Pathology of the Glenoid Round

PATHOLOGY OF THE GLENOID ROUND The only pathology concerning this structure in the context of sports medicine is the more or less significant rupture of this cartilage. The latter leads in a significant number of cases to the creation of an unstable shoulder. ➢ Rupture of the glenoid labrum ❉ Etiology This pathology, common when playing handball, can originate from violent trauma to the shoulder, dislocation or excessive repetition of micro-trauma. ❉ Diagnosis The labrum can be damaged along its entire perimeter, but anterior damage remains the most common. Injuries can range from simple blunting of the outer edge of the labrum to fracture with complete avulsion of the labrum. . Physical examination Athletes suffering from damage to their labrum may consult for various reasons: ● ● ● ● ● A sensation of jumping accompanied or not by a cracking sound. A real joint blockage, occurring due to innocuous movements. - Pain when performing the sporting gesture, which can lead to real apprehension. A feeling of instability in the shoulder. Two cases can arise: . The athlete has already presented an antero-internal dislocation of the shoulder. Their symptomatology dates from this time. . The interrogation revealed no dislocation, but repeated episodes of falls on the forearms or the shoulder stump (volleyball, judo, etc.) . Palpation of the labrum sometimes makes it possible to locate the injured region with great precision. Pressure from the thumb awakens the pain as in the case of palpation of the menisci of the knee. Reproducing the throwing or circumduction movement of the shoulder (swimming) makes it possible to specify the “hooking” phase of the bead. A real jump can sometimes be highlighted by the examiner during passive mobilization of the humeral head. The demonstration of the latter can be potentiated by a postero-anterior thrust of the humeral head carried out by the examiner. In the case of damage to the anterior labrum, it is the external rotation associated with abduction of the arm that causes the pain (movement of the arm). Conversely, a posterior attack will be highlighted by the internal rotation movement. If the lesion is old, this pathology can be complicated by capsular or ligament damage (long biceps). . X-ray examination Standard radiography is of little benefit. On the different incidences (face, external and internal rotations, profile), it is sometimes possible to find a notch in the glenoid. This examination is only of interest if a bone lesion is suspected (most often interlocking fracture of the anterior edge of the scapula). Two types of examinations can be offered, arthrography and MRI. The choice between these two examinations will depend on the general condition of the patient and any local complications. - Generally speaking, MRI will be offered to patients allergic to iodized products, while it will be contraindicated in athletes already locally presenting orthopedic material (artifacts). - On a local level, CT arthrography is the most effective examination to highlight evidence of a lesion of the labrum, associated or not, with cartilaginous damage to the humeral head. However, MRI will be preferred if involvement of the supraspinatus and/or long biceps is suspected. These two examinations identify the location and type of lesion of the labrum (blunt edge, tongue, breakage, free fragment, disinsertion...). Arthroscopy should not be offered as a screening test. ❉ Treatment The treatment will depend on the importance of the functional gene, the type of sport and its level of practice. In all cases, functional treatment will be undertaken (proprioceptive rehabilitation, subscapularis muscle training). The latter will be coupled with physiotherapeutic treatment intended to limit regional inflammatory phenomena. If this rehabilitation fails, a preglenoid abutment constitutes the treatment of choice. This stop will be made by arthroscopy. This intervention will consist of reinserting the injured part of the labrum, reconstituting the capsule and possibly the very often affected capsular reinforcing ligaments. Postoperative rehabilitation by gentle mobilization of the joint will complete the therapy. ➢ Unstable shoulder ❉ Etiology Anterior shoulder instability is the usual complication of anterointernal dislocation of the humerus. ❉ Diagnosis . Physical examination Clinically, the athlete consults for recurrent dislocations, a feeling of instability or even decapitation of the shoulder, a painful passage into abduction, a jump. This feeling is at the origin of an apprehension responsible for stopping the competition. In the majority of cases the athlete spontaneously reduces his dislocation. The examination looks for the initial trauma (type of dislocation), its severity (spontaneous reduction or not), its age and its treatment. We will also note the number of dislocations and the movement causing this instability (sometimes a simple stretching of the arm). The diagnosis is made on: * The existence of a previous painful point. * Limitation of external rotation movement in abduction. * The demonstration of anterior posterior capsular-ligamentous laxity of the head humeral (comparative study). X-ray examination The x-ray will be taken from the front, in profile, in support (the arm in line with the body) and with the arm armed. These images highlight (compared to the opposite side), either a lowering of the humeral head or a widening of the joint space. The examination will be completed by an arthrography scan or an MRI (see pathology of the glenoid labrum). We will systematically look for associated lesions: * Bone (fracture or notch of the anterior edge of the glenoid, impaction fracture of the humeral head) * Of the bead (disinsertion, rupture, erosion) * Muscular (supraspinatus, subscapularis, long biceps). ❉ Treatment Treatment may vary depending on whether it is a simple damage to the glenoid labrum or the entire capsulo-ligamentous system, but in both cases it will be surgical (even prolonged rehabilitation is insufficient). The intervention, arthroscopy for the labrum, arthrotomy in other cases, will be followed by cast immobilization and prolonged rehabilitation. Since recurrence after intervention is always dramatic, the resumption of handball remains very controversial. The difficulty of the problems posed by this instability must encourage the practitioner to prevent this type of chronic lesion through prolonged and effective treatment during the initial attack, even if the latter does not seem to be serious.