Shoulder injuries in athletes. Presented at BUSEMS 2014, Birmingham. Also see shoulderdoc.co.uk

1. Lennard Funk
Wrightington Upper Limb Unit
Salford University
lenfunk@shoulderdoc.co.uk

2. ANATOMY

3. Deep Muscles

4. Glenohumeral Ligaments

5. Labrum

6. Posterior
Inferior
Superior
Bankart
Reverse
Bankart
SLAP
Anterior

7. Common Injury Groups
• Contact Athletes
– Rugby
– Football
• Overhead Athletes
– Swimming, Racquets, Climbing, Cricket, Track & Field
• Trauma
– Motorsports
– Cycling
– Canoeing
– Horseriding
• Strength Athletes
– Powerlifting, weightlifting, Bodybuilding

8. Sport Popularity in UK
SPORT TV
Viewing
Participati
on
Interest
Football
46% 10% 45%
Rugby
Union
21% 6% 27%
Tennis 18% 3% 23%
Cricket 18% 2% 19%
Athletics 18% 2% 21%
Snooker 17% 5% 24%
Motorsport 16% NA 20%
Rugby
League
12% 2% 15%
Boxing 11% NA 14%
Golf 11% 6% 16%

9. My Elite Athletes (2010-2013) = 663
SPORT Percentage Commonest Path.
Rugby Union 37% (247) Anterior
LabralRugby
League
28% (182) Posterior
LabralFootball/
Soccer
8% (54) Anterior
LabralMotorsport 3% (22) Mixed Labral
TearsClimbers 3% (20) SLAP
Swimming 3% (18) Int Imping/
SLAPCricket 2% (14) Anterior
LabralParalympics 2% (13) Mixed Labral
TearsOthers 14% (93)

10. Repetitive
Overhead
Acute Trauma

11. "In an instant I knew my tour was over
and I could feel the tears coming,"
“I felt like a drowning man, I wanted to shout for help
but nobody could hear me.”

12. How can we help him?
• Technical Skills
• Knowledge:
– Risk factors
– Mechanism of Injury
– Pathology
– Effects of our surgery
• Recurrence Rates
• Complications

13. Predisposing Factors
• Player:
1.Laxity
Cheng et al. JBJSB 2007;
Akhtar & Robinson. BJSM
2010
2.Proprioception
Herrington, 2011
3.Isokinetics
Jones & Funk, 2010
4.Mass
5.Running Speed
6.Aerobic ability
7.Previous Injury
• Sport:
1. Speed of play
2. Timing
3. Fatigue
1. Physical
2. Mental

14. Forces

15. “The new GPS system which we wore during the Four Nations - attached to a
man bra under our shirts - consistently showed us that we were taking impacts
of 10 gs and upwards during a match.!
The gravity force of a car travelling at 100km/h that comes to a stop in 0.2
seconds is 14.2 gs.
And we don't have airbags!”
!
Jon Wilkin, Feb 2010

16. Injury Reduction
Predispostion Model Meeuwisse

17. Common Sports
CONTACT / COLLISION
OVERHEADFLEXIBILITY

18. Recurrent Instability Rates
(after arthroscopic stabilisation)
[Cho et al. Arthroscopy 2006]
CONTACT / COLLISION
OVERHEADFLEXIBILITY
29%
7%

19. Recurrent Instability
Rates in Contact Sports
• Non-operative = 80% [Arciero, 1994]
• Open Bankart repair = 12%
• Arthroscopic Stabilisation = 14%
[Larrain, 2006]
– First dislocation = 4%
– Recurrent dislocations = 24%
– Under 18yrs age = 30% [Nixon & Funk, 2013]

20. • RCT of Latarjet vs. Arthroscopic Bankart
• Recurrence rate at 5 years:
– Latarjet = 12%
– Arth. Bankart = 24%
• Return to sport the same!
• Complication Rates higher (20%)
Latarjet Procedure [Bessier et al. JOST. 2013]

21. Recurrence Summary
• Higher in contact/collision sport
• Higher in young
• Higher after surgery for recurrent
dislocations
!
• Arthroscopic = Open Bankart
• Lower after Latarjet procedure

22. WHY?

23. Overhead Athletes
Lo, Hsu & Chan - BJSM 1990

24. • Tackling Fatique = Reduced JPS
• End of range only
Proprioception & Fatigue
Herrington et al. Phys Ther Sport. 2008

25. Laxity
• ‘Lax’ shoulders = higher risk of
dislocation in rugby
– Cheng et al. JBJSB 2007
• High Beighton Score = higher risk of
dislocation in sports (not just
contact)
– Akhtar & Robinson. BJSM 2010

26. Isokinetic Strength
Nathan, Jones & Funk. SECEC. 2011
1. Those players that had rehabilitation following injury and
surgery had better strength & stability than those without
any shoulder injury.
2. Poor Isokinetic strength may be a risk factor for injury
3.Current rehabilitation methods are effective
4. Suggests this should applied to those that have not yet
suffered injury.

27. Common Injuries

28. Mechanisms of Injury
video analysis study
Direct Impact
Complex
Labral
Bony Bankart
PTCT
Flexed Fall
Posterior
Labral
RHAGL
Try Scorer
Bankart
SLAP
Rotator Cuff
Tackler
Bankart
SLAP
HAGL
Crichton, Jones & Funk - BJSM 2012

29. FOOTBALL
• SHOULDER:
!
• 2-4% of all injuries
!
• BUT:
– Longest period of time away from

30. Incidence Mills, Pritchard, Funk & Batty,
2010
0
27.5
55
82.5
110
2006 2007 2008 2009 2010
45 46
84
98
104
34
63
91 94
99
Left
Right

31. Player Position
• 25 Professional Footballers
– 15 Field players
– 10 Goalkeepers
Hart & Funk, KSSTA 2013

32. Clinical Examination:
Instability in Athletes
• True Instability
– Dislocation
– Subluxation
– Apprehension
– Large lesions
• Subclinical
Instability
– Dead Arm in ABER
– Pain in ABER
– Clunking
– No Apprehension
– Smaller lesions

33. Investigations
• No previous Surgery = MR
Arthrogram
!
• Previous Surgery = CT Arthrogram

34. MR Arthrogram v. Scope
Sensitivit
y
Specificity Accurac
y
SLAP 0.42 0.92 77%
Rotator Cuff
Tear
0.50 0.86 83%
Hill Sachs 0.91 0.78 90%
Bankart 0.85 0.83 86%
N Karlson, J Geoghan, L Funk; 2008

35. • An experienced Shoulder Surgeon
better
• Can correlate with clinical context

36. Classification of Lesions
Major ‘Minor’
• Bony Bankart!
• ALPSA!
• Rotator Cuff Tear!
• HAGL!
• Undisplaced Labral Tear!
• Partial Cuff Tear!

37. Timing of Surgery
• Early Surgery:
– ‘Major’ lesions
– Late in Season
– Unable to Return
• Rehab & Return:
– ‘Minor’ lesions
– Early season

38. Types of Surgery
• Mostly Arthroscopic Direct Repairs
• Latarjet for High-Risk/Revision

39. • Anterior Instability
– Revision surgery (even without bone loss)
– Chronic Bony Bankart (> 3months)
– Any Bony Glenoid Loss
– True dislocation in Front Row forward
(Rugby Union)
– Higher level of sports
Latarjet in Athletes

40. • Player-specific - tailored to suit the player’s age,
position, requirements, surgeon and therapists.
• Not ‘accelerated’ or ‘aggressive’ or ‘time specific’.
• Surgery-specific - dependent on the quality and
type of fixation achieved.
• Protocol is a ‘guide’ and not a prescription.
• Phase Progression - when the patient is able to
perform all of the exercises in the previous phase without
any discomfort or apprehension. Each phase is
introduced progressively.
Ben Macdonald, Mike Lancaster, Meiron Jones, Doug Jones,
Christine Holmes, Kathleen Tatlow, Lennard Funk - 2004
Sports Specific Rehab
lenfunk@shoulderdoc.co.uk

41. Sports Specific - Javelin
http://kellybram.wordpress.com/

43. Rugby Rehab Protocol
lenfunk@shoulderdoc.co.uk

44. Rugby Results ‘03-’05
Pain Satisfaction (%) Playing at
previous level
Pre-op 5 11% 0%
3 months 10 87% 89%
6 months 12 93% 94%
L Funk , K Roney,
CJSM, 2007

45. Time to return to play L Funk , K Roney,
CJSM, 2007

46. Return to Play
Repair! Months-post.op!
SLAP! 2.6!
Ant.*&*SLAP! 3!
Post.*&*SLAP! 4!
Ant.*Post.*&*SLAP! 5.5!
L Funk , K Roney,
CJSM, 2007

47. Arthroscopic Stabilisations
0"
1"
2"
3"
4"
5"
Ant" Post" Both"
Time"(months)"
Fourie & Funk, 2009

48. Return to play by time of
0"
1"
2"
3"
4"
5"
Begin" Mid" End" Out"
Time"(months)"
63% of all operations took place in the last three months or out of season
Fourie & Funk, 2009

49. 0"
1"
2"
3"
4"
5"
6"
≤20" 21*29" ≥30"
Time"(months)"
Return to play by age Fourie & Funk, 2009

50. Creighton et al.
CJSM 2010

51. Recurrences & Revisions
• 8/143 = 5.6% at 2 years
• All recurrent trauma
• 4 treated with Latarjet Procedures

52. 1. High demand; High forces; Fatigue
2. Increased Injuries & recurrence risk
3. Understand
4. Recognise
5. Appropriate imaging
6. Customised Surgery
7. Timing of Surgery
8. Sports-specific Rehabilitation
Athlete’s Shoulder

53. lenfunk@shoulderdoc.co.uk
THANK
YOU