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Biomechanics of the Throwing Shoulder

Neal S. ElAttrache, MD Kerlan-Jobe Orthopaedic Clinic Los Angeles, CA

Stabilizing Anatomy Multifactorial


Glenohumeral ligaments more important toward functional end range
Head CH suspenders SGHL MGHL-low and mid range abduction (+ subscapularis) IGHL-45 abduction and higher

Glenoid labrum
Adds depth Break stop/centers humeral

head Attachment for GH ligaments /biceps tendon

Stabilizing Anatomy Multifactorial


Glenoid articulation articular arc
Glenoid normally pear-

shaped Permits high degree of rotation and translation Low containment

Rotator cuff & scapular musculature (dynamic)


Prime stabilizer during

mid-range glenohumeral motion GH compression/head depressor/GH balance

Throwing Motion
Kinetic chain concept Sequence of body segment motions Legs and trunk act as force generation Shoulder is force regulation Arm is force delivery

Throwing Mechanics
Wind-up
upper ext flex, hands on ball, lead foot off ground

Throwing Mechanics

Late Cocking
Foot contact Max abd, ext rot (40 to 170

deg) Trapezius and Serratus Anterior force couple stabilizes scapula

Throwing Mechanics
Acceleration
Max ER to ball release Humerus IR 100 deg / 0.5 sec Accel of arm coincident with

decel of LE GH joint force estimated 860 N

Throwing Mechanics
Follow-through
Ball release, adduction

internal rotation, deceleration Trapezius, serratus anterior, rhomboids, posterior deltoid, teres minor

Throwing Mechanics

Throwing Mechanics
Hyperangulation

Kinetic Chain Alterations


Leg and trunk
Inflexibility, weakness, and imbalance create a slow arm Places the arm behind the trunk in the cocking phase

Scapula Dyskinesis
Scapula receives forces from the trunk and transfers them to the arm Must retract and protract around thoracic wall for cocking/accel to decel Proper timing critical Glenoid must be positioned and stabilized for the HH accel and decel

Scapula Dyskinesis
Lack of full retraction with cocking Assoc with tight pec major and minor, weak trapezius, serratus anterior, and rhomboids Excessive protraction causes hyperangulation

Scapular Dyskinesis
Kibler et al AJSM 1998
64 patients with Type II SLAPs Scapular dyskinesis in 60/64 41 winging of infero medial scap and depression of acromiom 19 lateral translation (mean 2.2 cm) and entire medial winging

Internal Impingement
Mechanical abutment of undersurface rotator cuff with posterior-superior labrum occurs when arm in abducted and ext rot position can occur with a perfectly reduced head

Internal Impingement
Abduction and External Rotation

Internal Impingement
Pathophysiology
more likely to occur in overhead athlete with

anterior translation normal posterior translation in ABD ER position

Jobe CM Arthroscopy 1995

Internal Impingement
Repetitive Compression Labrum Biceps Glenoid Rotator Cuff

Physiologic
H G RC

Pathologic

Pathologic

Internal Impingement

SLAP Lesions

SLAP Biomechanics
Type II SLAP lesion created
Subtle but significant increase ER of 3 deg Significant increase in GH translation

Arthroscopic SLAP repair


ER and GH translation significantly decreased No difference with intact superior labrum Panossian, Tibone, et al, JSES 2005

Rotator Cuff Tears

Posterior Capsular Fibrosis and Contracture


May precede SLAP lesion and rotator cuff tear Alters biomechanics of glenohumeral and scapulothoracic motion May worsen internal impingement of rotator cuff on glenoid rim
Grossman, Tibone, et al, JBJSA - 2005 Morgan Burkhart

Anterior Instability
Pathologic anterior translation
Jobe Andrews

Anterior capsular attenuation Anterior labral tear Can be secondary to superior labral tear

Internal Impingement Continuum Post capsule


Hyperangulation Hyper external rotation Microtrauma Impingement REHAB RTC tear/SLAP Muscle weakness Scapular dyskinesis Subluxation Instability contracture

Rehab of the Shoulder in the Overhead Athlete: Highlights


Restore ROM to normal Improve posterior capsule compliance Avoid excess stress on the anterior capsule Optimize lower extremity and trunk strength Strengthen scapular rotators, rotator cuff, and power muscles of the shoulder Dont forget endurance Know the mechanics

SLAP Repair

Rotator Cuff Tears


Repair vs. debridement

Posterior Capsular Contracture


Rehab Rehab Rehab Release?

Anterior Instability
Rehab to restore protective mechanics Repair anterior and/or superior labrum if torn Capsular plication for attenuation?*
* Not too tight

Summary
Shoulder instability in throwers is a continuum Usually involves breakdown of kinetic chain protection Must understand and reestablish kinetic chain function and synchrony Try to identify shoulder at risk early in continuum

Summary
As continuum progresses
Pathology occurs in all elements of restraint system

When this pathology prevents reestablishment of kinetic chain function


Must be able to surgically address each pathologic element

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