Common Baseball and Softball Injuries: Glenohumeral Internal Rotation Disorder (GIRD)

Shoulder injuries are common in baseball and other sports involving overhead activites. Prevention is possible and the first step in prevention is knowledge. In this post, we will examine a common shoulder condition of the glenohumeral joint called Glenohumeral Internal Rotation Disorder or GIRD. 

The genohumeral joint is what most people think of as the “ball and socket” of the shoulder. Clinically, it is the joint that connects the humerus and scapula. This important joint is what allows the arm to move in a circular motion. 

Baseball pitchers rely on the Glenohumeral Joint for throwing. The strain that pitchers put on this joint by repetitively throwing can lead to GIRD. GIRD is an injury that develops over time as a result of overuse and is not typically an acute injury. 

GIRD is defined as a 20⁰or greater loss of internal rotation of the throwing shoulder. Other symptoms include: 

• Vague pain in the shoulder with overhead pain
• Decrease in throwing performance (control and velocity)
• Occasionally, a decrease in motion
• Increased range of external rotation and decreased internal rotation vs. non-dominant shoulder

Normally, GIRD is treated using non-invasive methods. Surgery is not normally required to treat this condition.  A common treatment plan could include the following:

•  Rest from throwing for a period of 3-6 months
• Physical Therapy that includes various stretches for the posterior and inferior capsules

In rare cases where rest and physical therapy does not work, arthroscopic surgery may be performed to restore range of motion. However, most cases of GIRD can be treated non-surgically. If you suspect you suffer from GIRD or another shoulder injury, make an appointment to see Dr. Vitolo or your orthopedic surgeon.

Board Certification – Not All Are Created Equal

Recently, John Vitolo, MD passed the re-certification board examination with the American Board of Orthopedic Surgeons. This is a grueling and rigorous process requiring 120 hours of continuing education, a written and oral examination and a peer review.  Re-certification is required every 7 to 10 years. 

The American Board of Orthopedic Surgeons is not the only board to offer certification; however, the requirements of this board are more challenging than others in the field. To qualify for initial certification, surgeons must be a graduate of an accredited 4 year medical school and have successfully completed a 5 year accredited orthopedic residency program in the US or Canada.

In addition to being board certified in Orthopedic Surgery, Dr. Vitolo holds a sub-specialty certification in Sports Medicine from the ABOS. This sub-specialty certification requires an additional year of training/education, endorsement by the program director, peer review, documented experience with Arthroscopic Surgery and knowledge of non-operative conservative treatment of select injuries. 

Certifications given by the ABOS are given to an elite group of orthopedic surgeons. To become board certified requires commitment and a desire to continuing learning and provide the highest quality care to patients. By visiting an ABOS Board Certified surgeon, you can rest assured that you will receive optimal care.

Who is the American Board of Orthopedic Surgery?

·         Non-profit, private, independent organization - Founded in 1934

·         Established to serve the best interests of patients and the medical profession

·         Board establishes education standards for orthopedic surgeons

·         Standards are evaluated through standardized exams and practice evaluations

·         Membership is given only to distinguished orthopedic surgeons who have met set requirements and are active in patient care, education and research

To find out if your surgeon is certified by the ABOS or to find one that is, you can visit this link: https://www.abos.org/find-a-certified-orthopaedic-surgeon.aspx.

Preventing Overuse Injuries in Young Athletes this Baseball Season

Baseball season is here! Young athletes are ready to start training. While the old adage “practice makes perfect” is true, our youth need guidance in order to prevent injury.

Overuse injuries in school aged athletes are on the rise. The incidence of shoulder and elbow injuries among youth baseball and softball players is five times greater than it was in the year 2000.[i] Many of these baseball injuries are preventable.

In recent years, Little League Baseball has released guidelines and enforced regulations to help prevent injury in young athletes (see charts below). The league has put limits on pitch counts during games and also enforced required rest periods. All the guidelines are based on the age of the athlete.

While the guidelines from Little League Baseball are important, there are additional steps that can be taken at practices and off the field. Here are some tips:

1.  Always warm up – stretch, jog and begin with some easy, gradual throwing
2. Try different positions – different positions require the use of various muscle groups
3. REST – don’t play year round and allow rest between games
4. Focus on your form, accuracy and control
5. If you have shoulder or elbow pain, do not pitch
6. Talk to your parents and coaches about any pain – do not play through the pain!

Getting kids involved in sports at an early age is a great idea, but it is important to remember an injury can end their baseball career too soon. By following the suggestions outlined here, injury can be avoided and a lifelong love of baseball and activity can be built!

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[i] http://www.stopsportsinjuries.org/media/statistics.aspx

Maximum Pitch Counts and Required Rest Periods courtesy of Little League Baseball

Different Types of Meniscal Tears

In a recent blog post, we discussed meniscal tears and treatment of these injuries.  Today we will take a look at the 3 different shapes of meniscal tears. To recap, the meniscus is a c-shaped piece of cartilage in the knee that acts as a cushion between the thigh bone and shin bone. The primary function of the meniscus is to keep the knee stable and act as a shock absorber.

Types of Meniscal Tears:

1.      Longitudinal 
2.      Radial 
3.      Horizontal
  
Longitudinal Meniscal Tears

A longitudinal tear runs along the meniscus.  If the longitudinal tear is partial, it can heal without surgical intervention. If it does not heal properly, however, it can often lead to a full bucket handle tear (a complete tear that goes through the meniscus). Longitudinal tears are very common in young athletes and often present in conjunction with an ACL tear.

Radial Tears

Radial Tears occur along the inner edge of the meniscus and can be either partial or full.  Two common radial tears are oblique tears and parrot’s beak tears.  Oblique tears are probably the most common type of meniscal tears.  

Horizontal Tears

This type of tear goes through the meniscus and splits the meniscus into a top and bottom section. These tears are not as common and often begin as a result of degeneration or a minor injury.  Unfortunately, if left untreated, horizontal tears can leave the patient more susceptible to the more serious horizontal flap tear and can become complicated to fix. 

Developing a Treatment Plan:

It is important to remember that there are some key factors to consider when developing a treatment plan for a meniscal tear.  These factors include:

1. Patient’s age
2. Patient’s activity level 
3. Shape/location of the tear (complex tears can be a combination of longitudinal, radial and horizontal)
4. Related injuries (if any) that are present

Age and activity level are important to the success of a surgical repair of the meniscus. The younger and more active the patient, the more likely the repair will be successful. It is also extremely important to evaluate other injuries. For example, if you repair the meniscus, but fail to repair an ACL tear, recovery will be compromised. A full evaluation of each patient is necessary to determine an appropriate treatment plan.

If you feel you have a meniscal tear, it is important to see a doctor and he/she will develop a treatment plan that is best for you. 

Case Study: Shoulder Injury - Old and New

As an orthopedic surgeon it is my goal to treat injuries by restoring the normal anatomy that has been disrupted. In this case study we will discuss an unusual combination of shoulder injuries which required a unique treatment plan.

In this case, a patient came into the office with a dislocated shoulder. Upon examination, we found remnants of an old injury that left his shoulder anatomy compromised and a new injury that was severely hindering his shoulder function. Many doctors may have opted to only address the new injury, but we knew that the first objective was to restore the patient’s anatomy to normal (fix the old injury) and then address the new injury. 

After thorough evaluation, we discovered scapular dyskinesis (abnormal movement) with winging, a prominent AC joint (the AC joint is the joint where the collarbone and shoulder blade meet) and unstable left shoulder. An MRI further revealed an anterior labral tear and bankart lesion.  The scapular dyskinesis and prominent AC joint were due to the old injury that had not healed properly and likely led to the anterior labral tear and bankart lesion.  In order to give the patient the best chance of full recovery and normal shoulder function, we had to address both injuries. 

We opted for staged surgical procedures.  First, we would need to reconstruct the AC Joint, then 2 months later we would perform a second arthroscopic surgery to repair the bankart lesion and anterior labral tear.  Reconstructing the AC Joint was the first priority.  By performing the reconstruction, we would be restoring the shoulder to its natural anatomy. Restoration of the natural anatomy gives the patient the best chances for a full recovery from the second injury.  By ignoring the old injury (which led to the abnormality of the AC Joint), the chances of a full recovery from the labral tear and bankart lesion would be slim and leave the shoulder more prone to future injury.

Following the surgeries and postoperative physical therapy, we could not be more pleased with the results.  Four months after the second procedure: the scapular winging disappeared, the patient was pain-free, the instability of the shoulder was gone and the patient was able to return to full work duty without any restrictions.  The patient is thrilled with the results.  Following his first injury, he had never returned to “normal”, but now he reports that he is better than ever.  He has complete range of motion in the shoulder and is living pain free. A complete success in our book!

 

Ask the Orthopedic Surgeon: What is the meniscus?

Question:
I keep hearing of athletes tearing their meniscus.  What exactly is the meniscus and what does it do and what happens if it is torn?

Answer: 

What is the meniscus?
The meniscus is a c-shaped piece of cartilage in the knee that acts as a cushion between thigh bone and shin bone.  The meniscus acts as a shock absorber and keeps the knee stable.  The meniscus also distributes our weight evenly over the knee. The most common causes of a meniscal tear are a sudden twist of the knee or overuse.

What are the symptoms of a torn meniscus?

-        A “pop” may be felt at the time of the injury

-        Pain

-        Stiffness & Swelling

-        Limited range of motion

-        “Locking or Catching”

How is a torn meniscus treated?

Treatment of meniscal tears vary depending on the size, severity and location of the tear.  Tears that are small in size and on the outer edge of the meniscus may not require surgery.  In these cases, the protocol is RICE:  Rest, Ice, Compression and Elevation combined with anti-inflammatory medications (aspirin or ibruprofen). The patient may or may not be required to wear a brace.

If the meniscal tear is moderate to severe, a knee arthroscopy is often needed. Knee arthroscopies are performed through a small incision in the knee.  An orthopedic surgeon then inserts a small camera, which provides a clear view of the knee.  From there, the orthopedic surgeon either repairs the tear or removes the torn portion of the menisci.

Depending on the location of the tear, an orthopedic surgeon decides whether to remove or repair a tear.  The outer layer of the meniscus is often referred to as the ‘red zone’ because it has a good blood supply, which is necessary for healing.  The inner layer is sometimes referred to as the ‘white zone’, which lacks a decent blood supply and makes healing difficult.  If the tear is located in the red zone it is normally repaired, but if it is in the white zone, it is normally fully or partially removed.  Full removal is normally avoided, if possible, as it can leave the patient more prone to osteoarthritis in the future.

For a meniscal repair, the recovery time is about 3 months, with 4-6 weeks on crutches and physical therapy.  A partial menisectomy (removal of the meniscus) has a recovery time of about 6 weeks and only 3 days on crutches.  Physical therapy is needed as well.  In both cases, patients are able to return to full activity. 

If you have an orthopedic question for John Vitolo, MD, please email your question to kim_abbasi@skyvieworthopedic.com.  John Vitolo, MD is Board Certified in Orthopedic Surgery and Sports Medicine.  Skyview Orthopedic has offices in Sparta and Randolph.

*Picture Source:  American Academy of Orthopedic Surgeons