Over the years, shoulder labral repair surgeries have been trending down in overhead athletes. They often over-constrain the joint and decrease the range of motion, which can be very limiting to these athletes.
Here’s how we attempt to prevent this loss of motion.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 309: Shoulder Labral Repairs in Overhead Athletes
Listen and Subscribe to Podcast
You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!
Show Notes
Transcript
Matt Ellison:
All right, we got a long one here. So Seth from South Carolina wants to know, take a deep breath, in overhead athletes, we have labral repairs. Do the surgeons take into account retroversion of a throwing athlete’s shoulder? I’ve personally had this surgery and have the same experience with treating patients where they don’t want you to stretch them that much since they want the capsule to tighten up. The problem that seems to arise is they get 90 degrees of external back, which is normal, but as for overhead athletes, it’s usually around 120 degrees. I know personally because I have a lot of asymmetrical movement patterns in the gym. Obviously, this will be amplified even more if a pitcher is trying to regain velocity with limited payback into ER with patients-
Mike Reinold:
Layback.
Matt Ellison:
They are typically DC before we get them to a point that we can even try the extra ER back per surgeon even if they’re an athlete.
Mike Reinold:
Right. Which I feel like your last sentence just… Oh, great job, by the way. That was a good paragraph for me.
Yeah. I like that. That was very Ron Burgundy too. You’re like, look, I’m not going to change it to layback. I’m saying payback because that’s what he wrote. I like that. So that’s payback to you, Matt, but Seth, I apologize for that. I’m sure that was an auto correct, but I think you have a couple facets to this question. I mean, the second part was that you run out of visits before you can get them back to their thrower’s motion. Just to touch on that quickly. I think you got to re-tweak how you do your visits then if that’s the case because if you don’t have them back to thrower’s motion, you haven’t done your job. So I would say on that part, you’re going to have to extend that out a little bit, but I’ll start it off with this and then throw it out there.
Maybe Lenny or Mike or somebody can jump in here too, but there’s a reason why these surgeries are going away and these are almost like last ditch efforts now in overhead athletes. When scopes were becoming popular, decades ago, and we were doing this, we were trying to do these more often and I think our success rates with shoulder surgeries weren’t as high as we’d like, and just like you know, it’s because the surgeon doesn’t go in there and they do a certain thing and they know exactly how much range of motion that’s going to restrict, that they’re seeing instability and they’re putting some anchors and sutures in there and trying to tighten it up, and it’s subjective.
You can over-tighten it easy, you can under-tighten it easy, and remember, the surgeon’s job is to get rid of that instability. So they’re probably going to err on the side of being too tight more often, but just like you said, that’s the kiss of death in a baseball player. So I’d say that you’re right, and this is why we’re starting to see this less and less and less. So from there, I don’t know who wants to take this here. So Len, what are some tips here? How do you get them back to their thrower’s motion? He mentioned that 90 degrees. It seems like they’re just having all their people follow a general ortho protocol maybe and not do anything different, but what do you do different in your overhead athletes?
Lenny Macrina:
Yeah. I don’t want to say I’m aggressive. You can’t be aggressive with these. You got to protect. The primary goal, if this surgeon’s doing capsule shifts or even a slap repair or a labral repair with not necessarily a gross instability, meaning they didn’t dislocate, but the surgeon determines that they have a labral tear, they got to fix it, like Mike said, it’s very subjective how they fix things back down the capsule and the labrum back down to the glenoid rim, and so losing motion is common and that’s why our slap repairs failed big time is they stop, I think [inaudible] put out a study, they lose motion and so that’s a huge determinant of how they can get back to throwing a baseball. You need, as you said in the question, at least 115, 120 degrees of layback or external rotation to throw.
And if they end up with 90 because the protocol says only go to 90 or the surgeon says I want a stable shoulder first, don’t stretch them out, you have to listen, but man, you got to figure out ways to cut corners and get more visits after the three months is up because they do need that rotation. So again, the primary role of that surgeon is to get stability in a baseball player’s shoulder and anything after that, it’s a bonus. Now should that surgery have been done in the first place? I don’t know. We’re starting to question whether or not some of these labral repairs… not starting to, we know, if they’re doing a slap repair in a baseball player, basically, they have a 50/50 chance of getting back, I think at best, I would say at best, probably even worse now. That’s probably a 30% chance of getting back to throwing normally.
And so that’s like a last ditch, as Mike said, last ditch effort to play baseball and hopefully, you’ve tried everything and you’ve ruled out other stuff. We’re seeing a lot of anterior shoulder pain and things of that nature that is not necessarily labral. It looks labral on an MRI, but it’s not. It oftentimes could be a million things, it could be TOS, it could be pec, it could be lat, it could be teres, so many different structures on the front of the shoulder that you got to pay attention to. Neurovascular, I guess that would be TOS. So yeah, you have to figure out a way to get that motion back, but again, the primary role is to get a stable shoulder by the surgeon. They’re doing everything they can to get that stability back. It’s tough, but I don’t know. I would try to get into that surgeon’s head a little bit more and figure out what they saw in the shoulder and figure out how you can get that motion back.
Mike Reinold:
Yeah. I think you talked about the surgeon specifics a little bit too, Len. I think I like that. Some surgeons don’t work with a lot of overhead athletes. That’s not a negative, that’s not a slight towards them. They just don’t work with a lot of overhead athletes. So if you’re working with a surgeon that works with all football players that dislocate their shoulder and then they work with a baseball pitcher, I think the chances of them over tightening it is going to be high. So I think if you’re a baseball player and you need this type of surgery, you need to seek out whoever does the most of these in your area or even be ready to travel because I mean, heck, at this point in time, it’s a quick flight and probably less than a half day drive to somebody.
So you can find somebody that can probably help you with this because you really need to see somebody that understands the subtlety of this. Don’t over tighten it, don’t put a million anchors in there, and actually try to balance that blend between stability and mobility, which is good. What else? Anybody else have anything to add? I mean, I have a couple other thoughts, but I wanted to see if anybody else wanted to jump in there. I don’t know, Mike, what do you think? I know you work with a lot of these athletes with shoulder pain. I’d even be curious, how many labral repairs have we seen in the last year or two, do you think?
Mike Scaduto:
I’ve definitely seen quite a few and it’s 50/50 with how well they get back into throwing, to be honest, and the big thing is they get stiff, but in terms of strategies that I’ll use, the first step after I see a labral repair obviously is to protect the repair. So we’re not doing a ton of stretching or any real range of motion into external rotation at 90 probably for the first six to eight weeks, and then I’ll gradually start easing that back in. Obviously, checking the protocol and making sure that’s okay and talking with the doctor, but once we can, I’ll start easing that back in and tend to do less than 10 stretching at a higher frequency. So a good amount of our session will be low intensity passive range of motion into external rotation where we’re going just to the point of the end feel and just easing into it.
But doing a bunch of reps there. I will say in my experience, these people, somewhere in the 10 to 14-week mark, tend to get a little bit stiffer and they tend to start plateauing or start to lose a little bit of motion. So just be aware that there may be a point in the rehab where they do start to plateau and if you’re an insurance based model, maybe that’s where you’re running out of visits in that window. I would say that’s a big piece of education as to what patients can do on their own to maintain range of motion, whether that’s active assistive range of motion, some kind of gravity assisted range of motion, a low long duration stretch. Again, not where we’re pushing into an intensity that would jeopardize any kind of damage to the repair, but something to maintain motion, get them over that plateau, and then from there, I’m constantly measuring their range motion. Every time they come in, I’m taking a number before we start.
I’m taking a number after we do soft tissue, I’m taking a number if we are doing some joint mobilizations, I’m taking a range of motion number and I’m trying to restore that total arc into an acceptable range bilaterally. If we’re fortunate enough to have numbers for the shoulder pre-surgery, that gives us a target like what was your external rotation pre-surgery? We can kind of get close to that, and then I will say around the time where they start to think about getting back into throwing, if their external rotation is pretty good and their total arc is within 10, 15, 20 degrees of their non throwing side, I won’t push it a ton and let throwing maybe bring back some of that last little bit of external rotation and just continue to monitor so I’m not overstretching because we’re hypothesizing that throwing will help them get a little bit of range of motion back as long as they’re not super duper stiff, and then we’re just continuing to monitor what happens to their range of motion over time.
Mike Reinold:
I like that, Mike, and I think as an example in the clinic, which is really nice, just the last couple weeks, I had a baseball player that had this surgery and he started his throwing program because it was week X, but I thought he was significantly tight. So there’s a difference between just needing a little bit, like you mentioned, and being significantly tight. So you can definitely have that bounce back effect where, if you’re too tight and you start throwing, it’s going to get worse, it’s going to get way worse. I think the key, if you listen to what we heard so far, I think the key of putting all this together is gradual and steady progression of range of motion is probably going to help this person get better the best. If you break it up into chunks the first four weeks, you’re doing a lot of general range of motion within short, medium ranges of motion.
Then from week four to week eight, you gradually open that up to be a normal orthopedic person and that’s probably where Seth, your physicians are stopping you. From four to eight weeks, you progress to normal orthopedic, but from eight to 12 weeks, you progress to become a thrower because at 16 weeks, you got to pick up a ball. So you see how they all have to progress a little bit here? You want to be slowly working your way through that and I think if you’re on top of that person each week to week, hopefully you won’t have that little bounce back that, like Mike said, happens sometimes between 10 and 14. What tends to happen is that the person’s increasing their activities too much and annoying it a little bit, or they go on vacation or they’re out of the clinic away from you for a week or two in the middle. We see that a little bit and they have this bounce back. So good question, Seth.
I think the key to this obviously is starting from the beginning and just making sure that these people aren’t being over-treated. We’re not just jumping into surgeries when they don’t need them. Make sure they go through a good non-op treatment progression to see if they even need this and then if they do, it’s gradual, steady. Make sure you get that back over time and I’d space out your visits a little bit better. There’s going to be this range probably in the eight to 12 week zone where they’re going to be on cruise control with a lot of their therapy, but still need you to monitor and progress their range of motion and make sure they are getting it back. So good question, Seth, thanks so much. If you have a question like that, head to mikereinold.com, click on that podcast link and ask away, and please go to Apple Podcast, Spotify, subscribe, rate, review. We’d really appreciate it. We’ll see you on the next episode. Thanks so much.
