The shoulder and the overhead athlete

373 Pages·2004·19.001 MB·English

by  Sumant G. Krishnan MD, Richard J. Hawkins MD, Russell F. Warren

The Shoulder and the 
Overhead Athlete

1st Edition
2004

Lippincott Williams & Wilkins
Philadelphia

530 Walnut Street, Philadelphia, PA 19106 USA

978-0-7817-4614-4

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© 2004 by LIPPINCOTT WILLIAMS & WILKINS

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Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors,
editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make
no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner.

The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with
current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any
change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or
infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted
research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their
clinical practice.

10 9 8 7 6 5 4 3 2
Dedication
We dedicate this book to all of the athletes who teach us about the complexities and challenges of the shoulder and who remind us
how much we enjoy caring for them
Editors
Attending Orthopaedic Surgeon, Steadman Hawkins Clinic;
Sumant G. Krishnan MD
Head Team Physician,
Clinical Assistant Professor of Orthopaedic Surgery,
Denver Broncos and Colorado Rockies
University of Texas Southwestern Medical Center;
Vail, Colorado
Attending Orthopaedic Surgeon
Shoulder Service, W.B. Carrell Memorial Clinic;
Russell F. WARREN MD
Assistant Team Physician
Professor of Orthopaedic Surgery
Dallas Cowboys, Dallas Stars, and Southern Methodist
Weill Medical College of Cornell University;
University
Surgeon-in-Chief, Emeritus, and Attending Orthopedic
Dallas, Texas
Surgeon
Hospital for Special Surgery;
Richard J. Hawkins MD Head Team Physician,
Clinical Professor of Orthopaedic Surgery New York Giants
University of Colorado Health Sciences Center; Meadowland, New Jersey
P.ix

Contributing Authors Department of Orthopedics, Harris methodist Forth Worth
Hospital; Head Team Physician, Texas Rangers Baseball Team,
Forth Worth, Texas
Michael W. Allen PT, ATC, CSCS
Director of Physical Therapy Rick B. Cunningham MD
Steadman Hawkins Denver Clinic, Englewood, Colorado;,
Sports Fellow
Physical Therapist, Colorado Rockies, Denver, Colorado
University of Pittsburgh, Pittsburg, Pennsylvania
David W. Altchek MD
Andrea Hammer MD
Associate Attending Orthopaedic Surgeon Stanford Athletics, Arrillaga Family Sports Center, Stanford,
The Hospital for Special Surgery, New York, New York California
James R. Andrews MD Richard J. Hawkins MD
Orthopaedic Surgeon Clinical Professor
Alabama Sports Medicine and Orthopaedic Center, Department of Orthopaedics, University of Colorado, Denver,
Birmingham, Alabama Colorado;, Head Team Physician, Denver Broncos and
Colorado Rockies, Vail, Colorado
Champ L. Baker Jr MD
Charles P. Ho MD, PhD
Associate Clinical Professor
Department of Orthopaedic Surgery, Medical College of Director
Georgia, Augusta, Georgia National Orthopaedic Imaging Associates, California
Advanced Imaging, Atherton, California
Mark Baker PT
Brent Johnson MD
Director of Rehabilitation
Department of Orthopaedic Surgery, Indiana University,
The Hughston Clinic;, Physical Therapist, Columbus
Indianapolis, Indiana
Cottonmouths Hockey Team, Columbus, Georgia
Richard B. Jones MD
Ronnie P. Barnes MS, ATC
Director
Head Athletic Trainer
Mountain Sports Health, Mountain Orthopedic Associates,
New York Giants, Meadowlands, New Jersey
Clyde, North Carolina
Louis U. Bigliani MD
Thomas A. Joseph MD
Chief Clinical associate, Section of Sports Medicine and Shoulder
Center for Shoulder, Elbow & Sports Medicine, Department Surgery, The Orthopaedic Center, Canfield, Ohio
of Orthopaedic Surgery, Columbia-Presbyterian Medical
Center, New York, New York
Bryan T. Kelly MD
Fellow in Sports Medicine, Sports Medicine and Shoulder
Christine Boyd MD Service, Hospital for Special Surgery, New York, New York;,
Athletic Trainer, New York Giants, Meadowlands, New Jersey
Sports Medicine Fellow
Department of Sports Medicine, Stanford University,
Stanford, California Ben W. Kibler MD
Medical Director
Wayne Z. Burkhead MD Sports Medicine Center, Lexington Clinic;, Team Physician,
Shoulder Service, W.B. Carrell Memorial Clinic, Dallas, Texas Lexington Legends, Lexington, Kentucky
Patrick J. Casey MD Mininder S. Kocher MD, MPH
Alabama Sports Medicine and Orthopaedic Center,
Attending Orthopaedic Surgeon
Birmingham, Alabama
Department of Orthopaedic Surgery, Children's Hospital
Boston, Boston, Massachusetts;, Team Physician, Laswell
Donald A. Chu PT, PhD, ATC College, Newton, Massachusetts
Director
Performance Enhancement, Stanford Athletics, Arrillaga Sumant G. Krishnan MD
Family Sports Center, Stanford, California
Clinical Assistant Professor of Orthopaedic Surgery
University of Texas Southwestern Medical Center;, Attending
John E. Conway MD Orthopaedic Surgeon, Shoulder Service, W.B. Carrell
Memorial Clinic;, Assistant Team Physician, Dallas Cowboys,
Chief
Dallas Stars, and Southern, Methodist University, Dallas,
Texas
P.x

John E. Kuhn MD Peter Sallay MD
Department of Orthopedic Surgery, Indiana University,
Chief
Indianapolis, Indiana
Shoulder Surgery, Vanderbilt Sports Medicine;, Team
Physician, Vanderbilt University Athletic Department, Mark S. Schickendantz MD
Nashville, Tennessee
Clinic Instructor
William N. Levine MD Department of Orthopedic Surgery, Cleveland Clinic;,
Director of Orthopedic Services, Cleveland Indians
Assistant Professor
Professional Baseball Club, Cleveland, Ohio
Department of Orthopaedic Surgery, Columbia-Presbyterian
Medical Center, New York, New York Steven B. Singleton MD
Christopher G. Mazoué MD Orthopaedic Surgeon
Alabama Sports Medicine Institute, Birmingham, Alabama Ben Hogan Center/Harris Methodist Forth Worth, Fort Worth,
Texas
Patrick J. McMahon MD
Eric D. Smith MD
Assistant Professor
National Orthopedic Imaging Associates, California Advanced
Department of Orthopedic Surgery, University of Pittsburgh,
Imaging, Atherton, California
Pittsburgh, Pennsylvania
Walter G. Stanwood MD
John Mcmullen MS, ATC
Sports Medicine Center, Lexington Clinic, Lexington, Postdoctoral Fellow
Kentucky Center for Shoulder, Elbow & Sports Medicine, Columbia-
Presbyterian Medical Center, New York, New York
Gary W. Misamore MD
James E. Tibone MD
Clinical Associate Professor
Department of Orthopaedic Surgery, Indiana University;, Clinical Professor
Team Physician, Butler University and Indianapolis Colts, Department of Orthopaedic Surgery, University of Southern
Indianapolis, Indiana California;, Team Physician, University of Southern
California, Los Angeles, California
Robert J. Nowinski DO
John M. Tokish MD
Clinical Assistant Professor
Department of Orthopedic Surgery, Ohio University College Staff Orthopedic Surgeon
of Osteopathic Medicine, Athens, Ohio United States Air Force Academy Hospital;, Team Physician,
Falcon Football, United States Air Force Academy, Colorado
James O'Holleran MD
Springs, Colorado
Division of Sports Medicine
Russell F. Warren MD
Department of Orthopaedic Surgery, Children's Hospital,
Harvard Medical School, Boston, Massachusetts Professor of Orthopaedic Surgery
Weill Medical College of Cornell University;, Surgeon-in-
John W. Powell PhD, ATC
Chief, Emeritus, and Attending Orthopedic Surgeon, Hospital
Director for Special Surgery;, Head Team Physician, New York Giants,
Graduate Athletic Training Program, Michigan State Meadowlands, New Jersey
University;, Athletic Trainer, Michigan State University
Daniel E. Weiland MD
Athletic Teams, East Lansing, Michigan
Orthopedic Resident, Hospital for Special Surgery, New York,
William Prickett MD New York
Surgeon in Chief Andrew L. Whaley MD
Emeritus, Hospital of Special Surgery, New York, New York Fellow in Sports Medicine The Hughston Clinic, PC Columbus,
Georgia
Michael M. Reinold DPT, ATC
Coordinator of Rehabilitative Research and Clinical Kevin E. Wilk PT
Education, Healthsouth Sports Medicine and Rehabilitation
Adjunct Associate Professor
Center, American Sports Medicine Institute, Birmingham,
Division in Physical Therapy, Marquette University,
Alabama;, Tampa Bay Devil Rays Major league, Baseball
Milwaukee, Wisconsin;, Rehabilitation Consultant, Tampa
Organization, St. Petersburg, Florida
Bay Devil Rays Baseball Club, Tampa Bay, Florida
Scott A. Rodeo MD
Brian R. Wolf MD
Associate Professor
Assistant Professor
Sports Medicine and Shoulder Service, Hospital for Special
Department of Orthopaedic and Rehabilitation, University of
Surgery, New York, New York;, Associate Team Physician,
Iowa Hospitals and Clinics;, Co-Team Physician, University of
New York Giants, Meadowlands, New Jersey
Iowa Athletics, Iowa City, Iowa
P.xi
Foreword
It is an honor to be asked to write the foreword for this text on The Shoulder and the Overhead Athlete. The editors have done a
great job in gathering the experts; the contributors are to be congratulated on bringing us up-to-date scientifically and clinically, so
that we can treat the overhead athlete optimally.
To illustrate how much has been learned about the shoulder over the past few decades, I'd like to share with you a committee
meeting in the 1960s. At this committee meeting, a group of us—experts—decided to put together a course on the shoulder. After
hours of discussion, we decided we did not know enough for a whole course on just the shoulder. To fill in the course, we needed to
expand it to cover the shoulder, elbow and spine. Forty years later; we could fill many courses with the content of care of the
shoulder. Indeed, this book provides us with excellent information on just one single type of shoulder injury.
One of the strengths of this book is that it takes into consideration the issues of prevention and rehabilitation that we—as
surgeons—are just beginning to focus on. Coaches, physicians, trainers, strength and conditioning specialists, and therapists all
contribute to the care of the overhead athlete. As surgeons, we will each be given opportunities to work with these professionals.
We should approach them knowing that each of us has an important role in the treatment of the athlete.
When reading this book, we will want to keep all of this in mind: medicine and surgery as a “work in progress” and the multiple
disciplines directed to the care of the overhead athlete. It is this mind-set that will return our athletes to the field with 100% of
their abilities. Sometimes, when we see words in print, we believe it to be the gospel—the end-all-to-be-all. Yet, the practice of
medicine is fluid. I'm not certain there will ever be a “final word” on the clinical practice of shoulder injuries in the athlete. One of
the main benefits of this book is that it brings us to the next level in our quest for perfection.
Frank W. Jobe MD
Kerlan-Jobe Orthopaedic Clinic
Centinela Hospital Medical Center
P.xiii
Preface
Knowledge is of two kinds: we know a subject ourselves, or we know where we can find information
about it.
—Samuel Johnson
Almost ten years have passed since the last publication dedicated to shoulder injuries in athletes. During any meeting on shoulder
pathology, there is usually a session dedicated to the difference in each type of shoulder injury with regard to athletes versus other
patients. Shoulder injuries in athletes hold a separate place in both discussion and management. Furthermore, shoulder injuries in
overhead athletes represent yet another subset that is spoken of distinctly and with specific diagnostic and therapeutic challenges
when compared to other patients. We decided to attempt to gather each of those separate “discussion” in one place, one forum,
and one compilation.
Too often texts of this nature are dichotomously dedicated either to orthopaedic surgeons or to nonsurgical practitioners without
attempting to integrate the two. We have attempted to bridge this gap because shoulder injuries in overhead athletes should be
managed with a multidisciplinary approach: the majority of these patients are treated nonsurgically. In addition, prevention of the
injury in the first place holds the highest promise for allowing each of these athletes to reach their full potential. Orthopaedic
surgeons, physical therapists, athletic trainers, and anyone who cares for athletes participating in sports with overhead maneuvers
hopefully understand this “team” concept.
The writings should read as a personal “round-table” discussion with the renowned experts in each of their fields. The ideas
discussed here are neither dogma nor “the rule”—they are the ideas born from the continual and evolving understanding of this very
complex grouping of shoulder patients. The text is divided into sections dedicated to each problem that would be encountered in
the care of all overhead athletes—from adolescent pitchers, to high-school swimmers, to professional tennis players. The first eight
chapters are devoted to a general understanding, diagnosis, rehabilitation, and prevention of injury. The next group of chapters
focuses on specific disorders, from diagnosis to surgical treatment to return to play. The last section identifies and manages some of
the more common sport-specific shoulder injuries that make up yet another separate subsection in this complicated group of
athletes.
It is our sincere hope that everyone who cares for overhead athletes—be they any athlete such as a baseball player, football
quarterback, swimmer, tennis player, handball or volleyball player, javelin thrower, professional or amateur, adult or child, male or
female—will seek out this book and our collective “work in progress.” The more we begin to understand, the more we see that we
do not understand, the more our thinking “evolves,” and we continue to be enlightened in the process…that is the most important
purpose of this book. Please join us on this adventure.
Sumant G. Krishnan MD
Richard J. Hawkins MD
Russell F. Warren MD
P.xv
Acknowledgments
This book could not have been completed without the timely and thorough contributions from each author. These recognized
experts have many demands placed upon them on a daily basis, yet each found a way to adhere to our strict and short deadline for
publication. Each also provided what we feel is exceptionally written work that reads with a personal flair.
The editorial and publication team at Lippincott Williams & Wilkins (Jim Merritt, Michelle LaPlante, and Rakesh Rampertab)
produced this book from start to finish in a fraction of the time a text of this magnitude requires. Their attention to detail is borne
out by the quality of this publication.
Our respective staffs continue to amaze us with their abilities to coordinate the various and sundry tasks and appointments that
have allowed us to collaborate on this extensive project. They are too numerous to name individually, but each continues to be
essential to our work.
Last, but certainly not least, this work would not have been possible without the unwavering support and understanding of our
immediate families—Kim and Sophie (SGK), Susan (RJH), and Laurie (RFW). They tolerated the late nights and personal sacrifices
that become necessary in bringing a project like this to fruition.
We thank you with all of our hearts.
Sumant
Rich
Russ
Contents
Dedication
Foreword
Preface
Acknowledgments
Contents
Section I General Principles
1 The Overhead Athlete—Challenges and Decision-Making
2 Shoulder Anatomy and Biomechanics During Overhead Motions
3 Clinical Examination of the Overhead Athlete: The “Differential-Directed” Approach
4 Imaging of the Overhead Athlete
5 The Assessment of Outcomes for the Treatment of the Overhead Athlete
6 Resistance Training and Core Strengthening
7 Specific Exercises for the Throwing Shoulder
8 Interval Program and Its Implication for the Throwing Athlete
Section II Lesions of the Overhead Shoulder
9 Internal Impingement
10 Surgical Treatment of Partial Thickness Rotator Cuff Tears
11 Subacromial Impingement and Full Thickness Rotator Cuff Tears in Overhead Athletes
12 Unidirectional Anterior Instability
13 Unidirectional Posterior Instability
14 Multidirectional Instability
15 Disorders of the Biceps Tendon
16 Acromioclavicular Joint Disorders
17 Scapulothoracic Problems in Overhead Athletes
18 Fractures
19 Neurologic and Vascular Lesions
20 Disorders in Pediatric Athletes
Section III Sport-Specific Shoulder Injuries and Management in Overhead Athletes
21 Baseball
22 Football
23 Tennis
24 Swimming