7/16/2014 0 Comments
Special thanks to star physical therapist Leah Versteegen for providing this write up on a recent article from Sports Health.
The shoulder is one of the most mobile joints and most complex joints in the human body. It moves in no less than seven planes if you consider only movement at the glenohumeral joint. If you then take into consideration that the shoulder also involves the acromioclavicular and sternoclavicular joints as well as the scapula, the movement becomes even more complex. It is essential that the shoulder joint be controlled by well balanced muscles that control each of the aforementioned joints and the scapula, particularly in athletes that rely on shoulder strength and mobility for their sport. As the shoulder ages, well balanced movement becomes harder to achieve, presenting a challenge in injury prevention and treatment. The three most common shoulder diagnosis in the aging shoulder are rotator cuff pathology, osteoarthritis, and adhesive capsulitis.
Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. One study showed rates as high as 98 percent patient satisfaction after rotator cuff repair. The next logical question is what the most effective method of repair may be and as expected it depends on the type of tear and the patient (age, post-operative goals, health status, etc). The options are arthroscopic or open repair, single row or double row.
WIth a partial tear the tear can be completed to a full tear then repair or it can be repaired in situ, not completing the tear before repair. The former technique is most common, but in situ repairs are showing a lot of promise with research reports of 94 to 98 per cent patient satisfaction. From a biomechanical perspective, double row repairs are stronger but not necessarily leading to an advantage with clinical outcomes. Augmentation, another major mechanical emphasis in rotator cuff repair, involves using an extracellular matrix to help stimulate tendon healing. The tissue used for augmentation can be an autograft, allograft, xenograft, or synthetic material. Most recently, human dermal allograft shows the most promise with proven clinical results though new techniques for augmentation are being tested with platelet rich plasma and stem cells. Overall, it is important to differentiate age, desired level of sport, and type of sport before deciding on the treatment for rotator cuff pathology.
Osteoarthritis of the shoulder is not as common as the knee or hip, but it is not uncommon and can be quite debilitating for older athletes. Treatment options include debridement, capsular release, microfracture, glenoid resurfacing, or total shoulder arthroplasty. Again it is important to differentiate the athlete and desired goals in order to determine the best treatment. For the older recreational athlete (65 and older), total shoulder arthroplasty results in excellent long term survival rates and high level of return to sport. For younger patients (under 50) almost 50 per cent reported unsatisfactory results in on research study after total shoulder arthroplasty and survival rates were much lower than in their older counterparts. For the younger but still mature athlete, the less invasive treatments are thus more common. Though the research is inconclusive as to which option is best for this population, biological glenoid resurfacing is the most recent promising treatment added to the list of less invasive options. The resurfacing can be achieved with an Achilles tendon allograft, lateral meniscus allograft, or dermal allograft.
Adhesive capsulitis is most commonly known as frozen shoulder and is characterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as primary idiopathic or secondary to another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be the first option. Conservative treatment may include a steroid injection, physical therapy, or both. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.
When considering treatment options for shoulder pathology it is essential to consider the patients demographics, particularly age, and desired level of activity or sport participation. While older athletes may have a more progressive or advanced injury process, often they have lower performance goals.
John M. Tokish. The Mature Athlete’s Shoulder. In Sports Health. January/February 2014. Vol 6. No 1. Pp 31-35.
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