The athletes shoulder 2014 len funk

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Shoulder injuries in athletes. Presented at BUSEMS 2014, Birmingham. Also see shoulderdoc.co.uk

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The athletes shoulder 2014 len funk

  1. 1. Lennard Funk Wrightington Upper Limb Unit Salford University lenfunk@shoulderdoc.co.uk
  2. 2. ANATOMY
  3. 3. Deep Muscles
  4. 4. Glenohumeral Ligaments
  5. 5. Labrum
  6. 6. Posterior Inferior Superior Bankart Reverse Bankart SLAP Anterior
  7. 7. Common Injury Groups • Contact Athletes – Rugby – Football • Overhead Athletes – Swimming, Racquets, Climbing, Cricket, Track & Field • Trauma – Motorsports – Cycling – Canoeing – Horseriding • Strength Athletes – Powerlifting, weightlifting, Bodybuilding
  8. 8. Sport Popularity in UK SPORT TV Viewing Participati on Interest Football 46% 10% 45% Rugby Union 21% 6% 27% Tennis 18% 3% 23% Cricket 18% 2% 19% Athletics 18% 2% 21% Snooker 17% 5% 24% Motorsport 16% NA 20% Rugby League 12% 2% 15% Boxing 11% NA 14% Golf 11% 6% 16%
  9. 9. My Elite Athletes (2010-2013) = 663 SPORT Percentage Commonest Path. Rugby Union 37% (247) Anterior LabralRugby League 28% (182) Posterior LabralFootball/ Soccer 8% (54) Anterior LabralMotorsport 3% (22) Mixed Labral TearsClimbers 3% (20) SLAP Swimming 3% (18) Int Imping/ SLAPCricket 2% (14) Anterior LabralParalympics 2% (13) Mixed Labral TearsOthers 14% (93)
  10. 10. Repetitive Overhead Acute Trauma
  11. 11. "In an instant I knew my tour was over 
 and I could feel the tears coming," “I felt like a drowning man, I wanted to shout for help
 but nobody could hear me.”
  12. 12. How can we help him? • Technical Skills • Knowledge: – Risk factors – Mechanism of Injury – Pathology – Effects of our surgery • Recurrence Rates • Complications
  13. 13. Predisposing Factors • Player: 1.Laxity
 Cheng et al. JBJSB 2007; 
 Akhtar & Robinson. BJSM 2010 2.Proprioception
 Herrington, 2011 3.Isokinetics
 Jones & Funk, 2010 4.Mass 5.Running Speed 6.Aerobic ability 7.Previous Injury • Sport: 1. Speed of play 2. Timing 3. Fatigue 1. Physical 2. Mental
  14. 14. Forces
  15. 15. “The new GPS system which we wore during the Four Nations - attached to a man bra under our shirts - consistently showed us that we were taking impacts of 10 gs and upwards during a match.! The gravity force of a car travelling at 100km/h that comes to a stop in 0.2 seconds is 14.2 gs. And we don't have airbags!” ! Jon Wilkin, Feb 2010
  16. 16. Injury Reduction Predispostion Model Meeuwisse
  17. 17. Common Sports CONTACT / COLLISION OVERHEADFLEXIBILITY
  18. 18. Recurrent Instability Rates (after arthroscopic stabilisation) [Cho et al. Arthroscopy 2006] CONTACT / COLLISION OVERHEADFLEXIBILITY 29% 7%
  19. 19. Recurrent Instability Rates in Contact Sports • Non-operative = 80% [Arciero, 1994] • Open Bankart repair = 12% • Arthroscopic Stabilisation = 14% [Larrain, 2006] – First dislocation = 4% – Recurrent dislocations = 24% – Under 18yrs age = 30% [Nixon & Funk, 2013]
  20. 20. • RCT of Latarjet vs. Arthroscopic Bankart • Recurrence rate at 5 years: – Latarjet = 12% – Arth. Bankart = 24% • Return to sport the same! • Complication Rates higher (20%) Latarjet Procedure [Bessier et al. JOST. 2013]
  21. 21. Recurrence Summary • Higher in contact/collision sport • Higher in young • Higher after surgery for recurrent dislocations ! • Arthroscopic = Open Bankart • Lower after Latarjet procedure
  22. 22. WHY?
  23. 23. Overhead Athletes Lo, Hsu & Chan - BJSM 1990
  24. 24. • Tackling Fatique = Reduced JPS • End of range only Proprioception & Fatigue Herrington et al. Phys Ther Sport. 2008
  25. 25. Laxity • ‘Lax’ shoulders = higher risk of dislocation in rugby – Cheng et al. JBJSB 2007 • High Beighton Score = higher risk of dislocation in sports (not just contact) – Akhtar & Robinson. BJSM 2010
  26. 26. Isokinetic Strength Nathan, Jones & Funk. SECEC. 2011 1. Those players that had rehabilitation following injury and surgery had better strength & stability than those without any shoulder injury. 2. Poor Isokinetic strength may be a risk factor for injury 3.Current rehabilitation methods are effective 4. Suggests this should applied to those that have not yet suffered injury.
  27. 27. Common Injuries
  28. 28. Mechanisms of Injury video analysis study Direct Impact Complex Labral Bony Bankart PTCT Flexed Fall Posterior Labral RHAGL Try Scorer Bankart SLAP Rotator Cuff Tackler Bankart SLAP HAGL Crichton, Jones & Funk - BJSM 2012
  29. 29. FOOTBALL • SHOULDER: ! • 2-4% of all injuries ! • BUT: – Longest period of time away from
  30. 30. Incidence Mills, Pritchard, Funk & Batty, 2010 0 27.5 55 82.5 110 2006 2007 2008 2009 2010 45 46 84 98 104 34 63 91 94 99 Left Right
  31. 31. Player Position • 25 Professional Footballers – 15 Field players – 10 Goalkeepers Hart & Funk, KSSTA 2013
  32. 32. Clinical Examination: Instability in Athletes • True Instability – Dislocation – Subluxation – Apprehension – Large lesions • Subclinical Instability – Dead Arm in ABER – Pain in ABER – Clunking – No Apprehension – Smaller lesions
  33. 33. Investigations • No previous Surgery = MR Arthrogram ! • Previous Surgery = CT Arthrogram
  34. 34. MR Arthrogram v. Scope Sensitivit y Specificity Accurac y SLAP 0.42 0.92 77% Rotator Cuff Tear 0.50 0.86 83% Hill Sachs 0.91 0.78 90% Bankart 0.85 0.83 86% N Karlson, J Geoghan, L Funk; 2008
  35. 35. • An experienced Shoulder Surgeon better • Can correlate with clinical context
  36. 36. Classification of Lesions Major ‘Minor’ • Bony Bankart! • ALPSA! • Rotator Cuff Tear! • HAGL! • Undisplaced Labral Tear! • Partial Cuff Tear!
  37. 37. Timing of Surgery • Early Surgery: – ‘Major’ lesions – Late in Season – Unable to Return • Rehab & Return: – ‘Minor’ lesions – Early season
  38. 38. Types of Surgery • Mostly Arthroscopic Direct Repairs • Latarjet for High-Risk/Revision
  39. 39. • Anterior Instability – Revision surgery (even without bone loss) – Chronic Bony Bankart (> 3months) – Any Bony Glenoid Loss – True dislocation in Front Row forward (Rugby Union) – Higher level of sports Latarjet in Athletes
  40. 40. • Player-specific - tailored to suit the player’s age, position, requirements, surgeon and therapists. • Not ‘accelerated’ or ‘aggressive’ or ‘time specific’. • Surgery-specific - dependent on the quality and type of fixation achieved. • Protocol is a ‘guide’ and not a prescription. • Phase Progression - when the patient is able to perform all of the exercises in the previous phase without any discomfort or apprehension. Each phase is introduced progressively. Ben Macdonald, Mike Lancaster, Meiron Jones, Doug Jones, 
 Christine Holmes, Kathleen Tatlow, Lennard Funk - 2004 Sports Specific Rehab lenfunk@shoulderdoc.co.uk
  41. 41. Sports Specific - Javelin http://kellybram.wordpress.com/
  42. 42. Rugby Rehab Protocol lenfunk@shoulderdoc.co.uk
  43. 43. Rugby Results ‘03-’05 Pain Satisfaction (%) Playing at previous level Pre-op 5 11% 0% 3 months 10 87% 89% 6 months 12 93% 94% L Funk , K Roney, 
 CJSM, 2007
  44. 44. Time to return to play L Funk , K Roney, 
 CJSM, 2007
  45. 45. Return to Play Repair! Months-post.op! SLAP! 2.6! Ant.*&*SLAP! 3! Post.*&*SLAP! 4! Ant.*Post.*&*SLAP! 5.5! L Funk , K Roney, 
 CJSM, 2007
  46. 46. Arthroscopic Stabilisations 0" 1" 2" 3" 4" 5" Ant" Post" Both" Time"(months)" Fourie & Funk, 2009
  47. 47. Return to play by time of 0" 1" 2" 3" 4" 5" Begin" Mid" End" Out" Time"(months)" 63% of all operations took place in the last three months or out of season Fourie & Funk, 2009
  48. 48. 0" 1" 2" 3" 4" 5" 6" ≤20" 21*29" ≥30" Time"(months)" Return to play by age Fourie & Funk, 2009
  49. 49. Creighton et al. CJSM 2010
  50. 50. Recurrences & Revisions • 8/143 = 5.6% at 2 years • All recurrent trauma • 4 treated with Latarjet Procedures
  51. 51. 1. High demand; High forces; Fatigue 2. Increased Injuries & recurrence risk 3. Understand 4. Recognise 5. Appropriate imaging 6. Customised Surgery 7. Timing of Surgery 8. Sports-specific Rehabilitation Athlete’s Shoulder
  52. 52. lenfunk@shoulderdoc.co.uk THANK YOU

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