- Email: [email protected]
Rotator Cuff Tears in Adolescent Female Catchers
J Shoulder Elbow Surg (2009) 18, e13-e16
www.elsevier.com/locate/ymse
Rotator Cuff Tears in Adolescent Female Catchers Travis C. Burns, MDa, John R. Reineck, MDb, Sumant G. Krishnan, MDb,* a b
Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX Shoulder and Elbow Service, The Carrell Clinic, Dallas, TX
Rotator cuff tears are a well-recognized clinical entity in overhead athletes and in older patients. There are several possible etiologies for rotator cuff pathology, which vary based on age and sport participation.2,6,17,23,24,28,31,32 Significant academic work has been dedicated to examining the throwing motion and the associated shoulder pathology in overhead athletes.2,8,12-14,22 However, there are only 2 known reported cases of rotator cuff tears in adolescents.4,25 To our knowledge, we present the first reported cases of full-thickness rotator cuff tears in adolescent girls, both occurring in softball catchers.
Case reports Patient 1 The first patient was a 15-year-old right hand dominant catcher for her high school softball team. She complained of a 1-year history of posterior right shoulder pain with throwing out of the crouched position. Her pain reduced 75% when she stopped playing at the end of the season, but returned completely with the new season. She was referred to our service by her primary care physician after rest, anti-inflammatory medications, electrical modalities, and a supervised course of physical therapy did not relieve her symptoms. Physical examination demonstrated no muscle atrophy or scapular dyskinesia. She had symmetric total arc range of motion of her shoulders, with her dominant right
*Reprint requests: Sumant G. Krishnan, MD, The Carrell Clinic, 9301 N Central Expressway, Ste 400, Dallas, TX 75231. E-mail address: [email protected] (S.G. Krishnan).
shoulder demonstrating 10 more of external rotation and 10 less of internal rotation at 90 of abduction compared with the left shoulder. She did not demonstrate signs of hyperlaxity or posterior capsular tightness. Neer and Hawkins impingement tests were positive. Apprehension, crank, and relocation tests were positive for pain in the posterior shoulder. When supine, maximum abduction and maximum external rotation most closely reproduced her symptoms. Active compression and superior labrum anteroposterior tests (SLAPrehension) were positive at the glenohumeral joint with posterior pain. Initial examination was suggestive of a posterosuperior labral lesion, and a diagnostic injection into her glenohumeral joint relieved 100% of her pain. A magnetic resonance (MR) arthrogram revealed a posterosuperior labral tear with posterior extension and a suprascapular notch cyst. Positioning in abduction/ external rotation (ABER) revealed a full-thickness supraspinatus tear (Figure 1). A diagnostic arthroscopy revealed a 1- 1-cm fullthickness supraspinatus tear and a posterosuperior labral lesion. In an arthroscopic procedure, the labral lesion was repaired with 2 anchors posterior to the biceps insertion and the supraspinatus tear was repaired with a ‘‘triangle’’ double-row construct (1 medial anchor with mattress stitches and 2 lateral anchors with simple stitches). She was immobilized in a sling for 6 weeks. Passive range of motion was instituted under the supervision of a therapist immediately and progressed to full active motion at week 6. She began a throwing program at 3 months with a coach and progressed to unrestricted throwing at 6 months. At 12 months, she had range of motion equal to her preoperative motion, equal strength bilaterally with no pain, and returned to softball at her preinjury level.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board ofTrustees. doi:10.1016/j.jse.2009.02.017
e14
Figure 1 A magnetic resonance arthrogram in the abduction/ external rotation position demonstrates a full-thickness rotator cuff tear.
T.C. Burns et al.
Figure 2 Arthroscopic view shows a full-thickness supraspinatus tear.
Patient 2 The second patient was a 14-year-old right-hand dominant softball catcher for 5 years. She complained of a 6-week history of right shoulder pain and weakness that started during a softball camp where drills involved throwing up to 4 hours daily. The pain worsened during the next several weeks and was most pronounced at ball release. After a game 1 week before her clinic visit, the pain was so severe that she went to a local emergency department for evaluation. Results of plain radiographs were not diagnostic, and she was placed in a sling and referred for evaluation. Physical examination demonstrated no muscular atrophy or scapular dyskinesia. She had a symmetric total arc range of motion bilaterally. Significant weakness was present both with supraspinatus testing and with resisted external rotation at her side and at 90 . Examination of her biceps and superior labral anchor did not demonstrate pathology. MR arthrography demonstrated a full-thickness tear at the junction of the insertions of the supraspinatus and infraspinatus with the arm in the ABER position. A diagnostic arthroscopy revealed a 2- 2-cm supraspinatus tear without labral or chondral pathology (Figure 2). An arthroscopic rotator cuff repair was performed with the ‘‘triangle’’ double-row construct (Figure 3). She progressed through the same rehabilitation program as the first patient. At 12 months, she had full strength and range of motion and returned to playing softball at her preinjury level.
Discussion Shoulder injuries commonly develop in adolescent overhead athletes due to large rotational forces produced during
the throwing motion.18,20,26 Multiple authors have described chronic stress fractures of the proximal humeral physis, termed little league shoulder, in young male pitchers.3,9-11,21,28 Atraumatic instability is also seen in the pediatric population and may occur with throwing, swimming, or gymnastics.19,20 Conversely, rotator cuff tendonitis or rotator cuff tears are uncommon in adolescents. We believe these are the first reported cases of complete rotator cuff tears in adolescent girls, both occurring in softball catchers. The injury in this age group and their unique sport participation distinguish these patients from prior reports. Only 2 cases of rotator cuff tears in adolescents are found in the literature. Rickert and Loew25 reported a rotator cuff tear in association with a Bankart lesion in an adolescent after a bicycle accident. Battaglia et al4 reported the only known case in the literature of a rotator cuff tear in an adolescent overhead athlete. They presented a 13-yearold boy with a partial-thickness bursal-sided tear that required operative repair after failed conservative measures. The authors attributed the tear to strain from pitching and outlet impingement from a nonossified prominent acromial edge. Rotator cuff injuries in young overhead athletes have several proposed etiologies: extrinsic compression or outlet impingement as described by Neer, secondary subacromial impingement caused by subtle glenohumeral laxity or instability, tensile failure during early acceleration or deceleration phases of throwing, or both, and internal impingement of the posterosuperior glenoid and labrum with the articular side of the supraspinatus in abduction and external rotation.2,15-17,23,29,33 Neither of our patients complained of instability or had physical examination findings consistent with instability.
Cuff tears in adolescent female catchers
Figure 3 repair.
Final arthroscopic views shows dual-row rotator cuff
The first patient had a full-thickness supraspinatus tear and a concomitant posterosuperior labral tear. The labral findings have 3 plausible mechanical explanations: traction injury of the biceps during deceleration as described by Andrews et al,1 internal impingement as described by Walch et al32 and Jobe16, or the ‘‘peel-back’’ mechanism described by Burkhart and Morgan.7,29 This patient demonstrated her pain in maximal ABER, likely due to both internal impingement and a ‘‘peel-back’’ mechanism. The second case was an isolated full thickness supraspinatus tear after a recent increase in activity. Her 6-week history of shoulder pain with throwing indicates a probable tendinopathy preceding her complete rotator cuff tear, and the weakened tendon likely finally ruptured during a hard throw in game participation. MR arthrography with ABER positioning provided invaluable diagnostic data in these patients. In recent decades, many institutions have used ABER positioning as an additional sequence to help in diagnosing more difficult cases. The ABER positioning more closely approximates the overhead throwing position. When combined with direct MR arthrography, the ABER position is typically used to further evaluate for labral pathology and instability. However, several studies describe the use of MR arthrography and ABER positioning to further characterize articular surface partial thickness rotator cuff tears. Contrary to the increased tension placed on the inferior glenohumeral ligament and anterior labral structures, the rotator cuff is lax in this position. The loss of traction on the cuff structures helps unmask partial articular surface tears and secondary interstitial extension by allowing the contrast and fluid to interdigitate between the fibers. Previous studies demonstrated MR arthrography to be 84% to 95% sensitive and 96% to 100% specific for partial-thickness
e15 articular surface tears of the rotator cuff without ABER positioning.23,30 Our 2 patients also emphasize the utility of ABER positioning to improve visualization and characterization of unsuspected full-thickness rotator cuff tears. The ABER images in both patients demonstrated the complete nature of the tear that was not as readily apparent with standard coronal oblique images. ABER imaging usually adds approximately 10 extra minutes to the routine MR arthrography protocol at our institution and consists of repositioning, reperforming scout, and acquiring a set of T1 fat-saturated images. Selective addition of this ABER series may prove beneficial in the selection of a young, athletic population with suspected articular surface rotator cuff tears. We find it unusual that these first 2 reported rotator cuff tears in adolescent girls occurred in softball catchers. Although most studies on the throwing motion analyze pitchers due to the consistency of the motion, there is a paucity of information about throwing out of a crouch position. During the wind-up phase of the throwing motion, leg push-off and pelvic rotation initiate the kinetic chain to propel the upper extremity.15,25 Unlike pitchers who start from a standing position and have both time and core balance for sufficient wind up, the performance of a catcher is predicated on the ability to quickly release the ball from a crouched position. This emphasis on a hurried delivery from a crouched start may have prevented these 2 adolescent catchers from adequately establishing a stable core base or properly performing leg push-off and pelvic rotation to transfer energy to their upper extremity. Hence, all of the stress of their throwing motion may have been borne eccentrically by the rotator cuff with little benefit from core stability. Subacromial impingement due to subtle instability or muscle imbalance has been reported previously in young overhead athletes.4,5,13,16,27,29 Contact of the supraspinatus tendon with the acromion or the superior glenoid can lead to degeneration of the tendon and eventual failure, although this is uncommon in adolescents. A history or physical examination finding consistent with impingement in young overhead athletes should be treated promptly with rest, modifying sport exposure, a strengthening program based on core strengthening and scapular stabilization, teaching proper mechanics of throwing and energy transfer, and finally, a progressive supervised return to sport to prevent further injury. Continued attention should be given to young throwers to prevent further overuse injuries, because there appears to be a significant association between the number of pitches thrown during a season and the development of shoulder pain in young pitchers.22 These findings lead to a recommended pitch count and type based on age.22 Young catchers generally do not perform the number of overhead repetitions of young pitchers, but these athletes should also be monitored, especially during times of more intense training.
e16
Disclaimer Sumant G. Krishnan, MD, reports that he has received institutional/research support and consultant fees from DepuyMitek. All of the other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Investigational Review Board approval was not required.
References 1. Andrews JR, Carson W Jr, McLeod W. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-41. 2. Baker CL, Whaley AL, Baker M. In: Krishnan SG, Hawkins RJ, Warren RF, editors. Subacromial impingement and full thickness rotator cuff tears in overhead athletes. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 146-62. 3. Barnett LS. Little league shoulder syndrome: proximal humeral epiphysis in adolescent baseball pitchers. J Bone Joint Surg Am 1985;67:495-6. 4. Battaglia TC, Barr MA, Diduch DR. Rotator cuff tear in a 13-year-old baseball player: a case report. Am J Sports Med 2003;31:779-82. 5. Bigliani LU, D’Alessandro DF, Duralde XA, McIlveen SJ. Anterior acromioplasty for subacromial impingement in patients younger than 40 years of age. Clin Orthop Relat Res 1989;6:111-6. 6. Blevins FT, Hayes WM, Warren RF. Rotator cuff injury in contact athletes. Am J Sports Med 1996;24:263-7. 7. Burkhart SS, Morgan CD. Technical note: the peel-back mechanism: its role in producing and extending posterior Type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-40. 8. Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes: the ‘‘dead arm’’ revisited. Clin Sports Med 2000;19:125-58. 9. Cahill BR, Tullos HS. Little league shoulder. J Sports Med 1974;2:150-3. 10. Carson WG Jr, Gasser SI. Little leaguer’s shoulder: a report of 23 cases. Am J Sports Med 1998;26:575-80. 11. Dotter WE. Little leaguer’s shoulder: a fracture of the proximal epiphyseal cartilage of the humerus due to baseball pitching. Guthrie Clin Bull 1953;23:68-72. 12. Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomechanics 1999;32:1371-5. 13. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med 1980;8:151-8.
T.C. Burns et al. 14. Hong DA, Cheung TK, Roberts EM. A three-dimensional, sixsegment chain analysis of forceful overarm throwing. J Electromyogr Kinesiol 2001;11:95-112. 15. Hulstyn MJ, Fadale PD. Shoulder injuries in the athlete. Clin Sports Med 1997;16:663-79. 16. Jobe CM. Posterior superior glenoid impingement: expanded spectrum. Arthroscopy 1995;11:530-6. 17. Jobe FW, Tibone JE, Pink MM, Jobe CM, Kvitne RS. The shoulder in sports. In: Rockwood CA Jr, MatsenI FA 3rdI, editors. The shoulder. Philadelphia: WB Saunders; 1990. p. 1214-38. 18. Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-86. 19. Kocher MS, O’Holleran J. Disorders in pediatric athletes. In: Krishnan SF, Hawkins RJ, Warren RF, editors. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 284-98. 20. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000;30:117-35. 21. Kohler R, Trillaud JM. Fracture and fracture separation of the proximal humerus in children: report of 136 cases. J Pediatr Orthop 1983;3:326-32. 22. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med 2002;30:463-8. 23. Meister K, Thesing J, Montgomery WJ, Indelicato PA, Walczak S, Fontenot W. MR arthrography of partial thickness tears of the undersurface of the rotator cuff: an arthroscopic correlation. Skeletal Radiol 2004;33:136-41. 24. Neer CS 2nd. Impingement lesions. Clin Orthop 1983;173:70-7. 25. Rickert M, Loew M. Traumatic rupture of the rotator cuff in an adolescentecase report [German]. Z Orthop Ihre Grenzgeb 2000;138:340-3. 26. Rubin BD, Kibler WB. Fundamental principles of shoulder rehabilitation: conservative to postoperative management. Arthroscopy 2002; 18:29-39. 27. Sciascia A, Kibler WB. The pediatric overhead athlete: what is the real problem? Clin J Sport Med 2006;16:471-7. 28. Tibone JE. Shoulder problems of adolescence. Clin Sports Med 1983; 2:423-6. 29. Tibone JE, Elrod B, Jobe FW, Kerlan RK, Carter VS, Shields CL, et al. Surgical treatment of tears of the rotator cuff in athletes. J Bone Joint Surg Am 1986;68:887-91. 30. Tirman PF, Bost FW, Steinbach LS, et al. MR arthrographic depiction of tears of the rotator cuff: benefit of abduction and external rotation of the arm. Radiology 1994;192:851-6. 31. Tullos HS, Fain RH. Little league shoulder: rotational stress fracture of proximal humeral epiphysis. J Sports Med 1974;2:152-3. 32. Walch G, Boileau J, Noel E, Donnel ST. Impingement of the deep surface of the supraspinatus tendon on the posterior superior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg 1992;1:238-43. 33. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg 2006;14: 715-25.
www.elsevier.com/locate/ymse
Rotator Cuff Tears in Adolescent Female Catchers Travis C. Burns, MDa, John R. Reineck, MDb, Sumant G. Krishnan, MDb,* a b
Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX Shoulder and Elbow Service, The Carrell Clinic, Dallas, TX
Rotator cuff tears are a well-recognized clinical entity in overhead athletes and in older patients. There are several possible etiologies for rotator cuff pathology, which vary based on age and sport participation.2,6,17,23,24,28,31,32 Significant academic work has been dedicated to examining the throwing motion and the associated shoulder pathology in overhead athletes.2,8,12-14,22 However, there are only 2 known reported cases of rotator cuff tears in adolescents.4,25 To our knowledge, we present the first reported cases of full-thickness rotator cuff tears in adolescent girls, both occurring in softball catchers.
Case reports Patient 1 The first patient was a 15-year-old right hand dominant catcher for her high school softball team. She complained of a 1-year history of posterior right shoulder pain with throwing out of the crouched position. Her pain reduced 75% when she stopped playing at the end of the season, but returned completely with the new season. She was referred to our service by her primary care physician after rest, anti-inflammatory medications, electrical modalities, and a supervised course of physical therapy did not relieve her symptoms. Physical examination demonstrated no muscle atrophy or scapular dyskinesia. She had symmetric total arc range of motion of her shoulders, with her dominant right
*Reprint requests: Sumant G. Krishnan, MD, The Carrell Clinic, 9301 N Central Expressway, Ste 400, Dallas, TX 75231. E-mail address: [email protected] (S.G. Krishnan).
shoulder demonstrating 10 more of external rotation and 10 less of internal rotation at 90 of abduction compared with the left shoulder. She did not demonstrate signs of hyperlaxity or posterior capsular tightness. Neer and Hawkins impingement tests were positive. Apprehension, crank, and relocation tests were positive for pain in the posterior shoulder. When supine, maximum abduction and maximum external rotation most closely reproduced her symptoms. Active compression and superior labrum anteroposterior tests (SLAPrehension) were positive at the glenohumeral joint with posterior pain. Initial examination was suggestive of a posterosuperior labral lesion, and a diagnostic injection into her glenohumeral joint relieved 100% of her pain. A magnetic resonance (MR) arthrogram revealed a posterosuperior labral tear with posterior extension and a suprascapular notch cyst. Positioning in abduction/ external rotation (ABER) revealed a full-thickness supraspinatus tear (Figure 1). A diagnostic arthroscopy revealed a 1- 1-cm fullthickness supraspinatus tear and a posterosuperior labral lesion. In an arthroscopic procedure, the labral lesion was repaired with 2 anchors posterior to the biceps insertion and the supraspinatus tear was repaired with a ‘‘triangle’’ double-row construct (1 medial anchor with mattress stitches and 2 lateral anchors with simple stitches). She was immobilized in a sling for 6 weeks. Passive range of motion was instituted under the supervision of a therapist immediately and progressed to full active motion at week 6. She began a throwing program at 3 months with a coach and progressed to unrestricted throwing at 6 months. At 12 months, she had range of motion equal to her preoperative motion, equal strength bilaterally with no pain, and returned to softball at her preinjury level.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board ofTrustees. doi:10.1016/j.jse.2009.02.017
e14
Figure 1 A magnetic resonance arthrogram in the abduction/ external rotation position demonstrates a full-thickness rotator cuff tear.
T.C. Burns et al.
Figure 2 Arthroscopic view shows a full-thickness supraspinatus tear.
Patient 2 The second patient was a 14-year-old right-hand dominant softball catcher for 5 years. She complained of a 6-week history of right shoulder pain and weakness that started during a softball camp where drills involved throwing up to 4 hours daily. The pain worsened during the next several weeks and was most pronounced at ball release. After a game 1 week before her clinic visit, the pain was so severe that she went to a local emergency department for evaluation. Results of plain radiographs were not diagnostic, and she was placed in a sling and referred for evaluation. Physical examination demonstrated no muscular atrophy or scapular dyskinesia. She had a symmetric total arc range of motion bilaterally. Significant weakness was present both with supraspinatus testing and with resisted external rotation at her side and at 90 . Examination of her biceps and superior labral anchor did not demonstrate pathology. MR arthrography demonstrated a full-thickness tear at the junction of the insertions of the supraspinatus and infraspinatus with the arm in the ABER position. A diagnostic arthroscopy revealed a 2- 2-cm supraspinatus tear without labral or chondral pathology (Figure 2). An arthroscopic rotator cuff repair was performed with the ‘‘triangle’’ double-row construct (Figure 3). She progressed through the same rehabilitation program as the first patient. At 12 months, she had full strength and range of motion and returned to playing softball at her preinjury level.
Discussion Shoulder injuries commonly develop in adolescent overhead athletes due to large rotational forces produced during
the throwing motion.18,20,26 Multiple authors have described chronic stress fractures of the proximal humeral physis, termed little league shoulder, in young male pitchers.3,9-11,21,28 Atraumatic instability is also seen in the pediatric population and may occur with throwing, swimming, or gymnastics.19,20 Conversely, rotator cuff tendonitis or rotator cuff tears are uncommon in adolescents. We believe these are the first reported cases of complete rotator cuff tears in adolescent girls, both occurring in softball catchers. The injury in this age group and their unique sport participation distinguish these patients from prior reports. Only 2 cases of rotator cuff tears in adolescents are found in the literature. Rickert and Loew25 reported a rotator cuff tear in association with a Bankart lesion in an adolescent after a bicycle accident. Battaglia et al4 reported the only known case in the literature of a rotator cuff tear in an adolescent overhead athlete. They presented a 13-yearold boy with a partial-thickness bursal-sided tear that required operative repair after failed conservative measures. The authors attributed the tear to strain from pitching and outlet impingement from a nonossified prominent acromial edge. Rotator cuff injuries in young overhead athletes have several proposed etiologies: extrinsic compression or outlet impingement as described by Neer, secondary subacromial impingement caused by subtle glenohumeral laxity or instability, tensile failure during early acceleration or deceleration phases of throwing, or both, and internal impingement of the posterosuperior glenoid and labrum with the articular side of the supraspinatus in abduction and external rotation.2,15-17,23,29,33 Neither of our patients complained of instability or had physical examination findings consistent with instability.
Cuff tears in adolescent female catchers
Figure 3 repair.
Final arthroscopic views shows dual-row rotator cuff
The first patient had a full-thickness supraspinatus tear and a concomitant posterosuperior labral tear. The labral findings have 3 plausible mechanical explanations: traction injury of the biceps during deceleration as described by Andrews et al,1 internal impingement as described by Walch et al32 and Jobe16, or the ‘‘peel-back’’ mechanism described by Burkhart and Morgan.7,29 This patient demonstrated her pain in maximal ABER, likely due to both internal impingement and a ‘‘peel-back’’ mechanism. The second case was an isolated full thickness supraspinatus tear after a recent increase in activity. Her 6-week history of shoulder pain with throwing indicates a probable tendinopathy preceding her complete rotator cuff tear, and the weakened tendon likely finally ruptured during a hard throw in game participation. MR arthrography with ABER positioning provided invaluable diagnostic data in these patients. In recent decades, many institutions have used ABER positioning as an additional sequence to help in diagnosing more difficult cases. The ABER positioning more closely approximates the overhead throwing position. When combined with direct MR arthrography, the ABER position is typically used to further evaluate for labral pathology and instability. However, several studies describe the use of MR arthrography and ABER positioning to further characterize articular surface partial thickness rotator cuff tears. Contrary to the increased tension placed on the inferior glenohumeral ligament and anterior labral structures, the rotator cuff is lax in this position. The loss of traction on the cuff structures helps unmask partial articular surface tears and secondary interstitial extension by allowing the contrast and fluid to interdigitate between the fibers. Previous studies demonstrated MR arthrography to be 84% to 95% sensitive and 96% to 100% specific for partial-thickness
e15 articular surface tears of the rotator cuff without ABER positioning.23,30 Our 2 patients also emphasize the utility of ABER positioning to improve visualization and characterization of unsuspected full-thickness rotator cuff tears. The ABER images in both patients demonstrated the complete nature of the tear that was not as readily apparent with standard coronal oblique images. ABER imaging usually adds approximately 10 extra minutes to the routine MR arthrography protocol at our institution and consists of repositioning, reperforming scout, and acquiring a set of T1 fat-saturated images. Selective addition of this ABER series may prove beneficial in the selection of a young, athletic population with suspected articular surface rotator cuff tears. We find it unusual that these first 2 reported rotator cuff tears in adolescent girls occurred in softball catchers. Although most studies on the throwing motion analyze pitchers due to the consistency of the motion, there is a paucity of information about throwing out of a crouch position. During the wind-up phase of the throwing motion, leg push-off and pelvic rotation initiate the kinetic chain to propel the upper extremity.15,25 Unlike pitchers who start from a standing position and have both time and core balance for sufficient wind up, the performance of a catcher is predicated on the ability to quickly release the ball from a crouched position. This emphasis on a hurried delivery from a crouched start may have prevented these 2 adolescent catchers from adequately establishing a stable core base or properly performing leg push-off and pelvic rotation to transfer energy to their upper extremity. Hence, all of the stress of their throwing motion may have been borne eccentrically by the rotator cuff with little benefit from core stability. Subacromial impingement due to subtle instability or muscle imbalance has been reported previously in young overhead athletes.4,5,13,16,27,29 Contact of the supraspinatus tendon with the acromion or the superior glenoid can lead to degeneration of the tendon and eventual failure, although this is uncommon in adolescents. A history or physical examination finding consistent with impingement in young overhead athletes should be treated promptly with rest, modifying sport exposure, a strengthening program based on core strengthening and scapular stabilization, teaching proper mechanics of throwing and energy transfer, and finally, a progressive supervised return to sport to prevent further injury. Continued attention should be given to young throwers to prevent further overuse injuries, because there appears to be a significant association between the number of pitches thrown during a season and the development of shoulder pain in young pitchers.22 These findings lead to a recommended pitch count and type based on age.22 Young catchers generally do not perform the number of overhead repetitions of young pitchers, but these athletes should also be monitored, especially during times of more intense training.
e16
Disclaimer Sumant G. Krishnan, MD, reports that he has received institutional/research support and consultant fees from DepuyMitek. All of the other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Investigational Review Board approval was not required.
References 1. Andrews JR, Carson W Jr, McLeod W. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-41. 2. Baker CL, Whaley AL, Baker M. In: Krishnan SG, Hawkins RJ, Warren RF, editors. Subacromial impingement and full thickness rotator cuff tears in overhead athletes. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 146-62. 3. Barnett LS. Little league shoulder syndrome: proximal humeral epiphysis in adolescent baseball pitchers. J Bone Joint Surg Am 1985;67:495-6. 4. Battaglia TC, Barr MA, Diduch DR. Rotator cuff tear in a 13-year-old baseball player: a case report. Am J Sports Med 2003;31:779-82. 5. Bigliani LU, D’Alessandro DF, Duralde XA, McIlveen SJ. Anterior acromioplasty for subacromial impingement in patients younger than 40 years of age. Clin Orthop Relat Res 1989;6:111-6. 6. Blevins FT, Hayes WM, Warren RF. Rotator cuff injury in contact athletes. Am J Sports Med 1996;24:263-7. 7. Burkhart SS, Morgan CD. Technical note: the peel-back mechanism: its role in producing and extending posterior Type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-40. 8. Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes: the ‘‘dead arm’’ revisited. Clin Sports Med 2000;19:125-58. 9. Cahill BR, Tullos HS. Little league shoulder. J Sports Med 1974;2:150-3. 10. Carson WG Jr, Gasser SI. Little leaguer’s shoulder: a report of 23 cases. Am J Sports Med 1998;26:575-80. 11. Dotter WE. Little leaguer’s shoulder: a fracture of the proximal epiphyseal cartilage of the humerus due to baseball pitching. Guthrie Clin Bull 1953;23:68-72. 12. Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomechanics 1999;32:1371-5. 13. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med 1980;8:151-8.
T.C. Burns et al. 14. Hong DA, Cheung TK, Roberts EM. A three-dimensional, sixsegment chain analysis of forceful overarm throwing. J Electromyogr Kinesiol 2001;11:95-112. 15. Hulstyn MJ, Fadale PD. Shoulder injuries in the athlete. Clin Sports Med 1997;16:663-79. 16. Jobe CM. Posterior superior glenoid impingement: expanded spectrum. Arthroscopy 1995;11:530-6. 17. Jobe FW, Tibone JE, Pink MM, Jobe CM, Kvitne RS. The shoulder in sports. In: Rockwood CA Jr, MatsenI FA 3rdI, editors. The shoulder. Philadelphia: WB Saunders; 1990. p. 1214-38. 18. Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-86. 19. Kocher MS, O’Holleran J. Disorders in pediatric athletes. In: Krishnan SF, Hawkins RJ, Warren RF, editors. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 284-98. 20. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000;30:117-35. 21. Kohler R, Trillaud JM. Fracture and fracture separation of the proximal humerus in children: report of 136 cases. J Pediatr Orthop 1983;3:326-32. 22. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med 2002;30:463-8. 23. Meister K, Thesing J, Montgomery WJ, Indelicato PA, Walczak S, Fontenot W. MR arthrography of partial thickness tears of the undersurface of the rotator cuff: an arthroscopic correlation. Skeletal Radiol 2004;33:136-41. 24. Neer CS 2nd. Impingement lesions. Clin Orthop 1983;173:70-7. 25. Rickert M, Loew M. Traumatic rupture of the rotator cuff in an adolescentecase report [German]. Z Orthop Ihre Grenzgeb 2000;138:340-3. 26. Rubin BD, Kibler WB. Fundamental principles of shoulder rehabilitation: conservative to postoperative management. Arthroscopy 2002; 18:29-39. 27. Sciascia A, Kibler WB. The pediatric overhead athlete: what is the real problem? Clin J Sport Med 2006;16:471-7. 28. Tibone JE. Shoulder problems of adolescence. Clin Sports Med 1983; 2:423-6. 29. Tibone JE, Elrod B, Jobe FW, Kerlan RK, Carter VS, Shields CL, et al. Surgical treatment of tears of the rotator cuff in athletes. J Bone Joint Surg Am 1986;68:887-91. 30. Tirman PF, Bost FW, Steinbach LS, et al. MR arthrographic depiction of tears of the rotator cuff: benefit of abduction and external rotation of the arm. Radiology 1994;192:851-6. 31. Tullos HS, Fain RH. Little league shoulder: rotational stress fracture of proximal humeral epiphysis. J Sports Med 1974;2:152-3. 32. Walch G, Boileau J, Noel E, Donnel ST. Impingement of the deep surface of the supraspinatus tendon on the posterior superior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg 1992;1:238-43. 33. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg 2006;14: 715-25.