What are common symptoms of shoulder problems in throwers?

棒球运动员投掷时最常见的症状是疼痛，通常表现会下降, 比如速度的降低. 偶尔一个球员可能会觉得如果他们的肩膀感到松动或是出来的插座, but usually the problem is pain during or after throwing.

什么导致了投掷疼痛?

投掷后疼痛是典型的 肩袖肌腱发炎. Basically the shoulder is inflamed or irritated after throwing. 疼痛的确切原因尚不清楚，尽管有几种理论.

The first possibility is that the tendons are seeing too much stress. 这通常发生在某人试图在太短的时间内快速塑形的时候. The shoulder and rotator cuff tendons do not like large increases in stress whether it is early in the season or late in the season. Usually when the arm has just seen too much stress, recovery can be achieved with the usual treatments. This includes cutting back on throwing for a brief period, using ice after throwing or even a few times a day, anti-inflammatory medications and rehabilitation exercises. The rotator cuff exercises should initially be done below shoulder level and progressed to above shoulder level slowly. 如果你感到疼痛，那么要么是你做错了，要么是你的身体在告诉你什么. 当疼痛的原因是过度使用, it seems that the recovery is never as fast as you want, and patience by the athlete and coaches is difficult. How much time is given to recovery depends upon many factors.

当这些治疗不起作用时，可能需要考虑引起疼痛的其他可能原因. The most prevalent theory is that the pain is due to the 肩关节太松了. While the shoulder is not coming out of the socket, the theory is that the ligaments have become stretched to the point that the ball of the shoulder joint is sliding around too much. This puts more stress on the tendons, which causes them to hurt. The shoulder is not really coming out of the socket but the pain is believed to be due to a hidden or "occult" instability.

另一种理论认为疼痛可能是由于 上唇的眼泪. The labrum is a cartilage that goes around the socket and stabilizes the shoulder. 随着时间的推移，它会变得撕裂. Whether tears of the labrum can actually cause symptoms is controversial since it is possible that a labral tear is an indication the joint is loose but not actually the cause of the joint being loose.

如何进行诊断?

确定投掷运动员肩膀疼痛的原因是困难的，有几个原因. 问题的真相是很难确定肩膀是否松动. 研究表明，肩膀有一定程度的活动是正常的, 问题是，在检查肩膀时很难判断它是否太松. 尽管一些外科医生声称他们可以分辨, studies have shown that this examination is very subjective and probably not very reproducible among examiners. 换句话说, 在办公室里，很难通过推拉肩膀来判断肩膀是否太松, 尽管一些医生声称.

The same problem holds true for the detection of labrum injuries in the shoulder. 肩部的身体检查是复杂的，因为肌肉覆盖关节. 一些医生报告说，他们认为肩部的测试可以准确地检测出唇状撕裂, 但独立观察人士的研究在很大程度上证明，这些测试并不那么准确. Labrum tears do not produce a characteristic set of signs or set of pains that distinguish them from tendinitis pain.

另一个需要考虑的是 核磁共振成像 to make the diagnosis of instability, 上唇的眼泪 or rotator cuff tears. 核磁共振成像对评估肩袖很有帮助但对评估唇状肌就不那么有用了. Our experience has been that MRIs are generally over-read by the radiologist since they have to describe everything that they see that may be abnormal; in other words, the findings are frequently not as severe as they are made to sound since MRIs are not the most accurate way to evaluated these structures in the shoulder. Sometimes the changes they see in the labrum or rotator cuff are age-related changes that are not really an important part of the problem. 虽然这是有争议的, MRIs are not completely reliable for the evaluation of these structures, and unless the problem is obvious the reality is that MRIs have significant limitations in helping to make the diagnosis of hidden or subtle instability.

什么时候应该做手术?

在绝大多数情况下，决定做手术是因为没有其他方法有效. 在大多数情况下，在手术前很难知道肩膀是否真的不稳定. 一般来说，在手术前尝试所有可能的非手术技术是一个好的策略. 偶尔注射可的松可能有效，尽管它们的使用存在争议. Certainly a thrower should not have more than a couple of shots since they may weaken the tendons if many more than that are given.

There are other factors that should be considered before having shoulder surgery. 一是症状的严重程度. 另一个是球员是否认为他们能撑到赛季结束，得到急需的休息. Another is whether the player has a future in the sport. 如果有人想退出游戏, 那么一个大的行动可能是一个“长期运行”, 短的幻灯片.“另一个考虑因素是比赛水平, since a second stringer on the fraternity team is probably not going to need an operation to further their career.

Recovery time from an operation should also be considered. All of the operations for the throwing shoulder — whether it is an operation to tighten the shoulder or to fix a torn labrum — take about three months to heal. 做过这些手术的投掷运动员平均需要9到12个月才能完全恢复投掷. 有些球员恢复得更快, 但对于投手来说，由于投掷臂上的高应力，时间更长. 因此，这些行动不能掉以轻心，因为复苏并不短暂.

哪种手术方案是最好的?

就像医学中的许多事情一样，难题会产生很多观点和可能的解决方案. The usual approach to surgery in a shoulder that has failed nonoperative treatment is to perform 关节镜检查 to evaluate the shoulder. This is generally done with the patient asleep with a general anesthetic, although some physicians use only a nerve block to make the arm numb. 关节镜是评估肩关节内唇和其他结构的最佳方法. 进行哪一种手术取决于手术时究竟发现了什么. The findings generally fall into three groups:

The first group includes those that indicate that the shoulder is unstable. 这些发现包括 a torn labrum in the front of the shoulder (not the top where the bicep is attached) and wear on the ball (head) of the humerus. If these two findings are present, then the shoulder is undoubtedly unstable. 问题是，这些发现是罕见的，除了患者有 肩部脱位. 如果这些发现存在, 修复不稳定的选择包括切开肩部并修复损伤, an arthroscopic operation to repair the structures or a combination of arthroscopic operations with a heating of the capsule to shrink it. Each operation has advantages and disadvantages, which will be discussed later.

The second scenario is the shoulder that has findings that are believed to be related to instability but have not been convincingly related to instability. 这些发现包括 肌腱套部分撕裂, 二头肌肌腱附着的上唇撕裂(称为SLAP损伤)或“内接触”,“肩袖碰到肩膀后面的阴唇，就会产生症状. 在这些病例中，这些发现被视为肩部滑动过多的证据. Some physicians believe that if the labrum lesions are repaired with sutures or with absorbable tacks that the shoulder will be stable again. 这种修复只能在关节镜下进行. 然后必须确定肩膀是否松动，并且没有客观的方法来做到这一点. Since these changes are presumed to be due to 肩部不稳定, the choices for tightening up the shoulder are the same as mentioned above.

The third situation is when the shoulder is examined by arthroscope and there are no hard findings of instability. 换句话说, 绝对没有唇裂, no cartilage damage and no rotator cuff problems. 在这种情况下, the pain in the shoulder is presumed to be coming from the shoulder being too loose since there are no other identifiable problems. The options for tightening are the same as above, but traditionally an open capsular shift is performed. In the past two years thermal capsular shrinkage has been used since it has a few advantages to the open operation. 然而, thermal shrinkage has no published reports of the results, 尽管一些外科医生声称在这种情况下，它和开放手术一样成功.

手术的结果是什么?

Generally most players can get back to their previous level of throwing, and it takes on average nine months for most players to be able to compete. 手术后最初几周的康复类型取决于所做的手术类型, but by three months the player should have most of their range of motion back. A light throwing program can be started around four months, and it takes about three to four months to get all of the conditioning done to have the stamina to throw competitively.

There are not many scientific studies on the success of these operations. 更传统的操作, where an incision is made on the front of the shoulder, has been reported in the scientific literature. 手术两年后，大约80%的球员恢复到了以前的投掷水平. What this means is that a majority of players get back to throwing, but even with surgery some may drop out of the game, 有时是因为手臂以外的原因. 然而, 我们告诉玩家，这种操作不会让你的手臂变得仿生，也无法弥补糟糕的机制. 从手术中恢复需要艰苦的努力，你很有可能再次参加比赛.

热胶囊位移的结果已在科学会议上报告, but they have not been published in journals where the results can be scrutinized. 早期的报告显示，热转换确实使很大比例的球员回归投掷, 但确切的比例尚不清楚. The studies show that there are few complications with this operation, 但与之比较的黄金标准是上面讨论的公开程序.

约翰霍普金斯大学目前的方法

因为大多数的 肩腱炎 不用手术解决，重要的是要尽一切可能避免手术. 此外，如果肩部需要收紧，手术后的恢复时间也不会短. A careful physical examination of the shoulder is important, and regular radiographs or X-rays of the shoulder should be done. 如果做了核磁共振成像，我们建议做关节造影，在核磁共振成像之前在关节处放置染料.

All of this information is processed to determine whether surgery is indicated. The level of competitiveness of the athlete and where they are in their careers are important considerations when determining if surgery is warranted. A player who is already established and making money from his shoulder is a different consideration than the player who is considering giving up the game anyway. The length of time for recovery is an important consideration as well, since surgery has to be timed to maximize recovery for when the season begins at the level of play the person is involved in at that time.

If surgery is necessary, we utilize a nerve block where the arm is made numb. 然后我们进行全身麻醉，这样球员就不会记得手术过程中的任何事情. We first perform an 关节镜检查 and repair SLAP lesions through the arthroscope. If there is other damage that suggests the shoulder is loose, then we recommend an incision and an open operation. We feel that this procedure is indicated when there is more severe damage and feel that it is the gold standard for repairing loose ligaments.

If there is not so much damage in the shoulder at the time of surgery, then we have been using a thermal capsular shift procedure. While there are no published results on this technique, 我们认为对于没有明显的唇状软骨损伤的肩膀是最好的. We tend to use this operation more often in swimmers or volleyball players who have pain but not much damage in the joints.

手术的类型是有争议的，目前有几种选择. Each option should be carefully considered and discussed with your physician. The last factor to consider is the experience of the surgeon with each technique, as they may feel more comfortable with one procedure over another.