synchronized roles are absolutely paramount in

00:10:04.700 --> 00:10:07.879
maintaining dynamic stability. The rotator cuff

00:10:07.879 --> 00:10:10.700
muscles are the primary dynamic stabilizers here.

00:10:11.139 --> 00:10:13.240
Their main function is to compress the humeral

00:10:13.240 --> 00:10:16.019
head onto the glenoid surface, centering it and

00:10:16.019 --> 00:10:17.860
dynamically tightening the capsule ligamentous

00:10:17.860 --> 00:10:20.419
structures they attach to. These four muscles,

00:10:20.659 --> 00:10:23.159
subscapularis, supraspinatus, infraspinatus,

00:10:23.679 --> 00:10:26.759
and teres minor, effectively hug the joint, creating

00:10:26.759 --> 00:10:28.899
that dynamic compression. A hugging effect. I

00:10:28.899 --> 00:10:31.200
like that. It's a good visual. And the work by

00:10:31.200 --> 00:10:33.679
Wolker and colleagues was quite compelling. They

00:10:33.679 --> 00:10:36.059
show that even a 50 % decrease in rotator cuff

00:10:36.059 --> 00:10:39.039
muscle forces resulted in nearly a 50 % increase

00:10:39.039 --> 00:10:41.100
in anterior displacement of the humeral head

00:10:41.100 --> 00:10:43.600
in response to external loading. Wow, that really

00:10:43.600 --> 00:10:45.700
underscores their importance. It does. It shows

00:10:45.700 --> 00:10:47.980
just how vital their active contribution is.

00:10:48.440 --> 00:10:50.940
The subscatularis, in particular, provides anterior

00:10:50.940 --> 00:10:53.379
stability, especially when the arm is in neutral

00:10:53.379 --> 00:10:56.120
rotation. Now, you mentioned impingement earlier.

00:10:56.179 --> 00:10:58.679
Can you clarify the types we see? Yes. Within

00:10:58.679 --> 00:11:01.279
this dynamic system, we often differentiate between

00:11:01.279 --> 00:11:04.200
two primary types of impingement. External impingement

00:11:04.200 --> 00:11:07.100
is an abnormal contact between the coracoacromial

00:11:07.100 --> 00:11:09.740
arc, that's the roof of the shoulder, and superior

00:11:09.740 --> 00:11:12.500
surface of the rotator cuff. Internal impingement,

00:11:12.519 --> 00:11:15.039
on the other hand, involves abnormal contacts

00:11:15.039 --> 00:11:17.299
between the rotator cuff's articular surface,

00:11:17.700 --> 00:11:20.419
the underside, and the posterior glenode rim.

00:11:20.840 --> 00:11:23.019
This is particularly common in throwing athletes.

00:11:23.220 --> 00:11:25.500
And the cause of internal impingement is debated.

00:11:25.840 --> 00:11:28.340
There's an ongoing discussion, yes. It's often

00:11:28.340 --> 00:11:30.960
attributed to anterior micro instability and

00:11:30.960 --> 00:11:33.740
tightness of the posterior capsule. Others highlight

00:11:33.740 --> 00:11:36.539
that postural inferior capsular contracture can

00:11:36.539 --> 00:11:39.100
result in postural superior instability, leading

00:11:39.100 --> 00:11:41.980
to a peelback of the superior labrum and rotator

00:11:41.980 --> 00:11:44.559
cuff tearing. It's likely multifactorial in many

00:11:44.559 --> 00:11:47.139
cases. What about the biceps? The long head of

00:11:47.139 --> 00:11:50.250
biceps acts as a secondary stabilizer. Its role

00:11:50.250 --> 00:11:52.370
becomes predominant and critical when a rotator

00:11:52.370 --> 00:11:55.289
cuff or capsuligmentous deficiency coexists,

00:11:55.470 --> 00:11:57.250
which we often find in patients with insufficient

00:11:57.250 --> 00:12:00.830
rotator cuff function. Then we have the scapulothoracic

00:12:00.830 --> 00:12:04.230
muscles and their rhythm. The key scapular rotators

00:12:04.230 --> 00:12:07.169
include the trapezius, rhomboids, latissimus

00:12:07.169 --> 00:12:10.169
dorsi, serratus anterior, and levator scapulae.

00:12:10.879 --> 00:12:13.379
Codman's seminal concept of scapula thoracic

00:12:13.379 --> 00:12:15.559
rhythm describes the coordinated movement between

00:12:15.559 --> 00:12:18.259
the scapula thoracic joint, essentially a sliding

00:12:18.259 --> 00:12:20.580
surface between the scapula and the rib cage

00:12:20.580 --> 00:12:23.240
and the glenohumeral joint. So the shoulder blade

00:12:23.240 --> 00:12:25.639
has to move correctly with the arm. Absolutely.

00:12:26.120 --> 00:12:28.899
The scapula rotators enable the glenoid to modify

00:12:28.899 --> 00:12:31.559
its orientation to follow the humeral head during

00:12:31.559 --> 00:12:34.429
motion. This is crucial. Dysfunction, such as

00:12:34.429 --> 00:12:36.389
weakness or imbalance in the serratus anterior,

00:12:36.789 --> 00:12:39.389
can predispose athletes to rotator cuff tendonitis

00:12:39.389 --> 00:12:41.889
or atraumatic shoulder instability. Therefore,

00:12:41.970 --> 00:12:43.889
recovering the scapula thoracic rhythm through

00:12:43.889 --> 00:12:46.090
appropriate rehabilitation of these scapula rotators

00:12:46.090 --> 00:12:48.149
is absolutely essential, particularly in younger

00:12:48.149 --> 00:12:50.970
patients. And finally, proprioception, the septum

00:12:50.970 --> 00:12:54.639
joint position. Yes, proprioception. Numerous

00:12:54.639 --> 00:12:57.220
mechanoreceptors are located within the glenohumeral

00:12:57.220 --> 00:12:59.700
joint capsule, particularly concentrated in the

00:12:59.700 --> 00:13:02.559
anterior and inferior capsule. These are activated

00:13:02.559 --> 00:13:05.159
during movement, sending crucial signals to the

00:13:05.159 --> 00:13:07.899
stabilizing muscles. Here's the profound clinical

00:13:07.899 --> 00:13:10.919
implication. Progressive instability leads to

00:13:10.919 --> 00:13:13.399
increased capsular stretch and, consequently,

00:13:13.840 --> 00:13:16.779
proprioceptive loss or disorganization. Ah, so

00:13:16.779 --> 00:13:18.840
the instability damages the feedback system.

00:13:19.059 --> 00:13:21.659
Precisely. This disorganization can then lead

00:13:21.659 --> 00:13:24.500
to muscle patterning problems, repeated dislocations

00:13:24.500 --> 00:13:27.299
and subluxations, and can even progress to bony

00:13:27.299 --> 00:13:29.659
glenoid wear and affect core stability and the

00:13:29.659 --> 00:13:32.700
full kinetic chain. This interconnected cascade

00:13:32.700 --> 00:13:34.960
strongly supports the principle that early treatment

00:13:34.960 --> 00:13:37.179
and stabilization are highly advantageous. You

00:13:37.179 --> 00:13:39.559
want to stop that negative cycle. 2 .1 shoulder

00:13:39.559 --> 00:13:41.840
injuries in overhead athletes, the kinetic chain

00:13:41.840 --> 00:13:44.799
challenge. OK, let's zoom in now on the unique,

00:13:45.379 --> 00:13:47.700
often extreme demands placed on the shoulders

00:13:47.700 --> 00:13:51.409
of overhead athletes. think pitchers, tennis

00:13:51.409 --> 00:13:54.490
players, javelin throwers. How does their specialized

00:13:54.490 --> 00:13:57.049
high -velocity movement governed by this intricate

00:13:57.049 --> 00:13:59.610
kinetic chain you mentioned lead to very specific

00:13:59.610 --> 00:14:02.149
injury patterns that differ from, say, contact

00:14:02.149 --> 00:14:05.049
athletes? The kinetic chain is indeed the cornerstone

00:14:05.049 --> 00:14:07.850
of overhead athletic performance. We define it

00:14:07.850 --> 00:14:10.149
as an orchestrated system of sequential body

00:14:10.149 --> 00:14:12.870
positions and motions, precisely designed to

00:14:12.870 --> 00:14:15.370
efficiently transfer the maximum force generated

00:14:15.370 --> 00:14:17.830
in large muscles of the core and lower leg all

00:14:17.830 --> 00:14:20.090
the way up to the hand. This provides distal

00:14:20.090 --> 00:14:22.649
arm mobility on a stable proximal base at the

00:14:22.649 --> 00:14:25.269
scapula. What's critical to understand is that

00:14:25.269 --> 00:14:27.809
even with a fully functional kinetic chain, the

00:14:27.809 --> 00:14:30.289
repetitive tremendous forces created on the glenocumeral

00:14:30.289 --> 00:14:32.330
joint during the throwing motion can still lead

00:14:32.330 --> 00:14:34.409
to micro -damage of tendons and ligaments over

00:14:34.409 --> 00:14:37.070
time. Just the sheer repetitive force. Exactly.

00:14:37.750 --> 00:14:40.029
But crucially, shoulder symptoms in overhead

00:14:40.029 --> 00:14:42.690
athletes are predominantly related to a failure

00:14:42.690 --> 00:14:45.129
of this kinetic chain, specifically at the hip

00:14:45.129 --> 00:14:48.529
joint, the trunk, and the scapula. This failure

00:14:48.529 --> 00:14:50.929
fundamentally altered shoulder biomechanics,

00:14:51.110 --> 00:14:53.549
resulting in overstress on the glenohumeral structures

00:14:53.549 --> 00:14:55.750
themselves. So the shoulder takes the hip for

00:14:55.750 --> 00:14:58.950
a problem elsewhere? Very often, yes. Consider

00:14:58.950 --> 00:15:01.090
a compelling mathematical study that demonstrated

00:15:01.090 --> 00:15:04.389
that a mere 20 % reduction in trunk kinetic energy

00:15:04.389 --> 00:15:07.870
development necessitates a compensatory 33 %

00:15:07.870 --> 00:15:09.850
increase in velocity in the distal segments,

00:15:10.289 --> 00:15:12.570
the arm, to maintain the same energy at ball

00:15:12.570 --> 00:15:15.399
impact. This vividly highlights the profound

00:15:15.399 --> 00:15:17.600
impact of proximal dysfunction on the entire

00:15:17.600 --> 00:15:20.019
system. The shoulder ends up working overtime.

00:15:20.320 --> 00:15:22.340
That's a really clear illustration. How do these

00:15:22.340 --> 00:15:24.600
athletes typically present? Well, when it comes

00:15:24.600 --> 00:15:27.139
to diagnosis, we differentiate between two primary

00:15:27.139 --> 00:15:30.139
stages of presentation. The early stage is characterized

00:15:30.139 --> 00:15:32.440
by shoulder symptoms without anatomical failure.

00:15:33.220 --> 00:15:35.659
This often presents as inflammation, perhaps

00:15:35.659 --> 00:15:37.899
what's termed a disabled throwing shoulder or

00:15:37.899 --> 00:15:41.049
pathologic kinetic chain syndrome. Most symptoms

00:15:41.049 --> 00:15:43.049
at this stage can be effectively treated non

00:15:43.049 --> 00:15:45.929
-operatively. The advanced stage, however, involves

00:15:45.929 --> 00:15:48.289
anatomical failure that necessitates evaluation

00:15:48.289 --> 00:15:51.009
through advanced imaging studies like x -ray,

00:15:51.190 --> 00:15:54.289
CT, MRI, and ultrasound to confirm the diagnosis.

00:15:54.730 --> 00:15:56.730
And what specific injuries are common in this

00:15:56.730 --> 00:15:59.250
group? Within this population, we see very specific

00:15:59.250 --> 00:16:02.769
injuries in pathomechanisms. SLAP lesions, particularly

00:16:02.769 --> 00:16:05.769
type 2 superior labrum, anterior posterior lesions,

00:16:06.070 --> 00:16:08.769
and associated biceps tendonitis are common findings.

00:16:08.960 --> 00:16:12.120
Rotator cuff injuries also present uniquely here.

00:16:12.519 --> 00:16:14.779
Articular -sided partial thickness tears of the

00:16:14.779 --> 00:16:16.980
supraspinatus and infraspinatus tendons in this

00:16:16.980 --> 00:16:19.600
population may not always be true rotator cuff

00:16:19.600 --> 00:16:22.080
tears in the traditional sense. How so? They

00:16:22.080 --> 00:16:24.559
might actually represent detachment of the superior

00:16:24.559 --> 00:16:27.120
shoulder capsule from the greater tuberosity

00:16:27.120 --> 00:16:30.080
given its substantial attachment area. High -grade

00:16:30.080 --> 00:16:32.840
partial tears, or complete tears, present more

00:16:32.840 --> 00:16:35.480
typically with positive subacromial impingement

00:16:35.480 --> 00:16:38.690
tests and decreased muscle strength. Cadaveric

00:16:38.690 --> 00:16:41.490
studies show that superior capsule tears specifically

00:16:41.490 --> 00:16:43.990
increase anterior and inferior translations.

00:16:44.029 --> 00:16:46.950
Okay, what else? Dysfunction of the anterior

00:16:46.950 --> 00:16:49.730
capsular ligament complex, whether through tearing

00:16:49.730 --> 00:16:53.230
or elongation, leads to anterior shoulder instability

00:16:53.230 --> 00:16:56.049
and can significantly disable the throwing shoulder.

00:16:56.809 --> 00:16:59.110
We also see little league shoulder or proximal

00:16:59.110 --> 00:17:02.250
humeral epiphysealysis that's a specific epiphyseal

00:17:02.250 --> 00:17:04.970
plate injury common in adolescent throwing athletes

00:17:04.970 --> 00:17:06.970
due to repetitive stress on the weaker growth

00:17:06.970 --> 00:17:09.500
plate. Beyond structural issues, neurovascular

00:17:09.500 --> 00:17:12.700
entrapment is a possibility, including superscapular

00:17:12.700 --> 00:17:15.119
nerve entrapment, as well as vascular problems,

00:17:15.380 --> 00:17:17.700
such as effort thrombosis of the axillary artery

00:17:17.700 --> 00:17:20.099
or vein, or thoracic outlet syndrome, which are

00:17:20.099 --> 00:17:22.079
often quite difficult to diagnose. Any impingement

00:17:22.079 --> 00:17:24.839
types? Yes. Short or internal impingement is

00:17:24.839 --> 00:17:27.759
a critical pathomechanism here. It's that abnormal

00:17:27.759 --> 00:17:29.779
contact between the undersurface of the rotator

00:17:29.779 --> 00:17:33.319
cuff and the posterior superior labrum and glenoid

00:17:33.319 --> 00:17:35.930
during the late cocking phase of throwing. While

00:17:35.930 --> 00:17:38.829
it can be physiological to some degree, forceful

00:17:38.829 --> 00:17:40.950
internal impingement becomes pathological and

00:17:40.950 --> 00:17:42.730
is thought to be a primary cause of posterior

00:17:42.730 --> 00:17:45.829
rotator cuff injury and type 2 SLAP lesions.

00:17:46.210 --> 00:17:48.630
What increases that forceful contact? Key factors

00:17:48.630 --> 00:17:50.990
include posterior capsule tightness, increased

00:17:50.990 --> 00:17:53.650
shoulder abduction and external rotation, decreased

00:17:53.650 --> 00:17:56.130
internal rotator muscle strength, and increased

00:17:56.130 --> 00:18:00.180
scavular internal rotation or dyskinesis. Subacromial

00:18:00.180 --> 00:18:02.799
impingement, the more classic type, is mostly

00:18:02.799 --> 00:18:05.539
diagnosed in older overhead athletes and is often

00:18:05.539 --> 00:18:08.000
associated with decreased upward scapular rotation

00:18:08.000 --> 00:18:11.240
and post or inferior capsule tightness. The peel

00:18:11.240 --> 00:18:14.220
back mechanism is a specific pathomechanism described

00:18:14.220 --> 00:18:17.839
for type II SLAP lesions, where cadaveric studies

00:18:17.839 --> 00:18:20.119
have shown excessive humeral external rotation

00:18:20.119 --> 00:18:23.400
causes increased strain on and detachment of

00:18:23.400 --> 00:18:26.140
the superior labrum. And finally, Job and colleagues

00:18:26.140 --> 00:18:28.940
postulated that capsular laxity due to repetitive

00:18:28.940 --> 00:18:31.859
microtrauma in overhead athletes may result in

00:18:31.859 --> 00:18:34.099
increased shoulder laxity with secondary pathologies,

00:18:34.440 --> 00:18:36.680
dividing this as pathologic shoulder laxity.

00:18:36.920 --> 00:18:39.519
Given these complex and often subtle injuries,

00:18:40.000 --> 00:18:42.359
how do clinicians accurately diagnose them, especially

00:18:42.359 --> 00:18:44.339
when, as you said, imaging findings can sometimes

00:18:44.339 --> 00:18:46.599
be misleading? What are the absolutely crucial

00:18:46.599 --> 00:18:48.799
elements of the physical examination for an overhead

00:18:48.799 --> 00:18:51.519
athlete? This is where precision in physical

00:18:51.519 --> 00:18:53.880
examination becomes absolutely critical, because

00:18:53.880 --> 00:18:56.440
as you noted, imaging alone can be insufficient

00:18:56.440 --> 00:18:59.519
or even misleading due to asymptomatic pathology

00:18:59.519 --> 00:19:03.319
often found in athletes. A thorough physical

00:19:03.319 --> 00:19:05.539
examination for overhead athletes must include

00:19:05.539 --> 00:19:08.759
a detailed scapular assessment. Tests like the

00:19:08.759 --> 00:19:11.660
scapula spine distance test and the elbow extension

00:19:11.660 --> 00:19:14.960
and elbow push tests help assess scapular stabilizers.

00:19:15.500 --> 00:19:18.059
What about strength? For muscle strength evaluation,

00:19:18.299 --> 00:19:21.019
we use manual muscle testing on that 0 -5 scale,

00:19:21.460 --> 00:19:23.279
assessing shoulder abduction in the full can

00:19:23.279 --> 00:19:26.279
position and external and internal rotation strength.

00:19:26.539 --> 00:19:29.440
An abnormal result is typically defined as muscle

00:19:29.440 --> 00:19:31.740
strength on the dominant side being less than

00:19:31.740 --> 00:19:34.720
that on the non -dominant side. To assess posterior

00:19:34.720 --> 00:19:37.000
tightness, we perform the combined abduction

00:19:37.000 --> 00:19:39.859
test and horizontal flexion test meticulously,

00:19:40.240 --> 00:19:42.240
with the examiner fixing the scapula to prevent

00:19:42.240 --> 00:19:45.660
compensatory movement. Capsulaxity is evaluated

00:19:45.660 --> 00:19:48.539
via load and shift testing in anterior, posterior,

00:19:48.660 --> 00:19:51.299
and inferior directions, along with the anterior

00:19:51.299 --> 00:19:54.099
apprehension and relocation tests. It's abnormal

00:19:54.099 --> 00:19:56.240
when the dominant side shows increased laxity

00:19:56.240 --> 00:19:58.579
or the subject feels instability. And impingement

00:19:58.579 --> 00:20:01.380
tests. For subacromial impingement, we perform

00:20:01.380 --> 00:20:04.000
the standard Neer, Hawkins, and Yokum tests.

00:20:04.799 --> 00:20:06.920
Pain during any of these is considered abnormal.

00:20:07.150 --> 00:20:10.230
The hyper -external rotation test has a specific

00:20:10.230 --> 00:20:12.829
role in evaluating the peelback mechanism and

00:20:12.829 --> 00:20:15.509
pathologic internal impingement. To systematically

00:20:15.509 --> 00:20:18.190
evaluate these findings, a comprehensive scoring

00:20:18.190 --> 00:20:20.650
sheet like the HERA test can be incredibly useful

00:20:20.650 --> 00:20:23.329
in practice. Okay, so the physical exam is key,

00:20:23.509 --> 00:20:25.450
but what about imaging? You mentioned caveats.

00:20:25.710 --> 00:20:28.029
Yes, regarding imaging, it's vital to reiterate

00:20:28.029 --> 00:20:29.869
why it can be misleading in throwing athletes.

00:20:29.970 --> 00:20:33.250
Yeah. While MRI or MR arthrograms are useful

00:20:33.250 --> 00:20:35.369
for detecting partial or complete rotator cuff

00:20:35.369 --> 00:20:38.730
tears and SLAP lesions, it's crucial to understand

00:20:38.730 --> 00:20:41.109
that significant amounts of shoulder pathology,

00:20:41.269 --> 00:20:44.009
especially partial thickness tears found in maybe

00:20:44.009 --> 00:20:47.049
20, 86 % of patients in some studies, can actually

00:20:47.049 --> 00:20:50.029
be present in asymptomatic athletes. So a tear

00:20:50.029 --> 00:20:52.170
on MRI doesn't automatically mean it's the source

00:20:52.170 --> 00:20:55.869
of pain. Exactly. Therefore, we must stress the

00:20:55.869 --> 00:20:57.750
critical importance of performing a thorough

00:20:57.750 --> 00:21:00.869
history and physical examination. Pain may not

00:21:00.869 --> 00:21:03.029
be directly correlated with imaging findings,

00:21:03.529 --> 00:21:06.470
and even things like SLAP tears often do not

00:21:06.470 --> 00:21:08.589
require immediate intervention, especially if

00:21:08.589 --> 00:21:10.589
they appear incidental. Clinical correlation

00:21:10.589 --> 00:21:14.460
is everything. 2 .2 scapular dyskinesis. the

00:21:14.460 --> 00:21:16.460
unstable platform. You've highlighted scapular

00:21:16.460 --> 00:21:18.940
dyskinesis several times now as a critical factor

00:21:18.940 --> 00:21:20.700
in athletic shoulder injuries. Here's where it

00:21:20.700 --> 00:21:22.880
gets really interesting for me. How does this

00:21:22.880 --> 00:21:25.200
unstable platform of the scapula fundamentally

00:21:25.200 --> 00:21:27.200
disrupt shoulder function and contribute to this

00:21:27.200 --> 00:21:29.460
cascade of injuries? And most importantly for

00:21:29.460 --> 00:21:31.420
our audience, how can we accurately spot and

00:21:31.420 --> 00:21:33.759
assess it in clinical practice? The scapula's

00:21:33.759 --> 00:21:36.410
role is truly indispensable. It's a pivotal link

00:21:36.410 --> 00:21:38.930
in the kinetic chain, as we discussed. Think

00:21:38.930 --> 00:21:41.490
of it as the central segment bridging the larger

00:21:41.490 --> 00:21:44.170
body segments, generating force the legs and

00:21:44.170 --> 00:21:46.809
trunk, with the smaller arm segments producing

00:21:46.809 --> 00:21:50.509
precision and applying that force. Skillful athletic

00:21:50.509 --> 00:21:53.210
activities demand precise, coordinated motions

00:21:53.210 --> 00:21:56.250
of the scapula and the glenohumeral joint. Any

00:21:56.250 --> 00:21:58.630
alterations in these motions, either separately

00:21:58.630 --> 00:22:01.009
or coupled, can lead to inefficient shoulder

00:22:01.009 --> 00:22:03.490
function, decreased performance, and of course

00:22:03.490 --> 00:22:06.680
increased injury risk. So what exactly is scapular

00:22:06.680 --> 00:22:09.220
dyskinesis? Well, it's defined quite simply as

00:22:09.220 --> 00:22:11.799
the loss of control of normal resting scapular

00:22:11.799 --> 00:22:14.960
position and dynamic motion. It has a surprisingly

00:22:14.960 --> 00:22:18.160
high prevalence, found in perhaps 67 -100 % of

00:22:18.160 --> 00:22:19.900
patients with shoulder injuries in some studies.

00:22:20.059 --> 00:22:23.200
That high, really? Yes, but it's crucial to clarify

00:22:23.200 --> 00:22:26.000
this. Dyskinesis is best considered a potential

00:22:26.000 --> 00:22:28.609
impairment of optimum shoulder function. If it's

00:22:28.609 --> 00:22:30.670
found alongside shoulder symptoms, it certainly

00:22:30.670 --> 00:22:32.750
warrants further evaluation to determine its

00:22:32.750 --> 00:22:35.089
contribution, but it's not automatically the

00:22:35.089 --> 00:22:37.150
sole cause. Okay, so it's a finding that needs

00:22:37.150 --> 00:22:39.670
context. What pathologies is it associated with?

00:22:40.009 --> 00:22:42.730
There are strong associations between scapular

00:22:42.730 --> 00:22:45.130
dyskinesis and various shoulder pathologies,

00:22:45.430 --> 00:22:47.529
each with fairly clear underlying mechanisms.

00:22:47.750 --> 00:22:49.769
For instance, there's a high association with

00:22:49.769 --> 00:22:52.599
labral injury. Altered scapular position and

00:22:52.599 --> 00:22:55.099
motion, things like increased internal rotation

00:22:55.099 --> 00:22:58.059
and anterior tilt, change the glenohumeral alignment.

00:22:58.660 --> 00:23:00.980
This places increased tensile strain on the anterior

00:23:00.980 --> 00:23:03.519
ligaments, increases that peelback force on the

00:23:03.519 --> 00:23:06.240
biceps labral complex, and can create pathological

00:23:06.240 --> 00:23:09.039
internal impingement. And GRRD makes this worse.

00:23:09.279 --> 00:23:11.119
These effects are certainly magnified in the

00:23:11.119 --> 00:23:13.440
presence of glenohumeral internal rotation deficit,

00:23:13.779 --> 00:23:16.970
or GRR. The fact that manually retracting the

00:23:16.970 --> 00:23:19.450
scapula can often correct symptoms found in tests,

00:23:19.890 --> 00:23:22.690
like the modified dynamic label shear test, really

00:23:22.690 --> 00:23:24.670
highlights the role of dyskinesis. What about

00:23:24.670 --> 00:23:27.250
impingement? Impingement, both internal and external,

00:23:27.470 --> 00:23:30.069
is frequently seen in throwing athletes, often

00:23:30.069 --> 00:23:33.559
secondary to other pathology. Scapular dyskinesis

00:23:33.559 --> 00:23:35.900
contributes by altering the resting and dynamic

00:23:35.900 --> 00:23:38.579
scapular position, typically a loss of acromial

00:23:38.579 --> 00:23:41.579
upward rotation, excessive scapular internal

00:23:41.579 --> 00:23:44.740
rotation, and excessive scapular anterior tilt.

00:23:45.720 --> 00:23:48.160
These positions essentially create scapular protraction,

00:23:48.599 --> 00:23:51.319
which narrows the subacromial space and has been

00:23:51.319 --> 00:23:54.809
shown to decrease rotator cuff strength. Altered

00:23:54.809 --> 00:23:56.950
muscle activation patterns like increased upper

00:23:56.950 --> 00:23:59.970
trapezius activity and delayed or decreased lower

00:23:59.970 --> 00:24:02.849
trapezius and serratus anterior firing are also

00:24:02.849 --> 00:24:05.950
implicated. And AC joint injuries. How does dyskinesis

00:24:05.950 --> 00:24:08.390
link there? AC joint injuries remove the strut

00:24:08.390 --> 00:24:10.619
function of the clavicle. This allows what's

00:24:10.619 --> 00:24:12.779
called the third translation of the scapula,

00:24:12.839 --> 00:24:15.940
meaning it moves inferiorly and medially relative

00:24:15.940 --> 00:24:18.279
to the clavicle. This changes the biomechanical

00:24:18.279 --> 00:24:21.019
axis of scapular humeral rhythm, leading to excessive

00:24:21.019 --> 00:24:23.759
scapular internal rotation and protraction, and

00:24:23.759 --> 00:24:26.960
decreased dynamic acromial elevation. This protracted

00:24:26.960 --> 00:24:28.779
scapular position is directly linked to many

00:24:28.779 --> 00:24:31.599
dysfunctional problems seen in chronic AC separations,

00:24:31.880 --> 00:24:33.640
including impingement and reduced cuff strength.

00:24:33.720 --> 00:24:36.539
So it disrupts the whole shoulder girdle mechanism.

00:24:36.839 --> 00:24:39.279
Precisely. Clavicle fractures can also lead to

00:24:39.279 --> 00:24:41.599
dyskinesis if the clavicle anatomy isn't perfectly

00:24:41.599 --> 00:24:44.900
restored. Shortened male unions or non -unions

00:24:44.900 --> 00:24:47.440
alter scapular position towards internal rotation

00:24:47.440 --> 00:24:50.900
and anterior tilt. In these cases, dyskinesis

00:24:50.900 --> 00:24:53.059
can actually serve as a crucial clinical sign

00:24:53.059 --> 00:24:55.720
of potentially harmful alteration of clavicle

00:24:55.720 --> 00:24:58.440
anatomy, helping inform the decision for operative

00:24:58.440 --> 00:25:01.589
treatment. And finally, Though rare, scapular

00:25:01.589 --> 00:25:04.089
muscle detachment, typically the lower trapezius

00:25:04.089 --> 00:25:06.769
and rhomboids, is an often missed injury that

00:25:06.769 --> 00:25:09.349
directly causes dyskinesis, usually presenting

00:25:09.349 --> 00:25:11.930
with scapular protraction and lateral translation.

00:25:12.289 --> 00:25:14.390
Given these complex implications, how do clinicians

00:25:14.390 --> 00:25:16.910
accurately evaluate the presence and impact of

00:25:16.910 --> 00:25:19.829
scapula dyskinesis on, say, the throwing athlete?

00:25:20.309 --> 00:25:22.470
What specific tests should we be incorporating

00:25:22.470 --> 00:25:25.170
into our routine examinations? Evaluating the

00:25:25.170 --> 00:25:27.720
scapula requires a comprehensive approach. We

00:25:27.720 --> 00:25:30.440
must begin with a thorough history asking about

00:25:30.440 --> 00:25:34.039
past trauma to the scapula, clavicle, or AC joint,

00:25:34.440 --> 00:25:36.880
any spinal symptoms, and previous rehab efforts.

00:25:37.279 --> 00:25:40.460
The goals of the examination are, first, to establish

00:25:40.460 --> 00:25:43.500
the presence or absence of dyskinesis, second,

00:25:43.660 --> 00:25:45.519
to determine the effect of corrective maneuvers

00:25:45.519 --> 00:25:48.220
on the patient's symptoms, and third, to investigate

00:25:48.220 --> 00:25:50.799
potential underlying causes like bony issues,

00:25:51.079 --> 00:25:53.420
joint derangement, or muscle imbalances. How

00:25:53.420 --> 00:25:55.740
do you observe it? The scapular exam should ideally

00:25:55.740 --> 00:25:57.960
be performed from the posterior aspect, with

00:25:57.960 --> 00:26:00.920
the scapula fully exposed. We visually assess

00:26:00.920 --> 00:26:03.420
resting posture for any side -to -side asymmetry

00:26:03.420 --> 00:26:06.180
or prominence of the inferior medial or medial

00:26:06.180 --> 00:26:09.140
border. The optimum position for evaluating dynamic

00:26:09.140 --> 00:26:11.640
scapular dyskinesis is during active forward

00:26:11.640 --> 00:26:14.160
flexion watching the scapula move. And the corrective

00:26:14.160 --> 00:26:16.319
tests. Crucially, we use corrective maneuvers

00:26:16.319 --> 00:26:18.920
like the scapular assistance test, or SAT, where

00:26:18.920 --> 00:26:21.339
the examiner assists upward rotation, and the

00:26:21.339 --> 00:26:24.500
scapular retraction test, or SRT, where the examiner

00:26:24.500 --> 00:26:27.799
manually retracts the scapula. A positive SAT

00:26:27.799 --> 00:26:30.140
or SRT, meaning the patient's symptoms improve

00:26:30.140 --> 00:26:32.400
with the correction, strongly indicates that

00:26:32.400 --> 00:26:35.460
scapular dyskinesis is directly involved in producing

00:26:35.460 --> 00:26:37.859
those symptoms and highlights the immediate need

00:26:37.859 --> 00:26:40.099
for early scapular rehabilitation. What else

00:26:40.099 --> 00:26:42.779
should be checked? We also perform corcoid -based

00:26:42.779 --> 00:26:44.980
inflexibility assessment through palpation of

00:26:44.980 --> 00:26:47.599
the pectoralis minor and shorthead of the biceps,

00:26:47.880 --> 00:26:51.109
noting tenderness and top bands. Proximal kinetic

00:26:51.109 --> 00:26:53.190
chain screening, using tests like the one leg

00:26:53.190 --> 00:26:55.950
stability series, is useful to assess core and

00:26:55.950 --> 00:26:58.670
lower extremity contributions. And of course,

00:26:59.089 --> 00:27:01.549
a thorough glenohumeral exam is crucial for evaluating

00:27:01.549 --> 00:27:04.250
internal derangement and AC joint instability,

00:27:04.869 --> 00:27:07.069
paying special attention to assessing GRD and

00:27:07.069 --> 00:27:09.650
labral injuries, as both are frequently associated

00:27:09.650 --> 00:27:12.849
with dyskinesis. Remember, for accurate GRD measurements,

00:27:13.029 --> 00:27:15.589
the patient must be supine, with a second examiner

00:27:15.589 --> 00:27:18.390
stabilizing the scapula. So if the scapula is

00:27:18.390 --> 00:27:20.529
such a critical player, how do we get it back

00:27:20.529 --> 00:27:22.769
in the game effectively? What does this mean

00:27:22.769 --> 00:27:25.109
for rehabilitation to ensure not just recovery,

00:27:25.309 --> 00:27:27.950
but optimal athletic performance? Well, it means

00:27:27.950 --> 00:27:31.089
rehabilitation must absolutely start with optimizing

00:27:31.089 --> 00:27:34.380
the anatomy first. You can't effectively rehabilitate

00:27:34.380 --> 00:27:37.000
around a significant structural problem. Local

00:27:37.000 --> 00:27:39.240
issues like nerve injury or scapular stabilizer

00:27:39.240 --> 00:27:42.079
muscle detachment require repair or muscle transfer.

00:27:42.680 --> 00:27:44.980
Similarly, bony and tissue derangement issues,

00:27:45.240 --> 00:27:47.839
AC joint or clavicle injury, labral injury, rotator

00:27:47.839 --> 00:27:50.380
cuff disease, glenohumeral instability must be

00:27:50.380 --> 00:27:52.519
surgically addressed before effective rehabilitation

00:27:52.519 --> 00:27:55.359
can truly proceed. Get the foundation right first.

00:27:55.779 --> 00:27:59.059
Exactly. Once that foundation is set, we follow

00:27:59.059 --> 00:28:01.700
a comprehensive protocol. often based on established

00:28:01.700 --> 00:28:04.160
approaches like those from Ellen Becker and Cools.

00:28:04.640 --> 00:28:06.900
We typically begin with kinetic chain exercises

00:28:06.900 --> 00:28:09.559
focusing on the trunk and hips, starting from

00:28:09.559 --> 00:28:12.299
and ending at the ideal position of hip and trunk

00:28:12.299 --> 00:28:15.339
extension. These can often be initiated preoperatively.

00:28:16.200 --> 00:28:18.299
For flexibility, we address specific areas of

00:28:18.299 --> 00:28:20.640
tightness, particularly the anterior coracoid,

00:28:20.799 --> 00:28:23.000
the pectoralis minor, and shorthead of biceps

00:28:23.000 --> 00:28:26.099
and shoulder rotation. Exercises like the open

00:28:26.099 --> 00:28:28.200
book and corner stretch for the coracoid muscles

00:28:28.200 --> 00:28:30.619
and the sleeper and cross -body stretch for shoulder

00:28:30.619 --> 00:28:32.940
rotation are common recommendations. And the

00:28:32.940 --> 00:28:34.980
strengthening part. Periscapular strengthening

00:28:34.980 --> 00:28:38.420
is paramount. We emphasize achieving a position

00:28:38.420 --> 00:28:41.259
of scapular retraction as this is the most effective

00:28:41.259 --> 00:28:44.240
position to maximize the scapula's stabilizing

00:28:44.240 --> 00:28:47.660
roles. Exercises like the scapular pinch or trunk

00:28:47.660 --> 00:28:50.180
extension with scapular retraction can be done

00:28:50.180 --> 00:28:52.759
standing to simulate normal activation sequences.

00:28:53.049 --> 00:28:56.289
Once scapular control is achieved, we integrate

00:28:56.289 --> 00:28:59.089
scapular rotator cuff exercises, such as punches

00:28:59.089 --> 00:29:01.809
and shoulder dumps. These stimulate rotator cuff

00:29:01.809 --> 00:29:04.650
activation off a stabilized scapula and are performed

00:29:04.650 --> 00:29:06.710
in various planes using different resistance

00:29:06.710 --> 00:29:09.430
types. We particularly exploit the transverse

00:29:09.430 --> 00:29:11.690
plane for many activities and progressing towards

00:29:11.690 --> 00:29:14.390
sport. Finally, when strength and stabilization

00:29:14.390 --> 00:29:16.769
are achieved through controlled supervised rehabilitation,

00:29:17.369 --> 00:29:19.569
we implement a three area focus for effective

00:29:19.569 --> 00:29:22.769
transition back to sport. This involves one,

00:29:22.970 --> 00:29:26.269
lower extremity muscle power and endurance, two,

00:29:26.490 --> 00:29:28.710
integrated sports specific exercise to improve

00:29:28.710 --> 00:29:31.490
proprioception and muscle education, and three,

00:29:31.829 --> 00:29:33.750
upper extremity power and endurance using high

00:29:33.750 --> 00:29:36.769
repetition long lever exercises. This holistic

00:29:36.769 --> 00:29:38.890
progressive approach is absolutely vital for

00:29:38.890 --> 00:29:41.190
the athlete's full recovery and return to optimal

00:29:41.190 --> 00:29:44.299
performance. Okay, let's switch gears now. Moving

00:29:44.299 --> 00:29:46.680
from the precision -demanding overhead sports

00:29:46.680 --> 00:29:49.400
to the sheer force and collision inherent in

00:29:49.400 --> 00:29:51.880
sports like rugby, American football, and ice

00:29:51.880 --> 00:29:55.599
hockey, how do these high -energy impacts fundamentally

00:29:55.599 --> 00:29:57.799
change the injury landscape for the shoulder?

00:29:58.299 --> 00:30:00.339
What's particularly unique about the reckonisms

00:30:00.339 --> 00:30:03.119
and the apparently high frequency of concomitant

00:30:03.119 --> 00:30:05.200
injuries? It's a completely different dynamic,

00:30:05.500 --> 00:30:08.299
absolutely, driven by direct force and high -energy

00:30:08.299 --> 00:30:10.700
impacts. First, it might be useful to make a

00:30:10.700 --> 00:30:13.630
key distinction. Collision sports involve athletes

00:30:13.630 --> 00:30:15.670
purposely hitting or colliding with each other

00:30:15.670 --> 00:30:18.089
or inanimate objects, often with great force,

00:30:18.289 --> 00:30:21.490
like rugby, American football, ice hockey. Contact

00:30:21.490 --> 00:30:24.730
sports technically involve routine contact, but

00:30:24.730 --> 00:30:27.269
with lesser force, maybe like basketball or football.

00:30:27.939 --> 00:30:30.619
While collision implies greater risk, the terms

00:30:30.619 --> 00:30:32.640
are often used pretty synonymously in the literature.

00:30:32.900 --> 00:30:34.619
Right, but the forces involved are generally

00:30:34.619 --> 00:30:37.240
higher in collision sports. Definitely. And because

00:30:37.240 --> 00:30:40.319
of the physical nature of these sports, musculoskeletal

00:30:40.319 --> 00:30:42.720
injuries are incredibly frequent. The shoulder

00:30:42.720 --> 00:30:45.059
consistently ranks among the most common injury

00:30:45.059 --> 00:30:48.000
sites. Glenohumeral instability and rotator cuff

00:30:48.000 --> 00:30:51.200
injuries are particularly prevalent. Crucially,

00:30:51.680 --> 00:30:54.119
shoulder dislocation and instability account

00:30:54.119 --> 00:30:57.180
for the majority of playtime loss. Hetty and

00:30:57.180 --> 00:30:59.319
colleagues, for instance, reported a mean of

00:30:59.319 --> 00:31:02.380
81 days absent from play for shoulder dislocation

00:31:02.380 --> 00:31:05.200
in professional rugby union. That's a significant

00:31:05.200 --> 00:31:08.240
chunk of a season. 81 days. Wow. And the mechanisms.

00:31:08.680 --> 00:31:11.000
Different from throwing. Yes. Quite different.

00:31:11.440 --> 00:31:13.480
Shoulder injuries here can result from a direct

00:31:13.480 --> 00:31:16.000
blow to the shoulder itself, or indirectly from

00:31:16.000 --> 00:31:18.630
landing heavily on the affected shoulder. What's

00:31:18.630 --> 00:31:20.470
striking is that the tackling event alone is

00:31:20.470 --> 00:31:23.710
responsible for staggering 65 % of all shoulder

00:31:23.710 --> 00:31:27.130
injuries in rugby. The tackle itself. Yes. Video

00:31:27.130 --> 00:31:29.849
analysis studies, like one by Creighton and colleagues

00:31:29.849 --> 00:31:32.529
in elite rugby players, have identified three

00:31:32.529 --> 00:31:36.009
common mechanisms during tackles. The triscorer,

00:31:36.509 --> 00:31:38.430
high -proflection of the outstretched ball -carrying

00:31:38.430 --> 00:31:41.490
arm, the tackler, extension of the abducted arm

00:31:41.490 --> 00:31:44.049
behind the player during a tackle, and direct

00:31:44.049 --> 00:31:46.410
impact, a direct blow to the side of the shoulder.

00:31:47.160 --> 00:31:49.759
Posterior glenohumeral instability can also result

00:31:49.759 --> 00:31:52.019
from a blocking injury, as seen perhaps with

00:31:52.019 --> 00:31:53.980
an American football lineman blocking with the

00:31:53.980 --> 00:31:56.599
arm flexed and internally rotated. And you mentioned

00:31:56.599 --> 00:31:59.359
concomitant injuries are common. Yes, this brings

00:31:59.359 --> 00:32:02.420
us to a really unique aspect, the high incidence

00:32:02.420 --> 00:32:06.339
of concomitant injuries. Complex injuries involving

00:32:06.339 --> 00:32:08.779
multiple structures often occur after just a

00:32:08.779 --> 00:32:11.559
single traumatic event in these boards. Tischer

00:32:11.559 --> 00:32:14.720
and colleagues found that a significant 18 .2%,

00:32:14.720 --> 00:32:18.119
almost 1 in 5, of AC joint injuries exhibited

00:32:18.119 --> 00:32:20.779
concomitant intraarticular injuries that actually

00:32:20.779 --> 00:32:22.900
necessitated additional surgical intervention.

00:32:23.599 --> 00:32:25.599
This underscores the importance of appreciating

00:32:25.599 --> 00:32:27.819
that when a contact athlete presents with a shoulder

00:32:27.819 --> 00:32:30.339
injury, there is a strong likelihood of multiple

00:32:30.339 --> 00:32:32.380
coexisting pathologies that need addressing.

00:32:32.960 --> 00:32:34.700
You can't just focus on the most obvious injury,

00:32:34.960 --> 00:32:37.299
3 .2 rotator cuff injuries in contact athletes.

00:32:37.599 --> 00:32:39.660
Rotator cuff injuries are prevalent across all

00:32:39.660 --> 00:32:41.759
sports as you said but how do they specifically

00:32:41.759 --> 00:32:44.380
manifest and more importantly how are they managed

00:32:44.380 --> 00:32:46.539
differently in a contact athlete where direct

00:32:46.539 --> 00:32:49.460
impact is a constant threat compared to say an

00:32:49.460 --> 00:32:51.579
overhead thrower where it's more overuse? The

00:32:51.579 --> 00:32:53.859
manifestation and management in contact athletes

00:32:53.859 --> 00:32:56.900
indeed have distinct characteristics. In this

00:32:56.900 --> 00:32:59.680
population, rotator cuff injuries range from

00:32:59.680 --> 00:33:01.920
simple contusions right through to full thickness

00:33:01.920 --> 00:33:04.440
tears. It's noteworthy that contusions alone

00:33:04.440 --> 00:33:07.619
accounted for nearly half 47 % of all shoulder

00:33:07.619 --> 00:33:10.220
injuries in one study of a North American professional

00:33:10.220 --> 00:33:12.759
football team. So simple bruising is very common.

00:33:13.140 --> 00:33:15.700
And the tears themselves? Usually traumatic?

00:33:15.980 --> 00:33:18.839
Yes. For full thickness tears, the predominant

00:33:18.839 --> 00:33:21.259
mechanism of injury is traumatic. and they are

00:33:21.259 --> 00:33:23.460
typically associated with shoulder dislocations

00:33:23.460 --> 00:33:27.000
or subluxations. This differs from the microtrauma

00:33:27.000 --> 00:33:29.740
and overuse patterns often seen in overhead athletes.

00:33:30.460 --> 00:33:32.119
Tambay and colleagues reported that approximately

00:33:32.119 --> 00:33:34.619
half of professional rugby players with full

00:33:34.619 --> 00:33:37.539
-thickness rotator cuff tears also had concomitant

00:33:37.539 --> 00:33:40.839
labral injuries or bony bankart lesions, again

00:33:40.839 --> 00:33:42.740
highlighting that multi -injury pattern common

00:33:42.740 --> 00:33:45.240
in contact sports. So how do you manage them?

00:33:45.339 --> 00:33:48.420
Is surgery always needed for a tear? Not necessarily.

00:33:48.859 --> 00:33:51.519
When it comes to management strategy, Cuff contusions

00:33:51.519 --> 00:33:54.359
and partial tears can often be managed non -operatively.

00:33:54.819 --> 00:33:57.720
This typically includes pain control, a structured

00:33:57.720 --> 00:34:00.680
rotator cuff strengthening program, and perhaps

00:34:00.680 --> 00:34:03.440
consideration of subacromial corticosteroid injections

00:34:03.440 --> 00:34:05.920
for athletes with persistent bursal inflammation

00:34:05.920 --> 00:34:08.780
and pain. Surgical management is generally indicated

00:34:08.780 --> 00:34:10.699
for patients who don't respond to these conservative

00:34:10.699 --> 00:34:13.039
treatments, and certainly for those with full

00:34:13.039 --> 00:34:15.519
thickness cuff tears, especially in younger,

00:34:15.559 --> 00:34:18.719
active individuals. The advancements in arthroscopic

00:34:18.719 --> 00:34:21.079
techniques have been transformative here. They

00:34:21.079 --> 00:34:23.039
enable successful treatment of cuff tears in

00:34:23.039 --> 00:34:25.420
contact athletes with minimal soft tissue damage,

00:34:25.940 --> 00:34:27.739
allowing for a confident repair of the rotator

00:34:27.739 --> 00:34:30.639
cuff, and importantly, any associated pathology

00:34:30.639 --> 00:34:33.219
found at the same time. And the outcomes? Can

00:34:33.219 --> 00:34:35.840
they get back to playing rough sports? The outcomes

00:34:35.840 --> 00:34:38.019
are actually very encouraging. In that series

00:34:38.019 --> 00:34:40.579
by Tambi and colleagues I mentioned, an excellent

00:34:40.579 --> 00:34:43.460
91 .7 percent, that's 10 out of 11, of the elite

00:34:43.460 --> 00:34:45.900
rugby players were able to return to their pre

00:34:45.900 --> 00:34:48.500
-injury level of competition relatively early,

00:34:49.039 --> 00:34:51.880
on average around 4 .8 months after arthroscopic

00:34:51.880 --> 00:34:54.300
rotator cuff repair. That's impressive. It demonstrates

00:34:54.300 --> 00:34:56.800
that with the right surgical approach and rehabilitation,

00:34:57.880 --> 00:35:00.420
even significant injuries in these high -demand

00:35:00.420 --> 00:35:02.980
athletes can be effectively managed, allowing

00:35:02.980 --> 00:35:06.920
a return to collision sports. 3 .3 glenohumeral

00:35:06.920 --> 00:35:10.639
joint instability, a common challenge. Glenohumeral

00:35:10.639 --> 00:35:13.219
joint instability. This sounds like a really

00:35:13.219 --> 00:35:15.840
common and often disabling injury for the contact

00:35:15.840 --> 00:35:18.159
athlete, with implications that could potentially

00:35:18.159 --> 00:35:21.420
sideline careers. What are the key considerations

00:35:21.420 --> 00:35:23.760
when making treatment plans for these high stakes

00:35:23.760 --> 00:35:26.219
athletes, particularly regarding surgical timing

00:35:26.219 --> 00:35:29.039
and the specific techniques used? This is perhaps

00:35:29.039 --> 00:35:31.099
one of the most critical and complex decisions

00:35:31.099 --> 00:35:33.650
we face when treating contact athletes. While

00:35:33.650 --> 00:35:36.030
anterior instability comprises the majority of

00:35:36.030 --> 00:35:39.090
shoulder instability cases overall, recent studies

00:35:39.090 --> 00:35:41.349
indicate that posterior instability is actually

00:35:41.349 --> 00:35:43.650
increasing in this group and can account for

00:35:43.650 --> 00:35:46.170
as much as 10 -30 % of traumatic instability

00:35:46.170 --> 00:35:49.230
in contact athletes. So posterior instability

00:35:49.230 --> 00:35:51.050
is more common than we might think in this group.

00:35:51.150 --> 00:35:54.289
It appears so. And interestingly, posterior instability

00:35:54.289 --> 00:35:57.210
is also often associated with anterior instability

00:35:57.210 --> 00:35:59.869
and superior labral tears in these athletes,

00:35:59.929 --> 00:36:02.630
adding to the complexity. So the big question.

00:36:03.019 --> 00:36:06.780
Operate early or try non -operative first, especially

00:36:06.780 --> 00:36:09.659
if it happens midseason. Exactly. The choice

00:36:09.659 --> 00:36:12.400
between early surgery or non -operative treatment

00:36:12.400 --> 00:36:14.980
must be highly tailored to the individual athlete.

00:36:15.239 --> 00:36:18.219
especially for mid -season injuries. It's a decision

00:36:18.219 --> 00:36:20.420
that involves carefully weighing numerous factors.

00:36:20.960 --> 00:36:23.380
We have to consider the type of sport, the level

00:36:23.380 --> 00:36:26.000
of competition, the athlete's playing position

00:36:26.000 --> 00:36:29.039
and age. The specific path anatomy, things like

00:36:29.039 --> 00:36:32.219
significant glenoid bone loss or engaging hill

00:36:32.219 --> 00:36:35.059
-sax lesion, are major factors. Then there's

00:36:35.059 --> 00:36:36.960
the timing of the injury within the competitive

00:36:36.960 --> 00:36:39.639
season, the athlete's own career goals, and even

00:36:39.639 --> 00:36:41.619
the expectations from coaching staff or family

00:36:41.619 --> 00:36:44.530
members. It's a multifaceted discussion. And

00:36:44.530 --> 00:36:46.809
surgery usually means the season's over? Yes.

00:36:47.010 --> 00:36:49.250
It's important to acknowledge that surgical stabilization

00:36:49.250 --> 00:36:52.110
typically sidelines athletes for 4 -6 months,

00:36:52.530 --> 00:36:54.710
which is usually a season ending. This poses

00:36:54.710 --> 00:36:56.929
a significant dilemma for an in -season player

00:36:56.929 --> 00:36:59.769
and their team. So what does non -operative management

00:36:59.769 --> 00:37:01.550
look like if they want to finish the season?

00:37:01.869 --> 00:37:04.030
For non -operative in -season management, we

00:37:04.030 --> 00:37:06.250
can use accelerated rehabilitation protocols.

00:37:06.929 --> 00:37:09.030
These are designed for athletes strongly motivated

00:37:09.030 --> 00:37:11.269
to play through the season, reserving surgery

00:37:11.269 --> 00:37:14.070
for the off -season. These protocols minimize

00:37:14.070 --> 00:37:17.150
immobilization, perhaps none, or up to seven

00:37:17.150 --> 00:37:19.889
days max, and initiate supervised rehabilitation

00:37:19.889 --> 00:37:23.429
from day one, as tolerated. This starts with

00:37:23.429 --> 00:37:25.769
gentle range of motion exercises and cryotherapy,

00:37:26.210 --> 00:37:28.610
followed by rotator cuff and periscapular muscle

00:37:28.610 --> 00:37:31.190
strengthening once full ROM is achieved without

00:37:31.190 --> 00:37:33.809
discomfort. Sport -specific drills follow later.

00:37:34.010 --> 00:37:36.650
Can they play with a brace? Return to play with

00:37:36.650 --> 00:37:38.449
a motion -limiting brace was considered when

00:37:38.449 --> 00:37:41.320
specific comprehensive criteria are met. Little

00:37:41.320 --> 00:37:43.579
or no pain, the athletes' subjective feeling

00:37:43.579 --> 00:37:46.659
of stability, near -normal ROM, strength, and

00:37:46.659 --> 00:37:48.519
functional ability. But does it work? What are

00:37:48.519 --> 00:37:50.340
the recurrence rates? That's the major downside.

00:37:50.780 --> 00:37:52.519
Studies highlight significant recurrence rates

00:37:52.519 --> 00:37:54.739
with this approach. Buss and colleagues reported

00:37:54.739 --> 00:37:56.840
that while most athletes managed non -operatively

00:37:56.840 --> 00:38:00.079
return to play, 41 % experienced recurrence.

00:38:00.559 --> 00:38:02.599
Buttoni and colleagues reported an even higher

00:38:02.599 --> 00:38:06.179
recurrence rate of 75 % in their cohort treated

00:38:06.179 --> 00:38:10.130
non -operatively. 75%. That's very high. It underscores

00:38:10.130 --> 00:38:12.630
the challenges of managing significant instability

00:38:12.630 --> 00:38:15.929
non -operatively in contact athletes trying to

00:38:15.929 --> 00:38:18.469
continue playing. So when is surgery definitely

00:38:18.469 --> 00:38:20.969
the better option? Well, surgical treatment is

00:38:20.969 --> 00:38:23.289
indicated for failure of non -operative treatment,

00:38:23.630 --> 00:38:26.110
obviously. Or, importantly, the presence of high

00:38:26.110 --> 00:38:28.769
risk factors from the outset, such as significant

00:38:28.769 --> 00:38:32.449
glenoid bone loss or an engaging hill -sax lesion.

00:38:32.539 --> 00:38:34.960
These warrant early surgical intervention to

00:38:34.960 --> 00:38:37.000
prevent further damage and recurrence. And the

00:38:37.000 --> 00:38:40.039
type of surgery, has that changed? Yes, it has

00:38:40.039 --> 00:38:43.400
evolved. Historically, open bankart repair with

00:38:43.400 --> 00:38:46.219
a capsular shift was considered the gold standard

00:38:46.219 --> 00:38:49.360
for contact athletes due to its perceived robustness.

00:38:49.579 --> 00:38:52.000
However, with the development of new implants

00:38:52.000 --> 00:38:54.139
and significant advancements in arthroscopic

00:38:54.139 --> 00:38:56.739
surgical techniques, arthroscopic stabilization

00:38:56.739 --> 00:38:59.320
has gained enormous popularity and now offers

00:38:59.320 --> 00:39:02.039
comparable outcomes in many cases, with potentially

00:39:02.039 --> 00:39:04.440
less morbidity. But arthroscopy isn't always

00:39:04.440 --> 00:39:07.019
successful. No, and it's crucial to understand

00:39:07.019 --> 00:39:09.599
the risk factors for surgical failure, particularly

00:39:09.599 --> 00:39:12.329
with arthroscopy. Burkhart and De Beer famously

00:39:12.329 --> 00:39:14.530
reported a much higher recurrence rate after

00:39:14.530 --> 00:39:16.829
arthroscopic bankart repair for patients with

00:39:16.829 --> 00:39:19.570
significant glenoid bone loss and engaging heel

00:39:19.570 --> 00:39:23.190
sacs lesions. These critical bone defects compromised

00:39:23.190 --> 00:39:25.610
the procedure. Which brings us back to the glenoid

00:39:25.610 --> 00:39:28.590
tract concept. Exactly. Yamamoto and colleagues'

00:39:28.889 --> 00:39:31.329
glenoid tract concept is now invaluable for guiding

00:39:31.329 --> 00:39:34.250
clinical decision making in these cases. Remember,

00:39:34.510 --> 00:39:36.690
it defines the contact zone between the humerus

00:39:36.690 --> 00:39:39.849
and glenoid. If a Hill Sachs lesion remains within

00:39:39.849 --> 00:39:43.130
the glenoid track, on track, there is no risk

00:39:43.130 --> 00:39:45.909
of engagement. However, if it extends immediately

00:39:45.909 --> 00:39:48.550
over the glenoid track, off track, there is a

00:39:48.550 --> 00:39:50.530
high risk of engagement during functional movement,

00:39:51.010 --> 00:39:53.369
making simple soft tissue repair likely to fail.

00:39:53.530 --> 00:39:56.110
So what do you do for those off track or large

00:39:56.110 --> 00:39:59.320
bony defects? To address large humeral head defects,

00:39:59.659 --> 00:40:02.000
off -track hill sacks, surgical options include

00:40:02.000 --> 00:40:04.860
humeral head osteochondral allograft, or the

00:40:04.860 --> 00:40:07.599
infraspinatus rumbolisage procedure, where the

00:40:07.599 --> 00:40:09.780
infraspinatus tendon is sewn into the defect

00:40:09.780 --> 00:40:12.840
to prevent engagement. For significant glenoid

00:40:12.840 --> 00:40:15.800
bone loss, the Littarjet procedure is often considered.

00:40:16.380 --> 00:40:18.460
This involves transferring the coracoid process

00:40:18.460 --> 00:40:20.360
with its attached tendons to the front of the

00:40:20.360 --> 00:40:23.119
glenoid. How does Littarjet work? It provides

00:40:23.119 --> 00:40:26.380
stability through three key effects. a bone graft

00:40:26.380 --> 00:40:29.179
effect restoring the glenoid surface, a sling

00:40:29.179 --> 00:40:31.340
effect from the conjoined tendon acting like

00:40:31.340 --> 00:40:34.019
a hammock, and a capsular repair effect. It's

00:40:34.019 --> 00:40:35.519
important to acknowledge, though, that these

00:40:35.519 --> 00:40:38.400
are non -anatomic procedures and are associated

00:40:38.400 --> 00:40:40.519
with reported complication rates ranging from

00:40:40.519 --> 00:40:43.340
5 % to 30%, so patient selection and technical

00:40:43.340 --> 00:40:46.420
execution are key. Comprehensive algorithms exist

00:40:46.420 --> 00:40:48.400
now to help guide the management decisions based

00:40:48.400 --> 00:40:51.659
on these factors. 4 .1 acromioclavicular joint

00:40:51.659 --> 00:40:54.260
injuries, a persistent problem. Okay, let's move

00:40:54.260 --> 00:40:56.320
slightly away from the main ball and socket joint.

00:40:56.800 --> 00:40:58.820
Often overshadowed by the glenohumeral joint,

00:40:59.219 --> 00:41:02.260
the AC joint plays a subtle yet absolutely critical

00:41:02.260 --> 00:41:04.679
role in shoulder function, especially in those

00:41:04.679 --> 00:41:07.400
kinetic chain movements we talked about. Its

00:41:07.400 --> 00:41:09.699
injuries, however, seem notoriously tricky to

00:41:09.699 --> 00:41:12.139
classify and manage, particularly in contact

00:41:12.139 --> 00:41:14.730
athletes. What's crucial for us to understand

00:41:14.730 --> 00:41:17.570
about AC joint anatomy, its common injury patterns,

00:41:17.929 --> 00:41:20.610
and how do we accurately diagnose and approach

00:41:20.610 --> 00:41:23.010
treatment for these persistent problems? You've

00:41:23.010 --> 00:41:25.349
hit on a crucial point about the AC joint's often

00:41:25.349 --> 00:41:28.530
underestimated importance. It's a robust synovial

00:41:28.530 --> 00:41:31.949
articulation connecting the clavicle to the scapula,

00:41:32.250 --> 00:41:34.750
featuring an intraarticular fibrocartilaginous

00:41:34.750 --> 00:41:37.449
disc, though that disc rapidly degenerates beyond

00:41:37.449 --> 00:41:40.409
the fourth decade, typically. Its primary stabilizers

00:41:40.409 --> 00:41:42.489
are the dynamic muscles crossing the joint, the

00:41:42.489 --> 00:41:44.869
deltoid and trapezius, and the static ligaments.

00:41:45.329 --> 00:41:47.610
The acromioclavicular, AC ligaments providing

00:41:47.610 --> 00:41:50.170
anterior -posterior stability, and the coracoa

00:41:50.170 --> 00:41:52.789
collicular, CC ligaments, the conoid and trapezoid,

00:41:52.949 --> 00:41:54.829
providing vertical stability. And both sets of

00:41:54.829 --> 00:41:56.880
ligaments are important. Critically important,

00:41:57.420 --> 00:41:59.179
it's vital to understand that these injuries

00:41:59.179 --> 00:42:02.380
rarely occur in isolation, highlighting the importance

00:42:02.380 --> 00:42:05.360
of anatomic reconstruction of both the AC and

00:42:05.360 --> 00:42:07.840
CC ligaments for maximum healing strength if

00:42:07.840 --> 00:42:10.800
surgery is undertaken. Codman famously observed

00:42:10.800 --> 00:42:13.559
that the AC joint moves very little, but in many

00:42:13.559 --> 00:42:16.840
planes, and crucially, an intact ACJ is essential

00:42:16.840 --> 00:42:19.340
for scapula motion to be synchronously coupled

00:42:19.340 --> 00:42:22.059
with arm motion. Ah, so it links the clavicle

00:42:22.059 --> 00:42:24.579
and scapular movements. Precisely. If the ACJ

00:42:24.579 --> 00:42:26.960
is fixed, say with screws or plates, motion will

00:42:26.960 --> 00:42:29.980
be lost, limiting shoulder function, or the hardware

00:42:29.980 --> 00:42:32.440
will eventually fail due to this obligatory coupling

00:42:32.440 --> 00:42:35.679
of clavicle rotation with scapular motion. This

00:42:35.679 --> 00:42:37.980
is clinically significant, as long -standing

00:42:37.980 --> 00:42:40.739
type 3 AC joint injuries complete peers of both

00:42:40.739 --> 00:42:43.340
ligaments, lead to scapular dyskinesis in 71

00:42:43.340 --> 00:42:45.940
% of patients, often presenting as the so -called

00:42:45.940 --> 00:42:48.510
S -I -C -K scapular syndrome. So how do these

00:42:48.510 --> 00:42:51.510
injuries usually happen? Ethiologically, AC joint

00:42:51.510 --> 00:42:53.670
injuries typically result from a direct blow

00:42:53.670 --> 00:42:56.489
to the point of the shoulder, the lateral acromion,

00:42:56.849 --> 00:42:59.309
or indirectly from landing hard on the affected

00:42:59.309 --> 00:43:02.889
shoulder, driving the acromion and scapula inferiorly

00:43:02.889 --> 00:43:05.929
and anteriorly. This causes the clavicle to be

00:43:05.929 --> 00:43:08.989
relatively displaced superiorly, leading to sequential

00:43:08.989 --> 00:43:11.829
tearing of the AC and then the CC ligaments.

00:43:12.030 --> 00:43:14.030
In classification, you mentioned it's tricky.

00:43:14.230 --> 00:43:17.130
Yes, classification of AC joint injuries using

00:43:17.130 --> 00:43:19.570
the widely used Rockwood classification, types

00:43:19.570 --> 00:43:22.610
ISI based on displacement, is challenging because

00:43:22.610 --> 00:43:25.909
relying solely on radiographs has proven unreliable

00:43:25.909 --> 00:43:28.409
for determining the true pathological classification

00:43:28.409 --> 00:43:30.989
and guiding treatment. This led to the ISACOS

00:43:30.989 --> 00:43:33.809
upper limb committee's 2014 consensus document,

00:43:34.070 --> 00:43:36.269
which diversified the contentious type 3 injuries.

00:43:36.610 --> 00:43:38.949
The ones were both AC and CC ligaments are torn,

00:43:39.389 --> 00:43:42.130
but displacement varies into type I. functionally

00:43:42.130 --> 00:43:45.110
stable and type I functionally unstable. Based

00:43:45.110 --> 00:43:47.829
on clinical factors, not just x -rays. Exactly.

00:43:48.190 --> 00:43:50.090
This distinction is based on clinical factors

00:43:50.090 --> 00:43:52.869
assessed three to six weeks post -injury, including

00:43:52.869 --> 00:43:55.389
things like ongoing pain, especially over the

00:43:55.389 --> 00:43:58.369
anterior acromeon, rotator cuff, or medial scapular

00:43:58.369 --> 00:44:01.849
area, weakness during rotator cuff testing, decreased

00:44:01.849 --> 00:44:05.150
flexion and abduction ROM, and demonstrable scapular

00:44:05.150 --> 00:44:07.849
dyskinesis on observation. How do they look clinically?

00:44:08.119 --> 00:44:11.219
In clinical examination, complete AC joint disruptions,

00:44:11.460 --> 00:44:13.659
Rockwood grades III, present with that classical

00:44:13.659 --> 00:44:16.599
obvious deformity or step off. These may be locked,

00:44:16.800 --> 00:44:18.900
meaning not easily reducible in limiting scapular

00:44:18.900 --> 00:44:21.800
excursion, or shocked, unstable, but easily reducible.

00:44:22.400 --> 00:44:24.920
For less obvious disruptions, grade III -II,

00:44:25.139 --> 00:44:27.099
cross arm adduction often accentuates the injury,

00:44:27.639 --> 00:44:29.800
displacing the clavicle superiorly and posteriorly.

00:44:29.929 --> 00:44:32.889
The diagnostic triad of ACJ injury include the

00:44:32.889 --> 00:44:35.469
point tenderness directly over the joint, ACJ

00:44:35.469 --> 00:44:37.409
pain with cross -arm adduction, and importantly

00:44:37.409 --> 00:44:39.690
pain relief by local anesthetic injection into

00:44:39.690 --> 00:44:42.630
the joint. The Paxinos test can also be helpful.

00:44:42.789 --> 00:44:44.869
What about x -rays? Is there a specific view?

00:44:45.130 --> 00:44:47.610
For radiographic evaluation, the Zonka view,

00:44:48.050 --> 00:44:50.929
a 15 -degree cephalid tilt view, is considered

00:44:50.929 --> 00:44:53.409
the most accurate for visualizing the AC joint

00:44:53.409 --> 00:44:57.150
itself, though its an intra -observer reliability

00:44:57.150 --> 00:45:00.019
is acknowledged to be poor. Standard shoulder

00:45:00.019 --> 00:45:03.179
views often don't show it well. While CT scans

00:45:03.179 --> 00:45:05.559
are best for appreciating static bony displacement,

00:45:06.119 --> 00:45:07.880
clinical assessment can be equally reliable.

00:45:08.380 --> 00:45:10.719
MRI can be useful for assessing soft tissue damage,

00:45:11.219 --> 00:45:13.260
particularly the ligaments in acute scenarios.

00:45:13.610 --> 00:45:16.030
Management of AC joint injuries often sparks

00:45:16.030 --> 00:45:18.150
significant debate, doesn't it? Particularly

00:45:18.150 --> 00:45:20.130
regarding when to opt for non -operative versus

00:45:20.130 --> 00:45:22.170
operative approaches, especially considering

00:45:22.170 --> 00:45:24.309
the high functional demands and career implications

00:45:24.309 --> 00:45:26.469
for athletes. What's the current thinking and

00:45:26.469 --> 00:45:29.050
what principles guide that decision -making process?

00:45:29.429 --> 00:45:31.750
The management philosophy for AC joint injuries

00:45:31.750 --> 00:45:34.130
has definitely been shifting. Recent evidence

00:45:34.130 --> 00:45:36.710
increasingly supports initial primary non -operative

00:45:36.710 --> 00:45:39.449
treatment for even complete EC joint dislocations,

00:45:39.949 --> 00:45:42.590
type 3 and some higher grades. Reviews report

00:45:42.590 --> 00:45:45.449
successful outcomes in around 88 % of patients

00:45:45.449 --> 00:45:47.849
treated nonoperatively, comparable to operative

00:45:47.849 --> 00:45:50.469
groups in many studies. This really underscores

00:45:50.469 --> 00:45:53.150
that the grade of AC joint injury alone should

00:45:53.150 --> 00:45:55.349
not be the primary determinant for defining treatment

00:45:55.349 --> 00:45:58.010
options, due to that poor correlation with clinical

00:45:58.010 --> 00:46:00.710
symptoms we discussed. Patient function and symptoms

00:46:00.710 --> 00:46:03.500
are more important. So what does non -operative

00:46:03.500 --> 00:46:06.059
treatment involve? For non -operative treatment,

00:46:06.380 --> 00:46:08.340
particularly acute injuries less than a week

00:46:08.340 --> 00:46:11.360
old, initial management involves simple analgesia,

00:46:11.579 --> 00:46:14.699
topical ice therapy, and rest in a sling, primarily

00:46:14.699 --> 00:46:17.719
for comfort. A supportive broad -arm sling is

00:46:17.719 --> 00:46:20.280
generally preferred over a collar and cuff. The

00:46:20.280 --> 00:46:22.159
fling should typically be discarded once symptoms

00:46:22.159 --> 00:46:25.280
settle, usually within one week. Rehabilitation

00:46:25.280 --> 00:46:27.920
then follows a structured protocol, like Gladstone

00:46:27.920 --> 00:46:30.420
and colleagues' four -phase protocol. This progresses

00:46:30.420 --> 00:46:33.250
from phase one, pain control, immediate protective

00:46:33.250 --> 00:46:36.429
ROM isometrics, to phase two, isotonic strengthening,

00:46:37.010 --> 00:46:39.210
phase three, unrestricted functional participation,

00:46:39.630 --> 00:46:41.949
neuromuscular control, and finally phase four,

00:46:42.349 --> 00:46:44.230
return to activity with sports -specific drills.

00:46:44.469 --> 00:46:47.070
When can they return to contact sports? Contact

00:46:47.070 --> 00:46:49.449
sports and heavy lifting can usually be started

00:46:49.449 --> 00:46:52.030
as comfortable, typically around 6 -12 weeks

00:46:52.030 --> 00:46:54.889
post -injury. However, it's important to counsel

00:46:54.889 --> 00:46:57.309
patients that local discomfort may persist with

00:46:57.309 --> 00:47:00.210
activity for up to six months. And those concerning

00:47:00.210 --> 00:47:02.650
statistics from Cox show that a large proportion

00:47:02.650 --> 00:47:04.929
of athletes remain symptomatic at six months,

00:47:05.230 --> 00:47:07.690
particularly with grade three injuries, and 30

00:47:07.690 --> 00:47:10.010
% of overhead athletes were unable to continue

00:47:10.010 --> 00:47:12.349
at the same level of sport after non -operative

00:47:12.349 --> 00:47:15.090
treatment. So non -operative isn't always the

00:47:15.090 --> 00:47:17.630
final answer for high -demand individuals. When

00:47:17.630 --> 00:47:20.380
is surgery indicated? Surgical treatment is typically

00:47:20.380 --> 00:47:22.380
reserved for patients with high functional demands

00:47:22.380 --> 00:47:24.780
who remain symptomatic, those with a clinically

00:47:24.780 --> 00:47:27.900
symptomatic locked or unstable, shocked scapula,

00:47:28.219 --> 00:47:30.219
and patients who simply fail to improve after

00:47:30.219 --> 00:47:32.599
an initial three to six weeks of appropriate

00:47:32.599 --> 00:47:35.320
non -operative symptomatic management. The aim

00:47:35.320 --> 00:47:38.000
of surgery is to achieve a painless, stable shoulder

00:47:38.000 --> 00:47:40.539
with adequate mobility, strength, and muscle

00:47:40.539 --> 00:47:43.000
control, allowing the individual to return to

00:47:43.000 --> 00:47:45.280
their desired level of activity. And the surgical

00:47:45.280 --> 00:47:47.619
techniques. You mentioned over 100 historically.

00:47:47.929 --> 00:47:50.849
Yes. Historically, the proliferation of over

00:47:50.849 --> 00:47:53.869
100 different surgical techniques indicated a

00:47:53.869 --> 00:47:56.989
lack of consensus on the optimal treatment. Techniques

00:47:56.989 --> 00:47:59.190
like the Weaver -Dunn procedure, which involved

00:47:59.190 --> 00:48:01.710
transferring the coracochromial ligament, only

00:48:01.710 --> 00:48:04.389
reproduced about 25 % of the native cc ligament

00:48:04.389 --> 00:48:07.429
strength and had high failure rates. Hook plates

00:48:07.429 --> 00:48:09.809
provided stable reduction but could cause rotator

00:48:09.809 --> 00:48:12.349
cuff impingement and required secondary removal,

00:48:12.690 --> 00:48:14.789
often performing worse than cc ligament fixation.

00:48:14.889 --> 00:48:17.239
So what's the trend now? Current surgical trends

00:48:17.239 --> 00:48:19.760
are moving firmly towards anatomical restoration

00:48:19.760 --> 00:48:22.920
of both the CC and AC ligaments, often with some

00:48:22.920 --> 00:48:25.400
form of biological enhancement, using strong

00:48:25.400 --> 00:48:27.599
constructs that allow for early mobilization

00:48:27.599 --> 00:48:31.099
and reduce the risk of re -displacement. Choricoclavicular

00:48:31.099 --> 00:48:33.539
fixation has evolved from the original Bosworth

00:48:33.539 --> 00:48:36.619
screw to modern suture button constructs, like

00:48:36.619 --> 00:48:39.300
the dog bone or tightrope systems, now using

00:48:39.300 --> 00:48:41.460
multiple buttons and strong tape sutures for

00:48:41.460 --> 00:48:43.559
increased strength and arthroscopic amenability.

00:48:44.010 --> 00:48:47.349
Free graft augmentation or reconstruction, using

00:48:47.349 --> 00:48:49.710
tending grafts like Hercilus or Semitindinosis,

00:48:50.070 --> 00:48:52.050
placed in an anatomic position to reconstruct

00:48:52.050 --> 00:48:54.469
the trapezoid and conoid ligaments, has shown

00:48:54.469 --> 00:48:56.889
ultimate failure loads equivalent to native intact

00:48:56.889 --> 00:48:59.530
cc ligaments, although graft fixation itself

00:48:59.530 --> 00:49:02.420
remains a technical challenge. Loop reconstruction

00:49:02.420 --> 00:49:05.000
techniques, using synthetic ligaments like LARS

00:49:05.000 --> 00:49:07.639
or Surgilig, are purported to allow early post

00:49:07.639 --> 00:49:09.360
-operative functional treatment and potentially

00:49:09.360 --> 00:49:12.139
earlier recovery, with improved implant technology

00:49:12.139 --> 00:49:15.239
minimizing older issues like clavicular osteolysis.

00:49:16.000 --> 00:49:18.239
Repair and reinforcement of the superior AC ligament

00:49:18.239 --> 00:49:20.079
is also often combined with these techniques

00:49:20.079 --> 00:49:22.840
to improve horizontal stability. And your preferred

00:49:22.840 --> 00:49:25.599
technique? Our preferred technique involves the

00:49:25.599 --> 00:49:28.219
use of a strong synthetic polyethylene tetra

00:49:28.219 --> 00:49:30.940
-trophallate ligament. Specifically, the lyre's

00:49:30.940 --> 00:49:33.679
ligament. We use an anatomical construct, passing

00:49:33.679 --> 00:49:35.739
it through drill holes in the clavicle and around

00:49:35.739 --> 00:49:38.039
the coracoid, combined with a reefing repair

00:49:38.039 --> 00:49:41.179
of the ACJ capsule and the overlying delta trapecial

00:49:41.179 --> 00:49:44.260
fascia. This lyre's ligament actually exceeds

00:49:44.260 --> 00:49:46.960
the tensile strength of native CC ligaments and

00:49:46.960 --> 00:49:49.099
encourages fibroblast and collagen in growth.

00:49:49.309 --> 00:49:51.429
We've also modified this by adding a further

00:49:51.429 --> 00:49:53.510
figure of 8 loop around the coracoid and or over

00:49:53.510 --> 00:49:56.570
the ACJ via a drill hole in the acromeon to further

00:49:56.570 --> 00:49:59.030
improve horizontal stability and overall construct

00:49:59.030 --> 00:50:01.269
strength. Our own results with this have been

00:50:01.269 --> 00:50:03.690
positive, showing a low 2 % loss of reduction.

00:50:03.989 --> 00:50:06.590
And rehabilitation after surgery, is it milestone

00:50:06.590 --> 00:50:10.019
based? Absolutely. Postoperative rehabilitation

00:50:10.019 --> 00:50:12.340
is crucial, and progression through the phases

00:50:12.340 --> 00:50:15.159
is not time -based, but strictly milestone -based,

00:50:15.619 --> 00:50:17.480
depending entirely on the patient's responses

00:50:17.480 --> 00:50:20.980
and ability to progress safely. Phase 1 involves

00:50:20.980 --> 00:50:24.179
protective, gentle pendulum exercises and passive

00:50:24.179 --> 00:50:26.920
range of motion. Phase 2 progresses to light

00:50:26.920 --> 00:50:29.500
resistance and sport -specific rehabilitation

00:50:29.500 --> 00:50:32.079
including plyometrics and perturbation training.

00:50:32.719 --> 00:50:35.920
Phase 3 focuses intensely on regaining scapula

00:50:35.920 --> 00:50:38.599
and glenohumeral stability and control. and return

00:50:38.599 --> 00:50:41.699
to sport. Sport -specific rehabilitation commences

00:50:41.699 --> 00:50:44.340
within weeks. Return to sport participation and

00:50:44.340 --> 00:50:46.699
competition is graduated, always requiring input

00:50:46.699 --> 00:50:48.960
from the surgeon, the therapist, and the strength

00:50:48.960 --> 00:50:51.420
and conditioning coaches. Typically, this is

00:50:51.420 --> 00:50:53.480
achieved within three to four months for contact

00:50:53.480 --> 00:50:55.460
athletes, and perhaps six to nine months for

00:50:55.460 --> 00:50:57.860
overhead athletes, though some, like horse riders

00:50:57.860 --> 00:50:59.920
and cyclists, often return in less than three

00:50:59.920 --> 00:51:03.000
months. 4 .2 sternoclavicular joint injuries,

00:51:03.260 --> 00:51:05.639
the body's most stable joint, Right, if the AC

00:51:05.639 --> 00:51:08.679
joint can be subtly tricky, the sternoclavicular

00:51:08.679 --> 00:51:11.219
or SC joint presents a different challenge altogether.

00:51:11.840 --> 00:51:14.099
It's often described as inherently the most stable

00:51:14.099 --> 00:51:16.659
joint in the body, yet its injuries can be incredibly

00:51:16.659 --> 00:51:19.139
deceptive, even potentially life -threatening.

00:51:20.099 --> 00:51:22.519
What makes the SC joint so incredibly stable?

00:51:22.920 --> 00:51:25.139
What are the subtle diagnostic clues we should

00:51:25.139 --> 00:51:28.139
never miss? And how do their distinct characteristics

00:51:28.139 --> 00:51:30.679
dictate management, especially the really urgent

00:51:30.679 --> 00:51:33.519
ones? The SE joint is truly an anomaly in its

00:51:33.519 --> 00:51:36.480
stability. Despite having largely incongruent

00:51:36.480 --> 00:51:38.900
articular surfaces and a small contact area,

00:51:39.219 --> 00:51:42.159
it is extremely stable due to very robust static

00:51:42.159 --> 00:51:44.780
and dynamic stabilizers. Its static stabilizers

00:51:44.780 --> 00:51:47.019
include the inherent, albeit limited, congruity

00:51:47.019 --> 00:51:49.539
of the articular surfaces, the extremely strong

00:51:49.539 --> 00:51:52.039
anterior and posterior sternoclavicular ligaments.

00:51:52.429 --> 00:51:54.269
are the most important for anterocollectural

00:51:54.269 --> 00:51:57.110
stability. The intraarticular fibrocartilaginous

00:51:57.110 --> 00:51:58.829
disc, which divides the joint and acts a bit

00:51:58.829 --> 00:52:01.190
like a knee meniscus, and the interclavicular

00:52:01.190 --> 00:52:03.909
and costoclavicular ligaments. Dynamic stabilizers

00:52:03.909 --> 00:52:05.969
include the surrounding musculotendin assemblo,

00:52:06.050 --> 00:52:08.469
particularly the sternoplidomastoid, subclavius,

00:52:08.710 --> 00:52:11.369
and pectoralis major muscles. And there's a key

00:52:11.369 --> 00:52:13.849
point about younger patients. Yes. This is a

00:52:13.849 --> 00:52:16.619
crucial developmental point for clinicians. The

00:52:16.619 --> 00:52:19.019
epiphysis or growth plate of the medial end of

00:52:19.019 --> 00:52:21.699
the clavicle is the last epiphysis in the body

00:52:21.699 --> 00:52:24.559
to close, usually between 25 and 31 years old.

00:52:24.780 --> 00:52:27.440
This is critically relevant because significant

00:52:27.440 --> 00:52:29.679
traumatic injuries in patients younger than 25

00:52:29.679 --> 00:52:32.579
are far more likely to result in a displaced

00:52:32.579 --> 00:52:35.280
medial -physiol fracture, a growth plate injury,

00:52:35.579 --> 00:52:38.599
rather than a true SC joint dislocation, simply

00:52:38.599 --> 00:52:40.960
because the physis is inherently weaker than

00:52:40.960 --> 00:52:43.480
the incredibly strong SC joint ligaments before

00:52:43.480 --> 00:52:46.719
it fuses. So always consider a physio fracture

00:52:46.719 --> 00:52:49.280
in younger patients with apparent SCJ disruption.

00:52:49.639 --> 00:52:51.840
Absolutely. The SC joint itself moves in three

00:52:51.840 --> 00:52:54.519
planes. retraction, protraction, elevation, depression,

00:52:54.760 --> 00:52:56.860
and rotation coordinated with AC joint movement

00:52:56.860 --> 00:52:59.400
to optimally position the glenoid. How do we

00:52:59.400 --> 00:53:01.179
diagnose these injuries? What should we look

00:53:01.179 --> 00:53:03.980
for? When unraveling SCJ injuries, a detailed

00:53:03.980 --> 00:53:07.039
history is vital. Acute injuries typically involve

00:53:07.039 --> 00:53:09.420
a high -energy mechanism, like a direct blow

00:53:09.420 --> 00:53:12.280
or fall. Chronic problems may follow previous

00:53:12.280 --> 00:53:14.900
trauma or activity changes. In younger patients,

00:53:15.260 --> 00:53:17.659
Atraumatic instability can present with pain,

00:53:17.920 --> 00:53:20.260
clicking, or recurrent dislocation without a

00:53:20.260 --> 00:53:22.599
specific injury, and it's worth asking about

00:53:22.599 --> 00:53:25.340
connective tissue disorders like Ehlers -Danlos

00:53:25.340 --> 00:53:28.539
or Marfan's. On inspection, we look for deformity

00:53:28.539 --> 00:53:30.579
or muscle wasting compared to the other side.

00:53:31.079 --> 00:53:33.500
Palpation involves checking the SEC joint for

00:53:33.500 --> 00:53:35.920
swelling, differentiating between soft tissue

00:53:35.920 --> 00:53:38.559
swelling like effusion or synovitis, and hard

00:53:38.559 --> 00:53:41.019
swelling from a chronic dislocation or osteophytes,

00:53:41.219 --> 00:53:43.679
and assessing tenderness. We assess movements

00:53:43.679 --> 00:53:46.360
of the SE joint in all three planes. Protraction,

00:53:46.440 --> 00:53:48.780
retraction, arms forward. Elevation, depression,

00:53:49.019 --> 00:53:51.599
arms abducted. And rotation, arms abducted, elbows

00:53:51.599 --> 00:53:53.980
flexed. We palpate the anterior joint during

00:53:53.980 --> 00:53:56.179
movement for abnormal motion or clicking, which

00:53:56.179 --> 00:53:58.420
might suggest degenerative changes or disc pairs.

00:53:59.000 --> 00:54:01.059
In cases of instability, the medial clavicle

00:54:01.059 --> 00:54:03.940
may sublux or dislocate anteriorly. And imaging.

00:54:04.519 --> 00:54:08.059
CT seems key here. Yes, for imaging, while X

00:54:08.059 --> 00:54:11.059
-rays, AP, lateral, can be helpful, a CT scan

00:54:11.059 --> 00:54:14.380
is undoubtedly the investigation of choice. It

00:54:14.380 --> 00:54:16.219
accurately assesses the position of the medial

00:54:16.219 --> 00:54:18.900
clavicle relative to the sternum and crucially

00:54:18.900 --> 00:54:21.360
differentiates a true dislocation from a physio

00:54:21.360 --> 00:54:23.800
fracture. And most importantly, for posterior

00:54:23.800 --> 00:54:26.260
dislocations where there's any concern for mediastinal

00:54:26.260 --> 00:54:29.000
compromise, a CT angiogram should be undertaken

00:54:29.000 --> 00:54:31.480
as a matter of urgency to visualize the great

00:54:31.480 --> 00:54:34.059
vessels like the aorta and subplavian vessels

00:54:34.059 --> 00:54:36.619
and the tracheosophagus in relation to the displaced

00:54:36.619 --> 00:54:39.780
medial clavicle. So CT angio for suspected posterior

00:54:39.780 --> 00:54:43.679
dislocations. What about MRI? MRI offers poorer

00:54:43.679 --> 00:54:46.860
bony resolution compared to CT, but can effectively

00:54:46.860 --> 00:54:49.559
demonstrate ligamentous structures, intraarticular

00:54:49.559 --> 00:54:51.880
disc injuries, and the adjacent neurovascular

00:54:51.880 --> 00:54:54.199
anatomy if needed. Okay, what are the most concerning

00:54:54.199 --> 00:54:56.599
types of SC joint injuries, particularly those

00:54:56.599 --> 00:54:58.940
posterior dislocations you mentioned? How do

00:54:58.940 --> 00:55:01.420
their distinct, often life -threatening characteristics

00:55:01.420 --> 00:55:04.059
dictate management, including the need for urgent

00:55:04.059 --> 00:55:06.760
intervention and specialized surgical considerations?

00:55:07.380 --> 00:55:10.139
SC joint instability can be classified by direction,

00:55:10.380 --> 00:55:14.039
anterior, posterior, severity, sprain, subluxation,

00:55:14.179 --> 00:55:16.960
dislocation, or chronicity, acute, recurrent,

00:55:17.159 --> 00:55:20.019
persistent. But the Stanmore Triangle Classification

00:55:20.019 --> 00:55:23.019
is also useful as it considers the cause. Type

00:55:23.019 --> 00:55:26.619
I traumatic, type II atraumatic structural laxity,

00:55:27.079 --> 00:55:29.460
and type III non -structural muscle patterning.

00:55:29.530 --> 00:55:31.750
Let's focus on type one, the traumatic ones.

00:55:32.130 --> 00:55:34.329
Type A traumatic structural instability involves

00:55:34.329 --> 00:55:37.469
those high energy, high stakes injuries. Traumatic

00:55:37.469 --> 00:55:40.389
SE joint dislocations are rare, less than 1 %

00:55:40.389 --> 00:55:42.570
of upper limb injuries, usually resulting from

00:55:42.570 --> 00:55:45.449
significant force. The force is often indirect,

00:55:45.829 --> 00:55:47.590
transferred along the clavicle from a blow to

00:55:47.590 --> 00:55:50.699
the shoulder. A protracted scapula at impact

00:55:50.699 --> 00:55:53.260
increases the likelihood of posterior dislocation.

00:55:53.599 --> 00:55:56.519
A retracted scapula anterior dislocation. Like

00:55:56.519 --> 00:55:58.860
frequently, a direct anterior blow to the clavicle

00:55:58.860 --> 00:56:01.219
can drive the medial end posteriorly into the

00:56:01.219 --> 00:56:03.920
mediastinum. And posterior dislocation is a dangerous

00:56:03.920 --> 00:56:06.820
one. Acute posterior dislocations are a particular

00:56:06.820 --> 00:56:10.219
concern. Yes, due to their potential to cause

00:56:10.219 --> 00:56:12.840
mediastinal compromise, making them a potential

00:56:12.840 --> 00:56:15.840
medical emergency. Clinicians must be extremely

00:56:15.840 --> 00:56:18.539
vigilant for features such as dysphagia, difficulty

00:56:18.539 --> 00:56:22.019
swallowing, dyspnoea, shortness of breath, stridor

00:56:22.019 --> 00:56:24.860
hoarseness, or vascular symptoms like venous

00:56:24.860 --> 00:56:28.659
congestion or edema of the ipsilateral arm. These

00:56:28.659 --> 00:56:30.820
suggest pressure on the great vessels or the

00:56:30.820 --> 00:56:33.460
tracheosophagus. While these complications are

00:56:33.460 --> 00:56:36.300
rare, they can be devastating and their probability

00:56:36.300 --> 00:56:38.480
increases the longer the dislocation remains

00:56:38.480 --> 00:56:41.260
unreduced. How are they managed based on direction

00:56:41.260 --> 00:56:43.710
and timing? Management strategies depend critically

00:56:43.710 --> 00:56:46.260
on the direction and timing. Undisplaced ligamentous

00:56:46.260 --> 00:56:48.500
sprains, grade 1, and subluxations, grade 2,

00:56:48.800 --> 00:56:51.179
as well as minimally displaced medial -fusel

00:56:51.179 --> 00:56:53.599
fractures, are typically treated conservatively

00:56:53.599 --> 00:56:56.460
with reassurance, analgesia, ice, and a short

00:56:56.460 --> 00:56:58.679
period of immobilization in a sling for comfort.

00:56:58.960 --> 00:57:00.739
Patients are advised to avoid re -injury for

00:57:00.739 --> 00:57:03.079
about three months. What about acute anterior

00:57:03.079 --> 00:57:06.039
dislocations? For acute anterior dislocations,

00:57:06.360 --> 00:57:09.280
usually within 48 hours, a closed reduction under

00:57:09.280 --> 00:57:11.860
sedation or general anesthetic can be attempted

00:57:11.860 --> 00:57:15.079
by applying posterior pressure. However, the

00:57:15.079 --> 00:57:17.800
SC joint often re -dislocates immediately or

00:57:17.800 --> 00:57:21.480
soon after, with recurrence rates over 50%. Because

00:57:21.480 --> 00:57:23.340
of this high recurrence rate and the fact that

00:57:23.340 --> 00:57:25.880
anterior dislocations rarely cause long -term

00:57:25.880 --> 00:57:28.380
functional issues, most surgeons adopt a wait

00:57:28.380 --> 00:57:30.719
-and -see policy. Symptoms typically settle with

00:57:30.719 --> 00:57:32.519
conservative management over three to six months.

00:57:32.880 --> 00:57:35.159
Surgery is considered only in unusual situations,

00:57:35.360 --> 00:57:37.659
with significant, persistent symptoms despite

00:57:37.659 --> 00:57:39.980
adequate non -operative management and after

00:57:39.980 --> 00:57:41.659
-muscle patterning issues have been excluded.

00:57:41.869 --> 00:57:44.510
And acute posterior dislocations, urgent reduction.

00:57:44.869 --> 00:57:47.730
Yes, for acute posterior dislocations, again,

00:57:47.750 --> 00:57:50.449
ideally within 48 hours, there is a much greater

00:57:50.449 --> 00:57:53.090
imperative to reduce and maintain reduction due

00:57:53.090 --> 00:57:55.909
to that risk of mediastinal compromise. Closed

00:57:55.909 --> 00:57:58.590
reduction is undertaken under general anesthetic,

00:57:58.849 --> 00:58:00.610
often with fluoroscopy guidance, and involves

00:58:00.610 --> 00:58:03.110
specific maneuvers like placing a bolster between

00:58:03.110 --> 00:58:05.409
the scapulae, applying traction and extension

00:58:05.409 --> 00:58:07.849
to the abducted arm, and sometimes using a towel

00:58:07.849 --> 00:58:10.750
clip to grip and pull the medial clavicle anteriorly.

00:58:10.840 --> 00:58:13.420
Success rates for closed reduction are challenging,

00:58:13.820 --> 00:58:16.900
perhaps around 56 % within 48 hours, dropping

00:58:16.900 --> 00:58:19.840
significantly after that. Crucially, the on -site

00:58:19.840 --> 00:58:21.980
cardiothoracic surgeon should always be informed

00:58:21.980 --> 00:58:24.340
prior to booking for closed reduction due to

00:58:24.340 --> 00:58:26.280
the potential need for immediate open reduction

00:58:26.280 --> 00:58:29.179
if closed reduction fails or vascular complications

00:58:29.179 --> 00:58:31.869
arise during the attempt. What happens after

00:58:31.869 --> 00:58:34.409
successful reduction? Post -reduction, a figure

00:58:34.409 --> 00:58:36.570
of eight brace is often used for about four weeks

00:58:36.570 --> 00:58:38.829
to maintain scapular retraction and reduce stress

00:58:38.829 --> 00:58:41.150
on the joint, and contact sports are avoided

00:58:41.150 --> 00:58:44.110
for three, six months. When is open surgery needed?

00:58:44.389 --> 00:58:46.449
Open reduction and reconstruction are indicated

00:58:46.449 --> 00:58:49.190
for failed closed reductions, delayed presentations,

00:58:49.349 --> 00:58:52.530
more than a few days, or chronic posterior dislocations

00:58:52.530 --> 00:58:55.150
that cause significant functional deficit or

00:58:55.150 --> 00:58:57.449
carry a high risk of erosion into vital structures.

00:58:58.099 --> 00:59:00.960
Since the normal capsular and ligamentous stabilizers

00:59:00.960 --> 00:59:03.699
are usually damaged and only partially referable,

00:59:04.099 --> 00:59:05.900
additional reconstruction is typically required

00:59:05.900 --> 00:59:08.659
to maintain the reduction. Historically, wires

00:59:08.659 --> 00:59:11.119
and pins were used but were abandoned due to

00:59:11.119 --> 00:59:13.840
lethal complications like introthoracic migration.

00:59:14.840 --> 00:59:17.420
Current trends favor reconstruction using autograft,

00:59:17.880 --> 00:59:20.320
like palmaris longus or semitendinosus tendon,

00:59:20.639 --> 00:59:23.519
or allograft. A figure of eight reconstruction

00:59:23.519 --> 00:59:25.619
technique, where the graft is shuttled through

00:59:25.619 --> 00:59:28.119
drill holes in the sternum and clavicle, tensioned

00:59:28.119 --> 00:59:30.800
and sutured, is considered biomechanically superior.

00:59:31.440 --> 00:59:33.760
Synthetic ultra -strong braided sutures can also

00:59:33.760 --> 00:59:36.199
be used to augment the graft. And those medial

00:59:36.199 --> 00:59:38.980
-physial fractures and under -25s. Reiterate

00:59:38.980 --> 00:59:41.139
that these are fractures, not true dislocations.

00:59:41.400 --> 00:59:44.360
CT confirms the diagnosis. Most are un - or minimally

00:59:44.360 --> 00:59:47.059
displaced and managed non -operatively with immobilization.

00:59:47.820 --> 00:59:49.619
Open reduction is reserved only for those rare

00:59:49.619 --> 00:59:51.599
cases with mediastinal compressive symptoms.

00:59:51.849 --> 00:59:54.389
Briefly, what about the other types of instability?

00:59:54.670 --> 00:59:56.610
Type 2 in -traumatic structural instability,

00:59:56.789 --> 00:59:59.230
or hypermobility, is due to capsular laxity,

00:59:59.590 --> 01:00:02.329
often bilateral, and frequently seen with generalized

01:00:02.329 --> 01:00:05.110
ligamentous laxity syndromes. Patients present

01:00:05.110 --> 01:00:08.130
with pain, clicking, and medial clavicle subluxation

01:00:08.130 --> 01:00:10.510
prominence, usually less painful than traumatic

01:00:10.510 --> 01:00:13.250
instability. This is managed non -operatively

01:00:13.250 --> 01:00:15.510
initially, with physiotherapy focusing on muscle

01:00:15.510 --> 01:00:18.070
patterning. Surgery might be considered for failed

01:00:18.070 --> 01:00:21.210
rehab. SCJ disc pathologies can cause pain and

01:00:21.210 --> 01:00:23.210
clicking, potentially treated with arthroscopic

01:00:23.210 --> 01:00:27.309
resection. SCJ osteoarthritis is common, especially

01:00:27.309 --> 01:00:29.510
in middle -aged women, managed conservatively

01:00:29.510 --> 01:00:33.269
first. NSAIDS, ICE, activity modification, steroid

01:00:33.269 --> 01:00:36.550
injections. If that fails, surgical options include

01:00:36.550 --> 01:00:38.389
resection of the medial end of the clavicle,

01:00:38.809 --> 01:00:41.489
increasingly done arthroscopically. And finally,

01:00:41.670 --> 01:00:43.650
type 3 muscle patterning instability involves

01:00:43.650 --> 01:00:45.849
poorly coordinated neuromuscular control causing

01:00:45.849 --> 01:00:48.269
instability. This must be addressed with physiotherapy

01:00:48.269 --> 01:00:50.550
and biofeedback before consiching any stabilization

01:00:50.550 --> 01:00:53.429
surgery. Botulinum toxin might even be used preoperatively

01:00:53.429 --> 01:00:55.570
to temporarily weaken offending muscles and protect

01:00:55.570 --> 01:00:58.489
a surgical repair. 5 .1 clavicle fractures. More

01:00:58.489 --> 01:01:00.710
than just a broken collarbone. Okay, let's move

01:01:00.710 --> 01:01:03.590
on to clavicle fractures. They're incredibly

01:01:03.590 --> 01:01:06.030
common, aren't they? Accounting for a significant

01:01:06.030 --> 01:01:09.050
portion of upper limb injuries. Yet, the approach

01:01:09.050 --> 01:01:11.269
to managing them seems to have evolved dramatically

01:01:11.269 --> 01:01:14.030
from the historical conservative norms. What's

01:01:14.030 --> 01:01:16.769
the latest evidence on when to manage these conservatively

01:01:16.769 --> 01:01:19.369
versus surgically, and why does this distinction

01:01:19.369 --> 01:01:21.730
matter so much for athletes, especially when

01:01:21.730 --> 01:01:23.789
considering complications like non -union and

01:01:23.789 --> 01:01:26.210
malunion? Yes, clavicle fractures are very common.

01:01:26.670 --> 01:01:28.949
And the clavicle itself, that saw -shaped bone,

01:01:29.070 --> 01:01:31.349
is the only skeletal attachment of the scapula

01:01:31.349 --> 01:01:34.329
to the torso. This means a clavicle injury profoundly

01:01:34.329 --> 01:01:37.329
affects the entire shoulder biomechanics, disrupting

01:01:37.329 --> 01:01:40.429
that strut function. It's the first bone to ossify

01:01:40.429 --> 01:01:43.230
in the fetus, but its sternal end is the last

01:01:43.230 --> 01:01:45.889
epiphysis to fuse, as we discussed, around the

01:01:45.889 --> 01:01:48.730
25th year. Cervical factors make up perhaps up

01:01:48.730 --> 01:01:51.130
to 5 % of all fractures in the adult population,

01:01:51.510 --> 01:01:54.010
and the vast majority, 70 -80%, occur in the

01:01:54.010 --> 01:01:56.489
mid -shaft, which is the thinnest and most exposed

01:01:56.489 --> 01:01:59.170
segment. Who gets them most often? Incidence

01:01:59.170 --> 01:02:01.710
is highest in males under 20, often due to sports

01:02:01.710 --> 01:02:04.690
injuries, which account for about 45 % of cases

01:02:04.690 --> 01:02:07.949
in recent studies. Also, in polytrauma patients,

01:02:08.449 --> 01:02:10.670
early fixation of high -energy clavicle fractures

01:02:10.670 --> 01:02:14.389
is increasingly recognized for reducing ITU length

01:02:14.389 --> 01:02:16.909
of stay and facilitating mobilization. How do

01:02:16.909 --> 01:02:19.409
they typically present? Diagnosis is usually

01:02:19.409 --> 01:02:21.190
straightforward clinically. The typical mechanism

01:02:21.190 --> 01:02:23.369
is a fall onto the shoulder or a direct blow,

01:02:23.670 --> 01:02:26.730
resulting in a compressive axial force. If displaced,

01:02:27.030 --> 01:02:29.190
the fracture can shorten due to unopposed muscle

01:02:29.190 --> 01:02:31.909
action. The sternocleidomastoid muscle pulls

01:02:31.909 --> 01:02:34.610
the medial fragments superiorly and posteriorly,

01:02:34.630 --> 01:02:38.099
while Pectoralis major in deltoid pull the lateral

01:02:38.099 --> 01:02:40.800
fragment inferiorly and medially leading to that

01:02:40.800 --> 01:02:43.039
characteristic tautic or draw shoulder deformity

01:02:43.039 --> 01:02:45.619
and shortening. Careful assessment of the overlying

01:02:45.619 --> 01:02:47.800
skin for tinting by sharp fragments is crucial.

01:02:48.260 --> 01:02:49.960
Clinical measurement of clavicle length difference

01:02:49.960 --> 01:02:52.199
compared to the uninjured side and a thorough

01:02:52.199 --> 01:02:54.539
neurological examination are essential. Can we

01:02:54.539 --> 01:02:56.719
predict who might have problems healing? We can

01:02:56.719 --> 01:02:59.079
use a prognostic index to predict non -union

01:02:59.079 --> 01:03:03.099
risk. Factors like older age, female sex, shortening

01:03:03.099 --> 01:03:05.699
of greater than two centimeters, complete fracture

01:03:05.699 --> 01:03:08.760
displacement, being a smoker, and significant

01:03:08.760 --> 01:03:11.679
comminution are all negative predictive factors

01:03:11.679 --> 01:03:14.659
for union. So, for example, a 60 -year -old woman

01:03:14.659 --> 01:03:17.159
with a displaced, comminuted mid -shaft fracture

01:03:17.159 --> 01:03:20.559
has an approximate 75 % projected probability

01:03:20.559 --> 01:03:23.679
of non -union at 12 weeks if treated non -operatively.

01:03:24.219 --> 01:03:26.019
This clearly informs the management discussion.

01:03:26.380 --> 01:03:29.579
Right. So how has management changed? especially

01:03:29.579 --> 01:03:32.119
for displaced fractures. Well, undisplaced mid

01:03:32.119 --> 01:03:35.139
-shaft fractures, Robinson type 2a, are traditionally

01:03:35.139 --> 01:03:37.739
and still currently treated conservatively, usually

01:03:37.739 --> 01:03:40.000
with a broad arm sling, and they generally unite

01:03:40.000 --> 01:03:42.719
with excellent function. However, the management

01:03:42.719 --> 01:03:44.880
of displaced mid -shaft fractures has been the

01:03:44.880 --> 01:03:47.079
focus of the shift. Historically, these were

01:03:47.079 --> 01:03:49.320
also treated conservatively based on the belief

01:03:49.320 --> 01:03:51.760
that most heal well functionally, even if they

01:03:51.760 --> 01:03:54.039
unite in a shortened position. But this has been

01:03:54.039 --> 01:03:56.039
strongly challenged by more recent high -quality

01:03:56.039 --> 01:03:58.420
studies indicating significantly higher non -union

01:03:58.420 --> 01:04:00.679
rates than previously thought and potentially

01:04:00.679 --> 01:04:03.239
poorer functional outcomes, especially in younger

01:04:03.239 --> 01:04:05.679
active individuals. What about non -operative

01:04:05.679 --> 01:04:08.809
treatment itself, Sling or Figure of Eight? The

01:04:08.809 --> 01:04:11.289
broad arm sling is the most frequently used non

01:04:11.289 --> 01:04:13.690
-operative treatment now. It offers better patient

01:04:13.690 --> 01:04:15.789
satisfaction scores than the figure of eight

01:04:15.789 --> 01:04:18.090
bandage, which was also shown in some studies

01:04:18.090 --> 01:04:20.989
to have a higher non -union rate, possibly due

01:04:20.989 --> 01:04:24.070
to distracting forces. Crucially though, neither

01:04:24.070 --> 01:04:27.210
sling type can reliably reduce or hold the reduction

01:04:27.210 --> 01:04:30.329
of a displaced, shortened fracture. This means

01:04:30.329 --> 01:04:32.329
that conservative treatment for a significantly

01:04:32.329 --> 01:04:34.929
displaced fracture always results in some degree

01:04:34.929 --> 01:04:37.670
of malunion or healing in a shortened position.

01:04:37.840 --> 01:04:40.460
The sling is really just used for comfort until

01:04:40.460 --> 01:04:42.960
pain settles. So the push is towards surgery

01:04:42.960 --> 01:04:45.659
for displaced ones? Yes. The paradigm shift has

01:04:45.659 --> 01:04:47.920
been towards considering primary operative treatment

01:04:47.920 --> 01:04:50.460
for displaced mid -shaft fractures, particularly

01:04:50.460 --> 01:04:53.480
in active patients. Evidence from large trials,

01:04:53.500 --> 01:04:55.300
like those from the Canadian Orthopedic Trauma

01:04:55.300 --> 01:04:58.000
Association and UK trials, demonstrated that

01:04:58.000 --> 01:05:00.960
open reduction and internal fixation significantly

01:05:00.960 --> 01:05:04.159
reduced non -union rates down to around 2 % versus

01:05:04.159 --> 01:05:07.199
15 % non -operatively and were associated with

01:05:07.199 --> 01:05:09.380
better functional outcome scores and faster return

01:05:09.380 --> 01:05:12.400
to function. But is the function better if they

01:05:12.400 --> 01:05:15.909
do unite non -operatively? That's a key point.

01:05:16.610 --> 01:05:19.190
The improved outcome scores in the surgical groups

01:05:19.190 --> 01:05:21.849
primarily resulted from preventing non -union

01:05:21.849 --> 01:05:24.849
and malunion. There was actually little functional

01:05:24.849 --> 01:05:27.429
difference reported between surgically and conservatively

01:05:27.429 --> 01:05:30.250
managed fractures that did go on to unite, although

01:05:30.250 --> 01:05:33.130
union occurred faster with surgery. We must also

01:05:33.130 --> 01:05:35.309
acknowledge the higher complication rates infection,

01:05:35.849 --> 01:05:38.550
hardware issues, need for removal, and greater

01:05:38.550 --> 01:05:40.550
expense associated with surgical intervention.

01:05:40.760 --> 01:05:43.860
So the treatment choice really needs to be individualized,

01:05:44.340 --> 01:05:46.079
carefully weighing the benefits of preventing

01:05:46.079 --> 01:05:48.780
non -malunion against the risks of surgery, considering

01:05:48.780 --> 01:05:51.159
the patient's activity level and expectations.

01:05:51.619 --> 01:05:54.059
When surgery is indicated for clavicle fractures,

01:05:54.360 --> 01:05:56.519
what are the preferred techniques? What are their

01:05:56.519 --> 01:05:59.000
advantages and disadvantages? And what specific

01:05:59.000 --> 01:06:01.420
complications do clinicians need to be aware

01:06:01.420 --> 01:06:04.559
of? When surgery is indicated, plate fixation

01:06:04.559 --> 01:06:07.530
via open reduction and internal fixation, or

01:06:07.530 --> 01:06:10.010
IF, is the most common surgical intervention

01:06:10.010 --> 01:06:13.269
worldwide. Doing the technique, meticulous care

01:06:13.269 --> 01:06:16.150
is taken to identify and preserve the supraclavicular

01:06:16.150 --> 01:06:19.050
nerve branches overlying the clavicle. Modern

01:06:19.050 --> 01:06:21.989
anatomically contoured locking plates allow for

01:06:21.989 --> 01:06:24.530
precise anatomical restoration and are designed

01:06:24.530 --> 01:06:27.190
to be less prominent than older plates. Plates

01:06:27.190 --> 01:06:29.010
are typically placed on the superior surface,

01:06:29.250 --> 01:06:31.789
which is biomechanically advantageous and generally

01:06:31.789 --> 01:06:34.230
requires minimal soft tissue detachment if done

01:06:34.230 --> 01:06:37.360
carefully. Interfragmentary lag screw techniques

01:06:37.360 --> 01:06:39.940
can be used prior to plating to provide compression

01:06:39.940 --> 01:06:41.980
and stabilize oblique or butterfly fragments.

01:06:42.699 --> 01:06:44.780
Anterior plating is another option some surgeons

01:06:44.780 --> 01:06:47.519
prefer, arguing it reduces plate prominence.

01:06:47.639 --> 01:06:49.860
What are the downsides of plating? Complications

01:06:49.860 --> 01:06:52.260
include infection, though typically low, around

01:06:52.260 --> 01:06:55.519
1 to 5 percent, hardware prominence causing irritation,

01:06:55.639 --> 01:06:58.719
quite common, hardware failure, less common with

01:06:58.719 --> 01:07:01.139
modern plates, and the potential need for plate

01:07:01.139 --> 01:07:03.780
removal later on, which means a second operation.

01:07:04.700 --> 01:07:06.699
Reoperation rates are inherently higher with

01:07:06.699 --> 01:07:08.800
surgical treatment compared to non -operative

01:07:08.800 --> 01:07:10.860
treatment simply because of the possibility of

01:07:10.860 --> 01:07:13.739
hardware removal. What about rods or nails inside

01:07:13.739 --> 01:07:16.940
the bone? Intramedullary IM fixation is another

01:07:16.940 --> 01:07:19.599
technique. Its theoretical advantages include

01:07:19.599 --> 01:07:22.119
less soft tissue stripping, relative protection

01:07:22.119 --> 01:07:24.920
of the supraclavicular nerves, smaller incisions,

01:07:25.219 --> 01:07:28.500
and potentially shorter operating times. Historically,

01:07:28.780 --> 01:07:31.300
rigid pins or nails were used but were largely

01:07:31.300 --> 01:07:34.079
abandoned due to serious complications, including

01:07:34.079 --> 01:07:37.219
intra -thoracic migration. Modern techniques

01:07:37.219 --> 01:07:40.480
use elastic titanium nails, like ten nails, which

01:07:40.480 --> 01:07:42.559
provide a three -point fixation within the bone

01:07:42.559 --> 01:07:45.179
medulla and allow the fracture to heal primarily

01:07:45.179 --> 01:07:48.280
by callus formation. While potentially offering

01:07:48.280 --> 01:07:51.079
a rapid return to sport for some athletes, these

01:07:51.079 --> 01:07:53.800
nails are axially and rotationally less stable

01:07:53.800 --> 01:07:56.179
than clade fixation and significantly weaker

01:07:56.179 --> 01:07:59.139
biomechanically. They are generally not suitable

01:07:59.139 --> 01:08:01.780
for highly committed fractures and usually require

01:08:01.780 --> 01:08:04.420
removal once the fracture has healed. Beyond

01:08:04.420 --> 01:08:06.440
the initial healing phase, what are the long

01:08:06.440 --> 01:08:08.599
-term complications clinicians should be vigilant

01:08:08.599 --> 01:08:11.139
for with clavicle fractures, especially non -union

01:08:11.139 --> 01:08:13.780
and malunion? How do these complications impact

01:08:13.780 --> 01:08:15.679
an athlete's function and potentially their career?

01:08:15.869 --> 01:08:18.409
Long -term complications are indeed a significant

01:08:18.409 --> 01:08:20.789
concern, especially for high -demand individuals

01:08:20.789 --> 01:08:23.770
like athletes. While historically believed to

01:08:23.770 --> 01:08:26.909
be low, the non -union rate for displaced mid

01:08:26.909 --> 01:08:29.829
-shaft clavicle fractures treated non -operatively

01:08:29.829 --> 01:08:32.689
is now recognized as being significant, around

01:08:32.689 --> 01:08:36.369
15 .1 % in some meta -analyses compared to just

01:08:36.369 --> 01:08:39.050
2 .2 % in operatively treated fractures. And

01:08:39.050 --> 01:08:42.770
the risk factors are displacement, Yes. Risk

01:08:42.770 --> 01:08:44.989
factors for non -union include increasing age,

01:08:45.310 --> 01:08:47.609
female sex, initial shortening greater than two

01:08:47.609 --> 01:08:49.729
centimeters, complete fracture displacement,

01:08:50.270 --> 01:08:52.989
smoking, and significant combination. Non -union

01:08:52.989 --> 01:08:54.970
typically results from a failure of mechanical

01:08:54.970 --> 01:08:56.670
stability, too much movement at the fracture

01:08:56.670 --> 01:08:58.770
site, which prevents the conversion of soft callus

01:08:58.770 --> 01:09:01.329
to hard bone. Management of an established non

01:09:01.329 --> 01:09:03.829
-union requires achieving rigid fixation, usually

01:09:03.829 --> 01:09:06.449
with plate fixation, and often providing biological

01:09:06.449 --> 01:09:09.149
stimulation, for example, through judit decortication,

01:09:09.590 --> 01:09:11.430
drilling the medullary canals, or adding bone

01:09:11.430 --> 01:09:13.930
graft. Plate fixation offers reliable results

01:09:13.930 --> 01:09:16.189
with high union rates for non -unions. What about

01:09:16.189 --> 01:09:19.029
malunion, healing in the wrong position? Malunion,

01:09:19.310 --> 01:09:22.010
or healing with significant shortening or angulation,

01:09:22.489 --> 01:09:24.909
was previously considered primarily a cosmetic

01:09:24.909 --> 01:09:28.260
concern with good functional tolerance. However,

01:09:28.779 --> 01:09:31.079
more recent patient -reported outcome measures

01:09:31.079 --> 01:09:33.680
clearly show that significant malignans can cause

01:09:33.680 --> 01:09:36.600
persistent pain, a subjective loss of strength,

01:09:37.340 --> 01:09:39.359
rapid fatigue ability during overhead activities,

01:09:39.960 --> 01:09:42.819
and cosmetic concerns. How does it affect the

01:09:42.819 --> 01:09:45.260
biomechanics? The biomechanical consequences

01:09:45.260 --> 01:09:48.260
are quite profound. Shortening a rotational deformity

01:09:48.260 --> 01:09:50.560
of the clavicle's lever arm leads to a relative

01:09:50.560 --> 01:09:53.079
scapular protraction, altering the orientation

01:09:53.079 --> 01:09:55.319
of the glenoid and potentially causing scapular

01:09:55.319 --> 01:09:58.739
winging or abnormal scapulothoracic rhythm. This

01:09:58.739 --> 01:10:00.699
can decrease the resting tension of the shoulder

01:10:00.699 --> 01:10:03.060
girdle muscles, alter the force balance around

01:10:03.060 --> 01:10:05.300
the shoulder, leading to perceived weakness and

01:10:05.300 --> 01:10:07.699
decreased endurance, particularly affecting overhead

01:10:07.699 --> 01:10:09.739
activities which are critical for many athletes.

01:10:10.000 --> 01:10:12.500
Melunion has also been linked to symptomatic

01:10:12.500 --> 01:10:15.119
arthrosis, developing later at the AC and SC

01:10:15.119 --> 01:10:17.659
joints, and sometimes neurovascular problems

01:10:17.659 --> 01:10:20.539
or thoracic outlet syndrome due to bony encroachment

01:10:20.539 --> 01:10:22.779
on the brachial plexus or subclavian vessels.

01:10:23.420 --> 01:10:25.279
This could be especially profound in overhead

01:10:25.279 --> 01:10:28.319
athletes. Can Melunion be treated? Treatment

01:10:28.319 --> 01:10:30.279
for symptomatic Melunion typically starts with

01:10:30.279 --> 01:10:32.939
targeted physiotherapy focusing on scapular control

01:10:32.939 --> 01:10:36.050
and strengthening. If symptoms persist, despite

01:10:36.050 --> 01:10:38.529
this, surgical corrective osteotomy, essentially

01:10:38.529 --> 01:10:40.689
re -breaking the bone, restoring its length and

01:10:40.689 --> 01:10:43.090
alignment, and fixing it with a plate, can be

01:10:43.090 --> 01:10:45.270
considered after thorough preoperative planning,

01:10:45.829 --> 01:10:48.569
often involving CT scans and potentially 3D modeling.

01:10:49.189 --> 01:10:51.130
What about fractures at the ends of the clavicle?

01:10:51.550 --> 01:10:54.310
Briefly, lateral third fractures near the AC

01:10:54.310 --> 01:10:56.710
joint are classified based on their relationship

01:10:56.710 --> 01:10:59.989
to the corcaclavicular ligaments. Displacement

01:10:59.989 --> 01:11:02.470
occurs if these ligaments are torn, leading to

01:11:02.470 --> 01:11:06.270
high non -union rates, perhaps 22 -44 % non -operatively

01:11:06.270 --> 01:11:09.270
for unstable types. Undisplaced fractures are

01:11:09.270 --> 01:11:11.970
treated non -operatively while displaced. Unsafe

01:11:11.970 --> 01:11:14.149
fractures often require surgical intervention

01:11:14.149 --> 01:11:16.850
using various techniques like hook plates, distal

01:11:16.850 --> 01:11:19.649
clavicle plates, or CC ligament reconstruction

01:11:19.649 --> 01:11:22.890
augmentation. Medial third fractures near the

01:11:22.890 --> 01:11:25.430
SC joint are rare. less than 5 % of clavicle

01:11:25.430 --> 01:11:27.569
fractures, and due to the strong surrounding

01:11:27.569 --> 01:11:30.369
ligamentous structures, rarely displaced significantly.

01:11:31.029 --> 01:11:33.850
Most are treated conservatively. Displaced fractures

01:11:33.850 --> 01:11:35.869
require careful neurovascular assessment due

01:11:35.869 --> 01:11:38.590
to the close proximity of vital structures posteriorly.

01:11:38.930 --> 01:11:41.289
Expeditious reduction, potentially open, in a

01:11:41.289 --> 01:11:43.710
setting with vascular or thoracic surgical expertise

01:11:43.710 --> 01:11:46.069
available is crucial, if any compromise is evident.

01:11:46.250 --> 01:11:48.449
So pulling it all together for the high -performing

01:11:48.449 --> 01:11:50.569
athlete, when is surgical intervention truly

01:11:50.569 --> 01:11:52.689
indicated for a clavicle fracture to safeguard

01:11:52.689 --> 01:11:55.069
their career and functional longevity? It's a

01:11:55.069 --> 01:11:57.850
synthesis of all those factors. For young, high

01:11:57.850 --> 01:11:59.989
-demand athletes, particularly those whose sports

01:11:59.989 --> 01:12:02.449
demand repetitive or forceful overhead activity,

01:12:03.170 --> 01:12:05.770
non -union and significant malunion, especially

01:12:05.770 --> 01:12:08.409
two -centimeter shortening, are generally poorly

01:12:08.409 --> 01:12:11.170
tolerated and can be career limiting due to the

01:12:11.170 --> 01:12:13.750
functional deficits we discussed, pain, weakness,

01:12:14.250 --> 01:12:17.949
fatigue, altered mechanics. Therefore, for athletes

01:12:17.949 --> 01:12:20.350
presenting with significantly displaced, shortened,

01:12:20.550 --> 01:12:23.609
or segmental mid -shaft clavicle fractures, early

01:12:23.609 --> 01:12:26.029
operative fixation is often the preferred strategy.

01:12:26.279 --> 01:12:28.500
The goal here is to facilitate a predictable

01:12:28.500 --> 01:12:31.140
union, restore normal anatomy, and allow for

01:12:31.140 --> 01:12:33.539
an early, high -quality recovery, maximizing

01:12:33.539 --> 01:12:35.260
their chances of returning to peak performance

01:12:35.260 --> 01:12:37.680
and preserving their athletic careers. It's about

01:12:37.680 --> 01:12:39.960
minimizing the risk of those long -term complications.

01:12:40.520 --> 01:12:43.699
5 .2 pectoralis major ruptures. The power lifter's

01:12:43.699 --> 01:12:47.199
scourge. Okay, from bone to the sheer power of

01:12:47.199 --> 01:12:50.079
muscle. Let's turn our attention now to the pectoralis

01:12:50.079 --> 01:12:52.479
major. Ruptures of this muscle might seem a bit

01:12:52.479 --> 01:12:54.960
niche perhaps, but they are absolutely critical

01:12:54.960 --> 01:12:57.739
injuries for power athletes, aren't they? What's

01:12:57.739 --> 01:13:00.340
the classic mechanism of injury here? What are

01:13:00.340 --> 01:13:02.819
the telltale clinical signs we need for accurate

01:13:02.819 --> 01:13:06.079
diagnosis? And how does early recognition influence

01:13:06.079 --> 01:13:08.939
management and outcomes? Yes, pectoralis major,

01:13:09.180 --> 01:13:12.460
or PM, tendon ruptures predominantly occur in

01:13:12.460 --> 01:13:14.840
young adult males, typically between 20 and 40

01:13:14.840 --> 01:13:17.520
years of age, who engage in strenuous physical

01:13:17.520 --> 01:13:20.020
activity. Most classically, these ruptures happen

01:13:20.020 --> 01:13:21.979
during the eccentric phase, the lowering phase

01:13:21.979 --> 01:13:23.739
of the bench press maneuver in weight training.

01:13:24.180 --> 01:13:26.180
This is when the muscle is eccentrically loaded

01:13:26.180 --> 01:13:28.800
while in extension and abduction. So the muscle

01:13:28.800 --> 01:13:31.260
is lengthening under load. Exactly. That's when

01:13:31.260 --> 01:13:34.100
it's most vulnerable. However, other high -demand

01:13:34.100 --> 01:13:37.260
activities, such as rugby tackling, wrestling,

01:13:37.680 --> 01:13:39.880
martial arts like jujitsu, boxing, and gymnastics,

01:13:40.319 --> 01:13:42.920
have also been reported as causes. Importantly,

01:13:43.279 --> 01:13:45.039
there appears to be an association with the use

01:13:45.039 --> 01:13:47.819
of anabolic steroids. Animal studies suggest

01:13:47.819 --> 01:13:50.600
these substances can lead to alterations in collagen

01:13:50.600 --> 01:13:52.779
structure, making tendons potentially weaker

01:13:52.779 --> 01:13:55.439
or more brittle, and cause disproportionate increases

01:13:55.439 --> 01:13:57.500
in muscle strength relative to tendon strength,

01:13:58.000 --> 01:13:59.899
effectively lowering the stress required to cause

01:13:59.899 --> 01:14:02.579
a rupture. Interesting. Can you remind us of

01:14:02.579 --> 01:14:06.539
the anatomy and function? Certainly. The pectoralis

01:14:06.539 --> 01:14:09.699
major muscle comprises two main heads, a clavicular

01:14:09.699 --> 01:14:13.119
head, up apart, and a larger sternal head. lower

01:14:13.119 --> 01:14:15.720
part arising from the ribcage sternum and external

01:14:15.720 --> 01:14:18.979
oblique aponeurosis. These heads merge laterally

01:14:18.979 --> 01:14:21.920
to form a broad, flat tendon that twists on itself

01:14:21.920 --> 01:14:24.000
and inserts into the lateral lip of the occipital

01:14:24.000 --> 01:14:26.979
groove on the proximal humeral shaft. Functionally,

01:14:27.300 --> 01:14:29.420
the pectoralis major is a powerful adductor,

01:14:29.920 --> 01:14:32.500
an internal rotator of the arm, with the clavicular

01:14:32.500 --> 01:14:35.060
head contributing to forward flexion. While it

01:14:35.060 --> 01:14:37.239
might not be essential for mundane daily activities,

01:14:37.739 --> 01:14:39.859
it is an absolute necessity for maximal power

01:14:39.859 --> 01:14:42.119
production in strenuous and sporting endeavors.

01:14:42.739 --> 01:14:45.060
As mentioned, the muscle is under maximum stress

01:14:45.060 --> 01:14:47.399
when eccentrically loaded in extension and abduction,

01:14:48.020 --> 01:14:49.619
and it's typically the lower sternal segments

01:14:49.619 --> 01:14:51.899
that tend to fail first in a predictable sequence,

01:14:52.340 --> 01:14:54.479
often tearing off the humerus. How do patients

01:14:54.479 --> 01:14:57.050
usually present it? Is it obvious? Patients typically

01:14:57.050 --> 01:14:59.369
present early and can often recall the exact

01:14:59.369 --> 01:15:02.390
mechanism and time of injury quite vividly. They

01:15:02.390 --> 01:15:05.029
frequently describe hearing or feeling a distinct

01:15:05.029 --> 01:15:08.729
snap or pop at the time of rupture. However,

01:15:08.930 --> 01:15:11.409
despite this clear history, the diagnosis can

01:15:11.409 --> 01:15:13.590
sometimes still be missed initially, perhaps

01:15:13.590 --> 01:15:16.029
mistaken for a simple strain leading to delayed

01:15:16.029 --> 01:15:18.250
presentation for specialist treatment. What are

01:15:18.250 --> 01:15:21.329
the key signs on examination? In the acute setting,

01:15:21.810 --> 01:15:23.729
physical examination usually reveals varying

01:15:23.729 --> 01:15:27.000
degrees of swelling and bruising ecomosis, over

01:15:27.000 --> 01:15:29.399
the upper arm and chest wall, often tracking

01:15:29.399 --> 01:15:32.359
down the arm. Crucially, in both acute and chronic

01:15:32.359 --> 01:15:35.079
settings, several pathognomonic features are

01:15:35.079 --> 01:15:37.420
usually evident when compared carefully to the

01:15:37.420 --> 01:15:40.140
contralateral, uninjured side. There might be

01:15:40.140 --> 01:15:42.699
a visible or palpable defect. a dropped nipple

01:15:42.699 --> 01:15:45.300
sign on the affected side, a medially retracted

01:15:45.300 --> 01:15:47.439
pectoralis muscle belly, especially when contracting

01:15:47.439 --> 01:15:49.840
the muscle, and a noticeable loss of the sharp

01:15:49.840 --> 01:15:52.279
definition of the anterior axillary fold. How

01:15:52.279 --> 01:15:54.800
can you accentuate these signs? These features

01:15:54.800 --> 01:15:57.399
can often be accentuated by passively abducting

01:15:57.399 --> 01:16:00.420
the arm or, more effectively, with attempted

01:16:00.420 --> 01:16:03.399
resistive deduction or internal rotation, asking

01:16:03.399 --> 01:16:05.300
the patient to push their hand inwards against

01:16:05.300 --> 01:16:08.500
resistance. It's worth noting that partial tears

01:16:08.500 --> 01:16:10.520
may not present with all these signs so clearly,

01:16:11.220 --> 01:16:13.340
and acute swelling can sometimes obscure some

01:16:13.340 --> 01:16:16.119
findings, necessitating a high index of suspicion,

01:16:16.380 --> 01:16:20.760
especially with the typical history. While ultrasound

01:16:20.760 --> 01:16:23.159
can be a useful dynamic adjunct, particularly

01:16:23.159 --> 01:16:26.619
in experienced hands, magnetic resonance imaging,

01:16:26.899 --> 01:16:29.619
MRI, is generally considered the preferred imaging

01:16:29.619 --> 01:16:33.100
modality. MRI not only confirms the diagnosis,

01:16:33.199 --> 01:16:35.579
but provides vital information for surgical planning.

01:16:35.689 --> 01:16:38.189
It can show the precise location of the tear,

01:16:38.550 --> 01:16:41.050
tendon off bone, musculatendinous junction, or

01:16:41.050 --> 01:16:43.369
intramuscular, the degree of tendon retraction,

01:16:43.890 --> 01:16:45.890
the quality of the remaining tissue, and the

01:16:45.890 --> 01:16:48.050
presence of any intact portions of the tendon

01:16:48.050 --> 01:16:50.489
and partial tears. It is important, however,

01:16:50.810 --> 01:16:53.569
to specifically request a dedicated MRI sequence

01:16:53.569 --> 01:16:56.590
that visualizes the entire pectoralis major muscle

01:16:56.590 --> 01:16:59.210
and tendon as a standard shoulder MRI sequence

01:16:59.210 --> 01:17:01.710
focusing only on the glenohumeral joint might

01:17:01.710 --> 01:17:03.729
miss the injury or not show its full extent.

01:17:03.819 --> 01:17:05.960
So what's the optimal management for these tears

01:17:05.960 --> 01:17:07.920
and athletes? Is surgery usually recommended?

01:17:08.140 --> 01:17:10.060
And what are the long -term prospects for them

01:17:10.060 --> 01:17:11.920
getting back to sport and regaining their pre

01:17:11.920 --> 01:17:14.619
-injury power levels? The key factors determining

01:17:14.619 --> 01:17:16.819
the most appropriate management and the subsequent

01:17:16.819 --> 01:17:19.100
outcome really are the patient's age and activity

01:17:19.100 --> 01:17:21.720
level, the chronicity of the injury, how long

01:17:21.720 --> 01:17:24.380
ago it happened, and the precise location and

01:17:24.380 --> 01:17:26.840
extent of the tear along the muscle tendon unit.

01:17:27.119 --> 01:17:29.760
Who gets non -operative treatment? Non -operative

01:17:29.760 --> 01:17:32.890
management is primarily reserved for frail, elderly

01:17:32.890 --> 01:17:35.970
patients with a very sedentary lifestyle, or

01:17:35.970 --> 01:17:39.170
perhaps for very partial tears with minimal symptoms

01:17:39.170 --> 01:17:42.350
in lower demand individuals. It often results

01:17:42.350 --> 01:17:45.229
in acceptable functional outcomes in this specific

01:17:45.229 --> 01:17:48.649
low demand population. But for athletes? For

01:17:48.649 --> 01:17:50.949
young, active, and high demand patients, which

01:17:50.949 --> 01:17:52.949
includes virtually all competitive athletes,

01:17:53.550 --> 01:17:55.510
surgical repair is unequivocally the treatment

01:17:55.510 --> 01:17:58.420
of choice. This consistently yields the best

01:17:58.420 --> 01:18:01.439
long -term outcomes and demonstrably superior

01:18:01.439 --> 01:18:03.479
functional results, particularly regarding strength

01:18:03.479 --> 01:18:05.699
and power compared to non -operative treatment.

01:18:06.399 --> 01:18:08.319
The best outcomes with the highest chance of

01:18:08.319 --> 01:18:10.800
restoring near -normal anatomy and function are

01:18:10.800 --> 01:18:13.659
achieved with early direct surgical repair, preferably

01:18:13.659 --> 01:18:16.560
within the first few weeks of injury before significant

01:18:16.560 --> 01:18:19.449
tendon retraction and scarring occur. Can surgery

01:18:19.449 --> 01:18:22.210
still be done later if the diagnosis was missed?

01:18:22.550 --> 01:18:25.149
Yes, surgery can still be considered and often

01:18:25.149 --> 01:18:27.569
yields good results even in selected cases where

01:18:27.569 --> 01:18:30.250
diagnosis has been delayed or even in long -standing

01:18:30.250 --> 01:18:32.710
chronic cases particularly if the athlete has

01:18:32.710 --> 01:18:35.149
a significant functional deficit or ongoing pain.

01:18:35.319 --> 01:18:38.319
A direct repair back to the bone is usually possible

01:18:38.319 --> 01:18:40.600
using various fixation techniques, including

01:18:40.600 --> 01:18:43.699
suture anchors, cortical buttons, or transosseous

01:18:43.699 --> 01:18:46.539
sutures through drill holes in the humerus. Currently,

01:18:46.739 --> 01:18:48.819
no single technique has been clearly shown to

01:18:48.819 --> 01:18:51.880
be definitively superior to others. In chronic

01:18:51.880 --> 01:18:54.140
settings where direct repair is impossible due

01:18:54.140 --> 01:18:56.460
to excessive retraction or poor tissue quality,

01:18:57.000 --> 01:18:59.100
additional releases or grafting techniques using

01:18:59.100 --> 01:19:01.699
allograft or autograft tendon may be employed

01:19:01.699 --> 01:19:04.340
to bridge the gap. What's the rehab like after

01:19:04.340 --> 01:19:07.020
surgery? Postoperative rehabilitation involves

01:19:07.020 --> 01:19:09.460
an initial period of rest and protection, typically

01:19:09.460 --> 01:19:12.100
in a sling, often for three to six weeks, depending

01:19:12.100 --> 01:19:15.220
on the repair security. Active hand, wrist, and

01:19:15.220 --> 01:19:17.420
elbow exercises are usually allowed immediately.

01:19:18.039 --> 01:19:20.420
Early controlled passive or active assisted range

01:19:20.420 --> 01:19:22.600
of motion for the shoulder is often initiated

01:19:22.600 --> 01:19:25.640
within a safe range determined at surgery, with

01:19:25.640 --> 01:19:27.760
movements like external rotation and abduction

01:19:27.760 --> 01:19:30.840
generally avoided or limited initially to protect

01:19:30.840 --> 01:19:34.239
the repair. The sling is gradually weaned off,

01:19:34.380 --> 01:19:36.380
followed by a structured progression aimed at

01:19:36.380 --> 01:19:39.100
restoring active motion, then strength, and finally

01:19:39.100 --> 01:19:42.140
power. And the return to sport. Return to sports

01:19:42.140 --> 01:19:44.460
and unrestricted activity, including heavy lifting

01:19:44.460 --> 01:19:46.880
and contact, is usually achieved somewhere between

01:19:46.880 --> 01:19:48.680
three to six months from the time of surgery,

01:19:49.159 --> 01:19:50.979
though some protocols might extend this further

01:19:50.979 --> 01:19:53.680
for maximal strength activities. High return

01:19:53.680 --> 01:19:56.119
to sport rates are generally reported after successful

01:19:56.119 --> 01:19:58.520
surgical repair, underscoring the effectiveness

01:19:58.520 --> 01:20:00.640
of this approach for maintaining an athletic

01:20:00.640 --> 01:20:03.020
career that relies on upper body power. Okay,

01:20:03.199 --> 01:20:06.300
moving beyond acute injuries now, let's consider

01:20:06.300 --> 01:20:09.359
the long game. The cumulative, relentless toll

01:20:09.359 --> 01:20:12.840
of high -level sport can, unfortunately, lead

01:20:12.840 --> 01:20:15.300
to degenerative conditions like glenohumeral

01:20:15.300 --> 01:20:18.060
arthritis. This can be absolutely devastating

01:20:18.060 --> 01:20:20.279
for an athlete's career, potentially ending it

01:20:20.279 --> 01:20:23.340
prematurely. How exactly does arthritis tend

01:20:23.340 --> 01:20:25.880
to develop in this unique, high -demand population?

01:20:26.420 --> 01:20:29.119
And what are the often subtle diagnostic clues

01:20:29.119 --> 01:20:31.720
that clinicians might inadvertently miss, possibly

01:20:31.720 --> 01:20:52.279
leading to delayed treatment? For athletes, the

01:20:52.279 --> 01:20:54.359
primary aim of management when arthritis develops

01:20:54.359 --> 01:20:56.579
is generally to maximize function and performance

01:20:56.579 --> 01:20:58.579
while prolonging their careers for as long as

01:20:58.579 --> 01:21:00.899
safely possible. Is it the same type of arthritis

01:21:00.899 --> 01:21:03.739
we see in the general older population? Not usually.

01:21:04.279 --> 01:21:08.000
When we look at the etiology, primary osteoarthritis...

01:21:07.819 --> 01:21:10.399
The wear and tear type, with no obvious preceding

01:21:10.399 --> 01:21:12.600
cause, while it certainly occurs in older or

01:21:12.600 --> 01:21:15.020
lower demand individuals, is actually relatively

01:21:15.020 --> 01:21:18.060
rare in younger, high -level athletes. Its precise

01:21:18.060 --> 01:21:20.739
etiology in this specific group remains somewhat

01:21:20.739 --> 01:21:23.800
unclear. Interestingly, rotator cuff cares are

01:21:23.800 --> 01:21:26.420
uncommon in primary glenohumeral arthritis, unlike

01:21:26.420 --> 01:21:28.819
in the hip or knee. Secondary arthritis, however,

01:21:28.899 --> 01:21:30.520
is the predominant form we see in the athletic

01:21:30.520 --> 01:21:33.119
population. This stems from symptomatic chondral

01:21:33.119 --> 01:21:35.079
damage that occurs secondary to other problems,

01:21:35.520 --> 01:21:38.180
particularly trauma and most commonly acute or

01:21:38.180 --> 01:21:40.600
recurrent instability. So instability is a big

01:21:40.600 --> 01:21:43.699
risk factor. A huge risk factor. Patients who

01:21:43.699 --> 01:21:46.119
have suffered even a single shoulder dislocation

01:21:46.119 --> 01:21:49.140
have up to a 20 times greater risk of developing

01:21:49.140 --> 01:21:51.859
glenohumeral arthritis later in life compared

01:21:51.859 --> 01:21:54.590
to the general population. Repetitive overhead

01:21:54.590 --> 01:21:57.090
activities like those in the dominant arms of

01:21:57.090 --> 01:21:59.810
tennis players or throwing athletes often lead

01:21:59.810 --> 01:22:02.149
to conditions like internal impingement, which

01:22:02.149 --> 01:22:04.850
is associated with occult or hidden chondral

01:22:04.850 --> 01:22:07.369
trauma that can predispose to arthritis over

01:22:07.369 --> 01:22:11.369
time. Other less common causes include osteonecrosis,

01:22:11.560 --> 01:22:14.659
of vascular necrosis, osteochondritis dissecans,

01:22:15.140 --> 01:22:17.039
or the sequelae of previous joint infection.

01:22:17.260 --> 01:22:19.479
Is there any risk from treatments themselves?

01:22:20.039 --> 01:22:22.880
Yes. A critical, albeit rare, iatrogenic cause

01:22:22.880 --> 01:22:25.779
that needs mentioning is chondrolysis rapid cartilage

01:22:25.779 --> 01:22:28.789
destruction. There was a strong association identified,

01:22:28.869 --> 01:22:31.210
particularly during the 2000s, with the use of

01:22:31.210 --> 01:22:33.810
intraarticular pain infusion pumps, delivering

01:22:33.810 --> 01:22:36.590
continuous local anesthetic, especially bupophocaine,

01:22:36.949 --> 01:22:39.329
after arthroscopic surgery. This led to fulminant

01:22:39.329 --> 01:22:41.989
chondrolysis and devastating extensive clenohumeral

01:22:41.989 --> 01:22:44.329
arthritis developing in young patients within

01:22:44.329 --> 01:22:46.210
months of their index procedure. But not from

01:22:46.210 --> 01:22:48.390
single injections. It is crucial to note that

01:22:48.390 --> 01:22:50.630
this association has not been clearly established

01:22:50.630 --> 01:22:53.329
with standard single -shot injections of local

01:22:53.329 --> 01:22:56.250
anesthetic, which are commonly and safely used.

01:22:57.010 --> 01:22:58.789
Heightened awareness of the risks associated

01:22:58.789 --> 01:23:01.470
with continuous infusion pumps should hopefully

01:23:01.470 --> 01:23:04.029
significantly reduce any future incidents of

01:23:04.029 --> 01:23:07.359
this catastrophic complication. How do we diagnose

01:23:07.359 --> 01:23:10.260
arthritis in athletes? You mentioned subtle clues.

01:23:11.079 --> 01:23:13.399
Yes. Diagnosis requires clinicians to be particularly

01:23:13.399 --> 01:23:16.100
astute because the signs and symptoms can indeed

01:23:16.100 --> 01:23:19.859
be understated or non -specific initially. The

01:23:19.859 --> 01:23:22.060
athlete with early glenohumeral arthritis may

01:23:22.060 --> 01:23:24.500
present with complaints that demand careful diagnostic

01:23:24.500 --> 01:23:26.520
assessment to pinpoint the underlying cause.

01:23:26.859 --> 01:23:29.079
There's a real risk of narrowly focusing on more

01:23:29.079 --> 01:23:31.479
common shoulder pathologies often seen in athletes,

01:23:31.739 --> 01:23:34.420
things like partial thickness, rotator cuff tears,

01:23:34.939 --> 01:23:37.760
biceps tendinopathy, subacromial bursitis, or

01:23:37.760 --> 01:23:39.659
labral tears, which can potentially delay the

01:23:39.659 --> 01:23:41.960
diagnosis and appropriate management of the underlying

01:23:41.960 --> 01:23:44.460
chondral damage, significantly impacting the

01:23:44.460 --> 01:23:46.640
athlete's career trajectory. So we need to think

01:23:46.640 --> 01:23:50.159
beyond the usual suspects. Exactly. It's crucial

01:23:50.159 --> 01:23:52.920
to actively elicit those understated symptoms,

01:23:53.380 --> 01:23:55.659
perhaps subtle episodes of instability they might

01:23:55.659 --> 01:23:58.039
downplay, or just a slightly reduced ability

01:23:58.039 --> 01:24:00.680
to undertake previously performed tasks at their

01:24:00.680 --> 01:24:04.039
usual intensity or duration. Classic symptoms

01:24:04.039 --> 01:24:06.739
of more established arthritis include night pain,

01:24:07.180 --> 01:24:09.920
often described as a deep ache associated with

01:24:09.920 --> 01:24:12.279
inability to sleep on the affected side, and

01:24:12.279 --> 01:24:14.380
mechanical symptoms like clicking, grinding,

01:24:14.720 --> 01:24:17.039
or even transient locking with sudden sharp pain

01:24:17.039 --> 01:24:19.859
that limits activity. We must also emphasize

01:24:19.859 --> 01:24:21.939
that athletes may be functionally disabled by

01:24:21.939 --> 01:24:24.399
symptoms that wouldn't necessarily significantly

01:24:24.399 --> 01:24:26.779
affect the average member of the public. They

01:24:26.779 --> 01:24:28.880
often continue to play and function at a high

01:24:28.880 --> 01:24:31.579
level, but report a gradual deterioration in

01:24:31.579 --> 01:24:33.899
their capability to perform at their expected

01:24:33.899 --> 01:24:36.720
peak level. That subtle decline can be the first

01:24:36.720 --> 01:24:39.100
sign. What about the physical exam? Physical

01:24:39.100 --> 01:24:41.979
examination findings to look for include periscapular

01:24:41.979 --> 01:24:45.319
muscle wasting due to disuse or pain inhibition

01:24:45.319 --> 01:24:47.899
and crepitus during movement. which may be audible

01:24:47.899 --> 01:24:50.960
or just palpable by the examiner. The joint line

01:24:50.960 --> 01:24:54.000
itself may be painful on palpation, with posterior

01:24:54.000 --> 01:24:56.960
joint line tenderness often cited as a more specific,

01:24:57.359 --> 01:24:59.500
though not definitive, sign of underlying caudal

01:24:59.500 --> 01:25:02.140
damage. Range of motion restriction, particularly

01:25:02.140 --> 01:25:05.020
a loss of external rotation, both active and

01:25:05.020 --> 01:25:07.479
passive, and a painful arc of motion are also

01:25:07.479 --> 01:25:10.380
common findings. And imaging. How useful is MRA

01:25:10.380 --> 01:25:12.760
here? For imaging, standard radiographs are the

01:25:12.760 --> 01:25:15.500
essential initial investigation. AP radiographs

01:25:15.500 --> 01:25:17.260
are used to describe the degree of arthritis

01:25:17.260 --> 01:25:20.020
reliably using classifications like the Samuelson

01:25:20.020 --> 01:25:22.220
and Pareto classification, which categorizes

01:25:22.220 --> 01:25:24.500
patients into mild, moderate, and severe based

01:25:24.500 --> 01:25:27.439
on osteophyte size, glenohumeral joint space

01:25:27.439 --> 01:25:31.140
narrowing, and surface irregularity. While MRI

01:25:31.140 --> 01:25:33.720
and CT scans also play a role, their limitations

01:25:33.720 --> 01:25:36.600
in this context are key. Chondral surfaces in

01:25:36.600 --> 01:25:38.340
the glenohumeral joint are much thinner, around

01:25:38.340 --> 01:25:40.300
1 .5 millimeters on average, compared to the

01:25:40.300 --> 01:25:42.970
knee, which can be up to 10 millimeter. This

01:25:42.970 --> 01:25:45.409
makes visualizing subtle early chondral lesions

01:25:45.409 --> 01:25:48.069
challenging. Magnetic resonance imaging, MRI,

01:25:48.310 --> 01:25:50.449
scanning for arthritis, even with specialized

01:25:50.449 --> 01:25:53.470
cartilage sequences or FRN arthrography, actually

01:25:53.470 --> 01:25:55.649
lacks sensitivity and specificity for detecting

01:25:55.649 --> 01:25:57.449
these subtle early chondral lesions reliably.

01:25:57.930 --> 01:25:59.789
However, more profound full -thickness chondral

01:25:59.789 --> 01:26:02.239
loss is more easily evident. Computed tomography

01:26:02.239 --> 01:26:04.520
CT scans are particularly helpful for quantifying

01:26:04.520 --> 01:26:07.020
glenoid bone loss or wear patterns, especially

01:26:07.020 --> 01:26:08.859
if there are metal artifacts from previous surgery

01:26:08.859 --> 01:26:12.039
obscuring MRI, and 2D -3D reconstructions can

01:26:12.039 --> 01:26:14.039
assist with exact localization of osteophytes

01:26:14.039 --> 01:26:16.579
or loose bodies. So if imaging is limited for

01:26:16.579 --> 01:26:19.460
early stages, what's the gold standard? Due to

01:26:19.460 --> 01:26:22.000
these inherent limitations of non -invasive imaging

01:26:22.000 --> 01:26:25.319
modalities in accurately diagnosing subtle chondral

01:26:25.319 --> 01:26:28.000
damage, diagnostic arthroscopy unfortunately

01:26:28.000 --> 01:26:30.359
remains the gold standard for definitive diagnosis

01:26:30.359 --> 01:26:32.739
and staging, particularly in joints like the

01:26:32.739 --> 01:26:35.439
shoulder with inherently thinner articular cartilage

01:26:35.439 --> 01:26:38.600
layers. It allows direct visualization and probing

01:26:38.600 --> 01:26:42.319
of the cartilage surfaces. 6 .2 management strategies.

01:26:42.800 --> 01:26:45.350
Career -focused approaches. When we approach

01:26:45.350 --> 01:26:47.989
the management of an athlete grappling with glenohumeral

01:26:47.989 --> 01:26:50.369
arthritis, the objective, as you said, isn't

01:26:50.369 --> 01:26:53.470
merely to reduce pain. It's intricately woven

01:26:53.470 --> 01:26:56.829
with preserving their career, if possible. How

01:26:56.829 --> 01:26:59.210
do we strategically stratify treatment options?

01:26:59.689 --> 01:27:02.109
What are the specific nuances within each category,

01:27:02.470 --> 01:27:04.529
ranging from maintaining function to salvaging

01:27:04.529 --> 01:27:06.989
what's possible and ultimately facing those difficult

01:27:06.989 --> 01:27:09.369
career -ending decisions? This really requires

01:27:09.369 --> 01:27:12.109
a truly athlete -centered approach. because the

01:27:12.109 --> 01:27:14.310
principles and goals of managing glenohumeral

01:27:14.310 --> 01:27:17.010
arthritis in athletes are fundamentally different

01:27:17.010 --> 01:27:19.630
from those in the general older patient population.

01:27:20.909 --> 01:27:23.310
The professional athlete's primary aim is generally

01:27:23.310 --> 01:27:25.390
to maintain a career at the highest possible

01:27:25.390 --> 01:27:28.500
level for as long as possible. whereas recreational

01:27:28.500 --> 01:27:30.939
athletes may accept modifying their activities

01:27:30.939 --> 01:27:33.920
or lowering their participation level. Therefore,

01:27:34.340 --> 01:27:36.420
a solid understanding and appropriate management

01:27:36.420 --> 01:27:39.479
of the patient's specific aims, goals, and expectations

01:27:39.479 --> 01:27:42.560
are absolutely critical to achieving a positive

01:27:42.560 --> 01:27:45.180
outcome in this challenging degenerative condition.

01:27:46.159 --> 01:27:48.100
Athletes must be educated about their condition,

01:27:48.659 --> 01:27:50.859
taught how to interpret their symptoms, and actively

01:27:50.859 --> 01:27:53.619
participate in their management plan. Treatment

01:27:53.619 --> 01:27:56.319
options can be broadly categorized as palliative,

01:27:56.680 --> 01:27:58.960
reparative, restorative, and reconstructive.

01:27:59.359 --> 01:28:01.479
Let's start with options aiming to maintain their

01:28:01.479 --> 01:28:04.020
career. Okay. Career -maintaining options are

01:28:04.020 --> 01:28:06.300
generally appropriate for athletes with early

01:28:06.300 --> 01:28:08.979
or moderate stage arthritis who are aiming to

01:28:08.979 --> 01:28:10.920
continue performing at the highest possible level.

01:28:11.680 --> 01:28:13.859
The objective here is to mitigate symptoms that

01:28:13.859 --> 01:28:16.560
limit high -level function. These options are

01:28:16.560 --> 01:28:18.680
generally less invasive with lower morbidity

01:28:18.680 --> 01:28:21.180
and often achieve successful short to medium

01:28:21.180 --> 01:28:23.420
-term outcomes, though the underlying natural

01:28:23.420 --> 01:28:25.579
history of arthritis will ultimately determine

01:28:25.579 --> 01:28:28.000
longer -term career impacts. For professional

01:28:28.000 --> 01:28:30.039
athletes, awareness of the World Anti -Doping

01:28:30.039 --> 01:28:33.800
Agency, WADA, regarding allowed medications is,

01:28:33.800 --> 01:28:36.399
of course, essential. What does non -operative

01:28:36.399 --> 01:28:38.479
management involve here? First -line therapy

01:28:38.479 --> 01:28:40.840
includes activity modification, which might mean

01:28:40.840 --> 01:28:43.439
adjusting training load or technique rather than

01:28:43.439 --> 01:28:45.720
stopping completely, and the use of appropriate

01:28:45.720 --> 01:28:49.100
non -steroidal anti -inflammatory drugs, NSAIs,

01:28:49.420 --> 01:28:51.399
to decrease inflammation and improve function

01:28:51.399 --> 01:28:53.720
within WADA limits, if applicable. What about

01:28:53.720 --> 01:28:57.640
injections? Steroids, PRP. Injections, such as

01:28:57.640 --> 01:29:00.800
corticosteroids, hyaluronic acid, viscose supplementation,

01:29:01.239 --> 01:29:04.119
and platelet -rich plasma, PRP, can potentially

01:29:04.119 --> 01:29:06.699
provide short -term pain relief and can also

01:29:06.699 --> 01:29:09.239
act as a diagnostic tool, confirming the joint

01:29:09.239 --> 01:29:12.439
as the pain source. Crucially, injections must

01:29:12.439 --> 01:29:15.000
be performed under sterile conditions, ideally

01:29:15.000 --> 01:29:17.619
with fluoroscopic or ultrasound guidance, to

01:29:17.619 --> 01:29:20.829
ensure accurate intraarticular placement. And

01:29:20.829 --> 01:29:23.050
perhaps most importantly, injections should never

01:29:23.050 --> 01:29:25.649
be used simply as short -term solutions to get

01:29:25.649 --> 01:29:28.859
an athlete. through game or competition. This

01:29:28.859 --> 01:29:30.880
approach can have devastating consequences by

01:29:30.880 --> 01:29:33.279
masking pain, the body's protective mechanism,

01:29:33.619 --> 01:29:36.220
potentially leading to accelerated chondral degeneration.

01:29:36.779 --> 01:29:38.800
Corticosteroids themselves can also suppress

01:29:38.800 --> 01:29:41.600
collagen synthesis. So what is the goal of injections,

01:29:41.800 --> 01:29:43.739
then? The objective should be to provide temporary

01:29:43.739 --> 01:29:46.020
dampening of synovitis and pain to allow the

01:29:46.020 --> 01:29:48.000
athlete to engage more effectively in a structured

01:29:48.000 --> 01:29:50.520
strengthening and rehabilitation program, not

01:29:50.520 --> 01:29:52.659
to enable an immediate return to high impact

01:29:52.659 --> 01:29:54.939
activity while the joint is still inflamed or

01:29:54.939 --> 01:29:58.970
unstable. and physiotherapy, still core. Physiotherapy

01:29:58.970 --> 01:30:01.689
forms the absolute core of non -operative treatment.

01:30:02.390 --> 01:30:05.590
It must be individualized and sport -job specific,

01:30:05.949 --> 01:30:08.470
focusing on pain reduction, maintenance of range

01:30:08.470 --> 01:30:11.430
of motion, especially combating capsular contracture,

01:30:11.890 --> 01:30:14.489
and targeted strengthening. As arthritic shoulders

01:30:14.489 --> 01:30:16.930
often develop associated scapular dyskinesis,

01:30:17.310 --> 01:30:19.689
a tailored program focusing on scapular stabilization

01:30:19.689 --> 01:30:21.909
and regaining excellent scapular humeral rhythm

01:30:21.909 --> 01:30:24.800
is paramount. This should be combined with isometric

01:30:24.800 --> 01:30:27.460
strengthening and passive stretching. Hydrotherapy

01:30:27.460 --> 01:30:29.880
can also play a key role due to water's buoyancy

01:30:29.880 --> 01:30:32.060
and resistance properties. What if non -operative

01:30:32.060 --> 01:30:34.420
measures aren't enough? Arthroscopy. Yes, in

01:30:34.420 --> 01:30:36.319
patients with earlier stage disease who fail

01:30:36.319 --> 01:30:38.880
conservative measures, arthroscopic debridement

01:30:38.880 --> 01:30:41.539
and chondroplasty can be considered. This involves

01:30:41.539 --> 01:30:44.000
smoothing down unstable chondral flaps or frayed

01:30:44.000 --> 01:30:46.060
cartilage, which are thought to be pain generators.

01:30:46.819 --> 01:30:48.380
Best outcomes are generally seen in patients

01:30:48.380 --> 01:30:50.779
with congruent joints, meaning the joint surfaces

01:30:50.779 --> 01:30:53.239
still match reasonably well, minimal osteophyte

01:30:53.239 --> 01:30:55.779
or cyst formation, and relatively shallow lesions,

01:30:55.939 --> 01:30:57.800
less than two centimeters squared, affecting

01:30:57.800 --> 01:30:59.920
only one side of the joint, usually the humeral

01:30:59.920 --> 01:31:02.659
head. Adjunctive procedures performed at the

01:31:02.659 --> 01:31:05.279
time of arthroscopy can include lavage, washing

01:31:05.279 --> 01:31:07.779
out debris and inflammatory mediators, and removal

01:31:07.779 --> 01:31:10.659
of loose bodies. As the disease progresses, anterior

01:31:10.659 --> 01:31:13.039
capsule contracture can develop, leading to decreased

01:31:13.039 --> 01:31:15.600
external rotation and increased load on the posterior

01:31:15.600 --> 01:31:18.779
chondral surfaces. More comprehensive arthroscopic

01:31:18.779 --> 01:31:20.380
procedures for advanced disease might include

01:31:20.380 --> 01:31:23.300
a full -capsular release, subacromial decompression

01:31:23.300 --> 01:31:26.199
if needed, glenohumeral chondroplasty, AC joint

01:31:26.199 --> 01:31:28.920
excision, humeral osteoplasty, reshaping bone

01:31:28.920 --> 01:31:32.180
spurs, osteophyte resection, biceps tenodesis

01:31:32.180 --> 01:31:34.840
if the biceps tendon is involved, and even axillary

01:31:34.840 --> 01:31:37.020
nerve neuralysis if nerve irritation is suspected.

01:31:37.380 --> 01:31:39.239
Some promising results have shown these more

01:31:39.239 --> 01:31:41.760
comprehensive arthroscopic approaches, sometimes

01:31:41.760 --> 01:31:43.779
termed comprehensive arthroscopic management

01:31:43.779 --> 01:31:47.199
or CAM, can potentially delay the need for arthroplasty

01:31:47.199 --> 01:31:49.760
by up to two years in around 85 % of selected

01:31:49.760 --> 01:31:52.020
patients. What about options when things are

01:31:52.020 --> 01:31:55.319
more severe? Career salvaging options. These

01:31:55.319 --> 01:31:57.420
options come into play when career maintaining

01:31:57.420 --> 01:31:59.979
strategies are becoming less successful. or for

01:31:59.979 --> 01:32:02.680
more severe or symptomatic degenerative disease.

01:32:03.220 --> 01:32:05.800
While high -impact activity might still be possible

01:32:05.800 --> 01:32:08.260
after some of these, the overall success rates

01:32:08.260 --> 01:32:10.859
in a high -load athletic environment are certainly

01:32:10.859 --> 01:32:13.840
more circumspect. Athletes' expectations must

01:32:13.840 --> 01:32:16.199
be carefully managed as they may not recover

01:32:16.199 --> 01:32:18.779
sufficient function or symptom control to return

01:32:18.779 --> 01:32:21.680
to their desired pre -injury level. What procedures

01:32:21.680 --> 01:32:24.380
fall into this category? Microfracture is one.

01:32:24.859 --> 01:32:27.319
The principle borrowed from knee surgery is to

01:32:27.319 --> 01:32:30.140
penetrate the subchondral bone plate to stimulate

01:32:30.140 --> 01:32:32.539
a healing response from the bone marrow, leading

01:32:32.539 --> 01:32:34.640
to fibrocartilage formation over the defect.

01:32:35.359 --> 01:32:37.300
It requires meticulous surgical technique and

01:32:37.300 --> 01:32:40.420
a very slow, tailored rehabilitation protocol

01:32:40.420 --> 01:32:42.619
involving restricted weight bearing or loading.

01:32:43.619 --> 01:32:45.500
While successful in the knee for certain lesions,

01:32:45.920 --> 01:32:47.680
the literature supporting its use in the shoulder

01:32:47.680 --> 01:32:50.680
is minimal. Best outcomes, anecdotally, are reported

01:32:50.680 --> 01:32:53.600
for smaller, isolated humeral -side lesions in

01:32:53.600 --> 01:32:56.199
young, active patients. A potential advantage

01:32:56.199 --> 01:32:58.380
is that it doesn't appear to compromise future

01:32:58.380 --> 01:33:00.880
reconstructive options like arthroplasty. What

01:33:00.880 --> 01:33:04.079
about grafting, like cartilage transplants? Chondral

01:33:04.079 --> 01:33:06.659
or osteochondral grafting techniques are designed

01:33:06.659 --> 01:33:09.939
for more focal chondral lesions. Modalities include

01:33:09.939 --> 01:33:12.479
osteochondral allograft transplantation, using

01:33:12.479 --> 01:33:15.579
donor tissue, primary autograft transfer, OATS

01:33:15.579 --> 01:33:17.819
procedure, taking plugs from a non -weight -bearing

01:33:17.819 --> 01:33:21.460
area, staged autologous chondrocyte implantation,

01:33:21.680 --> 01:33:23.880
ACI, growing the patient's own cartilage cells

01:33:23.880 --> 01:33:26.579
in a lab and re -implanting them, or the use

01:33:26.579 --> 01:33:28.699
of synthetic scaffolds to encourage cartilage

01:33:28.699 --> 01:33:31.079
regrowth. Osteochondral grafting for humeral

01:33:31.079 --> 01:33:33.279
head defects has theoretical advantages but can

01:33:33.279 --> 01:33:35.380
have significant donor site morbidity if using

01:33:35.380 --> 01:33:37.960
autograft or availability issues with allograft.

01:33:38.180 --> 01:33:39.779
Reports specifically in the shoulder athlete

01:33:39.779 --> 01:33:42.119
population are limited. Biological resurfacing?

01:33:42.319 --> 01:33:45.140
What's that? This involves resurfacing an arthritic

01:33:45.140 --> 01:33:48.539
glenoid surface using biological tissues instead

01:33:48.539 --> 01:33:51.319
of a plastic component. Tissues used have included

01:33:51.319 --> 01:33:54.359
enfolded anterior capsule, allografts like fascia

01:33:54.359 --> 01:33:56.880
lata or Achilles tendon, or commercially available

01:33:56.880 --> 01:34:00.600
dermal tissue matrices or biologic patches. It's

01:34:00.600 --> 01:34:03.000
designed as a potential bone preserving alternative

01:34:03.000 --> 01:34:05.680
to prosthetic glenoid replacement, particularly

01:34:05.680 --> 01:34:08.180
in younger patients. It's typically an open procedure

01:34:08.180 --> 01:34:10.239
requiring prolonged rehabilitation, although

01:34:10.239 --> 01:34:12.000
advanced arthroscopic techniques are developing.

01:34:12.300 --> 01:34:14.739
Sporadic reports looking specifically at athletes

01:34:14.739 --> 01:34:16.600
show some good outcomes in the first couple of

01:34:16.600 --> 01:34:18.960
years, but long -term durability is still under

01:34:18.960 --> 01:34:21.939
investigation. And joint fusion. Arthrodesis.

01:34:22.340 --> 01:34:25.569
Seems drastic. Arthrodesis, or surgical fusion

01:34:25.569 --> 01:34:28.449
of the glenohumeral joint, has largely been consigned

01:34:28.449 --> 01:34:30.869
to historical significance for primary glenohumeral

01:34:30.869 --> 01:34:33.449
arthritis by the success of prosthetic implants.

01:34:34.029 --> 01:34:35.850
It's now mainly reserved for situations like

01:34:35.850 --> 01:34:38.510
failed arthroplasty, deep infection, or certain

01:34:38.510 --> 01:34:41.409
neurological injuries. However, it holds a unique

01:34:41.409 --> 01:34:44.550
albeit small niche place for a very specific

01:34:44.550 --> 01:34:47.689
subgroup of athletes. Despite creating a fused,

01:34:47.949 --> 01:34:50.970
immobile glenohumeral joint, a successfully united

01:34:50.970 --> 01:34:53.210
arthrodesis does allow patients to return to

01:34:53.210 --> 01:34:55.729
almost any desired level of sport, including

01:34:55.729 --> 01:34:58.270
full impact and heavy loading, as there are no

01:34:58.270 --> 01:35:00.310
implant -related restrictions or concerns about

01:35:00.310 --> 01:35:02.840
wear or loosening. Thus, for certain patients,

01:35:03.020 --> 01:35:05.100
perhaps those involved in heavy manual labor

01:35:05.100 --> 01:35:07.899
or specific high -impact sports, especially on

01:35:07.899 --> 01:35:10.199
their non -dominant side who prioritize the ability

01:35:10.199 --> 01:35:12.399
to perform high -impact or loading activities

01:35:12.399 --> 01:35:14.220
over achieving a functional range of motion,

01:35:14.819 --> 01:35:16.699
arthrodesis should potentially be discussed as

01:35:16.699 --> 01:35:19.300
an alternative to arthroplasty. It's a tradeoff

01:35:19.300 --> 01:35:22.079
between motion and unrestricted activity. Finally,

01:35:22.239 --> 01:35:24.880
the career -ending options. Yes. Inevitably,

01:35:25.079 --> 01:35:27.340
sometimes the damage is too extensive or symptoms

01:35:27.340 --> 01:35:30.609
too severe for career preservation. Activity

01:35:30.609 --> 01:35:32.869
modification, meaning the complete cessation

01:35:32.869 --> 01:35:35.350
of the specific sporting activities that exacerbate

01:35:35.350 --> 01:35:38.289
pain, is often the first line of management advised

01:35:38.289 --> 01:35:41.069
in many patients with advanced arthritis. But

01:35:41.069 --> 01:35:43.670
for a professional or serious recreational athlete,

01:35:44.189 --> 01:35:47.079
this is often the last resort. and, by definition,

01:35:47.460 --> 01:35:49.699
a career -ending decision regarding that sport.

01:35:50.279 --> 01:35:52.220
This difficult decision is typically made due

01:35:52.220 --> 01:35:55.000
to intractable pain significantly affecting quality

01:35:55.000 --> 01:35:57.500
of life, stiffness severely limiting function

01:35:57.500 --> 01:36:00.840
and performance, or the realization, often after

01:36:00.840 --> 01:36:03.119
failed attempts at salvaging procedures, that

01:36:03.119 --> 01:36:04.960
continued high -level sporting activity will

01:36:04.960 --> 01:36:07.000
significantly compromise their long -term joint

01:36:07.000 --> 01:36:14.310
health and overall quality of life. provides

01:36:14.310 --> 01:36:16.869
the most consistently positive and reproducible

01:36:16.869 --> 01:36:19.630
outcomes for pain relief and functional improvement

01:36:19.630 --> 01:36:22.949
in older patients with advanced arthritis. Modern

01:36:22.949 --> 01:36:25.670
implants and techniques are excellent. Options

01:36:25.670 --> 01:36:28.250
include heme arthroplasty, replacing only the

01:36:28.250 --> 01:36:30.550
humal head, sometimes with reaming of the glenoid,

01:36:30.770 --> 01:36:33.189
the ream and run technique, or total shoulder

01:36:33.189 --> 01:36:36.390
arthroplasty, replacing both surfaces. Cementless

01:36:36.390 --> 01:36:38.489
resurfacing arthroplasty is another option that

01:36:38.489 --> 01:36:40.890
aims to preserve bone stock and potentially offer

01:36:40.890 --> 01:36:43.569
easier revision surgery later, which is a consideration

01:36:43.569 --> 01:36:46.470
in younger patients. While short and medium term

01:36:46.470 --> 01:36:48.510
results of arthroplasty are generally positive

01:36:48.510 --> 01:36:50.850
even for younger active patients compared to

01:36:50.850 --> 01:36:52.930
their preoperative state, this must be weighed

01:36:52.930 --> 01:36:55.109
against the generally superior overall results

01:36:55.109 --> 01:36:57.689
and longer implant survival, typically seen with

01:36:57.689 --> 01:37:00.449
stem total shoulder arthroplasty in older populations.

01:37:01.199 --> 01:37:03.699
Crucially, however, for the professional or high

01:37:03.699 --> 01:37:06.600
-level recreational athlete, prosthetic arthroplasty

01:37:06.600 --> 01:37:08.640
is realistically only an option following the

01:37:08.640 --> 01:37:10.699
end of their competitive career. A prosthetic

01:37:10.699 --> 01:37:13.140
joint simply cannot tolerate the high forces,

01:37:13.619 --> 01:37:15.720
repetitive impacts, and extreme ranges of motion

01:37:15.720 --> 01:37:18.300
required by the vast majority of upper limb athletic

01:37:18.300 --> 01:37:21.180
pursuits without risking early failure, loosening,

01:37:21.279 --> 01:37:24.539
or fracture. It demands significant permanent

01:37:24.539 --> 01:37:27.239
activity adjustment and is, by definition, a

01:37:27.239 --> 01:37:29.199
career -ending decision for these athletes regarding

01:37:29.199 --> 01:37:31.890
high impact or high -demand sports. Finally,

01:37:31.970 --> 01:37:34.130
let's talk about the ultimate objective for any

01:37:34.130 --> 01:37:36.770
injured athlete, achieving a safe, effective,

01:37:37.029 --> 01:37:39.649
and hopefully sustainable return to play. What

01:37:39.649 --> 01:37:42.010
are the core evidence -based principles guiding

01:37:42.010 --> 01:37:44.369
modern rehabilitation after shoulder injury or

01:37:44.369 --> 01:37:46.810
surgery? And crucially, how do we objectively

01:37:46.810 --> 01:37:49.590
measure readiness moving beyond just a patient

01:37:49.590 --> 01:37:51.729
feeling better to making truly robust data -driven

01:37:51.729 --> 01:37:54.050
decisions about their return? This is absolutely

01:37:54.050 --> 01:37:56.569
where the science of recovery comes in, moving

01:37:56.569 --> 01:37:59.960
beyond just letting nature take its course. Effective

01:37:59.960 --> 01:38:02.460
rehabilitation extends far beyond simple pain

01:38:02.460 --> 01:38:05.220
management and reduction of inflammation, though

01:38:05.220 --> 01:38:08.479
those are important initial steps. It must encompass

01:38:08.479 --> 01:38:10.899
the meticulous restoration of optimal muscle

01:38:10.899 --> 01:38:13.399
strength and balance around the shoulder girdle,

01:38:13.699 --> 01:38:15.920
achieving functional joint range of motion specific

01:38:15.920 --> 01:38:19.199
to the athlete's needs, and crucially, a carefully

01:38:19.199 --> 01:38:21.560
managed progression to functional movements that

01:38:21.560 --> 01:38:24.560
precisely replicate the demands of the athlete's

01:38:24.560 --> 01:38:27.359
specific sport. This entire progression from

01:38:27.359 --> 01:38:30.340
early protection to high -level function is underpinned

01:38:30.340 --> 01:38:32.699
by a fundamental requirement for meticulous joint

01:38:32.699 --> 01:38:35.859
control. This necessitates explicit attention

01:38:35.859 --> 01:38:39.020
to restoring proprioceptive awareness, ensuring

01:38:39.020 --> 01:38:41.920
dynamic stabilization from the rotator cuff and

01:38:41.920 --> 01:38:44.579
scapular muscles, developing feed -forward mechanisms

01:38:44.579 --> 01:38:46.720
through anticipatory muscle responses before

01:38:46.720 --> 01:38:49.220
movement occurs, and training reactive muscle

01:38:49.220 --> 01:38:51.739
function to cope with unexpected perturbations

01:38:51.739 --> 01:38:54.159
during athletic activity. So it's much more than

01:38:54.159 --> 01:38:57.479
just strength and flexibility. Much more. And

01:38:57.479 --> 01:39:00.140
return -to -play decisions, therefore, absolutely

01:39:00.140 --> 01:39:02.739
must be based on objective measurements and criteria,

01:39:03.300 --> 01:39:05.420
not just time elapsed or subjective feeling.

01:39:05.609 --> 01:39:09.250
This involves a thorough evaluation of the athlete's

01:39:09.250 --> 01:39:11.649
overall health status, a clear assessment of

01:39:11.649 --> 01:39:14.310
the remaining participation risk, risk of re

01:39:14.310 --> 01:39:16.750
-injury or further damage, and consideration

01:39:16.750 --> 01:39:19.289
of extrinsic factors like equipment, playing

01:39:19.289 --> 01:39:22.369
surface or game intensity. McCarty and colleagues

01:39:22.369 --> 01:39:24.850
outlined what might be considered ideal criteria

01:39:24.850 --> 01:39:27.609
for return to play following shoulder stabilization

01:39:27.609 --> 01:39:30.840
surgery, which provide a good framework. Little

01:39:30.840 --> 01:39:33.140
or no pain, the patient's subjective impression

01:39:33.140 --> 01:39:35.319
of stability, feeling confident in the shoulder,

01:39:35.840 --> 01:39:37.680
near normal range of motion compared to the other

01:39:37.680 --> 01:39:40.140
side, near normal strength, often defined as

01:39:40.140 --> 01:39:42.760
90 % of the contralateral side, demonstrated

01:39:42.760 --> 01:39:44.819
normal functional ability in sport -specific

01:39:44.819 --> 01:39:47.439
tests, and execution of normal sport -specific

01:39:47.439 --> 01:39:50.319
skills without deficit or compensation. And the

01:39:50.319 --> 01:39:52.739
kinetic chain comes back into play here. Indispensably

01:39:52.739 --> 01:39:55.460
so. The kinetic chain concept is fundamental

01:39:55.460 --> 01:39:58.420
to effective rehabilitation, especially for overhead

01:39:58.420 --> 01:40:01.369
athletes. Remember, it's that open -linked system

01:40:01.369 --> 01:40:04.430
of segments, lower limbs, torso, scapula, GH

01:40:04.430 --> 01:40:07.069
joint, upper limb operating in a proximal to

01:40:07.069 --> 01:40:09.409
distal sequence to generate and transfer high

01:40:09.409 --> 01:40:12.350
velocity or force to the distal segment, the

01:40:12.350 --> 01:40:15.670
hand. The final velocity or force achieved depends

01:40:15.670 --> 01:40:18.270
on the contribution of each segment and the smooth

01:40:18.270 --> 01:40:20.789
interaction between them. Therefore, when assessing

01:40:20.789 --> 01:40:23.210
and rehabilitating the overhead athlete, each

01:40:23.210 --> 01:40:25.210
segment of the kinetic chain needs to be assessed

01:40:25.210 --> 01:40:27.529
to ensure it possesses the required range of

01:40:27.529 --> 01:40:30.770
movement and muscular control. Any break or inefficiency

01:40:30.770 --> 01:40:32.590
in that chain will overload another segment,

01:40:32.890 --> 01:40:35.529
often the shoulder. The scapula, as we've discussed,

01:40:35.630 --> 01:40:38.250
plays that pivotal role as a critical link, permitting

01:40:38.250 --> 01:40:40.170
effective force transfer from the trunk and legs

01:40:40.170 --> 01:40:42.949
and ensuring optimal glenohumeral joint alignment.

01:40:43.829 --> 01:40:45.729
This highlights the paramount need to identify

01:40:45.729 --> 01:40:48.050
and include correction of any suboptimal movement

01:40:48.050 --> 01:40:50.289
strategies elsewhere in the kinetic chain within

01:40:50.289 --> 01:40:53.310
the shoulder rehabilitation process. Fixing the

01:40:53.310 --> 01:40:55.659
shoulder in isolation often isn't enough. You

01:40:55.659 --> 01:40:58.600
also mentioned an alternating pattern of mobility

01:40:58.600 --> 01:41:00.960
and stability. Yes, that's a crucial concept

01:41:00.960 --> 01:41:03.460
within the kinetic chain, often attributed to

01:41:03.460 --> 01:41:05.319
physical therapists like Greg Cook and Michael

01:41:05.319 --> 01:41:08.479
Boyle. It suggests that optimal performance requires

01:41:08.479 --> 01:41:10.960
a balance between stability and mobility at different

01:41:10.960 --> 01:41:13.579
joints, often following an alternating pattern

01:41:13.579 --> 01:41:16.760
of the body. For example, The ankle needs mobility,

01:41:17.239 --> 01:41:19.899
the knee requires stability, the hip needs mobility,

01:41:20.279 --> 01:41:22.779
the lumbar spine needs stability, the thoracic

01:41:22.779 --> 01:41:25.760
spine requires mobility, the scapula needs stability

01:41:25.760 --> 01:41:28.659
as a platform, and the glenohumeral joint itself

01:41:28.659 --> 01:41:31.520
needs mobility. Dysfunction often occurs when

01:41:31.520 --> 01:41:33.460
a joint that should be mobile becomes stiff,

01:41:33.920 --> 01:41:36.140
forcing the adjacent joint that should be stable

01:41:36.140 --> 01:41:38.239
to compensate with excessive movement leading

01:41:38.239 --> 01:41:40.479
to injury. That makes sense. Are there specific

01:41:40.479 --> 01:41:43.319
screening tools for this? Integrating these components

01:41:43.319 --> 01:41:45.579
leads to the use of specific screening tools

01:41:45.579 --> 01:41:47.800
designed to assess these different segments.

01:41:48.560 --> 01:41:51.199
Examples commonly used include tests for thoracic

01:41:51.199 --> 01:41:53.899
rotation, like the locked lumbar rotation test,

01:41:54.319 --> 01:41:56.659
thoracic extension, example combined elevation

01:41:56.659 --> 01:41:59.340
test, shoulder internal and external rotation

01:41:59.340 --> 01:42:02.500
range, assessing GRD and total arc, hip internal

01:42:02.500 --> 01:42:05.279
and external rotation, and tests for core trunk

01:42:05.279 --> 01:42:07.800
endurance, like extensor, lateral, and flexor

01:42:07.800 --> 01:42:10.319
endurance tests. These help identify limitations

01:42:10.319 --> 01:42:12.869
throughout the chain. One of the most talked

01:42:12.869 --> 01:42:15.229
about concepts in athlete rehab, particularly

01:42:15.229 --> 01:42:18.050
for throwers, is glenohumeral internal rotation

01:42:18.050 --> 01:42:20.449
deficit, or GIRD, which you touched on earlier.

01:42:20.949 --> 01:42:23.029
Can you explain precisely what it is again, why

01:42:23.029 --> 01:42:25.229
it matters as a potential injury risk factor,

01:42:25.229 --> 01:42:27.229
and how we should measure it accurately in a

01:42:27.229 --> 01:42:29.869
clinical setting? Yes, glenohumeral internal

01:42:29.869 --> 01:42:33.250
rotation deficit, or GIRD, is a very common adaptive

01:42:33.250 --> 01:42:35.850
change observed specifically in overhead athletes,

01:42:35.949 --> 01:42:38.369
particularly throwers. It is characterized by

01:42:38.369 --> 01:42:40.649
a functional increase in glenohumeral external

01:42:40.560 --> 01:42:43.439
rotation on the dominant throwing side, coupled

01:42:43.439 --> 01:42:46.020
with a compensatory decrease in internal rotation

01:42:46.020 --> 01:42:49.279
on that same side. The total arc of rotational

01:42:49.279 --> 01:42:52.060
motion might remain similar side to side, but

01:42:52.060 --> 01:42:55.300
the arc itself is shifted posteriorly. The underlying

01:42:55.300 --> 01:42:57.500
mechanism is often thought to be adaptive tightness

01:42:57.500 --> 01:43:01.039
or contracture of the posterior inferior glenohumeral

01:43:01.039 --> 01:43:04.359
ligament PIGHL complex and the posterior inferior

01:43:04.359 --> 01:43:06.939
capsule, developed over time due to repetitive

01:43:06.939 --> 01:43:09.680
throwing motions. This tightness can lead to

01:43:09.680 --> 01:43:12.100
a post or superior shift of the point of clenocumeral

01:43:12.100 --> 01:43:14.560
articulation and the center of rotation during

01:43:14.560 --> 01:43:16.699
throwing. Why is this potentially problematic?

01:43:17.079 --> 01:43:19.739
From a clinical significant standpoint, increasing

01:43:19.739 --> 01:43:22.600
GRD, specifically a significant loss of internal

01:43:22.600 --> 01:43:25.180
rotation compared to the non -dominant side or

01:43:25.180 --> 01:43:27.460
compared to the total arc, may be associated

01:43:27.460 --> 01:43:29.699
with an increased injury risk in throwing athletes.

01:43:30.340 --> 01:43:32.020
It's thought to contribute to conditions like

01:43:32.020 --> 01:43:35.239
internal impingement and SLAP cares by altering

01:43:35.239 --> 01:43:37.640
joint mechanics. How do we measure it reliably?

01:43:38.079 --> 01:43:41.279
We assess GIRD relative to the total arc of motion

01:43:41.279 --> 01:43:44.140
of the glenohumeral joint. Total arc measured

01:43:44.140 --> 01:43:46.840
glenohumeral internal rotation plus measured

01:43:46.840 --> 01:43:49.779
glenohumeral external rotation. It's crucial

01:43:49.779 --> 01:43:52.199
to measure this accurately usually with the patient's

01:43:52.199 --> 01:43:54.680
supine, the shoulder abducted to 90 degrees,

01:43:54.880 --> 01:43:57.399
and the scapula stabilized by the examiner or

01:43:57.399 --> 01:44:00.119
an assistant to prevent scapula thoracic motion

01:44:00.119 --> 01:44:02.779
compensating for true glenohumeral rotation loss.

01:44:03.000 --> 01:44:05.300
It has been proposed that a healthy shoulder

01:44:05.300 --> 01:44:08.060
should ideally present with around a 180 -degree

01:44:08.060 --> 01:44:11.000
total arc of motion, or perhaps more functionally

01:44:11.000 --> 01:44:13.020
relevant, the total arc of motion should be roughly

01:44:13.020 --> 01:44:18.039
equal bilaterally within 510 degrees. While there's

01:44:18.039 --> 01:44:20.319
ongoing debate and research, generally accepted

01:44:20.319 --> 01:44:22.720
thresholds for concern often include a side -to

01:44:22.720 --> 01:44:24.899
-side difference of greater than 20 degrees for

01:44:24.899 --> 01:44:27.560
internal rotation loss, or a loss of total rotational

01:44:27.560 --> 01:44:30.060
range of motion greater than 510 percent compared

01:44:30.060 --> 01:44:32.720
to the contralateral side. These values are often

01:44:32.720 --> 01:44:35.180
considered potentially pathological and warrant

01:44:35.180 --> 01:44:38.260
intervention like targeted stretching. More specific

01:44:38.260 --> 01:44:40.380
predictive findings for injury risk have been

01:44:40.380 --> 01:44:42.819
proposed in certain populations, such as a loss

01:44:42.819 --> 01:44:45.119
of greater than 25 degrees into internal rotation

01:44:45.119 --> 01:44:48.180
in baseball players, or a loss of 20 degrees

01:44:48.180 --> 01:44:50.859
internal rotation combined with a 5 % loss in

01:44:50.859 --> 01:44:53.479
total ROM, doubling the risk for injury in professional

01:44:53.479 --> 01:44:56.149
baseball pitchers in one study. However, it's

01:44:56.149 --> 01:44:57.829
important to acknowledge that some studies have

01:44:57.829 --> 01:44:59.970
not found a direct or consistent association

01:44:59.970 --> 01:45:02.449
between GRD measurements alone and subsequent

01:45:02.449 --> 01:45:05.329
injury. So, while GRD is an important factor

01:45:05.329 --> 01:45:07.329
to assess and address particularly significant

01:45:07.329 --> 01:45:09.489
deficits, it should be considered as part of

01:45:09.489 --> 01:45:11.430
the broader clinical picture on kinetic chain

01:45:11.430 --> 01:45:14.630
assessment, not as an isolated risk factor. 7

01:45:14.630 --> 01:45:16.909
.2 Objective Strength and Proprioception Assessment

01:45:17.050 --> 01:45:20.649
Beyond range of motion measures like GID, accurately

01:45:20.649 --> 01:45:22.750
assessing shoulder strength and proprioception

01:45:22.750 --> 01:45:25.590
is absolutely crucial for making those safe return

01:45:25.590 --> 01:45:29.390
to play decisions. How do we get truly objective,

01:45:29.430 --> 01:45:32.390
reliable data on these parameters? How do we

01:45:32.390 --> 01:45:35.109
move beyond just subjective clinical impressions

01:45:35.109 --> 01:45:38.229
feel strong, given the known limitations of traditional

01:45:38.229 --> 01:45:40.409
methods like manual muscle testing? That's a

01:45:40.409 --> 01:45:42.329
vital question for evidence -based practice.

01:45:42.789 --> 01:45:44.550
When it comes to shoulder strength assessment,

01:45:44.649 --> 01:45:47.470
While standard manual muscle testing, MMT, using

01:45:47.470 --> 01:45:50.670
the Euro -5 Oxford scale, has good clinical utility

01:45:50.670 --> 01:45:53.310
for detecting growth weakness, it is inherently

01:45:53.310 --> 01:45:56.960
highly subjective. MMT is significantly prone

01:45:56.960 --> 01:45:59.699
to user error and bias, especially at the higher

01:45:59.699 --> 01:46:02.340
grades, grade four and five, where distinguishing

01:46:02.340 --> 01:46:04.380
subtle but potentially clinically significant

01:46:04.380 --> 01:46:06.859
weakness can be very difficult. It's often hard

01:46:06.859 --> 01:46:09.119
to present objective, quantifiable data using

01:46:09.119 --> 01:46:11.699
this method, and the results can be heavily influenced

01:46:11.699 --> 01:46:13.920
by the examiner's own experience and strength

01:46:13.920 --> 01:46:16.699
relative to the patient. So what's a better alternative

01:46:16.699 --> 01:46:19.140
for objective data? We strongly advocate for

01:46:19.140 --> 01:46:22.500
the use of handheld dynamometers. HHD has a much

01:46:22.500 --> 01:46:24.500
more objective and reliable method of strength

01:46:24.500 --> 01:46:28.180
evaluation. It's far superior to MMT for quantifying

01:46:28.180 --> 01:46:30.720
strength and crucially for evaluating subtle

01:46:30.720 --> 01:46:33.439
changes in muscle strength caused by injury dysfunction

01:46:33.439 --> 01:46:37.039
or rehabilitation progress. HHD provides objective

01:46:37.039 --> 01:46:39.380
numerical data, for example in kilograms or pounds

01:46:39.380 --> 01:46:41.739
of force, that can be tracked over time and compared

01:46:41.739 --> 01:46:43.600
to the contralateral side or normative data.

01:46:43.739 --> 01:46:46.279
It's particularly useful for assessing specific

01:46:46.279 --> 01:46:48.720
scapular stabilizer muscles, like the upper middle

01:46:48.720 --> 01:46:50.819
and lower trapezius and the serratus anterior,

01:46:51.239 --> 01:46:53.340
by resisting specific movements in standardized

01:46:53.340 --> 01:46:55.880
test positions. What about endurance, not just

01:46:55.880 --> 01:46:58.760
peak strength? Beyond peak strength, assessing

01:46:58.760 --> 01:47:01.340
muscular endurance is also incredibly important,

01:47:01.659 --> 01:47:03.520
especially in athletes performing repetitive

01:47:03.520 --> 01:47:06.600
tasks. Shoulder muscle fatigue has been proposed

01:47:06.600 --> 01:47:08.979
to be strongly associated with repeated arm use

01:47:08.979 --> 01:47:10.819
and the subsequent development of rotator cuff

01:47:10.819 --> 01:47:13.979
disorders and instability. The mechanism for

01:47:13.979 --> 01:47:16.640
this is postulated to be due to fatigue causing

01:47:16.640 --> 01:47:18.760
altered timing and coordination of the local

01:47:18.760 --> 01:47:21.859
muscle system around the shoulder girdle. Fatigue

01:47:21.859 --> 01:47:24.300
muscles absorb less energy before elongation,

01:47:24.539 --> 01:47:26.539
increasing the risk of tissue strain and injury

01:47:26.539 --> 01:47:29.420
during subsequent forceful movements. Enduris

01:47:29.420 --> 01:47:31.779
can be assessed using time tests or repetitions

01:47:31.779 --> 01:47:34.800
against submaximal resistance. Okay, and proprioception,

01:47:35.039 --> 01:47:36.760
that sense of joint position, how do we measure

01:47:36.760 --> 01:47:39.340
that objectively? Proprioception assessment is

01:47:39.340 --> 01:47:41.619
equally important, but perhaps even more challenging

01:47:41.619 --> 01:47:44.539
to quantify reliably in a standard clinical setting.

01:47:45.319 --> 01:47:48.880
We define proprioception as a sensory -offerant

01:47:48.880 --> 01:47:51.739
feedback mechanism that mediates joint position

01:47:51.739 --> 01:47:53.859
and movement sensibility with modular reflex

01:47:53.859 --> 01:47:57.079
stabilization. Essentially, it's the body's kinesthetic

01:47:57.079 --> 01:47:59.680
sense knowing where your joint is in space without

01:47:59.680 --> 01:48:03.159
looking. Why does it matter? Well, those mechanoreceptors

01:48:03.159 --> 01:48:05.239
within the capsule -laboral complex or on the

01:48:05.239 --> 01:48:07.779
shoulder, which detect joint position and movement,

01:48:08.140 --> 01:48:10.159
can be damaged due to local tissue trauma from

01:48:10.159 --> 01:48:12.859
injury or surgery. This can lead to significant

01:48:12.859 --> 01:48:15.399
deficiencies in joint proprioception. Reduced

01:48:15.399 --> 01:48:17.899
joint proprioception has been proposed as a significant

01:48:17.899 --> 01:48:19.899
contributing factor to functional instability

01:48:19.899 --> 01:48:22.100
and re -injury, as the joint doesn't know where

01:48:22.100 --> 01:48:25.060
it is as accurately, impairing protective muscle

01:48:25.060 --> 01:48:27.479
responses. How can we test it clinically without

01:48:27.479 --> 01:48:30.060
expensive equipment? While many high -tech laboratory

01:48:30.060 --> 01:48:33.180
devices exist, like isokinetic dynamometry with

01:48:33.180 --> 01:48:35.420
proprioceptive modes or electronic motion tracking

01:48:35.420 --> 01:48:37.979
devices, these are often costly and impractical

01:48:37.979 --> 01:48:41.119
for routine clinical use. However, we can advocate

01:48:41.119 --> 01:48:43.899
for more utilitarian, clinically applicable methods.

01:48:44.659 --> 01:48:46.579
The assessment of proprioception using reproduction

01:48:46.579 --> 01:48:48.720
of passive positioning is a valid and established

01:48:48.720 --> 01:48:51.920
method. This often involves joint angular replication

01:48:51.920 --> 01:48:55.149
tests. Typically, the examiner passively places

01:48:55.149 --> 01:48:57.149
the patient's injured shoulder into a specific

01:48:57.149 --> 01:48:59.890
angle or position. The patient consciously registers

01:48:59.890 --> 01:49:02.569
this position, often with eyes closed, the arm

01:49:02.569 --> 01:49:04.770
is returned to the resting start position, and

01:49:04.770 --> 01:49:06.689
the subject is then asked to actively replicate

01:49:06.689 --> 01:49:08.930
the test position as accurately as possible.

01:49:09.449 --> 01:49:11.189
The difference between the target angle and the

01:49:11.189 --> 01:49:13.409
reproduced angle is measured. This assesses the

01:49:13.409 --> 01:49:15.930
function of both static joint receptors and dynamic

01:49:15.930 --> 01:49:18.470
muscle spindles, shoulder joint stabilizers,

01:49:18.569 --> 01:49:20.890
and their input to position sets. Other practical

01:49:20.890 --> 01:49:23.489
open and closed kinetic chain exercises used

01:49:23.489 --> 01:49:26.289
in rehabilitation also challenge proprioception,

01:49:26.689 --> 01:49:28.630
such as attempting to hold a specific joint angle

01:49:28.630 --> 01:49:31.869
with eyes closed, or contralateral limb mirroring

01:49:31.869 --> 01:49:34.310
exercises where the patient tries to mirror the

01:49:34.310 --> 01:49:36.909
position or movement of their uninjured arm with

01:49:36.909 --> 01:49:39.270
their injured arm while keeping their eyes closed.

01:49:40.069 --> 01:49:42.270
These practical methods provide valuable clinical

01:49:42.270 --> 01:49:45.310
insights into an athlete's proprioceptive capabilities

01:49:45.310 --> 01:49:49.550
and help guide rehabilitation. 7 .3 Conclusion

01:49:49.550 --> 01:49:53.270
of Rehab Principles So, to synthesize all of

01:49:53.270 --> 01:49:55.869
that, effective rehabilitation for the athletic

01:49:55.869 --> 01:49:58.409
shoulder demands a truly profound understanding

01:49:58.409 --> 01:50:00.829
of sport -specific biomechanics and the demands

01:50:00.829 --> 01:50:03.590
placed on the joint. It requires a comprehensive

01:50:03.590 --> 01:50:06.270
biomechanical screening process, looking beyond

01:50:06.270 --> 01:50:08.270
the shoulder itself to assess the entire kinetic

01:50:08.270 --> 01:50:10.949
chain for any contributing deficits. We must

01:50:10.949 --> 01:50:12.970
utilize objective measurement tools for tracking

01:50:12.970 --> 01:50:15.689
progress in strength, endurance, range of motion,

01:50:16.069 --> 01:50:18.260
and proprioception. And fundamentally, there

01:50:18.260 --> 01:50:21.180
must be a commitment to a criterion -based milestone

01:50:21.180 --> 01:50:24.000
-driven progression through rehabilitation phases,

01:50:24.460 --> 01:50:26.840
rather than relying on rigid time -based protocols

01:50:26.840 --> 01:50:29.180
that don't account for individual variation in

01:50:29.180 --> 01:50:32.319
healing and response. This integrated objective

01:50:32.319 --> 01:50:34.539
and holistic approach is absolutely essential

01:50:34.539 --> 01:50:37.039
to guide a safe, effective, and sustainable return

01:50:37.039 --> 01:50:39.600
to play, ultimately protecting an athlete's career

01:50:39.600 --> 01:50:41.859
and their long -term joint health. This has been

01:50:41.859 --> 01:50:44.859
an incredibly comprehensive deep dive, truly

01:50:44.859 --> 01:50:47.140
unraveling the immense complexity of the shoulder.

01:50:47.720 --> 01:50:49.960
We've journeyed from its intricate anatomy and

01:50:49.960 --> 01:50:52.340
biomechanics right through to the diverse injury

01:50:52.340 --> 01:50:55.100
patterns seen in both overhead and contact athletes,

01:50:55.659 --> 01:50:58.220
and explored the nuanced, constantly evolving

01:50:58.220 --> 01:51:01.600
landscape of diagnosis and treatment. I feel

01:51:01.600 --> 01:51:03.800
we've moved far beyond a superficial understanding

01:51:03.800 --> 01:51:06.539
today, providing a framework for truly informed

01:51:06.539 --> 01:51:08.859
clinical decisions when faced with these challenging

01:51:08.859 --> 01:51:11.720
injuries. Indeed. And I think if there's one

01:51:11.720 --> 01:51:14.140
key takeaway for orthopedic professionals listening,

01:51:14.560 --> 01:51:16.739
it's that a deep understanding of the shoulder's

01:51:16.739 --> 01:51:18.840
interconnectedness, its role within the entire

01:51:18.840 --> 01:51:22.359
kinetic chain, is not just academic. It is absolutely

01:51:22.359 --> 01:51:24.560
paramount for effective practice. Because it

01:51:24.560 --> 01:51:26.800
allows for more precise diagnoses. Precisely.

01:51:26.890 --> 01:51:29.569
It helps identify those often mis -contributing

01:51:29.569 --> 01:51:33.229
factors, like subtle scapular dyskinesis or seemingly

01:51:33.229 --> 01:51:35.949
minor bony changes that can have major downstream

01:51:35.949 --> 01:51:38.489
effects. And ultimately it leads to the implementation

01:51:38.489 --> 01:51:41.069
of more effective, targeted, and often career

01:51:41.069 --> 01:51:43.270
-preserving interventions that truly address

01:51:43.270 --> 01:51:45.909
the unique demands and biomechanics of each individual

01:51:45.909 --> 01:51:48.579
athlete. It allows for more precise diagnoses,

01:51:48.960 --> 01:51:51.180
the identification of often missed contributing

01:51:51.180 --> 01:51:54.340
factors like scapular dyskinesis or subtle bony

01:51:54.340 --> 01:51:57.479
changes, and the implementation of more effective

01:51:57.479 --> 01:52:00.340
career -preserving interventions that truly address

01:52:00.340 --> 01:52:03.270
the unique demands of each athlete. Absolutely.

01:52:03.829 --> 01:52:05.970
Perhaps the biggest challenge for us as clinicians

01:52:05.970 --> 01:52:07.729
moving forward isn't just treating the injury

01:52:07.729 --> 01:52:10.449
we see on the scan or find in theater. It's about

01:52:10.449 --> 01:52:13.069
truly understanding and interpreting the unique

01:52:13.069 --> 01:52:15.750
athletic blueprint of each individual patient.

01:52:16.350 --> 01:52:18.590
That incredibly delicate balance of their innate

01:52:18.590 --> 01:52:21.409
constitutional factors like laxity, the acquired

01:52:21.409 --> 01:52:23.770
adaptations they've developed through years of

01:52:23.770 --> 01:52:26.029
sport, and their specific kinetic chain movement

01:52:26.029 --> 01:52:29.050
patterns. How do we continue to refine our ability

01:52:29.050 --> 01:52:31.090
to read that complex blueprint, not just so we

01:52:31.090 --> 01:52:33.670
can react effectively to injury, but so we can

01:52:33.670 --> 01:52:36.350
proactively support our athletes, manage their

01:52:36.350 --> 01:52:38.869
load, and guide them through the long, demanding

01:52:38.869 --> 01:52:41.510
arc of their careers and, importantly, beyond,

01:52:41.890 --> 01:52:44.989
into a healthy, active life afterwards. A powerful

01:52:44.989 --> 01:52:48.109
thought to consider indeed. How do we read that

01:52:48.109 --> 01:52:51.250
blueprint better? Thank you. If you found this

01:52:51.250 --> 01:52:53.750
deep dive insightful and valuable, please do

01:52:53.750 --> 01:52:56.210
take a moment to rate and share our deep dive

01:52:56.210 --> 01:52:58.329
with a colleague who might also benefit from

01:52:58.329 --> 01:53:01.180
these crucial insights. Professor Moimam, thank

01:53:01.180 --> 01:53:03.260
you so much for sharing your profound expertise

01:53:03.260 --> 01:53:05.579
and invaluable contributions to this incredibly

01:53:05.579 --> 01:53:07.659
detailed discussion today. It's been my pleasure.

01:53:07.760 --> 01:53:09.819
Thank you for having me. And to you, our listener,

01:53:10.020 --> 01:53:12.619
thank you for joining us on the deep dive. We

01:53:12.619 --> 01:53:15.060
encourage you to continue your own deep dives

01:53:15.060 --> 01:53:16.739
into knowledge. Until next time.