Riand N, Boulahia A, Walch G
Clinique et Policlinique d'Orthopédie et de Chirurgie de l'Appareil Moteur, Hôpital Cantonal, 24, rue Micheli-du-Crest, 1211 Genève 14, Suisse.
Rev Chir Orthop Reparatrice Appar Mot. 2002 Feb;88(1):19-27.
The painful shoulder is a well-recognized clinical entity in throwers although the pathogenic mechanisms involved are still debated. In 1991 Walch then Jobe developed the concept of posterosuperior impingement to explain lesions observed arthroscopically. This impingement between the deep aspect of the supraspinatus tendon and the glenoid occurs during loaded arm movements. The purpose of this work was to study the different types of lesions observed arthroscopically and to analyse outcome after arthroscopic debridement.
Our series included 75 thrower athletes who had shoulder pain for loaded arm movements. Pain was situated in the dominant shoulder in all cases. Clinically, the Jobe manipulation provoked pain in 52 patents, expression of a supraspinous disorder. After failure of conservative treatment, the patients underwent arthroscopy for assessment and debridement. At the time of arthroscopy, the patients had suffered pain for two years (mean 22.3 months). All 75 patients were seen for clinical and radiological assessment at least two years after arthroscopy.
Among the 75 arthroscopies, there were 67 (89%) partial tears involving the deep aspect of the cuff, associated in 90% of the cases with a labral lesion. Tears involved the supraspinatus in 40 cases, the supraspinatus and the infraspinatus in 24 and the infraspinatus alone in three. Eight patients were free of tendon lesions at arthroscopy. There were no full thickness tears. The labrum had a meniscal (45%) or non-meniscal aspect (55%) and appeared normal (18%), fringed (38%) or fissured (52%). The very large majority of the labral fissures were found behind the biceps insertion. Fissures of the labrum were found in front of the biceps insertion in only three cases (slap lesion). Arthroscopy demonstrated glenoid damage (soft cartilage, fissure, abrasion, wear). The humeral head also exhibited lesions of the cartilage facing the insertion of the infraspinatus. At last follow-up (minimum > 2 years), eight patients were very satisfied, 22 were satisfied and 45 were disappointed. Twelve patients had resumed their sports activities at their former level with loaded arm movement and one patient had interrupted all sports activities. At last follow-up, 22 patient had undergone another surgical procedure: 20 derotation osteotomies of the humerus, one anterior stabilization, one acromioplasty.
The notion of posterosuperior impingement is increasingly recognized as the cause of pain in thrower athletes. Loaded arm movements produce a physiological contact between the posteriorsuperior edge of the glenoid cavity and the deep aspect of the rotator cuff. Injury results from repeated loaded arm movements in throwers. In our series, all the patients had at least one lesion, either involving the cuff or the labrum. According to the Snyder classification, 80% of the supraspinatus lesions were grade 1 or grade 2. We did not have any full thickness tears. All patients with a normal cuff were found to have a lesion of the posterosuperior labrum. At arthroscopy, dynamic assessment evidenced an impingement between the supraspinatus (or the infraspinatus) and the labrum or the bony edge of the glenoid cavity. Only three patients had a labral lesion anterior to the biceps insertion that could be considered a type 1 or 2 slap lesion. Unlike earlier reports by others, we had disappointing results after debridement: 60% of the patients were disappointed after the procedure and only 40% were satisfied (22 patients) or very satisfied (8 patients). Patient satisfaction depended greatly on the level of sports activity attained after arthroscopy, the eight very satisfied patients had resumed their former level. None of the professional athletes or those competing at the international level were very satisfied with arthroscopic debridement. There was an inverse relationship between level of competition and patient satisfaction after debridement.
尽管投掷运动员肩部疼痛的致病机制仍存在争议，但这是一种广为人知的临床病症。1991年，瓦尔什和乔布提出了后上撞击的概念，以解释关节镜下观察到的病变。这种冈上肌腱深部与关节盂之间的撞击发生在手臂负重运动时。这项研究的目的是研究关节镜下观察到的不同类型病变，并分析关节镜清创术后的结果。
我们的研究系列包括75名因手臂负重运动而肩部疼痛的投掷运动员。所有病例疼痛均位于优势肩。临床上，52例患者在乔布手法检查时诱发疼痛，提示冈上肌紊乱。保守治疗失败后，患者接受关节镜检查以评估和清创。关节镜检查时，患者已疼痛两年（平均22.3个月）。所有75例患者在关节镜检查后至少两年接受临床和影像学评估。
在75例关节镜检查中，67例（89%）为部分撕裂，累及肩袖深部，90%的病例伴有盂唇损伤。40例撕裂累及冈上肌，24例累及冈上肌和冈下肌，3例仅累及冈下肌。8例患者在关节镜检查时无肌腱损伤。无全层撕裂。盂唇呈半月板样（45%）或非半月板样（55%），外观正常（18%）、边缘有 fringe（38%）或有裂隙（52%）。绝大多数盂唇裂隙位于肱二头肌止点后方。仅3例（SLAP损伤）盂唇裂隙位于肱二头肌止点前方。关节镜检查显示关节盂损伤（软骨软化、裂隙、磨损）。肱骨头也表现出与冈下肌止点相对的软骨损伤。在最后一次随访（最短>2年）时，8例患者非常满意，22例满意，45例不满意。12例患者已恢复到之前手臂负重运动的运动水平，1例患者中断了所有体育活动。在最后一次随访时，22例患者接受了另一次手术：20例肱骨旋转截骨术，1例前路稳定术，1例肩峰成形术。
后上撞击的概念越来越被认为是投掷运动员疼痛的原因。手臂负重运动会使关节盂后上缘与肩袖深部产生生理性接触。投掷运动员反复的手臂负重运动导致损伤。在我们的研究系列中，所有患者至少有一处损伤，要么累及肩袖，要么累及盂唇。根据斯奈德分类，80%的冈上肌损伤为1级或2级。我们没有全层撕裂。所有肩袖正常的患者均发现有后上盂唇损伤。在关节镜检查时，动态评估显示冈上肌（或冈下肌）与盂唇或关节盂骨边缘之间存在撞击。只有3例患者的盂唇损伤位于肱二头肌止点前方，可被认为是1型或2型SLAP损伤。与其他人早期的报告不同，我们清创术后的结果令人失望：60%的患者术后不满意，只有少40%（22例患者）满意或非常满意（8例患者）。患者满意度很大程度上取决于关节镜检查后达到的运动水平，8例非常满意的患者已恢复到之前的水平。没有职业运动员或国际水平的运动员对关节镜清创术非常满意。清创术后的竞争水平与患者满意度呈负相关。
