Matthew T. Boes and Craig D. Morgan
DEFINITION
Throwers place unique stress on their shoulder girdles due to the repetitive nature and magnitude of force associated with the activity.
Throwing athletes are prone to shoulder dysfunction due to chronic fatigue and weakening of the posterior shoulder musculature that over time leads to maladaptive contracture of the posteroinferior glenohumeral joint capsule.5
Posteroinferior capsular contracture alters the biomechanics of the glenohumeral joint during the throwing motion and produces a predictable constellation of injuries in disabled throwers, including superior labral and biceps anchor disruption, undersurface progressing to full-thickness rotator cuff tears, and disruption of the anteroinferior capsule or labrum.3
Symptoms resulting from these injuries have commonly been referred to as the “dead arm syndrome,” where the athlete cannot compete at the premorbid level due to shoulder discomfort with throwing and resultant loss of pitch velocity and control.3
Although most often seen in pitchers, similar shoulder dysfunction may occur in baseball position players as well as athletes in other sports requiring forceful and repetitive overhead activity.
ANATOMY
Eighteen muscles attach to the scapula and control its position on the chest wall.
Scapular position dictates glenoid position and orientation and is critical for normal glenohumeral function.
A force of up to 1.5 times body weight is generated during the throwing cycle. The scapular stabilizers and posterior rotator cuff muscles contract violently at ball release and protect the glenohumeral joint from the deceleration force of the arm.
The relative position of the glenohumeral ligaments changes with different arm positions. As the arm is brought into full abduction and external rotation (late cocking phase), the posterior band of the inferior glenohumeral ligament complex (PIGHL) moves from a posteroinferior position to a position directly inferior (6 o'clock) in relation to the glenoid.3
PATHOGENESIS
Posterior shoulder muscle weakness due to chronic, repetitive loading is the inciting lesion causing disability in throwers.
Posterior muscle weakness leads to shoulder dysfunction as a result of both scapular dyskinesis and PIGHL contracture. One of these pathologic entities may predominate in the disabled thrower, but they are generally intimately related.5
In scapular dyskinesis, the position of the scapula on the chest wall (or “scapular attitude”) is altered owing to loss of scapular elevation and retraction control. The scapula drops (infera), moves lateral from the midline (protraction), and abducts from the midline. The inferior scapular angle may also lift off the chest wall and pitch toward the front of the body (antetilt).
The predominant direction of these positional changes will vary depending on which scapular muscles are predominantly affected.
Altered scapular position causes abnormal tension on the insertion of scapular stabilizer muscles and over time leads to inflammation and pain (“traction tendinopathy”).5
PIGHL contracture involves failure of the weakened posterior shoulder muscles to counteract the distraction force of the arm after ball release exposes the PIGHL to abnormal stress due to the forward-flexed and adducted position of the arm at follow-through. Fibroblastic thickening and contracture of the PIGHL occur as a maladaptive response to greater stress (Wolf's law of collagen).
PIGHL contracture can be identified clinically as a scapular-stabilized glenohumeral internal rotation deficit (GIRD) in the throwing shoulder (designated by subscript “ts”) versus nonthrowing shoulder (subscript “nts”).3
The thickened PIGHL alters the normal biomechanics of the glenohumeral joint, particularly as the arm is brought into abduction and external rotation (late cocking phase). The normal glenohumeral contact point is shifted posteriorly and superiorly due to the thickened and contracted PIGHL occupying a position directly inferior to the humeral head in this arm position (FIG 1A,B).6
Alteration of the glenohumeral contact point leads to a predictable pathologic cascade with continued throwing.3
Posterosuperior shift allows greater clearance of the tuberosity over the posterosuperior glenoid rim, enabling pathologic hyperexternal rotation of the arm in the late cocking phase.
Increased external rotation of the throwing shoulder is adaptive in these athletes to some extent (used to maximize throwing arc and angular velocity at ball release).3 However, pathologic hyperexternal rotation leads to:
An abnormal posteriorly directed force vector and torsion on the biceps anchor. The biceps anchor ultimately fails and “peels back” medially along the posterosuperior glenoid neck (the “SLAP event”). SLAP tears are typically anterior and posterior or posterior subtypes of type II tears (the “thrower's SLAP”).8
Rotator cuff tears occur because of abrasion and torsion of tendon fibers. Torsion failure is most pronounced on the articular side of the tendons, resulting in partial undersurface tears most commonly seen in throwers. These tears may at times progress to full thickness with continued throwing.
Posterosuperior shift of the glenohumeral contact point causes relative relaxation and “pseudo-laxity” in the anterior capsule (FIG 1C,D). With continued hyperexternal rotation, tension may ultimately cause anteroinferior capsular fiber attenuation, leading to tertiary anterior glenohumeral instability, which occurs in about 10% of affected athletes. Discrete “Bankart-type” lesions of the labrum occasionally occur in this group. Anterior instability is a later event in the pathologic cascade, not the primary lesion as previously described.7
FIG 1 • A,B. Depiction of altered glenohumeral biomechanics due to an acquired posterior band of the inferior glenohumeral ligament complex (PIGHL) contracture and the resulting posterosuperior shift in the glenohumeral contact point as the arm is brought from neutral (A) to full abduction and external rotation (B), or late cocking phase. In the fully cocked position, the PIGHL occupies a position inferior to the humeral head, which forces the humeral head superiorly and tethers it posteriorly.C,D. Drawings in the axial plane showing relative relaxation of the anterior capsule in the late cocking position as a result of the posterosuperior shift in the glenohumeral contact point in a shoulder with PIGHL contracture. C. In a normal shoulder, the anterior capsule is taut over the cam shape of the humeral head. D. In PIGHL contracture, the humeral head shifts posteriorly, which decreases tension in the anterior capsule, creating relative laxity. C, center of glenoid .
NATURAL HISTORY
Athletes manifesting clinical findings of posterior muscle weakness and scapular asymmetry without signs of labral or rotator cuff pathology may correct their shoulder dysfunction with a progressive scapular muscle strengthening program and return to normal function when asymmetry resolves.
Throwers who have vague shoulder discomfort and demonstrate an internal rotation deficit (GIRD) are started on focused internal rotation stretches (“sleeper” stretches) to alleviate PIGHL contracture and restore normal glenohumeral biomechanics. GIRD reduction to less than 20 degrees removes the athlete from being at risk for shoulder injury and generally allows return to premorbid function.
Pain with throwing is indicative of injury to glenohumeral structures.
Once actual injury to glenohumeral structures, particularly the labrum, has occurred, mechanical symptoms ensue and the thrower will not be able to return to normal function without surgical repair.
PATIENT HISTORY AND PHYSICAL FINDINGS
Common early complaints include vague tightness in the shoulder and a difficulty or inability to “get loose” during a warm-up period.
Pitchers describe a loss of control and decrease in throwing velocity, which early on may be pain-free.
Pain is most prominent during the late cocking phase of throwing when the peel-back phenomenon of the superior labrum occurs, caused by the posterosuperior glenohumeral shift.4
Pain is localized to the posterosuperior shoulder and is described as “deep.”
Mechanical symptoms, such as painful popping or clicking, may occur after injury to the superior labrum, particularly during late cocking and early acceleration.
The surgeon should check for tenderness in the coracoid, the acromioclavicular joint, and the superomedial scapular angle.
Both shoulder girdles must be completely exposed or subtle asymmetry will be overlooked.
Inspection is done with the patient standing in front of fixed vertical and horizontal references (such as window blinds or door frames) so that affected and nonaffected shoulders can be compared for scapular height and malposition (FIG 2).
Superior and inferior angles as well as the medial scapular border are marked as a visual reference. Spinous processes are marked for a midline reference.
Asymmetry from the unaffected side when in protraction or infera indicates scapular stabilizer muscle weakness.
When in abduction or antetilt, increasing magnitude compared to opposite side signifies scapular muscle weakness.
Range-of-motion measurements are performed in the supine position with the scapula stabilized by anterior pressure over the glenohumeral joint directed into the examination table, which prevents contribution of scapulothoracic motion. Nonstabilized measurements will be erroneously high and will not reveal the true magnitude of glenohumeral pathology.
FIG 2 • Thrower with right scapular dyskinesis. Scapular asymmetry is highlighted by marking the superior and inferior scapular angles as well as the midpoint of the medial border. Affected right side shows scapular infera and protraction compared to the unaffected left side.
Measurements are made using a special goniometer that incorporates a carpenter's bubble level to provide a vertical reference point (perpendicular to floor) from which measurements are made.
External rotation (ER) + internal rotation (IR) = total mobility arch (TMA)
IRnts − IRts = glenohumeral internal rotation deficit (GIRD)
TMAts ≈ TMAnts in healthy throwers
GIRDts >20 degrees seen in “shoulders at risk” for injury; generally GIRDts ≈ loss of TMAts vs. TMAnts
Scapular relocation tests are performed in the supine position with the arm maximally forward-flexed. A positive test is indicated by pectoralis minor tension that is accentuated with the arm forward-flexed; traction at the coracoid insertion is relieved by scapular repositioning.
The specificity of tests for type II SLAP lesions in throwers has been determined as follows8 :
The modified Jobe relocation test is specific for posterior subtype. In throwers with SLAP tears, their usual pain is reproduced and they will localize to the posterosuperior joint line (“deep”). Pain in the abduction and external rotation (ABER) position is due to an unstable labrum; anterior pressure reduces the labrum and relieves pain.
O'Brien's test is specific for anterior subtype. A positive result is defined as pain with resisted forward flexion and pronation; pain is diminished or relieved with supination.
The Speed test is specific for anterior subtype. A positive result is defined as pain with resisted forward flexion.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs: anteroposterior (AP), scapular lateral, and axillary views to detect bone or joint space abnormalities
Magnetic resonance (MR) arthrography: We routinely order intra-articular contrast material because it improves the ability to detect labral and capsular abnormalities as well as partialthickness rotator cuff tears (FIG 3).
FIG 3 • Coronal MRI arthrogram study. The vertically oriented high-signal lesion in the substance of the biceps anchor (circle) suggests a superior labrum anterior-to-posterior (SLAP) tear. In addition, there is evidence of partial undersurface tearing of the supraspinatus tendon.
DIFFERENTIAL DIAGNOSIS
Subacromial irritation secondary to rotator cuff weakness and dysfunction
Various forms of anterior shoulder pain, acromioclavicular joint dysfunction, and posterior periscapular pain secondary to scapular dyskinesis and the SICK scapula syndrome (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis).5
Pain with throwing may occur with rare conditions such as bone tumors, stress fractures, and growth plate abnormalities.
NONOPERATIVE MANAGEMENT
Symptomatic athletes are begun on a scapular reconditioning program combined with internal rotation posteroinferior capsular “sleeper” stretches.
Scapular reconditioning focuses on regaining scapular elevation and retraction control; progress is assessed by repeat examination for normalization of scapular symmetry.
Initially bilateral shoulder shrugs and rolls are combined with retraction “no money” exercises.
The patient progresses to closed-chain “table top” movements and wall-washing motions.
Finally, prone “Blackburn”-type exercises are instituted.
“Sleeper” stretches focus on the posteroinferior capsular contracture that initiates the internal derangement in the glenohumeral joint (FIG 4). Response to a course of internal rotation stretching will determine the extent of the PIGHL contracture.
90% of athletes will decrease their GIRD to an acceptable magnitude with 10 to 14 days of focused stretching (less than 20 degrees) with near-normalization of TMAts and TMAnts.
The remaining 10% have recalcitrant PIGHL contracture and will show little or no decrease in GIRD after a period of stretching; they are termed stretch nonresponders. These are generally veteran athletes with longstanding GIRD and may require posteroinferior quadrant capsulotomy to regain internal rotation.
FIG 4 • “Sleeper” stretch of the posteroinferior capsule of the left shoulder. Patient lies on the affected side to stabilize the scapula and isolate stretch to the glenohumeral capsule. Affected shoulder and elbow are flexed 90 degrees. The opposite hand is used to exert a downward force on the affected arm to stretch the shoulder in internal rotation and decrease posterior band of the inferior glenohumeral ligament complex (PIGHL) contracture.
SURGICAL MANAGEMENT
Athletes presenting with pain and mechanical symptoms during throwing as well as findings suggestive of intra-articular pathology on MR arthrogram are indicated for arthroscopic evaluation and treatment.
Rarely, posteroinferior capsulotomy is indicated in throwers unresponsive to internal rotation stretching to decrease GIRD. This portion of the procedure is almost never necessary in a young thrower, however.
Contraindications to the surgical technique below include those similar to other elective arthroscopic shoulder procedures.
Preoperative Planning
Surgical treatment of the throwing shoulder may involve repair of the superior labrum as well as associated injuries to the rotator cuff and anterior capsulolabral structures, as well as contracture of the posteroinferior capsule.
All pathology must be anticipated before beginning the case, and all necessary instruments and materials need to be present on the back table to prevent intraoperative delays.
A fluid pump is used during the procedure to distend the joint and limit bleeding to improve visualization (set at 60 mm Hg). Prolonged procedures increase the risk of having to perform the surgery through distended tissue, which makes instrument manipulation in the joint difficult and can severely compromise the procedure.
The following order of possible intra-articular repairs is recommended to ease visualization and prevent loss of access to various locations in the joint:
Anteroinferior labral repair (if required)
Posterior SLAP repair
Anterior SLAP repair
Anterior capsular redundancy (if present)
Posteroinferior capsulotomy (if required)
Rotator cuff tear (if present)
Treatment of Associated Injury
We débride partial-thickness rotator cuff tears that represent less than 50% of the diameter and repair those larger than 50% of the diameter as described in Chapter SM-10.
Given the young age and high-level activity of these athletes, strong consideration should be given to repair in borderline cases.
Anteroinferior capsulolabral injury
Throwers may develop stretching and attenuation of the anteroinferior capsule, separation of the anteroinferior labrum from the glenoid rim, or a combination of the two.
We perform mini-plication of the anterior capsule in the following circumstances:
Evidence of frayed or attenuated anterior capsule with intact anterior labrum
A persistent drive-through sign after superior labral repair, or more than 120 degrees of external rotation at 90 degrees of abduction noted during the preoperative examination
Posterior capsular release is rarely indicated (about 10% of cases).
Response to internal rotation stretching is assessed preoperatively.
Patients displaying little to no response to stretching (unable to attain GIRD less than 20 degrees) are indicated for capsulotomy to allow restoration of full motion and normal glenohumeral biomechanics.
Positioning
A preoperative intrascalene nerve block is recommended to improve pain control postoperatively.
Antibiotics for skin flora are administered.
The patient is in the lateral decubitus position using an inflatable beanbag.
The arm is secured to a rope and pulley system that is attached to 10 pounds of weight.
A spring-gated, carabiner-type device is added between the end of the traction cord and the suspension pulley so that an unscrubbed assistant can remove the arm from traction during the procedure for dynamic diagnostic maneuvers (see below).
Advantages of the lateral decubitus position include:
Better visualization of the superior labrum and widening of the superior recess due to gravity for easier anchor placement and knot tying
Secure position of the arm, which negates the need for an assistant to hold the arm
Approach
The following arthroscopic portals are used to varying extents in the surgical treatment of disabled throwers:
Posterior: established first; main viewing portal
Anterior: main working portal: knot tying; anchor placement in anterosuperior glenoid rim
Posterolateral (“portal of Wilmington”): anchor placement in the posterosuperior glenoid; passage of sutures through the posterosuperior labrum. No cannulas are used in this percutaneous portal. Only small-diameter anchor insertion devices and suture passers are used to minimize injury to the cuff musculature because this portal traverses the muscular portion of the posterosuperior rotator cuff.
Anterosuperior: accessory portal added depending on the nature of the intra-articular pathology; may be used to view the anteroinferior labrum and capsule, or to assist in shuttling sutures through the anteroinferior capsule
TECHNIQUES
ESTABLISHING PORTALS
The posterior portal is established by identifying the posterolateral acromial border and making a 5-mm skin incision about 2 cm medial and 2 to 3 cm inferior to the posterior corner of the acromion in the palpated soft spot between the infraspinatus and teres minor portions of the rotator cuff.
A blunt trocar is directed from this incision anteriorly with gentle pressure to palpate the space between the rounded humeral head laterally and the glenoid rim medially.
The coracoid process is palpated with the opposite index finger and is used as a guide to direct the trocar to the correct plane into the glenohumeral joint.
The remaining portals are established after arthroscopic examination of the joint using an “outside-in” technique with an 18-gauge spinal needle.
The spinal needle creates minimal soft tissue trauma, and multiple passes can be made as needed to determine the proper location of secondary portals to yield unimpeded trajectories to areas of the joint requiring repair (TECH FIG 1).
TECH FIG 1 • 18-gauge spinal needle is used to localize the anterosuperior portal.
DIAGNOSTIC ARTHROSCOPY
The joint is systematically inspected to ensure that all areas are examined and no pathology is overlooked.
Areas requiring particular attention in disabled throwers include superior labrum and biceps anchor, rotator cuff insertion, posterior capsule and recess, and anteroinferior labrum and capsule.
We routinely perform provocative tests to assess both superior labral integrity and overall stability in the joint.
Peel-back test: The posterosuperior labrum is assessed dynamically for evidence of instability in the abducted and externally rotated position (late cocking position). The arm is released from traction and is brought into the full cocking position; an unstable labrum will fall off the glenoid rim and shift medially along the glenoid neck (TECH FIG 2A–D).
Drive-through test: Normally, intact capsular and labral restraints appose the humeral head into the glenoid such that easy passage of the arthroscope from posterior to anterior at the midpoint of the glenoid or sweeping of the scope from superior to inferior along the anterior glenoid rim is not possible. When these maneuvers are possible, they are nonspecific evidence of disruption of the labrum or capsular ligaments according to the “circle concept” of glenohumeral stability.3,9
TECH FIG 2 • A–D. Peel-back test performed intraoperatively to detect an unstable superior labrum. A. The arm is removed from the traction apparatus and is shown in the neutral position. B. Corresponding arthroscopic image to A. The biceps anchor is reduced to its normal anatomic position on the superior labrum in the neutral arm position. C. The arm is then brought into abduction and full external rotation to dynamically assess the stability of the biceps anchor. D. Corresponding arthroscopic image to C. An unstable labrum will fall medially off the superior glenoid and “peel back” along the glenoid neck with full cocking of the arm. E. A probe is introduced through the anterosuperior portal to palpate the stability of the labrum. F. Evidence of capsular irritation adjacent to a posterosuperior labral detachment. There is also adjacent fraying of the labrum.
After provocative tests, secondary portals are established depending on the pathology requiring repair as outlined above.
A probe is introduced to palpate structures and confirm visual findings (TECH FIG 2E).
Signs of labral injury may be subtle. 4 Careful inspection and probing are often required to detect:
Fraying and disruption of superior labral fibers inserting into the glenoid
Adjacent irritation of the capsule (TECH FIG 2F)
Disruption of the smooth contour of the articular cartilage at the glenoid rim
Superior labral sulcus more than 5 mm or a biceps root that can be displaced medially along the glenoid neck
INTRA-ARTICULAR DÉBRIDEMENT
A full-radius motorized shaver (Stryker Endoscopy, San Jose, CA) is used to gently remove frayed or flaplike tissue and loose debris from the joint.
Careful control of suction pressure on the shaver will ensure that only loose tissue is removed and the bulk of the repairable labrum is retained.
SUPERIOR LABRAL REPAIR
Site Preparation
We briefly outline our steps for SLAP repair because they may differ slightly from elsewhere in this text.
Regardless of the specific techniques used, the goal is secure fixation of the biceps anchor to the glenoid rim and obliteration of the peel-back phenomenon.
An arthroscopic rasp (Arthrex, Naples, FL) is used to separate any loose attachments of the labrum to the glenoid rim to mobilize the lesion and free it from medialized scar (similar to a medialized Bankart lesion).
A rasp is preferred over a sharp elevator, which can skive and injure normal labral tissue.
TECH FIG 3 • A motorized burr is used to prepare the glenoid bone bed before labral repair. Care is taken to prevent inadvertent damage to the labrum.
A motorized burr is used to remove cartilage from the rim and lateral glenoid neck, yielding a punctate-bleeding cortical bone bed to accept the repaired labrum (TECH FIG 3). This step is crucial to ultimate healing of the repair.
We prefer a burr with protective hood that prevents injury to labral tissue (SLAP burr; Stryker).
No suction is used while the burr is operating to prevent inadvertent injury to labral tissue.
Loose tissue and debris created by the rasp and burr are removed with the shaver.
Posterior Anchor Insertion
Evaluation is made for appropriate anchor location. The number of anchors used is arbitrary but must be sufficient to negate peel-back forces and stabilize the biceps anchor.
We prefer bioabsorbable, tap-in anchors for SLAP repair (3.0-mm BioSutureTack; Arthrex) because they are easier to control during insertion than the screwin type of anchors.
The previously established anterior portal used for probing is used for anterior anchor insertion.
For posterosuperior anchors, we prefer the percutaneous portal of Wilmington.
The approximate location of the skin incision for this portal is usually 1 cm anterior and 1 cm lateral to the posterolateral corner of the acromion (TECH FIG 4A).
A spinal needle is used to locate this portal to allow proper insertion angle for anchor placement in the glenoid rim at 45 degrees relative to the glenoid face to ensure secure fixation in bone and prevent skiving under the glenoid articular cartilage or along the glenoid neck (TECH FIG 4B).
A 4-mm skin incision is made and the Spear guide (3.5 mm; Arthrex) with sharp trocar is used to pierce the muscular portion of the posterior rotator cuff as it is advanced into the joint.
Penetration of the Spear guide is done under direct arthroscopic visualization to ensure that the guide enters the joint medial to the rotator cable, which marks the intra-articular location of the musculotendinous junction of the rotator cuff (TECH FIG 4C). Because of its small diameter and passage in the muscular portion of the cuff, there is minimal iatrogenic injury with this approach.
The sharp trocar is removed, and the Spear guide is brought immediately onto the glenoid rim adjacent to the previously prepared bone bed and held firmly in the proper orientation as described above (TECH FIG 4D).
An assistant passes the power drill into the guide and carefully advances the drill bit to the hilt.
Position of the Spear guide is carefully maintained as the drill is removed and the anchor is introduced in the guide and tapped into a fully seated position in the bone.
We insert these anchors to the hilt of the handle of the insertion device.
Gentle twisting inline with the anchor is often needed to remove it in dense bone.
Alternatively, gentle tapping with a mallet inline can be used to remove the inserter.
The Spear guide is removed and the anchor fixation is tested with gentle pulling on the sutures (TECH FIG 4E).
Suture Passage
Both suture limbs are brought out the anterior cannula using a looped suture retriever (Arthrex) (TECH FIG 5A).
The medial suture (closest to labrum) is designated for passage through the labrum.
TECH FIG 4 • A. Approximate location for the skin incision for the “portal of Wilmington.” B. 18-gauge spinal needle is used to accurately locate the portal of Wilmington to allow proper position and angle of insertion of suture anchors in the superior glenoid depending on the extent of the superior labral tear. C. The Spear guide pierces the joint capsule along the same trajectory determined by the spinal needle and medial to the rotator cable as described in the text. (The sharp obturator used to pierce the capsule for entry into the joint has been removed.) D. Spear guide is carefully positioned on the glenoid rim and held firmly in place during drilling and anchor insertion. Proper insertion angle (45 degrees to the glenoid face) is critical for firm fixation of the suture anchor in bone. E. Spear guide is removed. The suture anchor has been fully inserted in the glenoid rim, and fixation is tested with a steady pull on the sutures. (In this image, the anchor has been rethreaded with no. 1 PDS suture before the start of the case [see text]).
A small-diameter suture-passer device with a retrievable wire loop (Lasso SuturePasser; Arthrex) is used to shuttle the suture through the labrum.
The suture-passer device is brought into the joint via the same incision and trajectory as the Spear guide (TECH FIG 5B).
It is used to pierce the labrum from superior to inferior at the location of the anchor to achieve a solid bite of labral tissue (TECH FIG 5C).
The wire loop is advanced over the glenoid rim and retrieved through the anterior portal (TECH FIG 5D).
The previously identified suture is threaded into the loop and the suture-passer device is gently removed from the portal of Wilmington while shuttling the “post-limb” suture through the superior labrum.
Suture passage is done slowly and under visualization so that tangles may be identified and corrected from the anterior portal using the suture retriever (TECH FIG 5E,F).
TECH FIG 5 • A. Both suture limbs are retrieved through the anterosuperior portal. In this image, the suture anchor has been used with the FiberWire suture that the anchor is normally packaged with (see text). B. The suture-passing device is brought into the joint through the same trajectory as the Spear guide in the previous steps, minimizing the risk of inadvertent damage to the rotator cuff and capsule. C.The suture-passing device is advanced through the superior labrum from superior to inferior to capture the bulk of the labrum and is carefully advanced over the glenoid rim to prevent damage to the articular surface. The wire loop is advanced for retrieval from the anterosuperior portal. D. The wire loop is retrieved from the anterosuperior portal using a gated suture retriever. The previously identified “post-limb” suture (the suture closest to the labrum as they exit the fully seated anchor) is threaded into the wire loop. The suture-passing device and wire loop are then carefully withdrawn out the portal of Wilmington, shuttling the “post-limb” suture through the labrum. E. Passing suture limbs slowly allows for identification of suture tangling, which may occur during suture passage through the labrum. F. Slack sutures are easily untangled using a gated suture retriever to identify and untangle sutures from the anterosuperior portal. G. The “post-limb” suture (now through the labrum and exiting portal of Wilmington) is retrieved through the anterosuperior portal for knot tying. H. The knot is tied either anterior or posterior to the biceps tendon, depending on ease of approach. (This image shows a suture anchor that has been rethreaded with no. 1 PDS suture before the start of the case and is a different case example than the one in A–G.)
The post-limb suture is retrieved from the portal of Wilmington back to the anterior portal for knot tying either anterior or posterior to the biceps anchor, depending on ease of approach (TECH FIG 5G,H).
The above steps are repeated as needed for additional posterior anchors in the superior labrum.
Anterosuperior Repair
Anterosuperior anchors are placed through the anterior cannula with the same orientation concerns and technique as described for posterior anchors.
Anterior suture limbs are passed and retrieved through the same anchor, which can create tangling of sutures. In addition, given the orientation of passage and retrieval of anterior sutures through the anterior cannula, a “sawing” effect can be created as the suture is drawn through the tissue, which may damage the anterosuperior labrum.
To minimize this risk, we use a tissue-penetrating device with a gated suture-retriever loop (eg, BirdBeak; Arthrex) to retrieve the post-limb suture through the anterosuperior labrum.
Dynamic Assessment of Repair
Peel-back test: The peel-back phenomenon should be obliterated and the labrum should remain firmly fixed to the superior glenoid during full cocking of the arm (TECH FIG 6).
Drive-through test: Advancement through the joint at mid-glenoid should not be possible after SLAP repair; if this test continues to be positive, then additional anteroinferior capsular redundancy is likely (see below).
TECH FIG 6 • Completed repair after an additional suture anchor has been placed in the posterosuperior labrum. The peelback test shows no instability of the biceps anchor and firm fixation of the superior labrum to the glenoid rim.
MINI-PLICATION OF THE ANTERIOR CAPSULE
The extent of capsular plication is subjective. The goal is to obliterate redundant capsule by placing sutures sequentially from inferior to superior to eliminate anterior instability while preventing inadvertent restriction to full external rotation (TECH FIG 7A,B).
A rasp or “whisker” shaver (Arthrex) is used to abrade the capsule to aid in healing of the plication (TECH FIG 7C,D).
A “bite” capsule is taken laterally and advanced and sutured to the anteroinferior labrum, obliterating a redundant anterior recess (TECH FIG 7E,F).
Placement of sequential sutures allows for repeat examination to ensure anterior stability is restored without creating motion restriction (TECH FIG 7G).
Rarely, a discrete anteroinferior labral avulsion from the glenoid is present that is repaired as described elsewhere in the text. This is most easily accomplished before superior labral repair.
An additional anteroinferior portal may be required to achieve an appropriate anchor insertion angle onto the glenoid rim and to ease suture passage and management.
TECH FIG 7 • A. Multiple anterior plication sutures are used to obliterate redundant anteroinferior capsular tissue. B. Diagram in axial orientation to the glenoid showing accordionlike plication and shortening of the anterior capsule as it is sutured to the labrum. C. An arthroscopic rasp is used through the anterosuperior portal to abrade the capsular tissue and generate a healing response in the tissue after plication. D. Anterior capsule after abrasion and before suture placement. E. Starting anteroinferiorly, a pointed suture-passing device is used to suture a bite of lateral capsule to the labrum, as shown in F. As the knot is tied, this suture effectively shortens and reduces the anterior capsule. G. Multiple no. 1 PDS anteroinferior capsular plication sutures after tying of the final and most superior plication stitch.
POSTEROINFERIOR CAPSULOTOMY
As stated earlier, a posterior capsulotomy is indicated only in patients unable to attain a GIRD of less than 20 degrees to allow restoration of full motion and normal glenohumeral biomechanics (TECH FIG 8A).
Arthroscopic findings in these recalcitrant cases include inferior recess restriction and a thickened PIGHL (more than 6 mm thick).
Two techniques can be used.
Arthroscope in anterior portal and instrumentation in standard posterior portal
Arthroscope in standard posterior portal and instrumentation in portal of Wilmington. We prefer this method because it allows more direct visualization of the capsular tissue as it is released (TECH FIG 8B). A small-diameter cannula (5.5 mm) may be needed to allow easy passage of the cautery through the portal of Wilmington.
A hooked-tip arthroscopic electrocautery with long shaft (Meniscal Bovie; Linvatec) is used to create a full-thickness capsulotomy from the 6 o'clock to the 3 or 9 o'clock position in the posteroinferior quadrant.
The capsulotomy is made approximately a quarter-inch from the labrum.
Gentle sweeping motions are used to successively divide tissue under direct visualization (TECH FIG 8C–E).
It is critical to perform the procedure without chemical paralysis induced by the anesthesia staff.
Muscular twitching will alert the surgeon that the electrocautery is too close to the axillary nerve and causing injury.
If this occurs, the capsulotomy should be shifted to a more superior and medial position or abandoned altogether if no safe zone is found.
Posteroinferior capsulotomy typically results in a 50- to 60-degree increase in internal rotation immediately postoperatively.
TECH FIG 8 • A. Location of the posteroinferior quadrant capsulotomy. B. Intraoperative view showing the instrument placement for posteroinferior quadrant capsulotomy. The arthroscope is in the standard posterior viewing portal and the cautery is in the portal of Wilmington. A small-diameter cannula (5.5 mm) may be required for passage of the hook-tipped cautery device through the portal of Wilmington. C.View of the posteroinferior capsule showing thickening and restriction of the inferior recess. D. The hook-tipped cautery is used to successively divide the capsule about 3 to 5 mm from the labrum under direct visualization. E. Completed capsulotomy. Muscle fibers just posterior to the capsule are visible between the divided edges of the capsule.
POSTOPERATIVE CARE
Follow-up
Procedures are performed on an outpatient basis.
Return for dressing change postoperative day 1.
Ice or cooling pad is encouraged for first 48 hours.
Sutures are removed at 1 week.
Starting at 1 week, self-directed range-of-motion exercises are begun under specific guidelines (see below). Patients are seen regularly to assess progress and modify rehabilitation as needed.
Rehabilitation Time Table
Immediate
Passive external rotation with arm at side (not abduction) within specific parameters
Elbow flexion and extension
Capsulotomy patients are started on “sleeper” stretches on postoperative day 1.
Weeks 1 to 3
Pendulum exercises
Passive range of motion using pulley device in forward flexion and abduction to 90 degrees only
Start shoulder shrugs and scapular retraction exercises in sling.
Sling should be worn when not out for exercises.
Weeks 3 to 6
Sling is discontinued at 3 weeks.
Passive range of motion is advanced to full motion in forward flexion and abduction.
“Sleeper” stretches are started in patients not having capsulotomy.
Weeks 6 to 16
Stretching and flexibility exercises are continued.
Passive external rotation stretching in 90 degrees of abduction is begun.
Strengthening for rotator cuff, scapular stabilizers, and deltoid is started at 6 weeks.
Biceps strengthening is delayed until 8 weeks.
Daily “sleeper” stretches are continued.
4 months
Interval throwing program on level surface
Stretching and strengthening is continued (internal rotation stretches are emphasized).
6 months
Pitchers begin throwing full speed depending on pain-free progression through interval throwing program.
Continue daily internal rotation stretches.
7 months
Full-velocity throwing from mound
“Sleeper” stretches and scapular conditioning are performed daily indefinitely while the patient continues throwing competitively.
OUTCOMES
SLAP repair in high-level throwers: 182 pitchers treated over 8 years (one third professional, one third college, one third high school)2
92% returned to premorbid performance or better.
Average UCLA score was 92% excellent at 1 year and 87% excellent at 3 years.
164 pitchers undergoing SLAP repair and posteroinferior capsular stretching:
Average GIRD = 46 degrees preoperatively, 15 degrees at 2 years
Eight pitchers undergoing SLAP repair and posteroinferior quadrant capsulotomy:
Average GIRD = 42 degrees preoperatively, 12 degrees at 2 years
Average fastball velocity = 11-mph increase at 1 year
COMPLICATIONS
Similar to other arthroscopic shoulder reconstructions: rare incidence of infection; failed repair; painful adhesion formation; subacromial irritation; stiffness
Physicians and therapists must be vigilant about development of postoperative stiffness in overhead athletes. Stiffness can be addressed effectively with modification of the rehabilitation program if it is identified early with regular follow-up and directed therapy.
REFERENCES