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Mark Sanchez: A Questionable Decision

So, Mark Sanchez is evidently opting for the chance-it-and-see approach with the labral tear in his throwing shoulder. If you’d read my post on Matt Harvey – who also faces a surgery-now or possibly later decision – you’d be as skeptical as I.

Sanchez may have been on his way out even with a healthy shoulder. But regardless, that debate is moot. Injured he will miss out on much or all of this season – if he opts for rehab alone – even if he succeeds in restoring sufficient function and performance. What’s the point? If he is miraculously able to return, Sanchez would certainly be relegated to back-up status. Geno Smith will get his reps and, hopefully for the Jets, grow into his role gracefully. The first win was a welcome to the league gift from the Buccaneers.

If Sanchez finds by season’s end that – though he may feel pretty good day-to-day – his shoulder doesn’t cut it throwing repetitively and for distance, then he’ll face another six to nine months of rehab following surgery. That could put him back on the field sometime next summer. At best. It takes a while for a throwing shoulder to get into competitive shape.

So what if Phil Simms had a great year playing with a labral tear in 1993? That is not the norm; it is probably a notable exception. The nature of the tears may differ as well – that is something about which only the medical staff may be aware.

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And if, as was reported, Sanchez also suffered a dislocation when he went down in the pre-season, the instability in his shoulder is greater than that caused by an isolated labral tear. There would be other issues in play. Without all the facts, the two quarterbacks’ injuries cannot be compared.

Sanchez might be wise to rethink things. If he goes under the knife now, he is certain to avoid the lengthy cross-his-fingers-period. Of course, even surgery offers no promises – complications are always possible – but even pitchers can come back from labral procedures.

Though he is working on a long and lucrative contract after receiving an extension in 2012 (with 20.5 million having been guaranteed for 2012 and 2013), Sanchez is clearly not the quarterback of the Jets future. If he wants to salvage a back-up role for next season, even if for another team, he might be wise to get on with things now.

Follow Abby Sims on Twitter @abcsims.

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Mark Sanchez: A Bruise? Did You Buy In?

After Mark Sanchez took a hard hit late in the Jets third pre-season game and landed on his right shoulder, initial reports were that he’d sustained a deep contusion, a bruise. That never seemed likely, since the impact that generally causes an isolated bruise – like taking a helmet to the shoulder might – generally doesn’t also involve the type of trauma that landing on the shoulder does. Unfortunately, I know this not only from experience as a physical therapist but also on a more personal level having been hit by a car and thrown onto my right shoulder. But that’s a whole other story…

More recent reports on Sanchez have stated a range of things, and have done little to clarify the picture. In some, he was said to have suffered a torn labrum, while other columns said that he’d had a shoulder separation. It was also noted by several writers that, in addition to the new insult, Sanchez already had an underlying labral tear. Some reporters stated that immediately following the injury, team physicians reduced Sanchez’s shoulder separation (put the joint back in alignment) and that he subsequently had only a shoulder subluxation. Others spoke of Sanchez having had a frank dislocation. So, which was it, and why the mystery? Like you, I will wait and see once more information is released. However, the bottom line doesn’t look good for the quarterback who needed this season, possibly even as a backup, to prove he’s a keeper. 

First, let’s distinguish one diagnosis from the other. View image.

Shoulder dislocations versus subluxations and separations

All three are separate and distinct diagnoses.

A shoulder dislocation occurs when head of the humerus – the bone of the upper arm – separates from its socket at the shoulder joint (also known as the glenohumeral joint). The socket, or glenoid, is a portion of the scapula (shoulder blade). Structures that provide stability to the joint are damaged due to the trauma resulting in dislocation.

A dislocated shoulder may reduce (go back into place) spontaneously, though many require assistance in order to restore alignment. Surgical intervention to repair injured structures and restore stability to the shoulder may become necessary, particularly for athletes – due to the demands of sport – or young people (<18 at time of initial injury) who are likely to have repeated episodes after the initial trauma.

A shoulder subluxation is essentially a partial dislocation, and it too places undue stress on surrounding soft tissues and stabilizing structures. In fact, a major study of West Point cadets concluded that the damage caused by subluxations, which occur with greater frequency than dislocations, is likely to be as serious as that from dislocation.

A shoulder separation is an entirely different diagnosis from the others already discussed. The term refers to the separation of the clavicle (collarbone) from its attachment at the acromion (which is a part of the scapula that looks like a hood over the shoulder joint). Though a part of the shoulder girdle, the AC (acromioclavicular) joint is not a part of the shoulder joint. View image. 

The shoulder labrum

The labrum is a firm fibrocartilagenous structure that is attached to the inner socket of the shoulder and hip joints. In both cases, the labrum deepens the socket in order to provide more stability for the joint. By almost cupping the rim of the rounded head of the humerus at the shoulder and that of the femur at the hip, the labrum allows for the extraordinary ranges of motion at these “ball and socket” joints while protecting them from dislocation. Ligaments (which connect one bone to another at each joint) and the joint capsule (which surrounds each joint and its ligaments) are the other structures that serve to provide joint stability. At the shoulder, some of these ligaments attach directly to the labrum.

The Labrum is also the uppermost attachment of the long head of the biceps, the muscle in the upper arm whose primary function is to bend (flex) the elbow. Interestingly, studies have shown that the long head of the biceps also plays a large role in providing shoulder stability. It follows then that a labral tear that disrupts the origin of the long head of the biceps has an even greater impact on stability than one that does not. These are the ones that require surgery.

How can a labrum tear?

The most common injury to the labrum is not so much a tear as a dislocation of its upper (superior) end, running from the front (anterior) toward the rear (posterior) end of the structure. This is known as a SLAP Tear (Superior Labrum, Anterior to Posterior). Traumatic mechanisms of injury involve falling onto the shoulder, suffering a blow directly to the shoulder, or a dislocation – all of which are common in contact sports. Most shoulder dislocations affect the anterior (front) compartment of the shoulder and occur with trauma while the arm is elevated and outwardly rotated – as when going for a rebound in basketball.

Labral tears are also common amongst throwing athletes due to repetitive activities that stress the anterior compartment, like the cocking position of pitching. Other overhead sports can stretch the stabilizing structures of the front of the shoulder joint, stressing the labrum and creating tears from explosive motion or degenerative tears from wear and tear. This is especially the case when the rear (posterior) portion of the joint capsule is too tight.

Follow Abby Sims on Twitter @abcsims.

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Update: Roy Halladay Faces Surgery

Earlier this week when it was reported that Roy Halladay was headed to the DL with shoulder issues, it was almost a repeat of what happened only a year earlier when his performance fell off though he did not complain of pain.  At that time, Halladay was ultimately shut down to recover from a strained lat muscle. Now he is headed for the knife with what has been diagnosed as a frayed shoulder labrum, a partially torn rotator cuff and some bone chips. At the press conference held to announce Halladay’s impending surgery, it was stressed that the 35 year-old Phillies pitcher will take whatever steps are necessary both pre and post operatively and won’t rush back to the field. However, it was also said that he might still be able to play this season. Don’t count on it. The odds are not in his favor.

A lot depends on what is done in the operating room. Will the rotator cuff tear be repaired, or will the joint just be cleaned out, referred to as a debridement? The thickness and location of the tear will likely be the determining factors. If the labrum shows degenerative wearing at the edges, it may only require a bit of smoothing out. If a labral tear is evident once they are in the joint, Halladay will require a more robust surgery.  Unless he has only a simple debridement, after which rehab can progress more or less as tolerated (provided it is painfree), the immediate post-operative period is six weeks of boredom. During this healing phase, not much should be done other than to reduce inflammation, begin to restore passive shoulder mobility within a restricted range of motion, and keep muscles of the hand and forearm from weakening further. It is only afterward that a progression to achieve full range and strength can really begin.

After surgery, strength is depleted by disuse and as a response to inflammation. It must be rebuilt from the ground up. When a strengthening program is initiated, Halladay may not even be able to completely lift his arm (nor should he try), never mind a weight. That explains the slow nature of the process and the reason that it takes time to reach the point at which a player can begin a throwing program. 

It is likely that Halladay is looking at a minimum six-month recovery if more than a simple debridement is performed. To get to the point where he is throwing competitively, six months is even optimistic.  If it is a debridement alone, a minimum of four months may be realistic.  But, why would a 35-year-old want to risk his shoulder and rush to return to the field in mid-September? Unless we are talking about the National League Championship servies or World Series, don’t look for Halladay again this season.

Follow Abby Sims on Twitter @abcsims.

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A-Rod: A Matching Pair?

 

A-Rod: A Matching Pair?

37 year-old Yankees’ third baseman Alex Rodriguez, who reportedlycomplained of pain in his previously operated upon right hip during the playoffs, is slated for surgery next month to address a tear in his left hip. This newer injury evidently came to light in post-season examinations. Articles mentioning the status of Rodriguez’ uncooperative left hip seem to have overlooked the obvious question as to whether he also continues to have pain on the right. Without an official update, we are decidedly uninformed as to exactly why it was getting in his way at the close of the season or how it is faring now.

Rodriguez’ right hip surgery (in 2009) revealed that a labral tear was accompanied by a cyst within the joint as well as significant degenerative changes to the surface of the bone. These degenerative changes are likely to be the cause of his recent complaints.

Is Rodriguez’ condition unusual?

Certain

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elite athletes may be at a higher risk of intraarticular hip disorders (those within the joint) because of the unusual forces that their hips sustain. The injuries are most commonly related to hip impingement and generally include labral tears and/or chondral defects.

What is the labrum? See detailed image

Similar to the anatomy of the shoulder, the hip is a ball and socket joint with the ball at the end of the femur attaching via ligaments to the socket at the pelvis. The labrum is a fibrous cartilaginous structure that is situated along the inside rim of the socket, serving to deepen it and provide some suction for the ball thereby adding to the stability of the joint. It can be torn traumatically or by a degenerative process due to repetitive motion that is common in many sports (particularly hockey) or even in certain occupations, such as for carpet layers. Like the menisci in the knees, the labrum is poorly vascularized (has poor circulation), which is a primary reason it does not readily heal once injured.

What is a chondral defect?

The smooth glassy chondral surfacing that lines the ends of adjacent bones where they form joints is also known as articular (joint) cartilage, or hyaline cartilage. Degenerative changes or wear and tear to this region of a bone/joint is a hallmark of osteoarthritis.

What is hip impingement?

A combination of signs, symptoms and pathology that involves the end of the femur coming into contact with the rim of the acetabulum (socket), particularly during extreme ranges of motion (hip flexion, adduction and internal rotation). FAI (femoroacetabular impingement) is thought to be a factor in the development of degenerative arthritis at the hip, which entails abnormal changes in the bony contours. Those with congenital bony abnormalities may also be more prone to developing FAI. There are two types of hip impingement (known as Cam and Pincer), each of which entails different anatomical variations, though both generally result in labral pathology.

What does a labral tear feel like?

Those with labral tears generally complain of joint stiffness and on examination there is typically a loss of range of motion and pain at the end ranges of hip flexion/adduction/inward rotation (particularly with compression during a physical exam). Labral complaints might also include a catching or locking of the hip, and some people may also complain of a sense that the hip is unstable. MRI findings are generally used to support the diagnosis.

Can a labral tear be treated without surgery?

Rehab for a tear focuses on reducing inflammation and restoring range of motion while also addressing muscle strength and flexibility. For those players with sufficient relief, working back into play with a specificity of training is also important to determine if they will be able to tolerate the demands of sport. Those with persistent pain go on to have the labrum reattached to the socket or in some cases, a small portion of the labrum may be removed. These procedures are now performed arthroscopically.

Post-operative recovery

The goals of post-operative therapy are much like those for the non-operative patient except that the rehab period may last up to about six months. The exact timeframe would depend on the severity of the injury or injuries, the specific nature of the surgery and whether there were any other complicating factors.

Follow Abby on Twitter @abcsims