Dr. Josh Siegel: Keeping Athletes Stable & Injury-Free
Dr. Josh Siegel is the Sports Medicine Director at Access Sports Medicine & Orthopaedics in Exeter, New Hampshire. He completed a fellowship in Sports Medicine at the renowned American Sports Medicine Institute in Birmingham, Alabama, training with Dr. Jim Andrews and Dr. Bill Clancy. His work is focused mainly on shoulder and knee injuries in athletes. He is a founding member of Northeast Surgical Care, an ambulatory surgery center in Newington, New Hampshire and works closely with the University of New Hampshire Women's Hockey team. He is also team physician for Phillips Exeter Academy. He is involved in a variety of innovative developments in shoulder arthroscopy and has lectured nationally on these developments. He is a member of the American Academy of orthopaedic Surgeons, and in the American Orthopaedic Society for Sports medicine.
Shoulder1: Your interests currently focus on female athletes. For what type of injuries are they coming to you?
Dr. Siegel: Primarily knees and shoulders. In particular, ACL injuries, and shoulder instability. It is interesting that the number of shoulder injuries we see coming out of women's hockey has been increasing over the past 2-3 years. It's a somewhat different injury pattern than that seen in men's hockey. In men's hockey, a predominant number of injuries are contact injuries, such as fractures and acromioclavicular separations. In women’s hockey, non-contact injuries are occurring more frequently, such as ACL injuries and shoulder instability.
The NCAA injury statistics reports showed the incidence of ACL injuries in female athletes is 4 to 6 times that of comparable male athletes. You don’t see those numbers coming out for shoulders because shoulder instability is generally a subjective diagnosis. For instance, if your ACL tears, the knee swells and "gives way". There is a pop and MRIs confirm the diagnosis.
Shoulder instability, except for frank dislocations, is more difficult to diagnose. The patient complains of feelings of looseness, and little pain and virtually no swelling is associated after each episode. For these reasons, it may require multiple visits to establish the proper diagnosis and develop the proper treatment plan. Once the diagnosis is made, however, quite a bit can be done to help prevent both future instability episodes through an aggressive physical therapy and conditioning program.
Shoulder1: What do you mean by shoulder instability?
Dr. Siegel: There are different types of instability. There's gross instability, which is essentially a dislocating shoulder. In a true dislocation, a patient will generally need medical attention to "reduce" the shoulder back into its socket. Subluxations, or incomplete dislocations, are another form of instability. Often times a patient will state that their shoulder "slipped" out and went back in on its own. This is generally a subluxation. Pain from instability can be from the unstable incident or can be from overuse of the rotator cuff in an attempt to stabilize the loose shoulder. This is called instability-induced tendonitis, sometimes also called secondary impingement.
In the older population, tendonitis may be the result of a spur on the acromion rubbing on the rotator cuff, leading to irritation and even tearing of the rotator cuff tendons. This is unusual in the younger population, however. In younger patients the unstable shoulder may ride up causing the rotator cuff tendons to actually bump up against the acromion (the projection of the scapula that forms the "point" of the shoulder). They're sort of the same problem, but one is caused from a bone spur and the other is really caused from instability.
There's a third pathologic disorder, which is called internal impingement, which is really when the unstable shoulder rotates excessively (such as in a thrower). The rotator cuff bumps up against the glenoid, and it starts to tear the labrum (the tissue on the rim of the glenoid) and the posterior superior rotator cuff. This is an instability-induced problem.
All these things that lead to these rotator cuff problems have to be diagnosed and have to be studied to see what the underlying issue is. Is it a bone spur or instability? The diagnosis is critical, as it dictates the treatment.
Shoulder1: Why are you finding this instability in women?
Dr. Siegel: Ligamentous laxity tends to be higher in the female population than it does in the male. Women seem to be more flexible as a whole. Their joints are more loose as a whole compared to the male athlete. There are many theories in the literature, some explaining the higher injury occurrence on conditioning, some on posture, muscle ratios, hormonal differences, learning theories, and anatomical bony alignment. Personally, I believe it is multifactorial, with some or all of these factors raising the risk in the female population.
Just as increased laxity can lead to a higher incidence of knee injuries in women, increased laxity can also lead to a higher incidence of shoulder injuries in women. Because the shoulder may be a low demand joint in some sports, we tend to see fewer shoulder injuries in athletes than knee injuries. We're seeing more shoulder injuries in women’s hockey. We certainly see it a lot in women's basketball. Anyone who uses their arms in any prolonged fashion, whether it's a slapshot, bringing your arm up to protect yourself or overuse type injuries, such as in the swimming, diving, gymnastics or throwing sports can develop instability problems in the shoulder. Why is it higher in the female athlete? You can debate that forever.
Shoulder1: So what can an athlete do?
Dr. Siegel: The first thing needed is the diagnosis. After the diagnosis is made, I put the (patient) on an aggressive program of not just strengthening the rotator cuff but also dealing with functional activities, such as proprioception (understanding the position of a joint in space), neuromuscular training and balance-type of activities. Finally, my patients will get into an upper extremity plyometrics program.
We make (patients) go through a minimum of three months of conservative treatment, throwing basically every technique we know to get a shoulder to stabilize itself. If after 3 months they are still having instability-induced tendonitis or subluxations of their shoulder, then we start giving them operative options.
Shoulder1: What does a Plyometrics program include?
Dr. Siegel: That entails the use of medicine balls, trampolines, throwing exercises, progressive resistance exercise. A shoulder can be extremely strong, but if the muscles do not fire at the proper time, the shoulder can continue to "slip." We try to re-establish normal timing and coupling of the shoulder muscles to control some of the instability in the shoulder.
Shoulder1: How does the rotator cuff work to stabilize the shoulder?
Dr. Siegel: The rotator cuff is a group of four muscles, attached to bone through tendons. So the rotator cuff itself is actually a muscular-tendonous unit that controls rotation in the shoulder. Shoulders have capsules, or ligaments that surround them. The capsule in people who have laxity or a loose joint is what is loose. The capsule tends to be a big, pouched-out structure. In people whose shoulders are loose, that structure is gigantic, and it really doesn't confer much stability to the shoulder. Because we cannot control the laxity of the capsule, we attempt to stabilize the shoulder through the musculotendinous rotator cuff. It’s like having a beach ball on a tea plate. The beach ball (the ball of the shoulder) sits on a tea plate (the "socket" of the shoulder) and will roll off easily if left to balance on its own. If however, we can put pressure on the beach ball by pushing on it, it is much less likely to roll off the plate. Essentially, the rotator cuff is what puts the pressure on the beach ball. So you create forces – compression – across that joint, which in and of itself leads to some stability. This is the basis for developing strength in the rotator cuff.
The second way (the rotator cuff) leads to stability is by having opposite muscles working at the same time (agonist and antagonist muscles). If one muscle fires stronger than the other or at the wrong time compared to the other, then the shoulder will shift. This is the basis for neuromuscular and proprioceptive training.
Shoulder1: Whether an athlete or a non-athlete, what can a person do to prevent instability from happening in the first place?
Dr. Siegel: The way to do it is through a general rotator cuff exercise program. That can be done with Therabands (stretchy, inner tube-like bands). More importantly, however, is advancing the program beyond just strengthening to neuromuscular, proprioceptive, and plyometric programs. One does not need a lot of equipment or a gym. It is critical to receive proper instruction through your local gym, a certified athletic trainer, strength and conditioning coach, personal trainer, physical therapist, or other health care professional. Timing is important also; the average time to condition shoulder that has not been conditioned is three to four months. Attempting to rush the conditioning may itself lead to the injuries one is trying to avoid.