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IC 102-2023: Common Shoulder Problems in Overhead ...
IC 102 - Common Shoulder Problems in Overhead Athl ...
IC 102 - Common Shoulder Problems in Overhead Athletes: Surgeon Beware- This Isn’t Always So Straight Forward An Interactive, Round Table, Case-Based, Problem Solving Session (2/3)
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Video Transcription
So we know that this is what it is, but we'll try to give some hints on how to do this. This is sort of the guidelines. So this was a 19-year-old college rugby player. Rugby's a club sport at Tulane. We have male and female rugby, so we got to actually see a little bit of it. He was making a tackle, normal tackling, felt a burning pain in his arm, specifically did not dislocate, but his shoulder felt wrong. That's what he said. Not the toughest kid in the world, even though he's a rugby player. Tried to keep playing because rugby is continuous. You don't really get to come out, and they don't like to do injury timeouts. But his arm just didn't feel right when he made a tackle, and a quote in him was that basically it wouldn't do things. And so he couldn't explain it, it just wasn't right. And so pain kind of continued. His dad's a doc, and so they got some x-rays. X-rays were normal. That was in his clinic. Started doing some rehab with a therapist, and felt like his shoulder was moving a little bit. Again, no dislocations. It just didn't feel like it would sit in the right spot when he tried to do bench press, when he tried to do overhead press. And again, continued to play a little bit. So the questions, and maybe for discussion, we'll stop in a minute, is he's a rugby player, so it's a little bit of a different sport. So what are the characteristics that's kind of putting you going one way or another? He's 19, so you're not really looking about cuff stuff. Can you brace and play? And then what is your next step if you have a suspicion? Are you going to do a plain MRI? Because half these kids come in with plain MRI already. CT scan, MR arthrogram. If it's shifting and he's having a little bit of trouble with strength, is that one of the problems? And then shoulder injuries are very common in rugby, and we're going to see more of this, I think, in the NFL because they're teaching rugby tackling, but I'm going to skip this one and go, because this is his MRI, and on the picture on the right, radiologist put an arrow down so you could take a look at it. It's usually not this dramatic in terms of what you're looking at, but let's see if this will show. So here, this is sort of what's left of the capsule. There's nothing attached here. You have this big absinthe. This is actually, right here, his inferior capsule. That's supposed to be attached over here. And then the other one then on the lateral is that you see dye outside here kind of under the subscap. Normally, and this is a different one, this is a young lady that we did, also a rugby player, much more subtle. So when you look at this one, you can see that it's not attached here. That's the end of the capsule right here. So it's not as dramatic as his. And then again, to me, this dye leaking through the capsule but kind of under the subscap, I think that's pretty critical when you take a look at that. So that's, those are two different images of this kind of lesion. So questions to, we'll stop at for a second, and these are arthroscopic pictures. Obviously the top one is his, but he's in season. Rugby's a big deal for him. Can you let him play? Number two, can you brace him and let him play? And if you're going to brace him, what kind? And then what is the risk of further damage, because this is a different entity, right? And so we know that he has a humeral avulsion. He really doesn't have a labral tear. And so, but can these things get worse or can it tear further if he plays? So I think we'll stop here for a second and let everybody talk about it. All right, so let's get some consensus here. I told Jim, his dad brought him in and said, I don't know what's wrong with him. He's just a baby. He won't play. He needs to play. So it's very interesting there. So quitting the sport was, he was sort of trying to decide, but he really liked the sport so that's not really an option. So how many would try to brace him, do a little bit more, maybe more targeted rehab and let him play? It's a club sport, all right? And then how many would take him to surgery right away? All right, so that's pretty much 50-50. So who wants to talk about brace and play? I'm a big brace player. All right, then why would you operate right away? Ben. He has no floor. The fact that he doesn't feel right just walking around means that he has no floor. My main concern is how hard is it going to be for me to do surgery six weeks or eight weeks down there in that snake pit with all that stuff right there. Let me get that piece. I know where it is. Get it fixed as soon as I can. The snake pit being the axillary nerve. Let's define what we're dealing with there. Can I make a comment to that? Yes. So most of these patients, first of all, there's not a lot of natural history about haggles like there are about bankruptcy, number one. Number two, there's probably seven or eight different types of haggle. Most of them have very small labral lesions because all the energy went to the lateral side of the joint. The third thing is if you look at a sagittal MRI, and you may not have one, but if you look at the sagittal MRI and it's done either with contrast or it was done early and there's then you can actually see the extent of how much the IGHL is involved. If it's the whole IGHL, in my opinion, you should repair those open. And you can do those with a subscap sparing and be right on top of it. It's actually pretty easy. If it's just the anterior... Subscap split or sparing where you take the bottom down and really go find the whole thing and put your ankle at the bottom. Go between the muscle and the tendon. You can take a teeny bit, but you can leave the upper two-thirds absolutely virgin. You don't even have to touch it to get at it. If on the sagittal it only goes to six o'clock, you can probably fix that with a scope. But I think when they're dead entire IGHL, you have to do those open. And I think it's the same thing where these patients don't necessarily complain of overt instability. They're more vague. My shoulder doesn't feel right, just like this kid. It doesn't feel like it's in the right place. It's not as strong. It's a more vague symptomatology. But I know we've had kids play a whole season with these and then fix them. And they don't have, at least in the ones I've treated, they don't have bone loss. There are very few that have bone loss with this lesion. Larry and I wrote this paper on floating capsules a long time ago where they had both lesions. It's actually pretty rare. It's more common posterior to have a posterior vanguard and a raggle than a true haggle. So that's one of the things. The second thing is how many of you have seen a haggle lesion? Raise your hand. Okay. And how many people have done more than, say, 50 instability shoulder surgeries? So it happens. It's somewhere between 2% and 10% probably of shoulders. So if you've done more than 50 and you haven't seen it, it's probably seen you. And so I was just telling Jim, I just had a kid come in from one of the colleges. His third surgery and things didn't feel right. He had a couple of Bankart repairs. And then when we looked in, the first thing you saw was this big haggle. It actually opened him. And we'll talk about that in just a minute. But a bunch of different reasons. But this is what it looks like. When you look down the front, so this is sometimes some of these you see muscle through it. And sometimes it's just kind of frayed at the bottom. And then, as Bob said, this is our lesion here. This is one of ours that when you see this, that's a problem. Because this is a long time. This is where you're talking about delaying it. And then the capsule actually contracts, I think, in the front. It's very difficult to free it up arthroscopically. You go down to the bottom and all of this is torn. The edge is here. To try to pull that back is going to be a bit more difficult in trying to go all the way around the bottom. And so these are ones where you just have to have a suspicion. Because it doesn't fit the normal pattern. And the problem sometimes is they'll come in with a plain MRI and it doesn't show. And so if you're having those symptoms and they've had a plain MRI and nothing else is working, and the MRI is pretty much read as normal labral frame kind of thing, then you really want to do an MR arthrogram. So this is another one. This is a 6 o'clock haggle. And I usually do these arthroscopically. My partner, Dr. O'Brien, does them open. So we'll talk about that in a minute. So he tried playing in a brace one match or a couple of practices, and then he tried to play in a game and it just didn't work out. It just never felt right to him. So then the dad decided that he needed it fixed. And so now the question back to tables. Arthroscopic or open? So you guys should talk about it a little bit and see, because we've already started that discussion with Dr. Arciero. But how would you fix this? We'll take a timeout. We're going to vote. We'll be right back. I think we've had good discussion. How many people would do arthroscopic? And how many folks are going to do it open? Alright, so JT, why open? What does your table say first? Yeah, so we talked about this as a challenging situation. I think that arthroscopic has some challenges. The first is, number one, this guy's a contact athlete. So you're starting from behind because a contact athlete's going to have a higher failure rate with an arthroscopic technique. But do we know that with Haggles? We do not know that with Haggles. There's no data on that. That's correct. And then Remplissage, people are going to scope it and say, well, because on your axial image it did look like there might be a little high signal there, so it might have a CT. But then again, I don't like, Bob has taught us this with the Yang study in, I think, 2019 or so, where contact athletes failed at about 30% with Remplissage. I don't think that's a good idea. The open Bankart here, if you will, the open Bankart equivalent here, is an awesome approach for this. And you're right there, as you say. So I think this one's an open approach all day long, allows you to get to the whole thing, and you can reinforce that caption pretty well. Right. And arthroscopic. There were several people who raised their hand. Anybody want to take the scope part? Oh, that's a shame. But, Buddy, I mean, you know, I think it's sort of the pathoanatomy dictates, and you can see it if you have a good image and you have contrast. If you get an MR within 10 days of a significant instability, the blood will be in there. You don't need to stick them, and you'll see it pretty well. Right. Jim? Let me ask you this question. You know, we have fellows in residence all the time. I have fellows that come to our program that do not know how to do an open Bankart. They do not know how to do the anterior approach to the shoulders. And my point is, you know, we teach them it, but this is an anterior approach, but you got to get comfortable with that anterior approach. So, but they do total, but a lot of them do total shoulders in reverses, right? Yeah. So, it's not, and in fact, I would argue, you're totally right. I mean, when you talk about open Bankarts, it's just simply no exposure. But for this particular one, where you don't really have to have that finesse of either splitting the mid, you know, two-thirds, one-third, or taking the subscap off, which is tricky. It's very hard to do. You don't really have to do that on this. You can, Joe DeBeer says, you just separate the muscle above the circumflex vessels, and you'll see this lesion. I think sometimes you have to make an L up northward just a little bit, but I think it, don't you think it's easier than, an easier process for them to, our younger residents and fellows to accept because they do total shoulders in reverses? I don't think so, Bob. You know, the reason is, I think that when most of the fellows and residents, when we do a total shoulder, you're taking down that as a keel with that subscap. There's no finesse in managing the subscap in the three-quarters. And so they take that thing off. I think, as you have taught us, maybe more than anybody else, the subtleties of handling that subscap and managing that in an open vanguard is truly an art form. I put holes in it all the time. So this is, this was him. It went all the way down around the bottom. We put an anchor, this is actually looking from top down, and that's how you start repairing it. And we kind of zipped him up from bottom up. I do them with scope, but sometimes they'll say... Yeah, so what I do is I'll pass, let's see, let me back up a little bit. No, it's hard. Alright, so this was one, and this is to show you the beginning of the repair. So this was a different one. That's six o'clock, and then it came, it went up the front and then a little bit around the back. And so what I will do is I'll pass a stitch from back and front. So I'll put it in, put the stitch in, retrieve it through the front edge and then through the back edge of it and then place it up and put it with a little knotless anchor that first stitch, and that pulls the bottom one back up. So the anchor is really at either 6.30 or 7.30 instead of directly at 6 o'clock. There's no way to get it in here, so if you want to put it in the back, which is easier when you get started and then finish the front, is you just internally rotate the arm a little bit after you have your stitches in and it brings that bottom up and you put it right there. And then you bring it back, pull back, and then you can go up the front. And you know, the one thing I would tell you is I think this is a very difficult surgery. I've got a couple of them from a long time ago that just a massive struggle. And you can see how hard it is. This one we got it relatively acutely, we were able to peel him off and it went very nicely on his right shoulder. So this front to the left, and that's us passing the stitches around and tying it up, so you just saw that. I would say that, and this is another one, this is him, and then he just returned back to rugby, he's doing fine, he rehabbed really well, much tougher than his father thought he was going to be. And this is, I was just reading this, so I apologize, I didn't download it and everything, this is just me shooting a picture of an article that I was reading this one, and this was kind of a combination of veil and it's a series of haggles that they did, and about a third of them were done open and two-thirds were done arthroscopically, and there's really no difference in the two. And so one of the things, I think, if there's some takeaways, you know, rehab is big, Albert talked a little bit about this, for us, we do a lot of overhead plyometrics, especially with our contact sports, just doing all of this, and you know, other countries have much more experience with rugby than the U.S. does, and so you want to look over there, France and Argentina and places like that, and especially Australia, New Zealand, and South Africa, because they really will tell you what to do. They do have a high instance of bone lesions. This guy had no bone loss whatsoever. So it's usually good results, so number one, you've got to look for it, and then number two is an MR arthrogram. I would say that, and I don't think Mattson has any disciples here, but Mattson used to do his open bank cards by doing a tenotomy of the subscap and just laying it open, and then repairing the capsule and cinching it back up, and for haggles, I wouldn't even worry about a split. I would just go ahead and make a little tenotomy, like Bob talked about it, the bottom third, that's really just muscle, open it up, and then you're looking at everything, you know where the axillary nerve is, and it is a pretty easy approach. As Jim said, you've just got to be a little more delicate with your soft tissues, so that's one of the things we try to show our folks, but again, it's kind of a lost art on how to really manage that gently. It's a lateral approach. It's easier than a bank card, because once you cut the subscap, you're right there, and then you can see the capsule, and you can decide how you want to put it up, and it's an easy shot for the anchors, and then you can put your finger on the axillary nerve and keep it out of the way. Anyway, thanks. Thoughts? Concerns? Mike, you're back up. It was interesting, I was talking to Ed from Washington State, we were looking at, a lot of you probably read that web-based longitudinal, one of them was on the haggles, Brett Owens, and you guys, I'm seeing more of the capsular rents in the throwers and the volleyball players, and in that article, they call them the app haggle, the axillary pouch haggle. Those are truly a, when you see them, they're a little bit like the example you showed, but it's almost like a slit. It's almost in the pouch. It's not necessarily a... So I think, I'll go back here. I think there's some anatomical variance on the infracapsule where there's some little splits and separations, nothing bad. And then the ones where they're symptomatic and it's interesting because they're symptomatic and you pull down and it sort of reproduces their symptoms, and then as you abduct them and try to push down, it pretty much goes away because in some of these, the anterior and posterior bands are intact. So those, when you abduct and push down, in my opinion, I don't think you need to fix those. I think your anterior and posterior bands are intact and it's very subtle, subtle symptoms. But then when it starts to extend, like anything, then you want to repair it. But usually if you're there operating and you see that, I think you ought to fix it because it's part of the pathology. Kind of like Jim was talking about closing the posterior portal because you want to restore the integrity of the entire capsule. Do you think that's a... I've had a lot of experience with those splits because our radiologists at Barclays is really good, and they'll read these haggle lesions. So we had to have a discussion with them because I didn't want them to read them like that. Because every time we'd go in there, most of them, it was just a split. You know what I mean? And it was nothing more than a split. But some of the dye would leak out. And now you've got this haggle lesion on the MRI report. That was what was bothering me. And I said, Jeff, I haven't fixed one of those splits ever. And our results are very good. It's the ones that Buddy showed where that whole thing, it looks like a J. That little J there, that's the one we've been fixing. Those are, when you talk about in that group, do you think that's an accumulative lesion, or did it happen with one lesion? What do you think when you see those? Just because you said they're swimmers, they're repetitive overhead people. I think it probably happens with time. And it's subtle. We had a Stanford pitcher, and Dr. Stafford and I were trying to figure this out for a while. Actually, John Conway, we talked to him about it. He goes, I bet you anything it's a capsule of rent. And in this kid, it was. It wasn't just a split. It was a little more involved, and we repaired it with just PDS, something that would resorb. And the kid got back, and he's pitching in pro ball now. Was the rent in the anterior ligament? Well, on the pouch side to it. Yeah. We'll shoelace them and put it back in. That's kind of a different one. I'm talking about at 6 o'clock, there's going to be a little split. It'll be about that big. Jim, can I ask you a question? If you go through the effort of closing a posterior portal, which may be 5, 6 millimeters because you want to maintain the integrity of the entire capsule, but you're going to leave a split where there's a disruption of the capsule alone, explain to me how you make that decision and the rationale for that. If it's important to close that posterior portal for capsular integrity, but it's okay to leave a split because clearly there's disruption of the capsular integrity if there's a split, right? Yeah, I'm worried about giving him a contraction down there. That's what I'm worried about. And the tissue isn't great down there. So I'm worried about limiting his motion when I do that. I'm not going to limit his motion in the back. So do you think that that split is an adaptive change similar to maybe the hypermobility of the posterior superior labrum? That's what I've seen all the time. Explain how you differentiate a pathologic one where you think you need to fix it. I think you were just touching on that with your shoelace technique and the like. Because we're talking about a lesion that's not truly a haggle lesion. It's not a humeral detachment. We're talking about a split within the capsule itself. So the splits, this is what I do. The splits that are anterior or inferior in that anterior or inferior band, those are the ones I'll do that shoelace technique and put it in with an anchor. I definitely fix those. I think that that band is very important. The ones that are straight up and down at the 6 o'clock position down there, they're a little like that. I've been leaving them alone forever. I just don't want to put that, you know, bunch it up down there. But I think, Mike, the one you're talking about is not that little 6 o'clock position. It's more up at 4 o'clock. Well, that's different. It's on the pouch side of the anterior-inferior glen-humeral ligament. I'll make it even more confusing. If you have someone that's a swimmer, a pitcher, a gymnast, and they don't have a little bit of generalized laxity, and they're doing a sport that requires increased laxity of the shoulder, they're going to have adaptive splits. And so if you do a bait, we actually have a 15.2-lane score for hyperlaxity. And if you're in the higher numbers, you know, 10, 11, 12, 13, you're very loose-jointed, and they're never going to have that. They just have the lax capsule. But if they're tight, you know, if they're baiting like 3, 3 or 4, and they're very tight-jointed, and they're trying to swim or do something where they require hyperlaxity, that capsule has to have little splits in it. I'm not disagreeing with you on that. What I'm trying to get to is... If you get to surgery... Which ones you address and which ones you leave alone, right? And that may be part of it, their overall ligamentous laxity. I think the location and the pattern of it is part of it. And I'm just trying to help myself and the attendees understand sort of that decision-making. I think you need to fix every one of those. Well, I think the other thing to look at is in your female athletes, when they have traumatic instability, they almost always have a haggle lesion somewhere. And I fix every one of those. And I'll do it first and then tension the capsule on the glenoid side, but you could do it the other way if you wanted. But it's no different than when Bob does an open Bankart, and he does the Bankart, and then he tensions the capsule on your way out. Or at least that's what you've always told me. So, yeah. So you do that, you do it open, you should do it with a scope. Alright. Well, thanks. Thanks to everyone for coming, and please hopefully give us a good review. Real quick, if the faculty could stick around, and Bob, and thank you again. If there's any questions, let us know. Thanks. Thank you.
Video Summary
The video discussed a case of a 19-year-old college rugby player who experienced a shoulder injury while making a tackle. The player felt a burning pain in his arm and his shoulder felt wrong, although no dislocation occurred. Despite the discomfort, the player continued to play with the injury. X-rays initially appeared normal, but further examination with an MRI revealed a capsular lesion called a haggle. The haggle presented as a tear in the inferior capsule, with dye leaking outside the capsule near the subscapularis muscle. The video discussed the appropriate next steps for treatment, including whether to let the player continue to play with a brace or proceed with surgery. The pros and cons of arthroscopic and open surgery were also discussed. The video emphasized the importance of rehab and targeted exercises in the recovery process, as well as the role of MR arthrography in diagnosing haggle lesions. The speaker also highlighted the prevalence of shoulder injuries in rugby and the increasing adoption of rugby tackling techniques in the NFL. The video concluded with a discussion among the panelists about their opinions on the best course of action for the player's treatment.
Asset Caption
Felix Savoie, MD
Keywords
shoulder injury
rugby player
capsular lesion
haggle
MRI examination
surgery options
rehabilitation process
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