Shoulder pain in the throwing athlete was at one time attributed to subacromial impingement, even though we now know that this is a rare entity in the young population. Tibone et al35 were the first to report the lack of success treating throwers with "chronic overuse disorders" by acromioplasty. Only 43% of the patients (including just 4 of 14 pitchers) returned to their preoperative level of competition following surgery. Acromio-plasty alone was used with unflattering results by Kvitne et al.4 Andrews et al36 treated athletes with debridement of both rotator cuff and labral pathology, resulting in a 76% return to same level sport. Payne et al22 reported on debridement of partial-thickness rotator cuff tears, noting decreased return to competition when instability was present in addition to a tear. The patients with a history of an insidious onset of symptoms were much less likely to return to their preinjury sports level (45%), and this probably represents the patients with true internal impingement. Glasgow et al29 identified similar findings when studying débridement of labral tears; patients with increased glenohumeral laxity did not fare as well postopera-tively when compared to throwers with stable shoulders.
It was becoming clear that the rotator cuff tears and labral pathology noted in throwers' shoulders were not the primary underlying problem, but instead the result of a cascade of events leading to mild anteroinferior instability. Failure to recognize and address this pathologic laxity has compromised surgical outcomes. Armed with that knowledge, Jobe et al31 retrospectively reviewed the cases of 25 overhand-throwing athletes who failed conservative management and were then treated with an open capsulolabral reconstruction. Eighteen of the 25 athletes returned to their prior competitive level for at least 1 year. Altchek et al37 proposed a less invasive method of addressing the anterior capsule through a horizontal capsular incision. The use of open stabilization was improving overall results, but continued to be somewhat unpredictable in returning athletes to the same level of play.
At our institution, James Andrews began using TACS to address the instability associated with internal impingement in overhead athletes in July 1997. The addition of thermal energy represented an evolution in the overall approach to athletes with this malady. This prompted us to undertake a two-phase retrospective study to investigate the effects of adding TACS to standard treatment for internal impingement in the thrower's shoulder.32 In phase I, group A consisted of 51 baseball players treated surgically between January 1, 1995 and December 31, 1996. Forty-nine of the 51 patients demonstrated increased glenohumeral laxity on examination under anesthesia. Forty-four of the 51 demonstrated partial-thickness rotator cuff tears that were débrided, and 40 of 51 had evidence of labral pathology (13 treated with repair and 37 with débridement). Capsular laxity was not addressed in this subset of patients. The phase I, group B patients included 31 baseball players who underwent shoulder arthroscopy between July 1997 and December 1997. Treatment was the same as group A except for the addition of TACS to address capsular laxity. Both groups maintained at least 2-year follow-up.
In phase I, group A (no TACS), 80% (41/51) of players returned to play. The mean time to return to competition was 7.2 months. At 2 years postoperatively, 67% of individuals were still competing, with 61% at the presurgical level or higher. In group B (TACS), 97% (30/31) returned to competition at an average of 7.4 months, and 87% were still competing at the same level or higher 2 years after the procedure. Although patients treated without TACS fared relatively well initially, they began to lose their ability to compete at the same level over time much more so than the TACS subjects. Of the group A patients without a repairable SLAP lesion, 71% were still competing at 2 years versus 100% of similar patients in group B. If a SLAP repair was performed, the numbers worsened for both subsets of patients (group A, 50% and group B, 73% at 2 years). Average loss of external rotation measured 7 degrees.34
Phase II of the study addressed the association of SLAP lesions and anterior capsular laxity. This limb of the study dealt with elite throwers and found that adding TACS to a SLAP repair in throwers with internal impingement increased return to play from 42% (no TACS) to 91% (with TACS augmentation). This retrospective study provides strong evidence that addressing capsular laxity at the time of arthroscopy can significantly improve the most important outcome measure in this population—return to play at the preoperative level of competition.
Reinold et al34 studied 130 overhead athletes at an average of 29.3 months following the use of TACS to augment treatment of internal impingement. Eighty-seven percent of subjects returned to competition at average of 8.4 months following the procedure, and at latest follow-up, 88% reported a good or excellent result. They concluded that TACS of the gleno-humeral joint is a viable option for overhead athletes with pathologic instability.
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Since World War II, there has been a tremendous change in the makeup and direction of kid baseball, as it is called. Adults, showing an unprecedented interest in the activity, have initiated and developed programs in thousands of towns across the United States programs that providebr wholesome recreation for millions of youngsters and are often a source of pride and joy to the community in which they exist.