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RETURN TO PLAY (RTP) SHOULDER AND ELBOW
July 29, 2016
Mark Sytsma, MD
Bronson Sports Medicine Specialists
• I have no conflicts of interest of relevant financial relationships relating to this talk.
Disclosure
Return to Play (RTP)
• Background
• Shoulder injuries
– Fracture, dislocations, stinger, AC injuries, Clavicle fractures
• Elbow injuries
– Dislocation, fracture, ligament injuries
• Youth and overuse injuries
Why We Cover Sports
• Most injuries do not have serious consequences…but some do!
• Hours of preparation, observation and training for a few critical moments.
• ALWAYS be prepared!
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Why We Cover Sports
• OUR PRIMARY GOAL
– The health and wellbeing of our athletes
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Goals of Sideline Management
• Assess the athlete quickly and diagnose the problem
• Is this an injury that will allow the player to return?
– Finger dislocation vs ankle fracture
Return to Play (RTP)
• Depends on the sport
– Contact vs non-contact
– Specific position
• Depends on the body part injured
– Example: Non-dominant hand in a soccer player
• Depends on the level of sport
– Higher levels may absorb more risk
Above All Else
• Protect the athlete
– More important than the desires of the athlete, coach, parent, etc…
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Shoulder Injuries
• Stinger/Burner (Dr. Jensen)
– Dead arm, numbness and tingling from shoulder to hand
– Caused by direct contact and stretch to the brachial plexus (nerves exiting neck)
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Stinger/Burner
• Always evaluate for pain in the shoulder joint
– May indicate shoulder instability event
• Return to play?
– Sensation returns
– Normal shoulder strength (Rotator cuff test)
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Shoulder Dislocation
• Most common major joint dislocation
• 90+% anterior
• Mechanism
– Force or fall on Abducted, ER arm: anterior dx
– Force or fall on Adducted, IR arm: posterior dx
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Shoulder Dislocation
• Many spontaneously reduce. Pain
– “shift” or “slip”
• Locked dislocation
– Reduce
– Transfer to hospital if not reducible
• RTP?
Shoulder Dislocation
• Return to play?
– Sport, body part, level
– Consider surgery after first dislocation (new evidence)
• Often 3-6+ weeks
• Shoulder brace?
Shoulder Dislocation
• Younger Athletes (<25)
– High risk for recurrent dislocations/instability
• Mature athletes (>40)
– Must evaluate for acute rotator cuff tears
AC Separation
• Most common shoulder injury in contact sports
– Tenderness (+/-swelling/deformity) directly at AC joint
• Continuum of severity
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AC Separation
• Mechanism: direct hit to or fall on shoulder
• If lower grade (Type 1,2), may RTP if shoulder strength and motion are normal
AC Separation
• Most have weakness within shoulder due to pain on day of injury
– No return on day of injury
• RTP: 1-4 weeks
• For persistent pain without weakness
– Low grade injury (Type 1 or 2)
– Local anesthetic injections can be useful
• Do not inject with steroids
• Surgery: out of contact for 5+ months
Sternoclavicular Dislocation
• Much less common than AC injuries
• Mechanism: usually a direct blow to chest
• Anterior dislocation (more common)
– Deformity
• Posterior dislocation (more consequences)
– Difficulty breathing or swallowing
Sternoclavicular Dislocation
• May be a fracture through growth plate
– Fuses at age 20-25
• No return to play
– Seek medical care
– DO NOT reduce
Clavicle Fracture
• 35% of shoulder fractures involve the clavicle
• Mechanism: direct contact or fall on shoulder
• Most commonly involve the middle 1/3
Clavicle Fracture
• Clavicle fractures
– Diagnosis
• Deformity?
• Tenderness to palpation directly over the clavicle
– Unable to return to play
• Strength will be decreased
• If minimally displaced, still at significant risk for displacement
– Sling and X-ray evaluation
Clavicle Fracture
• If non-displaced or minimally displaced
– Nonoperative
– RTP?
• Midshaft, displaced, shortened
– Operative, RTP?
Clavicle Fracture
• Clavicle Fractures
– Distal fractures may mimic AC injuries
– If significantly displaced, usually managed operatively
Elbow Ligament Injuries
• Ulnar collateral ligament (Tommy John Ligament)
Elbow Ligament Injuries
• Throwing athletes
– Pop or acute pain along inside of elbow
– Remove from play immediately
• Medical evaluation
– RTP?
• Direct contact
– May brace (depending on sport)
– RTP?
Elbow Dislocation
• Second most common major joint dislocation
– 80% posterolateral
• Mechanism:
– Fall or direct blow
• Simple dislocation (50-60%)
– Ligament injury only
• Complex dislocation
– Fracture + ligament injury
Elbow Dislocation
• NO immediate return to play
– Usually 2+ months before return to contact sports if it is a simple dislocation
Elbow Fractures
• Mechanism: Fall or direct contact
Pediatric Elbow Fractures
• Usually involve growth plates
• Ligaments usually don’t tear, growth plates separate/fracture
Elbow Fractures
• Exam
– Deformity, swelling, or loss of motion
– Pain with direct palpation over the bone
• Remove from play
– Splint
– Obtain X-rays or appropriate studies
Elbow Fractures RTP
• Never return a young athlete immediately to play if they have bone or joint tenderness
• Need full motion and strength
• RTP 6+ weeks
– Longer for contact sports and articular fractures
– Sport, location, level
Overuse Injuries
• Primarily with overhead sports
– Baseball, volleyball, Tennis, Etc…
• You can NOT play through pain
– Remove from competition
– Medical evaluation
http://www.stopsportsinjuries.org/
Questions?
Thank you! bronsonhealth.com