Mild symptoms and early phases of the disorder are treated conservatively with "active rest," which includes a complete break
Box 23-3 Internal Impingement: Nonoperative Treatment Options
• Initially treated with anti-inflammatory modalities nonsteroidal auti-inflammatory drugs, ice, iontophoresis, and occasionally a corticos-teroid injection)
• Throwing cessation
• Therapy emphasizing scapular and rotator cuff strengthening, posterior shoulder flexibility, and end-range dynamic stability
• Gradual return to throwing; interval throwing program from throwing along with physical therapy. The length of time off of throwing varies. Axe25 proposes 2 days off for every day that symptoms have been present (maximum 12 weeks), but in general 2 to 6 weeks is appropriate, based on the severity and chronicity of the symptoms (Box 23-3). Anti-inflammatory measures to "cool down" the irritated shoulder can be beneficial in accelerating the rehabilitative process. This includes non-steroidal anti-inflammatory drugs, occasionally a corticosteroid injection, and physical therapy modalities like iontophoresis. Wilk et al10 described a rehabilitation protocol for the conservative management of internal impingement that emphasizes dynamic stability, rotator cuff strengthening (targeting the posterior cuff), and a scapular stabilization program. Stretching to improve soft-tissue flexibility in internal rotation and horizontal adduction is also initiated with avoidance of aggressive mobilization of anterior and inferior glenohumeral structures. Drills using proprioceptive neuromuscular facilitation patterns and rhythmic stabilization are included. Perturbation and stabilization drills at end-range external rotation are essential to improve proprioception, neuromuscular control, and dynamic stability.
A formal throwing mechanics evaluation may be helpful, particularly in the younger athlete with less specialized training. The mature athlete with altered or poor throwing mechanics may also benefit from biomechanical and professional evaluation. Once an appropriate "rest" period has passed and symptoms are relieved, throwing is resumed with an interval throwing program; however, the shoulder should be completely pain free prior to resuming any throwing activities. Intensity is advanced based on symptoms, or the lack thereof, with the goal of returning to effective throwing.26,27
One of the most challenging decisions facing clinicians who treat throwing athletes is whether surgical treatment is indicated and when the most appropriate time for surgery might be. Timing is based on a number of issues including injury pattern, degree of injury, potential for improvement without surgery, and temporal issues regarding the current and future seasons. Surgical intervention (Box 23-4) for internal impingement should be
Box 23-4 Internal Impingement: Surgical Indications
• Failure of a comprehensive nonoperative treatment program of at least 3 months' duration
• Mechanical symptoms with posterior labral signs
• Magnetic resonance imaging and examination findings consistent with internal impingement undertaken only when 3 months of a solid nonoperative protocol have failed to allow a return to activity and the physical examination and radiographic studies are consistent with this particular diagnosis. The clinician must be aware that SLAP lesions often are present in this population and will typically present with mechanical symptoms and positive labral findings on examination, thus differentiating them from internal impingement alone. Experience has taught us that throwing athletes with SLAP lesions generally fare poorly without surgical repair and a more aggressive strategy should be employed.28,29
The goal of surgery is aimed at repairing or removing any abnormalities encountered in the shoulder and addressing the underlying pathologic process, which is often anterior and inferior laxity. The difficulty managing patients with internal impingement centers on what Wilk et al10 have termed the thrower's paradox. This refers to the need for a thrower to have enough laxity so as to achieve the extreme external rotation necessary to maintain velocity, while at the same time avoiding pathologic laxity or instability. With that in mind, a detailed and closely supervised postoperative rehabilitation protocol is of paramount importance.
Our surgical approach begins with an examination under anesthesia, followed by arthroscopy in the lateral decubitus position (Box 23-5). A standard posterior portal in the soft spot is established, and a complete diagnostic arthroscopy is performed. The rotator cuff and labrum are carefully viewed from both anterior and posterior portals to gain a complete understanding of the pathology present. Rotator cuff tears are described by their location, depth, and quality of tissue. It is rare to have a partial tear in this younger population that is both less than 33% thickness and of sufficient quality to repair. Therefore, we commonly proceed with debridement of the tear back to healthy tissue. When the delaminated tissue from the torn fragment is retracted and of good quality or the tear exceeds 50% of the thickness of the cuff, then arthroscopic repair should be undertaken. This usually consists of a suture anchor at the articular margin, and horizontal mattress sutures securing the delaminated portion of the tendon back to the intact cuff.
Labral fraying can be debrided, but the labrum must be inspected carefully for any evidence of instability or a SLAP tear (Fig. 23-4). Failure to recognize and treat an unstable superior labrum will likely result in treatment failure.28 Techniques for repair of SLAP lesions can be found in Chapter 22.
Again, it is essential to understand that the underlying pathology frequently revolves around mild anteroinferior instabil-ity.12,30,31 Failure to address this problem, when present, will lead
Box 23-5 Internal Impingement: Operative Treatment
• Débride or fix the partial-thickness rotator cuff tear
• Débridement of labral fraying and stabilization of SLAP (superior labrum anterior to posterior) lesion, if present
• Arthroscopic capsular plication or thermal-assisted capsular shrinkage, when appropriate
• Strict postoperative adherence to the physical therapy protocol and close monitoring of progress is essential in obtaining a successful outcome
• Adjust therapy on an individual basis to avoid excessive laxity or stiffness
to compromised results.32 Excess laxity can be treated with suture plication of the capsule, but we prefer to use limited TACS with a monopolar device (Oratec TAC-S, Menlo Park, CA). Perhaps the most difficult aspect of the decision-making process is determining who needs to have capsular laxity addressed and just how much of a shift to perform. In general, we try to have a good feel for the amount of laxity present in the shoulder based on examination in the clinic and the examination performed under anesthesia. Intraoperatively, assessing the capsular redundancy and getting a feel for the pathology present can help direct treatment. Our technique involves prebending the application probe 20 to 30 degrees a few centimeters from the tip; this allows adequate application of the tip of the probe to the capsule around the curvature of the humeral head. Although the probe may be used through a cannula, we prefer to place it directly through the portals without cannulas in order to improve maneuverability. Initially, we employed a "painting" technique of the anterior, inferior, and posterior capsule; however, we now believe that the majority of patients require only selective treatment of the anteroinferior capsule, and we use a "striping" or "cornrow" technique. The camera is placed in the posterior portal and the anterior and inferior portions of the capsule are treated with the probe set at 75°C. Thermal treatment must be tailored to each individual shoulder, and in those that display a more global laxity picture, a portion of the posterior capsule may also need to be treated.
Burkhart et al11 have proposed that the essential lesion of internal impingement is posteroinferior capsular contracture that leads to decreased internal rotation in abduction and excessive external rotation. This, in turn, will produce a SLAP lesion and the resulting increase in shoulder laxity can be erroneously interpreted as anteroinferior instability.11,24 Their data indicate that 90% of these patients can be successfully treated with a nonoperative program emphasizing posteroinferior capsular stretching to reduce glenohumeral internal rotation deficit to an acceptable level. They believe that the 10% that fail such treatment can undergo an arthroscopic posterior capsulotomy through the diseased, contracted tissue to improve internal rotation and alleviate the problem.11
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