Abstract
Background:
Anterior capsular tears are often associated with traumatic glenohumeral instability episodes; however, there are not many previous descriptions in the literature without occurrence of frank dislocation. This video will discuss the presentation of a throwing athlete with an anteroinferior capsular tear in his dominant shoulder who underwent successful arthroscopic repair.
Indications:
Based on the patient's clinical symptoms, magnetic resonance imaging arthrogram findings, and failure to return to play despite attempts at conservative management, he was determined to be a candidate for arthroscopic repair.
Technique Description:
Arthroscopic repair consisted of reapproximation of the avulsed capsular tissue to its attachment point medially using suture anchors in the glenoid and a side-to-side repair of the mid-substance extension of the capsular split.
Results:
Arthroscopic repair of the anteroinferior capsular tear allowed the patient to return to his previous level of sport.
Discussion/Conclusion:
In the present case and a previous case series, surgical repair of anterior capsular tears, whether arthroscopic or open, can yield good results in throwing athletes aiming to return to prior levels of performance.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
In this video, we will discuss the presentation of a throwing athlete with an anteroinferior capsular tear in his dominant shoulder, as well as the indications and surgical technique for arthroscopic repair.
Here are our disclosures.
The following topics will be covered in this video.
We will utilize a case presentation to demonstrate the indications for arthroscopic repair of an anteroinferior capsular tear of the shoulder. Our patient is a right-hand-dominant, 22-year-old, division 1 collegiate pitcher who had previously been evaluated over the last year for episodic posterior right shoulder pain, which presented like internal impingement of the shoulder. His treatment had comprised of activity modification, rest, and trainer-mediated rehab, which allowed him to pitch well. However, late in the season he began complaining of new anterior shoulder pain after a long outing, which he experienced mainly during the late cocking phase of throwing. He also lost velocity and his ability to locate his pitches.
His pain did not improve with rest or rehabilitation, and he was ultimately unable to return to play. On his physical examination, he had no focal tenderness to palpation, full pain-free range of motion, and normal strength. His only positive provocative testing included mild anterior shoulder pain with forceful apprehension maneuvers and mild anterior shoulder pain with resisted throwing.
Radiographs were obtained, which were normal. A magnetic resonance imaging (MRI) arthrogram was subsequently obtained to further evaluate for the presence of capsulolabral pathology.
Coronal and axial sections from his MRI arthrogram are shown here. On the coronal image to the left, an anteroinferior capsular injury is present with contrast extravasating from the joint. On the axial image to the right, it is evident that the capsular tissue is torn and flipped within the joint space.
Orthogonal imaging further highlights the capsular tissue displaced within the joint space. The capsular tear was seen to extend up to the humerus, but was not avulsed from it, like with a humeral avulsion of the glenohumeral ligament (HAGL).
Based on the patient's clinical symptoms, MRI arthrogram findings, and failure to return to play despite attempts at conservative management, he was determined to be an operative candidate. Arthroscopic intervention was selected for this patient based on previous recommendations outlined by Gulotta et al 2 for medial or mid-substance anterior capsular tears, with open conversion being reserved for inaccessible pathology based on the initial diagnostic arthroscopy.
This procedure was performed on an outpatient basis under regional anesthesia. Requisite materials for arthroscopic capsular repair are listed here. The patient is positioned beach chair per surgeon preference on a specialized operating room table. We used a surgeon-controlled arm holder (DJO Global ADAPTABLE Shoulder; DJO Global, Inc) for positioning and manipulation of the operative extremity intraoperatively.
The procedure begins with an examination under anesthesia and diagnostic arthroscopy of the shoulder. Of note, there is an incidental finding of a cordlike middle glenohumeral ligament and sublabral foramen present. No significant clinical pathology is evident until viewing across the anteroinferior glenoid, where the capsular tear is seen avulsed from the glenoid neck anteriorly. There is also a small, adjacent anteroinferior labral tear.
Examining further, the capsular split is seen extending further inferiorly toward its attachment on the humerus. The 30° arthroscope was exchanged for the 70° arthroscope to improve visualization within this region. The capsular tear was manipulated and able to be reduced. Next, a suture anchor (Arthrex Suturetak; Arthrex Inc) was placed, and the capsular tissue was repaired to its attachment point medially on the glenoid neck and it was reapproximated to the labrum. It is important to note that the repair was performed with the shoulder maintained in external rotation to avoid over-tensioning the repair and over-constraining the shoulder. Next, the capsular split was repaired in side-to-side fashion with 1.3 mm, flat-braided suture (Arthrex SutureTape; Arthrex Inc) using a curved suture passer and nitinol wire loop. There was noted to be residual capsular tearing off the glenoid anteroinferiorly, which was repaired and anchored with one final knotless suture anchor (Arthrex Knotless Fibertak; Arthrex Inc). The final video sequencing showcases the final repair configuration.
Some of the potential complications of an anterior capsular repair are listed here and include shoulder stiffness, inability to return to prior performance, failure to heal the capsular tear or recurrent tearing, chondral injury, infection, and neurovascular injury.
Postoperatively, patients are maintained in a shoulder sling until postoperative week 6 and are restricted from performing active shoulder abduction, external rotation, or extension initially. They begin gradual passive, active, and active-assisted range of motion at postoperative week 5. During postoperative weeks 7 to 20, trainer- or therapist-mediated rehabilitation focuses on gradual stretching and strengthening of the shoulder. Patients are restricted from throwing or overhead sports until 5 to 6 months postoperatively, at which point they may be evaluated to initiate an interval throwing program once several parameters for shoulder range of motion and strength are met. Baseball pitchers are further evaluated for initiation of mound progressions at 9 months postoperatively.
Anterior capsular tears are often associated with traumatic glenohumeral instability episodes; however, there are not many previous descriptions in the literature without occurrence of frank dislocation.2,3 Case reports have described humeral avulsion of the glenohumeral ligament caused by repetitive microtrauma in overhead athletes; however, there is a scarcity of descriptions in throwing athletes or baseball players.1,4 In 2014, Gulotta et al 2 reported a case series of 5 professional baseball players found to have anterior capsular tears of the throwing shoulder without incidence of an acute traumatic injury or dislocation event. In this series, 3 shoulders underwent repair arthroscopically, and 2 shoulders were repaired in open fashion. 2 Four of 5 patients returned to their pre-injury level of performance at a mean 13.3 months postoperatively. 2 The authors concluded that surgical repair, whether arthroscopic or open, can yield good results in throwing athletes aiming to return to prior levels of performance. 2 Notably, the athlete described in this current case ultimately returned to his prior level of performance and was able to resume pitching at the division 1 collegiate level.
From the Department of Orthopaedic Surgery at the University of Virginia, we thank you for watching.
Our references are listed here.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: F.W.G. is a paid presenter or speaker for Arthrex, Inc.; receives publishing royalties, financial, or material support from Saunders/Mosby-Elsevier; and is a paid consultant for Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
