Rotator Cuff Tears in the Throwing Athlete

Abstract

Tears of the rotator cuff, both partial, and less commonly, full thickness, are relatively common in the throwing athlete. The rotator cuff is subjected to enormous stresses during repetitive overhead activity. The supraphysiological strains, especially when combined with pathology elsewhere in the kinetic chain, can lead to compromise of the cuff fabric, most commonly on the undersurface where tensile overload occurs. Exacerbation by a tight posterior capsular, anterior instability, and internal impingement render the cuff progressively compromised, with intrinsic shear stresses and undersurface fiber failure. Advances in imaging technology, including contrast magnetic resonance imaging, dynamic ultrasound, and arthroscopic visualization have enhanced our understanding of cuff pathology in this athletic population. Unfortunately, this has not yet translated into how to best approach these athletes to return them to their previous level of activity. Nonoperative management remains the mainstay for most throwers, with arthroscopic debridement an effective surgical option for those with refractory symptoms. Despite technological advances in cuff repair in the general population, comparable outcomes have not been achieved in high-level throwers. Widespread appreciation that securing the cuff operatively will likely end an athletes' throwing career has led to adopting a surgical approach that emphasizes debridement over repair for nearly all partial and full-thickness tears. Whether advances in surgical technique will ultimately permit definitive and lasting repairs that allow overhead throwers to return to their previous level of sports remains unknown at this time.

Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes

“…These complaints may range from chronic pain to decreased velocity to mild pain at the tail end of a game [18]. While the majority of complaints may be insidious in onset, the athlete may also experience a "pop" (which may represent an acute tear of the tendon or labrum).…”

“…This threshold is lower for bursal-sided tears which often have a mechanical component such as clicking or catching with the arm abducted [15]. Given the tendency to constrain the joint with classic repair techniques, a threshold of 75% has been suggested for repair in overhead athletes [18]. The decision to perform a repair in this setting may be influenced by an athlete's age and other coexistent pathology.…”

“…Even the tears that are mildly symptomatic are usually clinically irrelevant as the athlete does not experience enough pain or impaired ability to desire surgical treatment. Additionally, when obtained too acutely, there may be artificial rotator cuff signal in overhead athletes suggesting a more significant zone of injury that does not resolve back to baseline until almost 1 week after competition [18].…”

“…Partial thickness tears of greater than 75% are typically repaired [18]; however, it is well-known that some high level professional pitchers continue to be effective despite documented full thickness rotator cuff tears [18]. In the general population, the 50% threshold has been typically cited for deciding between debridement and repair, with tears involving less than 50% of the tendon footprint being debrided and tears involving greater than 50% of the tendon footprint generally requiring repair.…”

“…Ultimately, patient age, tissue quality, depth and involvement of the tear, and surgical experience come into play when finalizing the surgical plan. A repair may be indicated in any symptomatic full thickness tears and partial tears exceeding 75% of the tendon thickness [18]. Given some of the unpredictability involved with surgical repair, all options should be discussed and explanations based on evidence-based medicine should be given.…”