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Internal impingement commonly occurs in overhead athletes and is very common amongst elite baseball pitchers. In which phase of throwing does this pathologic process occur?
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Internal impingement refers to the impingement within the glenohumeral joint which occurs as the posterosuperior glenoid labrum makes contact with the greater tuberosity, causing impingement on the posterior rotator cuff. This occurs commonly among baseball pitchers during late cocking and early acceleration as the shoulder joint reaches it's maximum external rotation.
Drakos et al studied internal impingement in overhead athletes. In their review, they describe how adaptations to throwing including increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all predispose these individuals to internal impingement. They recommend initial nonoperative treatment, with a focus on increasing the range of motion and improving scapular function. If this fails, surgical treatment should address microinstability to ensure good outcomes.
Illustration A shows an example of internal impingement as the shoulder reaches its maximal external rotation. The posterior rotator cuff is "pinched" between the greater tuberosity and the posterosuperior labrum.
Drakos MC, Rudzki JR, Allen AA, Potter HG, Altchek DW
J Bone Joint Surg Am. 2009 Nov;91(11):2719-28. PMID: 19884449 (Link to Abstract)
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A 19-year-old left-hand dominant collegiate baseball pitcher has left shoulder pain with late cocking and early acceleration of the ball. His velocity has decreased over the past 2 months. Rotator cuff strength is normal, he denies symptoms of instability, and Hawkins impingement testing is unremarkable. MRI with contrast reveals no intra-articular lesions. What is the most likely physical exam finding in this patient?
Positive sulcus sign
Decreased external rotation of the affected shoulder
Positive Speed's test
Decreased abduction of the affected shoulder
Decreased internal rotation of the affected shoulder
Internal rotation contracture (GIRD - glenohumeral internal rotation deficit) occurs most commonly in throwing athletes and is thought to be due to a tight posteroinferior capsule. It typically presents with pain while throwing and decreased velocity. Physical exam will often reveal increased external rotation, and an isolated internal rotation deficit without further positive provocative tests. Sulcus sign testing is performed by pulling downward on elbow or wrist with the shoulder in an adducted position and is usually indicative of inferior glenohumeral instability, due to superior glenohumeral laxity. The Speed's test, which is commonly used to evaluate for biceps tendinitis, involves positioning the arm in 90 deg of forward flexion (FF) and the forearm in supination. The patient then resists attempts at pushing the arm downward, with pain/weakness being a positive test.
Burkhart et al, in Part 1 of 3, present a thorough summary of the disabled throwing shoulder that encompasses biomechanics, pathoanatomy, kinetic chain considerations, surgical treatment, and rehabilitation.
Instr Course Lect. 2006;55:29-34. PMID: 16958436 (Link to Abstract)
Burkhart SS, Morgan CD, Kibler WB.
Arthroscopy. 2003 Apr;19(4):404-20. PMID: 12671624 (Link to Abstract)
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Mineralization of the posterior-inferior glenoid has been implicated as a possible source of pain in which athletic population?
The Bennett's lesion is mineralization of the posterior-inferior glenoid observed in overhead athletes. it is felt to be a traction spur of the posterior inferior glenohumeral capsule which is repetitively stressed during the deceleration and follow-through phases of the throwing cycle.
Wright and Paletta documented 22% of major league pitchers in their series had radiographic evidence of a Bennett's lesion, although none required surgical treatment.
Illustration A is an axillary radiograph showing a posterior glenoid radiodensity consistent with a Bennett's lesion.
Wright RW, Paletta GA
Am J Sports Med. 32(1):121-4. PMID: 14754734 (Link to Abstract)
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The term internal impingement is used in throwers to describe a condition where the posterior-superior glenoid labrum impinges on which structure?
The anterior rotator cuff
The posterior rotator cuff
The anterior glenohumeral ligaments
The posterior glenohumeral ligaments
The biceps tendon
Internal impingement is seen in throwers with the arm in a cocked position of abduction and external rotation. Often due to posterior soft tissue tightness, the posterior cuff impinges on the posterior superior labrum and is felt to contribute to SLAP tears and articular sided cuff tears.
Heyworth BE, Williams RJ 3rd.
Am J Sports Med. 2009 May;37(5):1024-37. Epub 2008 Dec 4. PMID: 19059895 (Link to Abstract)
Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS
Arthroscopy. 2000 Jan-Feb;16(1):35-40. PMID: 10627343 (Link to Abstract)
Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM
Am J Sports Med. 2006 Mar;34(3):385-91. PMID: 16303877 (Link to Abstract)
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A baseball pitcher has aching pain in the posterior shoulder after throwing. On exam, he has a 30 degree internal rotation deficit and is diagnosed with internal impingement. Stretching should focus on which aspect of the joint capsule?
Internal impingement is when the posterior rotator cuff pinches against the poster-superior labrum. It is implicated in the development of articular sided rotator cuffs and SLAP tears. This patient has a glenohumeral internal rotation deficit (GIRD) which is felt to contribute to this pathology. Treatment is directed at posterior capsule and rotator cuff stretching. This if often performed with the sleeper stretch, which is shown in the illustration below. The paper by Burkhart et al reviews the pathoanatomy of the throwing shoulder and notes that the use of a prophylactic posterior-inferior stretching program has been shown to decrease both GIRD and subsequent throwing injuries. The reference by Tehranzadeh reported the MRI finding of thickening of the posterior band of the inferior glenohumeral ligament on a small series of throwers with GIRD.
Tehranzadeh AD, Fronek J, Resnick D.
Clin Imaging. 2007 Sep-Oct;31(5):343-8. PMID: 17825744 (Link to Abstract)
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Approach to Throwing Shoulder: John Kelly, MD(CSSE #10, 2017)
Video shows arthroscopic shoulder debridement for Internal Impingement in a pitc...