Hot topics Regarding Overhead Throwing From This Year’s ASMI Conferenceby Paul Kohler, MS, OTR/L, CHT | Leave a Comment
The American Sports Medicine Institute’s Annual Conference on sports injuries was held on January 29-31st of this year. In its 34th year, this particular conference focused primarily on the health, safety and treatment of overhead throwing athletes, with emphasis on baseball pitchers. The ASMI, located in Birmingham, AL, was founded by Dr. James Andrews. Well revered in the sporting community, Dr. Andrews was the first orthopedic physician to describe the SLAP (Superior Labrum from Anterior to Posterior) lesion of the shoulder. Over the course of his career, Dr. Andrews has become a coveted surgeon for high profile athletes, with a list that includes, but not limited to John Smoltz, Roger Clemens, Drew Brees, Peyton Manning, Allen Iverson and Hulk Hogan. Along with Dr. Andrews, the ASMI Conference featured a who’s who in sports medicine with over 30 different speakers, including presentations by Glen Fleisig, Ph.D., Kevin Wilk, DPT, FAPTA, Anthony Romeo, MD, Neal ElAttrache, MD and George Davies, DPT, M. Ed., CSCS, ATC, CSCS, FAPTA.
Giving a brief summary of all the topics discussed in just one blog would not do justice to the conference. Therefore, the next few blogs will highlight some of the key topics discussed. Today, we start with a common shoulder injury in the overhead throwing athlete, the SLAP tear.
Dr. Anthony Romeo, Dr. Michael Shepard and Dr. James Andrews discussed new techniques to improve outcomes in Type II SLAP repairs. In a 2011 study by Neri, et. al. of 23 elite overhead throwing athletes treated with SLAP repairs, 57% (13/27) returned to a previous level of performance, 26% (6/23) returned to play with pain and 17% (4/23) never pitched again. In a similar study by Fedoriw, et. al., 48% of pitchers returned to play and 7% returned to play with pain. These results are a far cry from the 85-90% return to play after Tommy John surgery from 2006-2012 (Watson et. al., 2013). In an effort to improve their results, physicians and bioengineers are teaming up to produce better surgical techniques. One new technique is knotless suture anchors. In many instances, suture knots left above the glenoid rim and in the labrum during SLAP repair have caused friction in the shoulder joint, resulting in inflammation and possible tears of the rotator cuff. Knotless suture technology and skilled physician implementation can significantly decrease the chance of future pathology in the shoulder following SLAP repair.
Another new technique involves augmenting the SLAP repair with a biceps tenodesis. In a tenodesis procedure, the tendon of a muscle is cut away from its origin and placed in a position closer to its insertion. In the case of the biceps, the tendon is cut away from the glenoid tubercle and superior labrum, and then reattached in a position lower down the arm. In the lay population, the tendon is traditionally placed on the humeral head. However, presenter Dr. Anthony Romeo described a new technique in which the biceps tendon is reattached subpectorally. He explained how years of repetitive pitc
hing can loosen structures supporting the biceps tendon, allowing the tendon to rub back and forth over the boney bicipital groove. Over time, the constant translation creates a small tear along the biceps tendon in areas not typically seen in the lay population. Placement of the tendon in the humeral head may be acceptable for most people, but pain may persist in the overhead throwing athlete. Dr. Romeo stressed that patients must meet a specific criteria for this type of surgery, but reported his preliminary results have been encouraging.
While the before mentioned techniques show promise, one treatment all physicians at the conference agreed upon was conservative treatment. Multiple presentations outlined preventative approaches for limiting risk of shoulder injury and/or conservative rehab strategies if an injury is diagnosed. Dr. Kevin Wilk, Dr. Rafael Escamilla (Ph.D, PT, CSCS, FACSM), and Russ Pain, PT discussed the importance of maintaining flexibility and conditioning throughout the entire kinetic chain from the ankles up to the wrists and throwing with efficient mechanics. Key points included:
- Maintain appropriate rotational range in motion in the shoulder joint
- Maintain a good balance between flexibility and stability in the shoulder capsule
- Maintain flexibility in the legs and hips
- Core training is essential
- Strengthen and train the posterior muscle groups responsible for deceleration of the arm
- Shoulder abduction should be at 80-100 degrees at foot contact (Escamilla 1998, Fleisig 1999)
- Inadequate external rotation at foot contact increases force (risk for injury) in the shoulder (Escamilla 1998, Fleisig 1999)
- Excessive external rotation in late cocking phase increases risk of injury (Escamilla 1998, Fleisig 1999)
Through advancements in conservative treatment, professional baseball has seen a decrease in shoulder injuries. Research by Dr. Conte found that the number of days on the DL for the shoulder was 32% compared to 24% for the elbow from 2001-2003. However, recent data from 2011-2013 reveals a positive trend in shoulder injuries, as the number of days on the DL for the shoulder was 18% compared to 35% for the elbow. Which brings me to our next blog….Have ulnar collateral ligament injuries in the elbow become an “epidemic” in baseball? (Dr. Neal ElAttrache, Los Angeles Dodgers)
Strauss, Eric J., et al. “Role of the superior labrum after biceps tenodesis in glenohumeral stability.” Journal of Shoulder and Elbow Surgery 23.4 (2014): 485-491.
Fleisig, G. S., R. F. Escamilla, and S. W. Barrentine. “Biomechanics of pitching: mechanism and motion analysis.” Injuries in Baseball. Philadelphia, PA: Lippincott-Raven (1998): 3-22.
Fleisig, Glenn S., et al. “Kinematic and kinetic comparison of baseball pitching among various levels of development.” Journal of biomechanics 32.12 (1999): 1371-1375.
Neri, Brian R., et al. “Outcome of Type II Superior Labral Anterior Posterior Repairs in Elite Overhead Athletes Effect of Concomitant Partial-Thickness Rotator Cuff Tears.” The American journal of sports medicine 39.1 (2011): 114-120.
Fedoriw, Wasyl W., et al. “Return to play after treatment of superior labral tears in professional baseball players.” The American journal of sports medicine 42.5 (2014): 1155-1160.
Singaraju, Vamsi M., et al. “Biceps tendinitis in chronic rotator cuff tears: a histologic perspective.” Journal of Shoulder and Elbow Surgery 17.6 (2008): 898-904.
Brady, Paul C., et al. “Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.3 (2015): 470-476.
McClure, Philip, et al. “A randomized controlled comparison of stretching procedures for posterior shoulder tightness.” journal of orthopaedic & sports physical therapy 37.3 (2007): 108-114.
Bailey, Lane B., et al. “Mechanisms of shoulder range of motion deficits in asymptomatic baseball players.” The American Journal of Sports Medicine (2015): 0363546515602446.
Wilk, Kevin E., et al. “Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers A Prospective Study.” The American journal of sports medicine 43.10 (2015): 2379-2385.