Shoulder:The Shoulder in Athletes - Revision history

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Alexandre.laedermann at 23:33, 10 July 2021

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 In a 2013 article, Kibler et al. further refined their analysis based on their well-known and widely circulated protocol. They review all dysfunctions to be corrected, insist on the value of rehabilitation and recommend caution before considering a surgery because the tears are often adaptive.
-Since surgery rarely allows return to sports at the same level, prevention plays an important role. Kibler et al. are very critical when analyzing the results of surgical treatment, which are highly variable, probably due to the very different selection of patients from one author to another, but there is also no precise postoperative follow-up of the tears treated, their localization, concomitant pathologies, and the type of postoperative rehabilitation protocol. Patient motivation is also difficult to gauge. It is therefore important to identify shoulders at risk, typically where one shoulder is lower than the other, with internal or glenohumeral rotation deficits (''Figure 14'') and scapular dysfunctions or ‘SICK scapula’ (please, refer to clinical examination).
+Since surgery rarely allows return to sports at the same level, prevention plays an important role. Kibler et al. are very critical when analyzing the results of surgical treatment, which are highly variable, probably due to the very different selection of patients from one author to another, but there is also no precise postoperative follow-up of the tears treated, their localization, concomitant pathologies, and the type of postoperative rehabilitation protocol. Patient motivation is also difficult to gauge. It is therefore important to identify shoulders at risk, typically where one shoulder is lower than the other, with internal or glenohumeral rotation deficits (''Figure 14'') and scapular dysfunctions or ‘SICK scapula’ ( S: Scapular malposition, I: Inferior medial corner prominence, C: Coracoid pain and malposition, K: Kinesis abnormalities of scapular movements; please, refer Clinical Examination/Inspection section).
 [[File:1562634000435-lg.jpg|center|thumb|600x600px|''Figure 14.'' Internal rotational deficit or glenohumeral internal rotation deficit (GIRD) and increased total range of motion, deficit total range of motion deficit with external hyperrotation at the expense of internal hyporotation. Glenohumeral internal rotation deficit (GIRD) > 20 degrees characterize a shoulder at risk. ''Reproduced from XX with permission.'' ]]
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 =====Inspection=====
-The following must be checked: A shoulder that is ‘too low’; Atrophy (supra- or infraspinous fossa) suggesting a neurological diagnosis; Scapulothoracic dyskinesia (SICK scapula; S: Scapular malposition, I: Inferior medial corner prominence, C: Coracoid pain and malposition, K: Kinesis abnormalities of scapular movements, ''Figure 17''). Static scapular malposition in 3 directions in reference to contralateral shoulder (''Figure 17''): inferior - difference in vertical height (cm); lateral - difference in lateral displacement (cm); abduction - difference in angular degrees of medial scapular margin from plumb midline
+The following must be checked: A shoulder that is ‘too low’; Atrophy (supra- or infraspinous fossa) suggesting a neurological diagnosis; Scapulothoracic dyskinesia (SICK scapula; ''Figure 17''). Static scapular malposition in 3 directions in reference to contralateral shoulder (''Figure 17''): inferior - difference in vertical height (cm); lateral - difference in lateral displacement (cm); abduction - difference in angular degrees of medial scapular margin from plumb midline
 [[File:1562635351134-lg.jpg|center|thumb|300x300px|''Figure 17.'' Twenty-six-year-old female tennis player suffering from chronic shoulder plain. Inspection reveals a low and lateral scapula (black arrow), an augmented distance between the scapula and the median line (white arrow) and a preeminent inferomedial border (circle). ''Reproduced from XX with permission.'']]

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 ===Etiology===
-Swimming is a unique activity because it requires primarily the upper body for the propulsive force, with 90% of the driving force provided primarily by the torque generated from the shoulder. To swim at an elite level, each swimmer must log between 60,000 and 80,000 meters per week, which is equivalent to 30,000 strokes per arm. Fundamentally, the swim stroke requires the shoulder to move to range-of-motion extremes while tremendous muscular force is exerted upon the shoulder.<ref>Demarie S, Chirico E, Gianfelici A, Vannozzi G. Anaerobic capacity assessment in elite swimmers through inertial sensors. Physiol Meas. 2019 Jul 03;40(6):064003</ref><ref>Lee M, Szuttor K, Holm C. A computational model for bacterial run-and-tumble motion. J Chem Phys. 2019 May 07;150(17):174111</ref><ref>Yuan ZM, Li M, Ji CY, Li L, Jia L, Incecik A. Steady hydrodynamic interaction between human swimmers. J R Soc Interface. 2019 Jan 31;16(150):20180768</ref>
+Swimming is a unique activity because it requires primarily the upper body for the propulsive force, with 90% of the driving force provided primarily by the torque generated from the shoulder. To swim at an elite level each swimmer must log between 60,000 and 80,000 meters per week, which is equivalent to 30,000 strokes per arm. Fundamentally, the swim stroke requires the shoulder to move to range-of-motion extremes while tremendous muscular force is exerted upon the shoulder.<ref>Demarie S, Chirico E, Gianfelici A, Vannozzi G. Anaerobic capacity assessment in elite swimmers through inertial sensors. Physiol Meas. 2019 Jul 03;40(6):064003</ref><ref>Lee M, Szuttor K, Holm C. A computational model for bacterial run-and-tumble motion. J Chem Phys. 2019 May 07;150(17):174111</ref><ref>Yuan ZM, Li M, Ji CY, Li L, Jia L, Incecik A. Steady hydrodynamic interaction between human swimmers. J R Soc Interface. 2019 Jan 31;16(150):20180768</ref>
 ===Epidemiology===
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 *Middle recovery
-It is important for the athlete to have a properly balanced shoulder regarding muscle strength. Improper muscle balancing can cause the onset of shoulder pain.  An absolute or sudden increase in training yardage and poor technique can also be associated with the onset of pain. The coaching staff can observe a dropped elbow during the recovery phase of the freestyle stroke as one of the early signs of possible injury.
+It is important for the athlete to have a properly balanced shoulder regarding muscle strength. Improper muscle balancing can cause the onset of shoulder pain. An absolute or sudden increase in training yardage and poor technique can also be associated with the onset of pain. The coaching staff can observe a dropped elbow during the recovery phase of the freestyle stroke as one of the early signs of possible injury.
 ===History and Physical===
@@ Line 389: / Line 389: @@
 ===Evaluation===
-Plain radiographs are obtained initially to rule out any abnormal anatomic variations. Following evaluation by a sports medicine physician, an MRI may be ordered to better identify pathology in the muscles, tendons, ligaments, and cartilage or to exclude other structural causes, such as labral cysts. Although many shoulder diagnoses can be reached based on the physical examination alone, MRI is useful in confirming a diagnosis or when shoulder pain appears to have more than one source. An MRI arthrogram can be considered when a labral or tendon tear is suspected, Although imaging is an important part of the diagnosis, caution is warranted in interpreting imaging because repetitive motion creates asymptomatic pathology in many athletes.
+Plain radiographs are obtained initially to rule out any abnormal anatomic variations. Following evaluation by a sports medicine physician, an MRI may be ordered to better identify pathology in the muscles, tendons, ligaments, and cartilage or to exclude other structural causes, such as labral cysts. Although many shoulder diagnoses can be reached based on the physical examination alone, MRI is useful in confirming a diagnosis or when shoulder pain appears to have more than one source. An MRI arthrogram can be considered, when a labral or tendon tear is suspected. Although imaging is an important part of the diagnosis, caution is warranted in interpreting imaging because repetitive motion creates asymptomatic pathology in many athletes.
 ===Treatment / Management===
 ====Nonsurgical Management====
-Eliminating acute inflammation is the priority in shoulder rehabilitation. After a swimmer, first experiences pain, ice, NSAIDs, and rest can prevent progression. If pain continues or worsens, a 7-day to 10-day course of NSAIDs and rest is ideal but often proves difficult if the injury occurs during the middle or late part of the season. At a minimum, effort should be made to reduce yardage to below the point of pain. For swimmers with impingement, tendinitis, or scapular dyskinesis, a subacromial and/or glenohumeral corticosteroid injection may be beneficial diagnostically and for pain reduction.<ref>Kancherla VK, Heckman DS, Carolan GF. Luxatio erecta humeri in the swimmer's shoulder: A combination of ligamentous laxity and motion dyskinesis. J Emerg Trauma Shock. 2016 Jan-Mar;9(1):39-40</ref><ref>Hibberd EE, Laudner K, Berkoff DJ, Kucera KL, Yu B, Myers JB. Comparison of Upper Extremity Physical Characteristics Between Adolescent Competitive Swimmers and Nonoverhead Athletes. J Athl Train. 2016 Jan;51(1):65-9</ref>
+Eliminating acute inflammation is the priority in shoulder rehabilitation. After a swimmer, first experiences pain, ice, NSAIDs, and rest can prevent progression. If pain continues or worsens, a 7-day to 10-day course of NSAIDs and rest is ideal but often proves difficult, if the injury occurs during the middle or late part of the season. At a minimum, effort should be made to reduce yardage to below the point of pain. For swimmers with impingement, tendinitis, or scapular dyskinesis, a subacromial and/or glenohumeral corticosteroid injection may be beneficial diagnostically and for pain reduction.<ref>Kancherla VK, Heckman DS, Carolan GF. Luxatio erecta humeri in the swimmer's shoulder: A combination of ligamentous laxity and motion dyskinesis. J Emerg Trauma Shock. 2016 Jan-Mar;9(1):39-40</ref><ref>Hibberd EE, Laudner K, Berkoff DJ, Kucera KL, Yu B, Myers JB. Comparison of Upper Extremity Physical Characteristics Between Adolescent Competitive Swimmers and Nonoverhead Athletes. J Athl Train. 2016 Jan;51(1):65-9</ref>
 Stretches that focus on the posterior capsule are important for preventing and reversing impingement. When they are coupled with overstretching of the anterior capsule, swimmers can create imbalances that worsen impingement. The swimmer can stretch the posterior capsule by horizontally adducting the arm and using the contralateral arm to pin it against the body.
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 ====Surgical Management====
-Surgery is appropriate for structural pathologies. An athlete may elect symptomatic management rather than surgery so that he or she may continue competing until the pain begins to interfere with daily life. For swimmers with persistent multidirectional instability, a capsular plication or inferior capsular shift procedure should be considered. Athletes should be aware. However, that training volumes may need to be reduced permanently to avoid pain. A subacromial exploration and removal of the hypertrophied, inflamed, and scarred tissue (thereby maintaining the structural integrity of the shoulder) is an option for athletes who obtain only limited relief from physical therapy. For swimmers with a labral tear in whom nonsurgical treatment has failed, the next treatment option is labral debridement or repair.
+Surgery is appropriate for structural pathologies. An athlete may elect symptomatic management rather than surgery, so that he or she may continue competing until the pain begins to interfere with daily life. For swimmers with persistent multidirectional instability, a capsular plication or inferior capsular shift procedure should be considered. Athletes should be aware. However, that training volumes may need to be reduced permanently to avoid pain. A subacromial exploration and removal of the hypertrophied, inflamed, and scarred tissue (thereby maintaining the structural integrity of the shoulder) is an option for athletes who obtain only limited relief from physical therapy. For swimmers with a labral tear in whom nonsurgical treatment has failed, the next treatment option is labral debridement or repair.
 ===Enhancing Healthcare Team Outcomes===
-Swimmer's shoulder is best managed by an interprofessional team that includes the orthopedic nurse. The shoulder provides the greatest range of motion of all joints in the body but also possesses the greatest inherent instability. As a result of the complexities, combinations, and variations encountered when examining the painful swimmer’s shoulder, a correct diagnosis can be challenging. A range of provocative tests and imaging studies is critical in identifying the source of the pain and in determining the appropriate treatment. Although some pathology may be managed symptomatically by ice and NSAIDs, athletes with persistent pain should seek evaluation by a sports medicine physician who may be able to offer more aggressive treatments. Physical therapy can be especially helpful in balancing muscle groups, reducing in-season symptoms, and potentially preventing future injuries.
+Swimmer's shoulder is best managed by an interprofessional team that includes the orthopedic nurse. The shoulder provides the greatest range of motion of all joints in the body, but also possesses the greatest inherent instability. As a result of the complexities, combinations, and variations encountered when examining the painful swimmer’s shoulder, a correct diagnosis can be challenging. A range of provocative tests and imaging studies is critical in identifying the pain source and in determining the appropriate treatment. Although some pathology may be managed symptomatically by ice and NSAIDs, athletes with persistent pain should seek evaluation by a sports medicine physician, who may be able to offer more aggressive treatments. Physical therapy can be especially helpful in balancing muscle groups, reducing in-season symptoms, and potentially preventing future injuries.
 Most swimmers do have a good outcome with treatment, but recurrence is not uncommon. Hence, the efforts of a strong interprofessional team for ongoing management will yield the best patient results.<ref>Tovin BJ. Prevention and Treatment of Swimmer's Shoulder. N Am J Sports Phys Ther. 2006 Nov;1(4):166-75</ref>

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 =====Inspection=====
-The following must be checked: A shoulder that is ‘too low’; Atrophy (supra- or infraspinous fossa) suggesting a neurological diagnosis; Scapulothoracic dyskinesia (SICK scapula; S: Scapular malposition, I: Inferior medial corner prominence, C: Coracoid pain and malposition, K: Kinesis abnormalities of scapular movements, Figure). Static scapular malposition in 3 directions in reference with contralateral shoulder (Figure): Inferior: difference in vertical height (cm) Lateral: difference in lateral displacement (cm) Abduction: difference in angular degrees of medial scapular margin from plumb midline
+The following must be checked: A shoulder that is ‘too low’; Atrophy (supra- or infraspinous fossa) suggesting a neurological diagnosis; Scapulothoracic dyskinesia (SICK scapula; S: Scapular malposition, I: Inferior medial corner prominence, C: Coracoid pain and malposition, K: Kinesis abnormalities of scapular movements, ''Figure 17''). Static scapular malposition in 3 directions in reference to contralateral shoulder (''Figure 17''): inferior - difference in vertical height (cm); lateral - difference in lateral displacement (cm); abduction - difference in angular degrees of medial scapular margin from plumb midline
-[[File:1562635351134-lg.jpg|center|thumb|300x300px|''Figure 17.'' Twenty-six-year-old female tennis player suffering from chronic shoulder plain. Inspection reveals a low and lateral scapula (black arrow), an augmented distance between the scapula and the median line (white arrow) and a preeminent inferomedial border (circle).]]
+[[File:1562635351134-lg.jpg|center|thumb|300x300px|''Figure 17.'' Twenty-six-year-old female tennis player suffering from chronic shoulder plain. Inspection reveals a low and lateral scapula (black arrow), an augmented distance between the scapula and the median line (white arrow) and a preeminent inferomedial border (circle). ''Reproduced from XX with permission.'']]
@@ Line 187: / Line 187: @@
 =====Evaluation of mobility of other articular joints in the body=====
-The back and legs should be examined, including lumbar mobility, especially the internal rotation of the contralateral hip, and concluded in the single-leg stance. A complete physiotherapy assessment can help define muscle weakness for example.
+The back and legs should be examined, including lumbar mobility, especially the internal rotation of the contralateral hip, and concluded in the single-leg stance. A complete physiotherapy assessment can help to define, for example, muscle weakness.
 =====Non-specific tests=====
-Anterior subacromial impingement tests may prove false-positive. During rotator cuff testing, frequently there is pain and loss of strength in Jobe's maneuver, more rarely in Patte’s maneuver or in resisted external rotation (ER1). Signs of hyperlaxity (indicate a bad prognosis). Instability tests can be painful, but usually give no clear apprehension or subluxation. Relocation test is usually positive in posterosuperior impingement (Figure).
+Anterior subacromial impingement tests might appear false-positive. During rotator cuff testing, frequently there is pain and loss of strength in Jobe's maneuver, less frequently in Patte’s maneuver or in resisted external rotation (ER1). Signs of hyperlaxity indicate a bad prognosis. Instability tests can be painful, but usually give no clear apprehension or subluxation. Relocation test is usually positive in posterosuperior impingement (''Figure 18'').
 ======Relocation test======
-[[File:1562635352307-lg.jpg|center|thumb|300x300px|The patient is positioned supine, with the elbow flexed to 90 degrees and abducted to 90 degrees. The physician then applies an external rotation force to the shoulder, if the patient reports apprehension in any way, the apprehension test is considered to be positive. At this point, the therapist may apply a posteriorly directed force to the shoulder - if the patient's apprehension or pain is reduced in this position, the Jobe’s Relocation test is considered to be positive. It is important to note that the therapist should always release the relocation force before releasing the patient back into neutral rotation for risk of shoulder dislocation.<ref>Jobe F, Tibone J, Jobe C, Kvitne R. The shoulder in sports. In: Rockwood CA MF, eds. , ed. The shoulder. Philadelphia: WB Saunders; 1990:961-90.</ref>]]
+[[File:1562635352307-lg.jpg|center|thumb|300x300px|''Figure 18.'' The patient is positioned supine, with the elbow flexed to 90 degrees and abducted to 90 degrees. Then the physician applies an external rotation force to the shoulder, if the patient reports apprehension in any way, the apprehension test is considered to be positive. At this point, the therapist may apply a posteriorly directed force to the shoulder - if the patient's apprehension or pain is reduced in this position, the Jobe’s Relocation test is considered to be positive. It is important to note that the therapist should always release the relocation force before releasing the patient back into neutral rotation for risk of shoulder dislocation.<ref>Jobe F, Tibone J, Jobe C, Kvitne R. The shoulder in sports. In: Rockwood CA MF, eds. , ed. The shoulder. Philadelphia: WB Saunders; 1990:961-90.</ref> ''Reproduced from Jobe with permission.'']]
 ======Articular range of motion tests======
-The patient must be examined not only in the standing position, but also supine on a table in order to block scapulothoracic movements, and look for: All amplitudes (anterior elevation, abduction-internal rotation, ER1, ER2, IR2); Glenohumeral internal rotation deficit (GIRD) > 20 degrees and total range of motion deficit > 5 degrees in the comparative examination.
+The patient must be examined not only in the standing position, but also supine on a table in order to block scapulothoracic movements, and checked for: All amplitudes (anterior elevation, abduction-internal rotation, ER1, ER2, IR2); Glenohumeral internal rotation deficit (GIRD) > 20 degrees and total range of motion deficit > 5 degrees in the comparative examination.
 =====Specific tests for superior labral tear from anterior to posterior (SLAP) lesions=====
-The literature is particularly rich on this subject, with almost as many different tests as publications. Despite the often-flattering initial reliability of their promoters, it should be noted that few of these tests are used by other practitioners. Meserve et al., In their 2009 meta-analysis, retain only 6 valid articles out of 198 initially identified (defined by the presence of a descriptive MRI, arthroscopic or arthrotomy reference to the tear, a test used by at least two authors, and the exclusion of cadaveric studies). In the end only the three best tests were retained, which could be consequently adopt.<ref>Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Am J Sports Med 2009;37:2252-8.</ref>
+The literature is particularly rich on this subject, with almost as many different tests as publications. Despite the often-flattering initial reliability of their promoters, it should be noted that few of these tests are used by other practitioners. In their 2009 meta-analysis Meserve et al. retain only 6 valid articles out of 198 initially identified publications (defined by the presence of a descriptive MRI, arthroscopic or arthrotomy reference to the tear, a test used by at least two authors, and the exclusion of cadaveric studies). At the end only the three best tests were retained that could be consequently adopted.<ref>Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Am J Sports Med 2009;37:2252-8.</ref>
 ======Dynamic Labral Shear test (O’Driscol test)======
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 ======Active compression test (better known as O’Brien’s test)======
-It is an active elevation against resistance, with the patient standing, shoulder flexed at 90 degrees and adducted at 15 degrees, elbow extended (Figure). The test is considered positive if there is pain in pronation but not in supination. This is the most sensitive (47% to 78%), but the least specific (11% to 73%) test. When testing negative, a superior labral tear from anterior to posterior (SLAP) lesion is very unlikely.[[File:1562635352717-lg.jpg|center|thumb|600x600px|Active compression test (O’Brien test): Active elevation against resistance test, with the patient standing, shoulder flexed at 90 degrees and 15 degrees adduction, elbow extended. The test is considered positive if there is pain in pronation but no pain in supination.]]
+It is an active elevation against resistance, with the patient standing, shoulder flexed at 90 degrees and adducted at 15 degrees, elbow extended (''Figure 19''). The test is considered positive, if there is pain in pronation but not in supination. This is the most sensitive (47% to 78%), but the least specific (11% to 73%) test. When test is negative, a superior labral tear from anterior to posterior (SLAP) lesion is very unlikely.[[File:1562635352717-lg.jpg|center|thumb|600x600px|''Figure 19.'' Active compression test (O’Brien test): Active elevation against resistance test, with the patient standing, shoulder flexed at 90 degrees and 15 degrees adduction, elbow extended. The test is considered positive, if there is pain in pronation but no pain in supination. ''Reproduced from XX with permission.'']]
 ======Crank test======
-The examiner stabilizes the scapula with one hand and keeps the elbow flexed at 90 degrees with the other, applying centripetal force in the humeral axis at 160 degrees abduction, applying small medial and lateral rotational movements. Pain indicates a positive test. Sensitivity varies from 13% to 58% with specificity varying from 56% to 83% depending on the study. A positive result for this test, in addition to the O'Brien test, reinforces the diagnostic suspicion of superior labral tear.[[File:1562635670214-lg.jpg|center|thumb|600x600px|Crank test: The examiner stabilizes the scapula with one hand and keeps the elbow flexed at 90 degrees with the other, applying centripetal force in the humeral axis at 160 degrees of abduction, applying small medial and lateral rotational movements. Pain indicates a positive test.]]
+The examiner stabilizes the scapula with one hand and keeps the elbow flexed at 90 degrees with the other, applying centripetal force in the humeral axis at 160 degrees abduction, and small medial and lateral rotational movements. Pain indicates a positive test. Sensitivity varies from 13% to 58%, while specificity ranges from 56% to 83% depending on the study. A positive result for this test, in addition to the O'Brien test, reinforces the diagnostic suspicion of superior labral tear.[[File:1562635670214-lg.jpg|center|thumb|600x600px|''Figure 20.'' Crank test: The examiner stabilizes the scapula with one hand and keeps the elbow flexed at 90 degrees with the other, applying centripetal force in the humeral axis at 160 degrees of abduction, applying small medial and lateral rotational movements. Pain indicates a positive test. ''Reproduced from XX with permission.'']]
 ======Speed or Palm-up test======
-This is a resisted elevation test in the scapular plane in supination at 90 degrees of elevation (Figure). Pain indicates a positive test. This is the least sensitive (4% to 48%) but also the most specific (67% to 99%) test. A negative result therefore indicates the unlikelihood of superior labral tear, but a positive result in all three tests is pathognomonic of a superior labral tear from anterior to posterior (SLAP) lesion.[[File:1562635830697-lg.jpg|center|thumb|600x600px|''Figure 22. '''Speed test or palm-up test.''' This is a resisted elevation test in the scapular plane in supination at 90 degrees of anterior forward flexion. Pain indicates a positive test.'']]
+This is a resisted elevation test in the scapular plane in supination at 90 degrees of elevation (''Figure 21''). Pain indicates a positive test. This is the least sensitive (4% to 48%), but the most specific (67% to 99%) test. A negative result, therefore, indicates the unlikelihood of superior labral tear, but a positive result in all three tests is pathognomonic of a superior labral tear from anterior to posterior (SLAP) lesion.[[File:1562635830697-lg.jpg|center|thumb|600x600px|''Figure 21.'' Speed test or palm-up test. This is a resisted elevation test in the scapular plane in supination at 90 degrees of anterior forward flexion. Pain indicates a positive test. ''Reproduced from XX with permission.'']]
 ======Kim’s test======

@@ Line 46: / Line 46: @@
 They reported that simple debridement allowed 85% of athletes to resume their sport at the same level (''Figure 4 and Video 2'').
-[[File:1563120680305-lg.mp4|center|thumb|300x300px]]
+[[File:1563120680305-lg.mp4|center|thumb|300x300px|''Video 2. Reproduced from XX with permission.'' ]]
-[[File:1562632003772-lg.jpg|center|thumb|600x600px|Simple labral debridement.]]
+[[File:1562632003772-lg.jpg|center|thumb|600x600px|''Figure 4.'' Simple labral debridement. ''Reproduced from XX with permission.'' ]]
-The authors accounted for the labral tears by repeated biceps traction on its labral tendon attachment, progressively disinserting it from the superior glenoid rim (chronic microtrauma, Figure).
+The authors accounted for the labral tears by repeated biceps traction on its labral tendon attachment, progressively disinserting it from the superior glenoid rim (chronic microtrauma, ''Figure 5'').
-[[File:1562632304186-lg.jpg|center|thumb|611x611px|In the theory of Andrews et al, labral tears occur by repeated biceps traction on the labral attachment, gradually leading to its detachment from the superior glenoid rim.]]
+[[File:1562632304186-lg.jpg|center|thumb|611x611px|''Figure 5.'' In the theory of Andrews et al, labral tears occur by repeated biceps traction on the labral attachment, gradually leading to its detachment from the superior glenoid rim. ''Reproduced with permission from XX.''<ref name=":3" />]]
-This progressive avulsion is taken-up by Burkhart et al. as the aptly termed ‘peel-back mechanism’ observed by reproducing the cocking phase under arthroscopic control, confirming the medial pivot of the posterosuperior labrum around the posterosuperior glenoid rim (Figure and Video).<ref>Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-40.</ref>
+This progressive avulsion is taken-up by Burkhart et al. as the aptly termed ‘peel-back mechanism’ observed by reproducing the cocking phase under arthroscopic control, confirming the medial pivot of the posterosuperior labrum around the posterosuperior glenoid rim (''Figure 6 and Video 5'').<ref name=":13">Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-40.</ref>
-[[File:1563120680799-lg.mp4|center|thumb|500x500px]]
+[[File:1563120680799-lg.mp4|center|thumb|500x500px|''Video 3. Reproduced with permission from XX.'']]
 {| class="wikitable"
 |+
-![[File:1562632305935-lg.jpg|center|thumb|400x400px|A: Arthroscopic view (right shoulder) of a labral tear, elbow at side:  before performing the arthroscopic dynamic test when the arm is cocked with retropulsion, and the appearance of Burkhart’s peel-back mechanism.|alt=]]
+|[[File:1562632305935-lg.jpg|center|thumb|400x400px|''Figure 6A.'' Arthroscopic view (right shoulder) of a labral tear, elbow at side:  before performing the arthroscopic dynamic test when the arm is cocked with retropulsion, and the appearance of Burkhart’s peel-back mechanism. ''Reproduced with permission from XX.''<ref name=":13" />|alt=]]
-![[File:1562632306643-lg.jpg|center|thumb|400x400px|B: Arthroscopic view (right shoulder) of a labral tear, elbow at side:  confirming the medial pivot of the posterosuperior labrum around the posterosuperior glenoid rim.<br />|alt=]]
+|[[File:1562632306643-lg.jpg|center|thumb|400x400px|''Figure 6B.'' Arthroscopic view (right shoulder) of a labral tear, elbow at side:  confirming the medial pivot of the posterosuperior labrum around the posterosuperior glenoid rim.<br />|alt=]]
 |}
 ====Theory of trauma by compression or distraction====
-In 1990, Snyder et al. classified superior labral tears, which they defined by the acronym SLAP (superior labral tear from anterior to posterior), still used today (Figure).<ref>Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-9.</ref>
+In 1990, Snyder et al. classified superior labral tears, which they defined by the acronym SLAP (superior labral tear from anterior to posterior), still used today (''Figure 7'').<ref name=":14">Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-9.</ref>
 Snyder’s 4 stage classification of superior labral SLAP lesions
-[[File:1562632308971-lg.jpg|center|thumb|600x600px|Stage I; Tear with partial detachment of the labrobicipital complex; stage II; detachment of the entire labrobicipital complex; Stage III; detachment of the labrobicipital complex creating a ‘bucket handle’ tear; and SLAP IV; the labrobicipital detachment extends longitudinally into the intra-articular portion of the long head of the biceps).]]
+[[File:1562632308971-lg.jpg|center|thumb|600x600px|''Figure 7.'' Stage I: tear with partial detachment of the labrobicipital complex; stage II: detachment of the entire labrobicipital complex; stage III: detachment of the labrobicipital complex creating a ‘bucket handle’ tear; and stage IV: the labrobicipital detachment extends longitudinally into the intra-articular portion of the long head of the biceps). ''Reproduced from XX with permission.''<ref name=":14" />]]
-It is however a retrospective study of 700 arthroscopies, performed between 1985 and 1988, with only 2 throwing athletes out of 27 patients having superior labral tear from anterior to posterior (SLAP) lesions (mainly type II, Figure, Video).[[File:1563120680520-lg.mp4|center|thumb]]
+However, it is a retrospective study of 700 arthroscopies, performed between 1985 and 1988, with only 2 throwing athletes out of 27 patients, who had superior labral tear from anterior to posterior (SLAP) lesions (mainly type II, ''Figure 8, Video 4'').[[File:1563120680520-lg.mp4|center|thumb|''Video 4. Reproduced with permission from XX.'']]
-[[File:1562632785154-lg.jpg|center|thumb|600x600px|SLAP II, detachment of the entire labrobicipital complex.]]
+[[File:1562632785154-lg.jpg|center|thumb|600x600px|''Figure 8.'' SLAP II, detachment of the entire labrobicipital complex ''reproduced with permission from XX .'']]
-Contrary to the theory of Andrews et al., Snyder et al. believe that the origin is essentially traumatic, according to two mechanisms: a fall stopped by the palm of the hand, arm outstretched (compressive force on the labrum, Figure) or a violent traction with extended arm (distractive force on the biceps and its labral attachment, Figure).
+Contrary to the theory of Andrews et al., Snyder et al. believe that the origin is essentially traumatic, according to two mechanisms: a fall stopped by the palm of the hand, arm outstretched (compressive force on the labrum, ''Figure 9A'') or a violent traction with extended arm (distractive force on the biceps and its labral attachment, ''Figure 10'').
-Origin of lesion with a compressive force on the labrum[[File:1562632785166-lg.jpg|center|thumb|600x600px|SLAP lesion of traumatic origin caused by a fall, stopped by the palm of the hand, arm extended forward (compressive force on the labrum).]]
+''Origin of lesion with a compressive force on the labrum''[[File:1562632785166-lg.jpg|center|thumb|600x600px|''Figure 9A.'' SLAP lesion of traumatic origin caused by a fall, stopped by the palm of the hand, arm extended forward (compressive force on the labrum). ''Reproduced from XX with permission.'' ]]
-[[File:1562632784848-lg.jpg|center|thumb|1020x1020px|SLAP lesion of traumatic origin caused by violent traction with arm extended (distractive force on the biceps and its labral attachment).]]
+[[File:1562632784848-lg.jpg|center|thumb|1020x1020px|''Figure 9B.'' SLAP lesion of traumatic origin caused by violent traction with arm extended (distractive force on the biceps and its labral attachment). ''Reproduced from XX with permission.'' ]]
 These two tear mechanisms have been confirmed in cadaveric models.<ref>Bey MJ, Elders GJ, Huston LJ, Kuhn JE, Blasier RB, Soslowsky LJ. The mechanism of creation of superior labrum, anterior, and posterior lesions in a dynamic biomechanical model of the shoulder: the role of inferior subluxation. J Shoulder Elbow Surg 1998;7:397-401.</ref><ref>Clavert P, Bonnomet F, Kempf JF, Boutemy P, Braun M, Kahn JL. Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: a cadaveric model of a fall on the outstretched hand. J Shoulder Elbow Surg 2004;13:45-50.</ref>

@@ Line 17: / Line 17: @@
 ==Thrower’s Shoulder==
 ===Introduction===
-The subject of thrower’s shoulder is vague and the term needs elaboration. It is not clear what symptomatologies and pathologies and to which athletes does this term apply. It is not necessarily synonymous with superior labral tear from anterior to posterior (SLAP) tears or posterosuperior impingement.
+The subject of thrower’s shoulder is vague and the term needs elaboration. It is not clear what symptomatologies and pathologies are and to which athletes this term can be applied to. It is not necessarily synonymous with superior labral tear from anterior to posterior (SLAP) tears or posterosuperior impingement.
-An athlete will no doubt seek help when their performance is constrained by painful symptoms. Secondary phenomena may be involved, such as internal disturbances, cracking, strength loss, ‘dead arm syndrome’ (characterized by discomfort either after arm cocking or at the start of throwing). This discomfort can be more or less debilitating, ranging from a decrease in performance to complete cessation, or even the end of a professional career.
+No doubt athletes will seek help when their performance is constrained by painful symptoms. Secondary phenomena may be involved, such as internal disturbances, cracking, strength loss, ‘dead arm syndrome’ (characterized by discomfort either after arm cocking or at the start of throwing). This discomfort can be more or less debilitating, ranging from a decrease in performance to complete cessation, or even the end of a professional career.
-Athletes susceptible to these disorders are also not always strictly throwers, such as baseball pitchers. In fact, a contact component can also occur in tennis, volleyball, handball, water polo or rugby (arm cocking countered by an opponent). Thus, all sports that involve arm cocking can fit into this nosological framework (Figure).
+Athletes susceptible to these disorders are also not always strictly throwers, such as baseball pitchers. In fact, a contact component can also occur in tennis, volleyball, handball, water polo or rugby (arm cocking countered by an opponent). Thus, all sports that involve arm cocking can fit into this nosological framework (''Figure 1'').
-[[File:1562631780138-lg.jpg|center|thumb|350x350px|Illustration of a late cocking and throwing phase of a baseball player.]]
+[[File:1562631780138-lg.jpg|center|thumb|350x350px|''Figure 1.'' Illustration of a late cocking and throwing phase of a baseball player. ''Reproduced with permission from XX'']]
-As to pathogenesis, too much importance has been attributed to superior labral tear from anterior to posterior (SLAP) lesions to explain these painful shoulders, so a classification of the numerous pathologies is essential for defining a therapeutic strategy.
+As to pathogenesis, too much importance has been attributed to superior labral tear from anterior to posterior (SLAP) lesions to explain these painful shoulders, so a classification of the numerous pathologies is essential to define a therapeutic strategy.
 There is not always a consensus between terminologies and theories worldwide. This is probably partly explained by the fact that there is a great cultural diversity between athletes from different countries. In fact, the literature has been flooded with articles evoking the pathologies developed by the baseball pitcher, a favorite sport in North America, while not mentioned at all in Europe, where contact sports like rugby or handball are more prolific. Faced with these very different terminologies and athletes, a practical classification, based on clinical, paraclinical and functional examinations, so as to discuss therapeutic options. Anatomic lesions must be differentiated from non-lesional dysfunction where preventive treatments are of great importance.
@@ Line 31: / Line 31: @@
 ===Theories and controversies in the last 30 years explaining pain and pathogenesis===
 ====Anterior subacromial impingement theory====
-Neer et al. were among the first to propose this theory, but Tibone et al. showed disappointing results for open acromioplasty, with only 22% of throwers resuming activity at the same performance level.<ref>Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41-50.</ref><ref>Tibone JE, Jobe FW, Kerlan RK, et al. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin Orthop Relat Res 1985:134-40.</ref>
+Neer and co-authors were among the first to propose this theory, but Tibone et al. showed disappointing results for open acromioplasty: only 22% of throwers resumed activity at the same performance level.<ref>Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41-50.</ref><ref>Tibone JE, Jobe FW, Kerlan RK, et al. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin Orthop Relat Res 1985:134-40.</ref>
 ====Microinstablity theory====
 In 1979, Frank Jobe et al. developed the ‘microinstability’ theory, in which anterior instability was caused by repetitive stretching of the anterior capsuloligamentous structures through repeated arm cocking movements. Although success has been reported in 68% of cases with capsular ligamentous retention procedures, the results of capsular tightening were mediocre.<ref>Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 1991;19:428-34.</ref>
-[[File:1562631781102-lg.jpg|center|thumb|400x400px|Lesions in throwing athletes are related to subtle anterior instability.|alt=]]<br />
+[[File:1562631781102-lg.jpg|center|thumb|400x400px|''Figure 2.'' Lesions in throwing athletes are related to subtle anterior instability. ''Reproduced with permission from XX.''|alt=]]<br />
 ====Theory of microtrauma caused by repetitive biceps traction====
-In 1985, Andrews et al. were the first to see, under arthroscopy, superior labral tears (Figure and Video) in 36 throwing athletes (sometimes associated with articular rotator cuff tears, Figure).<ref name=":3">Andrews JR, Carson WG, Jr., McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-41.</ref>
+In 1985, Andrews et al. were the first to see superior labral tears ''under'' arthroscopy (''Figure 3 and Video 1'') in 36 throwing athletes (sometimes associated with articular rotator cuff tears, ''Figure 3'').<ref name=":3">Andrews JR, Carson WG, Jr., McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-41.</ref>
 <br />
-[[File:1563120680503-lg.mp4|center|thumb|280x280px]]
+[[File:1563120680503-lg.mp4|center|thumb|280x280px|''Video 1.'' Reproduced from ''XX with permission''. ]]
-[[File:1562631911060-lg.jpg|center|thumb|600x600px|Arthroscopy of a throwing athlete’s right shoulder with a partial-thickness articular lesion in the rotator cuff (Ellman 2).]]
+[[File:1562631911060-lg.jpg|center|thumb|600x600px|''Figure 3.'' Arthroscopy of a throwing athlete’s right shoulder with a partial-thickness articular lesion in the rotator cuff (Ellman 2). ''Reproduced from XX with permission.'' ]]
-They reported that simple debridement allowed 85% of athletes to resume their sport at the same level (Figure and Video).
+They reported that simple debridement allowed 85% of athletes to resume their sport at the same level (''Figure 4 and Video 2'').
 [[File:1563120680305-lg.mp4|center|thumb|300x300px]]

@@ Line 5: / Line 5: @@
 *There are four major theories that have been used to explain pathology in the overhead athlete: Frank Jobe's micro-instability theory, Christopher Jobe’s hyperabuction theory, Walch's posterosuperior impingement theory, and Burkhart, Kibler, Morgan’s posterosuperior instability and superior labral tear from anterior to posterior (SLAP) lesion theory.
-*Clinical examination must look for stiffness (in internal rotation: glenohumeral internal rotation deficit (GIRD) > 20 degrees), instability, rotator cuff pathology and other more specific SLAP tests (active compression, crank, speed, Dynamic Labral Shear test (O'Driscoll's test)).
+*Clinical examination must look for stiffness (in internal rotation: glenohumeral internal rotation deficit (GIRD) > 20 degrees), instability, rotator cuff pathology and other more specific SLAP tests: active compression, crank, speed, Dynamic Labral Shear test (O'Driscoll's test).
 *The anatomical assessment, ideally using simple radiographs and magnetic resonance arthrography (MRA), may be complemented by an isokinetic functional assessment looking for external rotator imbalance where the external to internal strength ratio is < 66%.
-*Treatment is mostly conservative (and ideally preventive), involving a structured rehabilitation program: correction of athletic movements (keeping the elbow forward and avoiding excessive retropulsion to limit internal impingement, compact serve), range of motion recovery by ‘sleeper stretching’, and eccentric external rotator strengthening, ideally in isokinetic mode.
+*Treatment is mostly conservative (and ideally preventive), involving a structured rehabilitation program: correction of athletic movements (keeping the elbow forward and avoiding excessive retropulsion to limit internal impingement, compact serve), range of motion recovery by ‘sleeper stretching’, and eccentric external rotator strengthening, ideally in an isokinetic mode.
-*The surgical indication must be rational and carefully thought-out because the results are often disappointing for the athlete. The idea is not to try to fix everything and to remember that many “findings” are in fact adaptations of the throwing athlete. It is thus important that every effort is made to identify the true cause of the pain.
+*The surgical indication must be rational and carefully thought-out because the results are often disappointing for athletes. The idea is not to try to fix everything and to remember that many “findings” are in fact adaptations of the throwing athlete. Thus, it is important that every effort is made to identify the true cause of the pain.
-*Surgical treatment is often ‘salvage’ in nature because, even if the published results show improved functional scores, only half of the patients return to the same sports level, whatever technique is used. Surgical treatment of concomitant tears can lead to stiffness, preventing a return to previous athletic performance.
+*Surgical treatment is often ‘salvage’ in nature, because even if the published results show improved functional scores, only half of the patients return to the same sports level, whatever technique is used. Surgical treatment of concomitant tears can lead to stiffness, preventing a return to previous athletic performance.
 *Full thickness rotator cuff repair often spell the end of a professional sports career.
 ==Key words==
-Thrower’s shoulder; superior labral tear from anterior to posterior SLAP lesions; Labrum repair; Posterosuperior impingement; Arm cocking pain; Dead arm; Glenoplasty; Sleeper stretch; Arthrolysis.
+Thrower’s shoulder; superior labral tear from anterior to posterior (SLAP) lesions; Labrum repair; Posterosuperior impingement; Arm cocking pain; Dead arm; Glenoplasty; Sleeper stretch; Arthrolysis.
 ==Thrower’s Shoulder==

@@ Line 118: / Line 118: @@
 In 2002, Crockett et al. highlighted a torsional adaptation of the humerus in young throwing athletes during the acceleration phase of throwing, which results in humeral hyper-retroversion, delaying the onset of mechanical impingement on the dominant side.<ref>Crockett HC, Gross LB, Wilk KE, et al. Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-6.</ref>
-It is a positive and protective adaptation. Of the 45 arthroscopic debridement failures, Walch et al. then proposed 20 humeral derotational osteotomies, the results of which were reported by Riand et al. (Figures).<ref>Riand N, Levigne C, Renaud E, Walch G. Results of derotational humeral osteotomy in posterosuperior glenoid impingement. Am J Sports Med 1998;26:453-9.</ref>
+It is a positive and protective adaptation. Of the 45 arthroscopic debridement failures, Walch et al. then proposed 20 humeral derotational osteotomies, the results of which were reported by Riand et al. (Figures).<ref name=":2">Riand N, Levigne C, Renaud E, Walch G. Results of derotational humeral osteotomy in posterosuperior glenoid impingement. Am J Sports Med 1998;26:453-9.</ref>
 Derotational osteotomy
@@ Line 350: / Line 350: @@
 =====Derotational osteotomy=====
-This is an invasive procedure reserved only for top level young athletes who are motivated and aware of the risks. In any case, the patient must be informed of all possible complications. The indications remain exceptional.<ref>Riand N, Levigne C, Renaud E, Walch G. Results of derotational humeral osteotomy in posterosuperior glenoid impingement. Am J Sports Med 1998;26:453-9.</ref>
+This is an invasive procedure reserved only for top level young athletes who are motivated and aware of the risks. In any case, the patient must be informed of all possible complications. The indications remain exceptional.<ref name=":2" />
 [[File:1562639058298-lg.jpg|center|thumb|386x386px|Derotational osteotomy. Postoperative X-ray of a derotational osteotomy.]]