Throwing After Labrum Surgery
Our American appetite for year-round sports has grown over the past 20 years and with that has come a new generation of young athletes suffering the consequences. In sports that require repeated overhand motion or throwing, a torn or partially torn labrum has become as detrimental and feared as a torn ACL in the knee. Tremendous pressure is placed today on these young athletes to push the boundaries of play, with the hope gaining a college scholarship, but are we pushing them too far? And are we leveraging the cost of higher education on the risk of overuse sporting injury?
Tens of thousands of young overhand athletes undergo labral surgery every year in the U.S. Of these some have sustained a traumatic injury such as a dislocated shoulder, but the majority have worn and stressed the Labrum slowly over a long period of time. The daily grind, year-round competition, and concurrent multi-sport participation all are taking their toll on our young overhand athletes. There is no real off-season anymore and young bodies and joints are not getting the downtime they need and deserve. So it’s a bitter pill to swallow when at the very moment they are poised to go to the next level, and reap the fruits of their labor, a torn Labrum strikes and puts them on the bench. This is not just an inconvenient bump in the road, but potentially a road-block influencing their activity and their future.
Return to the previous or higher level of play in overhand athletes such as pitchers, volleyball hitters, swimmers, or javelin throwers, to name a few, runs in the neighborhood of 60-80% on average versus 80-90% with ACL reconstruction. The reasons for this are not fully understood, but we do know that the shoulder joint is more complex in its movement that any other joint in the body, and the demands placed on it especially with pitching and volleyball hitting are extreme. Often the torn labrum is simply the body’s way of adapting to these demands, allowing the excessive range of movement and forces required to launch a baseball or softball or volleyball at high velocity. But this comes at the price of potential injury in the end.
The Labrum is a rubbery bumper of cartilage that runs the circumference of the socket (Glenoid) of the shoulder joint. It helps to cushion and stabilize the joint, but when torn or injured it causes pain and dysfunction. Before the Labrum actually tears pitchers and other throwers will begin to experience symptoms of tightness, weakness, and lack of ball control. They will be unable to get the shoulder warmed-up and loose and they cannot find their “slot.” Over time they will lose speed and finally the pain begins. The shoulder begins to pop and catch, and they are unable to throw at all. A similar progression occurs with volleyball hitters and swimmers, however they will often feel shifting and too much looseness in the shoulder, along with the pain. This culminates in symptoms that sideline them from their sport. Some athletes will think that a single injury has occurred at this point, but in reality this is the Labrum finally giving way to the pressure and trauma of years of over-use.
When these symptoms of pain, catching, popping, weakness, loss of control occur it’s important to have a formal evaluation by an orthopaedic surgeon with knowledge and experience in the realm of the throwing/overhand athlete. Talking to the athlete about the symptoms often is more critical even then physical examination or MRI in understanding the chronology of events. On examination the shoulder is weak and the rotator cuff muscles although not torn are fatigued and contributing to the dysfunction of the shoulder. The muscles that control the shoulder blade are also weak and worsening the problem. MRI with a fluid injection into the joint called and arthrogram is the best imaging tool to identify a tear. Even then many tears will not be seen with MRI and the final diagnosis is made with the arthroscopic surgical camera at the time of surgery.
For some athletes rehabilitation and physical therapy alone will bring them back to normal function and no pain, even in the face of a torn Labrum. However for the overhand athlete it is much more difficult to get back in the game with therapy. If they have failed in conservative care then arthroscopic suturing or repair of the labrum is the treatment of choice. As mentioned above the majority will be able to return to their sport after surgery, but not as many as we would like, and perhaps not at the same level as before. So the question remains, to Throw or not to Throw?
Overhand athletes who have undergone surgery but have not made it back to the level that they desire hit a crossroads. The can continue to push the envelope and risk re-injury or potentially more surgery, or “not throw” and hang it up on the competitive scene, saving their shoulder for a healthy and happy life. Some will take the risk and push on with the sport, but many will step down from competition and save their shoulder to live and enjoy another day. Some are compelled to continue on through the pain to maintain or gain a scholarship.
For overhand athletes who are not yet injured, but pushing themselves year-round in their sport the real question becomes “am I going to be good to my shoulder and give it some rest?” The answer should be yes, and for those of you out there with no symptoms prevention is the key. Little League Baseball along with American Sports Medicine Institute have provided our young throwers with a template for some level of restraint and common sense with its guidelines that not only limit pitch counts, but also recommend total rest from the overhand sport for 3 months out of every year. Meeting with a physical therapist to get on a thrower’s exercise program is also the smart way to go. These are the types of common sense steps that we can take for prevention in our current environment of hyper –competitive youth sports.
Finally, for those of you struggling with your shoulder, unsure if there is a problem, it’s time to see an orthopaedic sports medicine specialist to be evaluated and treated before your shoulder crosses the line into the realm of surgery. Often you can make it back without invasive procedures, and you can learn strategies to keep it that way for life.