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Yankees’ Prospect Faces Shoulder Surgery

It was another blow for the Yankees yesterday when Luis Torrens, a minor league catcher and top prospect from the international class of 2012 was diagnosed with a season ending labral tear in his right shoulder. Torrens, who will be 19 in May, is scheduled for surgery with Dr. David Altchek on March 5th.

Baseball America reported that while playing amateur ball in Venezuela, Torrens played shortstop and then third base before scouts recognized that his body type and skills were best suited for playing behind the plate. Touted for his defensive ability, quick release, throwing accuracy and strong arm, Torrens’ season in Charleston at The Class A level last year was curtailed by a shoulder strain and he achieved greater success finishing out the shortened season with Staten Island. Torrens, who also shows promise as a hitter, was ranked by Baseball America as the best player on last years SI club and as the Yankees ninth best prospect coming into the 2015 season.

A little about 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 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.

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.

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 also stretch the stabilizing structures of the front of the shoulder joint, stressing the labrum and creating tears either from explosive motion or degeneration due to wear and tear. This is especially the case when the rear (posterior) portion of the joint capsule is too tight.

The Yankees won’t feel the loss of Luis Torrens at the major league level this season, but by losing a year of development, his debut with the big club might be further off than intended. He is young and should heal well however, and his future remains bright.

Follow Abby Sims on Twitter @abcsims.

 

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?

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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

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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

Erik Bedard and Me. A Shoulder Repair Story

Erik Bedard, a Mariners pitcher who has spent much time on the DL, and I have one thing in common, and no, you guessed correctly, it is not the value of our contracts! We compared notes recently on our shoulders, as both of us had labral repair surgery in the last year – Erik’s was in September and mine three months later. He had two anchors to secure his labrum to the bone and mine required five. As Bedard said to me, “wow, you’d never pitch again!” He’s probably right about that, but actually, I feel fortunate just to be back in the clinic working with patients. It has taken awhile. As for pitching, I hope to be able to see Erik return to the lineup sometime soon.Â

As I write this I am sitting in the stands at Safeco Field under a sunny and brilliant blue sky; it doesn’t always rain in Seattle, though this season has been closer to that stereotype than is the norm. I’m watching warm-ups and listening to the music that fills the almost empty ballpark – it is magical. There is something so special about the rituals of baseball that it is almost spiritual…. Anyway, I digress…back to business…

What is a labrum?

The labrum is a fibrocartilagenous structure that is attached to the 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

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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 primary 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, hence Erik Bedard’s injury. Repetitive activities that stress the anterior compartment, like the cocking position of pitching, or other overhead sports can stretch the stabilizing structures of the front of the shoulder joint, stressing the labrum and creating tears from explosive motion and degenerative tears from wear and tear. This is especially the case when the rear (posterior) portion of the joint capsule is too tight.

Are labral tears usually isolated injuries?

On occasion, surgery to repair the labrum is accompanied by other procedures such as that to tighten up or repair the joint capsule (generally a Bankart repair, which repairs the front of the capsule). Tears of the capsule and ligaments are usually from dislocation and, when involved, these must be restored to protect the shoulder from recurrent injury.Â

The shoulder may also require debridement, a procedure to simply clean out the joint, smooth any fraying portions of the rotator cuff (the tendons of four muscles that attach right next to each other at the shoulder), and also to remove any bone spurs that are found. Rotator cuff involvement and spurring may occur due to altered mechanics of the joint after injury but tears of the rotator can also occur from trauma (such as dislocation).

Studies have reported that approximately 40% of those with SLAP Tears also have some issues with the rotator cuff. Unfortunately, my surgery involved all of these procedures – debridement to smooth a partial rotator cuff tear, clear away a spur and decompress the area under the clavicle, a Bankart repair of the anterior lower joint capsule and the ultimate five-anchor SLAP Repair. My pitching days are definitely over and the empathy I have for my patients is at an all-time high!

Why does it take so long to recover from a SLAP Repair?

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After any surgery to repair a structure, there is generally a six-week period of time during which the most important thing is to protect the repair and allow for a healing response of the involved tissues. For the SLAP Repair at the shoulder, this means wearing a sling and not performing any significant activities with the arm. A post-operative shoulder is stiff – range of motion is restricted as a result of the procedures themselves as well as due to the immobilization that follows. Work to slowly restore mobility is paramount and strengthening of the entire upper extremity (including the forearm and hand muscles) is also crucial to build toward full function and decrease the likelihood that overuse injuries will result from residual weakness.  Reduced use during the pre-operative period of injury, disuse following surgery, and inhibition of muscles from swelling post-operatively all takes a toll on muscle strength. However, it takes normal strength of all the muscles of the shoulder girdle in order to achieve ideal mechanics of the shoulder joint. Without the proper recruitment of the musculature, the shoulder is prone to impingement and other overuse injuries that will be discussed in later columns.

Potential causes and treatment for Tiger Woods’ neck pain

Tiger Woods is in the news again, this time for withdrawing from The Players Championship in the middle of the final round at Sawgrass with complaints of neck pain. Tiger was quoted as saying that he first experienced neck pain before the Masters, which was played in early April. He claimed to have been playing through the pain since that time. By Sunday the pain had evidently become untenable. However, while at the Masters, Tiger was reported to have responded to questioning about injuries he suffered in his November accident by saying that in addition to a “busted-up lip” he’d also had a “pretty sore neck”.

There has been much speculation about the nature of Tiger’s injury and the degree to which it has been a factor. Some have advanced the idea that he is simply suffering the consequences of a history of aggressive training. That seems very unlikely. Others said his condition was probably brought on by stress – and we all know he has had plenty of that! There were skeptics who pointed to Tiger’s ability to put on a good show at the Masters in spite of the pain he now claims to have had. Did this same pain cause him to miss the cut last week and result in another sub-Tiger performance at Sawgrass? That is definitely plausible because pushing himself might have exacerbated the symptoms and made his condition worse over time. Whatever the situation, it does seem clear that all is not well with Tiger Woods. Obviously, only Woods truly knows how he has felt since his accident, the extent to which his neck had been an ongoing issue and whether the pain has escalated to the point that it was clearly counterproductive to attempt to play through it, especially in a losing effort.

Tiger reportedly said that he was experiencing tingling in his hand along with neck pain and he was planning to undergo an MRI. Despite the valuable diagnostic information that MRIs can provide, they are not foolproof. Sometimes they don’t show all that is going on (false negative results) and in other instances they seem to show a more involved condition than is actually present (false positive findings). Along these lines it is also helpful to note that repeated studies assessing the MRIs of healthy subjects (without complaints of pain) found that a significant percentage had positive findings in spite of their lack of symptoms. With this in mind, a physical exam will also provide insight as to what might be causing Tiger’s symptoms and how to proceed once a diagnosis is made.

Causes of radiating pain

There are a number of potential causes for radiating (also called radicular) pain in the upper extremity; some don’t even involve the spine at all. This type of pain is generally due to compression or stretch of a nerve. Compression can be from a bulging or herniated disc in the cervical (neck) region, from a narrowing of the spaces in the spine (due to arthritic changes) where nerves exit, from pressure at the first rib, or from a muscle spasm that causes a constriction. Compression of a nerve can also occur in the arm itself (due to scar tissue or swelling, etc), causing tingling, numbness or weakness below the constricted area. For instance, in Carpal Tunnel Syndrome the compression is at the wrist and causes symptoms in the hand.

Tightness of a nerve results in excessive tension on that nerve, and is another possible cause of radiating symptoms. In addition, a traumatic nerve stretch is likely to provoke acute neurologic pain. The latter is typical of the “stingers” and “burners” that football players often experience.

Treatment

The specific nature of an injury and the findings on physical exam determine the

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nature of treatment. If a disc is involved, manual or mechanical traction may be beneficial. Massage and other manual techniques to release the tension in the soft tissues of the cervical region, shoulder girdle and upper back are also helpful, particularly just prior to working on the spine itself. If range of motion of the neck (or shoulders) is restricted, therapy should include work to restore full mobility. When nerves are tight, tensioning techniques to release them are enormously beneficial. In addition, working toward normal upper body strength should be a part of any therapy program for the cervical spine. An imbalance of strength can result in compensatory reliance on muscles that go into overdrive as a result, causing pain from muscle tension or spasm. This is most common at the upper trapezius muscle, which runs from the neck to the shoulder (and acts to hike the shoulder toward the ear).

A focus on posture, alignment, muscle recruitment patterns and the mechanics used in sports performance are also vital aspects of care. Attention to activities of daily living and how they are performed should also be addressed as part of a comprehensive treatment program. For instance, someone who sits hunched over a computer, has a less than ideal ergonomic set-up of the workspace or cradles the phone between the ear and shoulder rather than using a headset is a candidate to develop neck pain. Improper sleeping positions (especially lying prone – on one’s stomach – with the neck rotated all the way to the side) or using the wrong pillow can also predispose to neck problems, and sufferers might even need advice as to how to modify the way they sleep.

Understanding how elevated levels of stress can impact neck pain is also part of good care. In my experience, neck and back pain as well as jaw (TMJ) pain seem to be the orthopedic conditions most influenced by a patient’s level of stress. For those who recognize that stress is an issue, relaxation training or other coping mechanisms (music, improving sleep patterns, counseling…) may be advocated.

Anti-inflammatories and/or muscle relaxants may be prescribed in the more acute phases of treatment and only when signs and symptoms are severe and alarming (such as a loss of sensation, isolated muscle weakness and a significant alteration of reflexes) is surgery considered.

As for Tiger Woods, with the ever-present glare of the media upon him, we will soon learn more about his condition by way of whatever is leaked or released to the press.Â

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It may or may not be the full story. Tiger will be the only one who will know…