Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve.

Eighty-three athletes with medial elbow instability underwent reconstruction of the anterior band of the ulnar collateral ligament with a muscle-splitting approach without transposition of the ulnar nerve. The purposes of this study were to describe postoperative neurologic outcomes in all 83 athletes and to describe the 2-year follow-up in 33 athletes. Postoperatively, 5% of this group had transient ulnar nerve symptoms, all of which resolved with nonoperative management. There were no reoperations for nerve dysfunction and no permanent nerve problems. At 2- to 4-year follow-ups, 93% of the highly competitive athletes who had not had a prior surgical procedure had an excellent result. All athletes, regardless of whether they had a prior procedure, were able to return to their sport. These surgical modifications to the ulnar collateral ligament reconstruction yielded a decreased postoperative complication rate and improved outcomes compared with the results of prior procedures.

A modification of the relocation test: arthroscopic findings associated with a positive test.

Thirteen overhand-throwing athletes who failed at least 3 months of physical therapy while restricted from throwing and who demonstrated a positive modified relocation test at 90 degrees, 110 degrees, and/or 120 degrees were clinically and arthroscopically examined. On arthroscopic examination, all patients demonstrated articular surface pathology. Eleven patients had fraying of the undersurface of the rotator cuff, and 10 patients had fraying of the posterosuperior labrum. With 90 degrees shoulder abduction, 8 patients had rotator cuff contact with the posterosuperior labrum. When the shoulder was abducted to 110 degrees, all patients demonstrated such contact. At 120 degrees of abduction, 12 patients revealed contact. The presence or absence of pain during the modified relocation test correlated with the presence or absence of cuff contact with the posterosuperior labrum 79% of the time. Six patients had a positive modified relocation test at all levels of abduction. These patients included 2 with SLAP lesions, 1 with a Bankart lesion, and 1 with a complete tear of the rotator cuff.

The painful shoulder in the swimming athlete.

Given the popularity of swimming and the high risk of injury associated with the sport, many clinicians come into contact with the swimmer's shoulder. This article describes the mechanism of injury, diagnostic tools, and subtle signs of injury for swimmer's shoulder. It focuses on conservative treatment for the injury, including methods for stretching and strengthening and eliminating acute inflammation.

Anatomy of provocative tests for impingement syndrome of the shoulder.

The purpose of this study was to describe the extra- and intra-articular anatomic relationships present during the Neer and Hawkins tests. Nine fresh-frozen cadaveric shoulders were positioned in the impingement position described by Neer (n = 5) or that described by Hawkins (n = 4), embedded in polyurethane, and studied with the use of a cross-sectional technique. All shoulders placed in the Neer position demonstrated soft tissue contact with the medial acromion and contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid rim. Shoulders placed in the Hawkins position demonstrated consistent contact between soft tissues and the coracoacromial ligament. In all Hawkins positioned shoulders, contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid was observed. The subscapularis tendon was deformed by the coracoid in 1 of the Hawkins positioned specimens. Although factors inherent to human subjects such as edema and muscle tone may influence the anatomy, these provocative tests for subacromial impingement appear to elicit contact consistent with impingement.

Electromyographic analysis of deltoid and rotator cuff function under varying loads and speeds.

The purpose of this study was to compare the effect of increasing loads and doubling speed on the deltoid and rotator cuff muscles during isotonic scapular plane abduction (scaption) with neutral humeral rotation. These muscles were studied in 16 volunteers with asymptomatic shoulders with the use of fine wire electromyography. The addition of load to the arm during scaption caused an increase in electromyographic activity during the first 90 degrees of motion. Furthermore electromyographic activity decreased during the final 30 degrees of motion with each increase in load. Doubling the speed caused an increase in electromyographic activity during the first 60 degrees of motion while causing a decrease in activity in the final 60 degrees. This study demonstrates the response of the rotator cuff and deltoid muscles to varying loads and speeds during the most basic shoulder motion. With the data obtained in this study, rehabilitation exercises and experimental shoulder models can be refined to reflect this more physiologic situation.

Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff.

SUMMARY: The purpose of this article is to describe the outcome of an arthroscopic examination and the pathology in symptomatic shoulders of 41 professional overhand throwing athletes. With the arm in the position of the relocation test, 100% of the subjects had either contact between the rotator cuff undersurface and the posterosuperior glenoid rim or osteochondral lesions. Other key findings included undersurface cuff fraying in 93%, posterosuperior labral fraying in 88%, and anterior labral fraying in 36% of the subjects. This study supports the concept of impingement of the posterior cuff undersurface with the posterosuperior glenoid rim in the overhand throwing athlete with shoulder pain.

Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement.

The purpose of this study was to compare subjects with subacromial impingement and subjects with normal shoulders with respect to muscle activity. Fifteen subjects in each group were studied by means of fine-wire electromyography. The middle deltoid and rotator cuff muscles were evaluated during isotonic scaption from 30 to 120 degrees. Overall, the impingement group demonstrated decreased mean muscle activity in comparison with the group of normal subjects. The magnitude of diminished activity was statistically significantly different (P < .05) during the 30- to 60-degrees arc for the infraspinatus, subscapularis, and middle deltoid muscles; in addition, the infraspinatus muscle demonstrated significantly depressed activity during the 60- to 90-degrees arc. In the impingement group, the supraspinatus and teres minor revealed a diminution of muscle function in comparison with shoulders in the normal group; the difference was not significant. This study demonstrates that muscle activity in subjects with impingement is most notably decreased in the first arc of motion. Also of clinical relevance is the fact that the inferior force vector (from the infraspinatus and subscapularis) is less functional in subjects with impingement than is the superior compressive vector (from the supraspinatus). Thus, humeral head depression during the critical first portion of elevation may be insufficient in people with subacromial impingement.

Electromyographic investigation of stretching: the effect of warm-up.

OBJECTIVE: To compare the fine wire electromyographic (EMG) firing patterns during static stretches in the biceps femoris, soleus, and gastrocnemius before and after warm-up as well as over time. DESIGN: Experimental single group pretest-posttest design. SETTING: Biomechanics research laboratory. PARTICIPANTS: Sixteen healthy volunteers 23 to 36 years of age with no history of lower extremity injury. INTERVENTION: Subjects performed one hamstring stretch and four calf stretches for 90 seconds, bicycled for 30 minutes as a warm-up, and stretched again. MAIN OUTCOME MEASURE: EMG was recorded at time 0, 30, 60, and 90 seconds during the stretches before and after warm-up. Recorded values were normalized to EMG during maximum manual muscle testing (MMT). A two-way analysis of variance with repeated measures (p < 0.05) was done to compare EMG activity during stretching before and after warm-up as well as over time. RESULTS: Low EMG activity was seen for all muscles (< 20% MMT). It was constant over the time of the stretch for all muscles, but it increased in the soleus during the bent knee stretch position. There was a statistically significant decrease in the EMG activity after the warm-up for the gastrocnemius using the traditional and heel off stretching positions and for the soleus using the heel off stretching position (p < 0.05). The biceps femoris EMG activity showed no significant differences before and after warm-up. CONCLUSIONS: EMG activity during static stretching was low. Overall, the EMG activity remained constant with time for a given stretch position. EMG of the soleus and gastrocnemius was significantly less after warm-up for some stretches, whereas the EMG activity of biceps femoris showed no differences before and after warm-up.

Electromyographic analysis of shoulder function during the volleyball serve and spike.

The purpose of this study was to describe the electromyographic (EMG) pattern and relative intensities of 8 shoulder muscles during the volleyball serve and spike in 15 professional or collegiate-level athletes. The EMG analysis was synchronized with high-speed cinematography to discern phases of the spike and serve. During the spike, the anterior deltoid and supraspinatus functioned together to elevate and place the humerus throughout all phases. During cocking the infraspinatus and teres minor acted together to rotate the humerus externally. In acceleration, however, these muscles behaved independently; activity of the teres minor remained high, whereas the activity of the infraspinatus declined. The anterior wall muscles functioned to decelerate the humerus during cocking and acted as internal rotators during acceleration. Muscle activities recorded for the serve followed similar patterns as those seen for the spike, but with lower amplitudes. These data illustrate the complex sequence of shoulder muscle activity necessary to play competitive volleyball.

Shoulder reaction time and muscle-firing patterns in response to an anterior translation force.

The primary restraint preventing humeral head translation is the capsuloligamentous system. Muscle forces can also decrease translation; however, the timing and magnitude of muscle response has not been previously reported. Fine wire electromyographic analysis of the biceps long head, anterior deltoid, pectoralis major, latissimus dorsi, and rotator cuff muscles was performed after an anterior translation force was applied to 15 normal shoulders. The reflex response time (time to 5% maximal muscle test), the protection response time (time to 20% maximal muscle test), the duration of the protection response, and the magnitude of the protection response were calculated. The shoulder reaction data showed 2 consistent patterns. Activation of the anteriorly located muscles preceded the posteriorly located muscles, and the rotator cuff muscles fired with greater magnitude than the more peripherally located muscles.

Shoulder muscle firing patterns during the windmill softball pitch.

The purpose of this study was to describe the activity of eight shoulder muscles during the windmill fast-pitch softball throw. Ten collegiate female pitchers were analyzed with intramuscular electromyography, high-speed cinematography, and motion analysis. The supraspinatus muscle fired maximally during arm elevation from the 6 to 3 o'clock position phase, centralizing the humeral head within the glenoid. The posterior deltoid and teres minor muscles acted maximally from the 3 to 12 o'clock position phase to continue arm elevation and externally rotate the humerus. The pectoralis major muscle accelerated the arm from the 12 o'clock position to ball release phase. The serratus anterior muscle characteristically acted to position the scapula for optimal glenohumeral congruency, and the subscapularis muscle functioned as an internal rotator and to protect the anterior capsule. Although the windmill softball pitch is overtly different from the baseball pitch, several surprising similarities were revealed. The serratus anterior and pectoralis major muscles work in synchrony and seem to have similar functions in both pitches. Although the infraspinatus and teres minor muscles are both posterior cuff muscles, they are characteristically uncoupled during the 6 to 3 o'clock position phase, with the infraspinatus muscle acting more independently below 90 degrees. Subscapularis muscle activity seems important in dynamic anterior glenohumeral stabilization and as an internal rotator in both the baseball and softball throws.

Comparative electromyographic analysis of shoulder muscles during planar motions: anterior glenohumeral instability versus normal.

This study compared the electromyographic activity of rotator cuff and scapular muscles between subjects with anterior instability and subjects with normal shoulders. Thirty-eight patients were studied; 23 had anterior instability that was subsequently surgically confirmed, and 15 had normal shoulders. Fine wire electrodes were inserted into the subscapularis (upper and lower portions), supraspinatus, infraspinatus, rhomboid, serratus anterior, and trapezius (upper and lower portions) muscles. Abduction, scapular plane abduction (scaption), and forward flexion were performed over the range of motion and later divided into 30 degrees intervals. In both abduction and scaption, the supraspinatus demonstrated significantly less electromyographic activity from 30 degrees to 60 degrees in shoulders with anterior instability compared with normal shoulders (p < 0.05). During all three motions, shoulders with anterior instability demonstrated significantly less electromyographic activity in the serratus anterior when compared with normal shoulders (p < 0.05). This occurred at 30 degrees to 120 degrees of abduction and at 0 degree to 120 degrees of scaption and forward flexion. None of the other muscles demonstrated significant differences. These differences during planar motions were similar to those demonstrated during challenging overhead sport motions. Early rehabilitation efforts should focus both on the rotator cuff and scapular muscles to establish smooth, coordinated shoulder motion.

Shoulder pain in golf.

This discussion and the three case examples illustrate different etiologies of shoulder problems in the golfer. Age and the mechanics of an individual swing are factors to consider when defining the core problem. In summarizing shoulder pain in the golfer, perhaps the key point is that a thorough patient evaluation is essential to diagnose the problem accurately. It is only with a specific and accurate diagnosis that an optimal treatment program can be designed, and successful outcomes will be the result.

Preventative exercises in golf: arm, leg, and back.

In summary, a sport-specific exercise program for golfers includes warming up, stretching, strengthening, and cardiovascular conditioning. The goals of such a program incorporated with playing the game of golf are to optimize performance and prevent injuries. The integration of each of these components represents a well-balanced fitness approach to sport and enhances the enjoyment of the game.