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Lennard Funk
Wrightington Upper Limb Unit
Salford University
lenfunk@shoulderdoc.co.uk
ANATOMY
Deep Muscles
Glenohumeral Ligaments
Labrum
Posterior
Inferior
Superior
Bankart
Reverse
Bankart
SLAP
Anterior
Common Injury Groups
• Contact Athletes
– Rugby
– Football
• Overhead Athletes
– Swimming, Racquets, Climbing, Cricket, Track & Field
• Trauma
– Motorsports
– Cycling
– Canoeing
– Horseriding
• Strength Athletes
– Powerlifting, weightlifting, Bodybuilding
Sport Popularity in UK
SPORT TV
Viewing
Participati
on
Interest
Football
 46% 10% 45%
Rugby
Union
21% 6% 27%
Tennis 18% 3% 23%
Cricket 18% 2% 19%
Athletics 18% 2% 21%
Snooker 17% 5% 24%
Motorsport 16% NA 20%
Rugby
League
12% 2% 15%
Boxing 11% NA 14%
Golf 11% 6% 16%
My Elite Athletes (2010-2013) = 663
SPORT Percentage Commonest Path.
Rugby Union 37% (247) Anterior
LabralRugby
League
28% (182) Posterior
LabralFootball/
Soccer
8% (54) Anterior
LabralMotorsport 3% (22) Mixed Labral
TearsClimbers 3% (20) SLAP
Swimming 3% (18) Int Imping/
SLAPCricket 2% (14) Anterior
LabralParalympics 2% (13) Mixed Labral
TearsOthers 14% (93)
Repetitive
Overhead
Acute Trauma
"In an instant I knew my tour was over 

and I could feel the tears coming,"
“I felt like a drowning man, I wanted to shout for help

but nobody could hear me.”
How can we help him?
• Technical Skills
• Knowledge:
– Risk factors
– Mechanism of Injury
– Pathology
– Effects of our surgery
• Recurrence Rates
• Complications
Predisposing Factors
• Player:
1.Laxity

Cheng et al. JBJSB 2007; 

Akhtar & Robinson. BJSM
2010
2.Proprioception

Herrington, 2011
3.Isokinetics

Jones & Funk, 2010
4.Mass
5.Running Speed
6.Aerobic ability
7.Previous Injury
• Sport:
1. Speed of play
2. Timing
3. Fatigue
1. Physical
2. Mental
Forces
“The new GPS system which we wore during the Four Nations - attached to a
man bra under our shirts - consistently showed us that we were taking impacts
of 10 gs and upwards during a match.!
The gravity force of a car travelling at 100km/h that comes to a stop in 0.2
seconds is 14.2 gs.
And we don't have airbags!”
!
Jon Wilkin, Feb 2010
Injury Reduction
Predispostion Model Meeuwisse
Common Sports
CONTACT / COLLISION
OVERHEADFLEXIBILITY
Recurrent Instability Rates
(after arthroscopic stabilisation)
[Cho et al. Arthroscopy 2006]
CONTACT / COLLISION
OVERHEADFLEXIBILITY
29%
7%
Recurrent Instability
Rates in Contact Sports
• Non-operative = 80% [Arciero, 1994]
• Open Bankart repair = 12%
• Arthroscopic Stabilisation = 14%
[Larrain, 2006]
– First dislocation = 4%
– Recurrent dislocations = 24%
– Under 18yrs age = 30% [Nixon & Funk, 2013]
• RCT of Latarjet vs. Arthroscopic Bankart
• Recurrence rate at 5 years:
– Latarjet = 12%
– Arth. Bankart = 24%
• Return to sport the same!
• Complication Rates higher (20%)
Latarjet Procedure [Bessier et al. JOST. 2013]
Recurrence Summary
• Higher in contact/collision sport
• Higher in young
• Higher after surgery for recurrent
dislocations
!
• Arthroscopic = Open Bankart
• Lower after Latarjet procedure
WHY?
Overhead Athletes
Lo, Hsu & Chan - BJSM 1990
• Tackling Fatique = Reduced JPS
• End of range only
Proprioception & Fatigue
Herrington et al. Phys Ther Sport. 2008
Laxity
• ‘Lax’ shoulders = higher risk of
dislocation in rugby
– Cheng et al. JBJSB 2007
• High Beighton Score = higher risk of
dislocation in sports (not just
contact)
– Akhtar & Robinson. BJSM 2010
Isokinetic Strength
Nathan, Jones & Funk. SECEC. 2011
1. Those players that had rehabilitation following injury and
surgery had better strength & stability than those without
any shoulder injury.
2. Poor Isokinetic strength may be a risk factor for injury
3.Current rehabilitation methods are effective
4. Suggests this should applied to those that have not yet
suffered injury.
Common Injuries
Mechanisms of Injury
video analysis study
Direct Impact
Complex
Labral
Bony Bankart
PTCT
Flexed Fall
Posterior
Labral
RHAGL
Try Scorer
Bankart
SLAP
Rotator Cuff
Tackler
Bankart
SLAP
HAGL
Crichton, Jones & Funk - BJSM 2012
FOOTBALL
• SHOULDER:
!
• 2-4% of all injuries
!
• BUT:
– Longest period of time away from
Incidence Mills, Pritchard, Funk & Batty,
2010
0
27.5
55
82.5
110
2006 2007 2008 2009 2010
45 46
84
98
104
34
63
91 94
99
Left
Right
Player Position
• 25 Professional Footballers
– 15 Field players
– 10 Goalkeepers
Hart & Funk, KSSTA 2013
Clinical Examination:
Instability in Athletes
• True Instability
– Dislocation
– Subluxation
– Apprehension
– Large lesions
• Subclinical
Instability
– Dead Arm in ABER
– Pain in ABER
– Clunking
– No Apprehension
– Smaller lesions
Investigations
• No previous Surgery = MR
Arthrogram
!
• Previous Surgery = CT Arthrogram
MR Arthrogram v. Scope
Sensitivit
y
Specificity Accurac
y
SLAP 0.42 0.92 77%
Rotator Cuff
Tear
0.50 0.86 83%
Hill Sachs 0.91 0.78 90%
Bankart 0.85 0.83 86%
N Karlson, J Geoghan, L Funk; 2008
• An experienced Shoulder Surgeon
better
• Can correlate with clinical context
Classification of Lesions
Major ‘Minor’
• Bony Bankart!
• ALPSA!
• Rotator Cuff Tear!
• HAGL!
• Undisplaced Labral Tear!
• Partial Cuff Tear!
Timing of Surgery
• Early Surgery:
– ‘Major’ lesions
– Late in Season
– Unable to Return
• Rehab & Return:
– ‘Minor’ lesions
– Early season
Types of Surgery
• Mostly Arthroscopic Direct Repairs
• Latarjet for High-Risk/Revision
• Anterior Instability
– Revision surgery (even without bone loss)
– Chronic Bony Bankart (> 3months)
– Any Bony Glenoid Loss
– True dislocation in Front Row forward
(Rugby Union)
– Higher level of sports
Latarjet in Athletes
• Player-specific - tailored to suit the player’s age,
position, requirements, surgeon and therapists. 
• Not ‘accelerated’ or ‘aggressive’ or ‘time specific’. 
• Surgery-specific - dependent on the quality and
type of fixation achieved. 
• Protocol is a ‘guide’ and not a prescription.
• Phase Progression - when the patient is able to
perform all of the exercises in the previous phase without
any discomfort or apprehension. Each phase is
introduced progressively.
Ben Macdonald, Mike Lancaster, Meiron Jones, Doug Jones, 

Christine Holmes, Kathleen Tatlow, Lennard Funk - 2004
Sports Specific Rehab
lenfunk@shoulderdoc.co.uk
Sports Specific - Javelin
http://kellybram.wordpress.com/
The athletes shoulder 2014 len funk
Rugby Rehab Protocol
lenfunk@shoulderdoc.co.uk
Rugby Results ‘03-’05
Pain Satisfaction (%) Playing at
previous level
Pre-op 5 11% 0%
3 months 10 87% 89%
6 months 12 93% 94%
L Funk , K Roney, 

CJSM, 2007
Time to return to play L Funk , K Roney, 

CJSM, 2007
Return to Play
Repair! Months-post.op!
SLAP! 2.6!
Ant.*&*SLAP! 3!
Post.*&*SLAP! 4!
Ant.*Post.*&*SLAP! 5.5!
L Funk , K Roney, 

CJSM, 2007
Arthroscopic Stabilisations
0"
1"
2"
3"
4"
5"
Ant" Post" Both"
Time"(months)"
Fourie & Funk, 2009
Return to play by time of
0"
1"
2"
3"
4"
5"
Begin" Mid" End" Out"
Time"(months)"
63% of all operations took place in the last three months or out of season
Fourie & Funk, 2009
0"
1"
2"
3"
4"
5"
6"
≤20" 21*29" ≥30"
Time"(months)"
Return to play by age Fourie & Funk, 2009
Creighton et al.
CJSM 2010
Recurrences & Revisions
• 8/143 = 5.6% at 2 years
• All recurrent trauma
• 4 treated with Latarjet Procedures
1. High demand; High forces; Fatigue
2. Increased Injuries & recurrence risk
3. Understand
4. Recognise
5. Appropriate imaging
6. Customised Surgery
7. Timing of Surgery
8. Sports-specific Rehabilitation
Athlete’s Shoulder
lenfunk@shoulderdoc.co.uk
THANK
YOU

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The athletes shoulder 2014 len funk

  • 1. Lennard Funk Wrightington Upper Limb Unit Salford University lenfunk@shoulderdoc.co.uk
  • 7. Common Injury Groups • Contact Athletes – Rugby – Football • Overhead Athletes – Swimming, Racquets, Climbing, Cricket, Track & Field • Trauma – Motorsports – Cycling – Canoeing – Horseriding • Strength Athletes – Powerlifting, weightlifting, Bodybuilding
  • 8. Sport Popularity in UK SPORT TV Viewing Participati on Interest Football 46% 10% 45% Rugby Union 21% 6% 27% Tennis 18% 3% 23% Cricket 18% 2% 19% Athletics 18% 2% 21% Snooker 17% 5% 24% Motorsport 16% NA 20% Rugby League 12% 2% 15% Boxing 11% NA 14% Golf 11% 6% 16%
  • 9. My Elite Athletes (2010-2013) = 663 SPORT Percentage Commonest Path. Rugby Union 37% (247) Anterior LabralRugby League 28% (182) Posterior LabralFootball/ Soccer 8% (54) Anterior LabralMotorsport 3% (22) Mixed Labral TearsClimbers 3% (20) SLAP Swimming 3% (18) Int Imping/ SLAPCricket 2% (14) Anterior LabralParalympics 2% (13) Mixed Labral TearsOthers 14% (93)
  • 11. "In an instant I knew my tour was over 
 and I could feel the tears coming," “I felt like a drowning man, I wanted to shout for help
 but nobody could hear me.”
  • 12. How can we help him? • Technical Skills • Knowledge: – Risk factors – Mechanism of Injury – Pathology – Effects of our surgery • Recurrence Rates • Complications
  • 13. Predisposing Factors • Player: 1.Laxity
 Cheng et al. JBJSB 2007; 
 Akhtar & Robinson. BJSM 2010 2.Proprioception
 Herrington, 2011 3.Isokinetics
 Jones & Funk, 2010 4.Mass 5.Running Speed 6.Aerobic ability 7.Previous Injury • Sport: 1. Speed of play 2. Timing 3. Fatigue 1. Physical 2. Mental
  • 15. “The new GPS system which we wore during the Four Nations - attached to a man bra under our shirts - consistently showed us that we were taking impacts of 10 gs and upwards during a match.! The gravity force of a car travelling at 100km/h that comes to a stop in 0.2 seconds is 14.2 gs. And we don't have airbags!” ! Jon Wilkin, Feb 2010
  • 17. Common Sports CONTACT / COLLISION OVERHEADFLEXIBILITY
  • 18. Recurrent Instability Rates (after arthroscopic stabilisation) [Cho et al. Arthroscopy 2006] CONTACT / COLLISION OVERHEADFLEXIBILITY 29% 7%
  • 19. Recurrent Instability Rates in Contact Sports • Non-operative = 80% [Arciero, 1994] • Open Bankart repair = 12% • Arthroscopic Stabilisation = 14% [Larrain, 2006] – First dislocation = 4% – Recurrent dislocations = 24% – Under 18yrs age = 30% [Nixon & Funk, 2013]
  • 20. • RCT of Latarjet vs. Arthroscopic Bankart • Recurrence rate at 5 years: – Latarjet = 12% – Arth. Bankart = 24% • Return to sport the same! • Complication Rates higher (20%) Latarjet Procedure [Bessier et al. JOST. 2013]
  • 21. Recurrence Summary • Higher in contact/collision sport • Higher in young • Higher after surgery for recurrent dislocations ! • Arthroscopic = Open Bankart • Lower after Latarjet procedure
  • 22. WHY?
  • 23. Overhead Athletes Lo, Hsu & Chan - BJSM 1990
  • 24. • Tackling Fatique = Reduced JPS • End of range only Proprioception & Fatigue Herrington et al. Phys Ther Sport. 2008
  • 25. Laxity • ‘Lax’ shoulders = higher risk of dislocation in rugby – Cheng et al. JBJSB 2007 • High Beighton Score = higher risk of dislocation in sports (not just contact) – Akhtar & Robinson. BJSM 2010
  • 26. Isokinetic Strength Nathan, Jones & Funk. SECEC. 2011 1. Those players that had rehabilitation following injury and surgery had better strength & stability than those without any shoulder injury. 2. Poor Isokinetic strength may be a risk factor for injury 3.Current rehabilitation methods are effective 4. Suggests this should applied to those that have not yet suffered injury.
  • 28. Mechanisms of Injury video analysis study Direct Impact Complex Labral Bony Bankart PTCT Flexed Fall Posterior Labral RHAGL Try Scorer Bankart SLAP Rotator Cuff Tackler Bankart SLAP HAGL Crichton, Jones & Funk - BJSM 2012
  • 29. FOOTBALL • SHOULDER: ! • 2-4% of all injuries ! • BUT: – Longest period of time away from
  • 30. Incidence Mills, Pritchard, Funk & Batty, 2010 0 27.5 55 82.5 110 2006 2007 2008 2009 2010 45 46 84 98 104 34 63 91 94 99 Left Right
  • 31. Player Position • 25 Professional Footballers – 15 Field players – 10 Goalkeepers Hart & Funk, KSSTA 2013
  • 32. Clinical Examination: Instability in Athletes • True Instability – Dislocation – Subluxation – Apprehension – Large lesions • Subclinical Instability – Dead Arm in ABER – Pain in ABER – Clunking – No Apprehension – Smaller lesions
  • 33. Investigations • No previous Surgery = MR Arthrogram ! • Previous Surgery = CT Arthrogram
  • 34. MR Arthrogram v. Scope Sensitivit y Specificity Accurac y SLAP 0.42 0.92 77% Rotator Cuff Tear 0.50 0.86 83% Hill Sachs 0.91 0.78 90% Bankart 0.85 0.83 86% N Karlson, J Geoghan, L Funk; 2008
  • 35. • An experienced Shoulder Surgeon better • Can correlate with clinical context
  • 36. Classification of Lesions Major ‘Minor’ • Bony Bankart! • ALPSA! • Rotator Cuff Tear! • HAGL! • Undisplaced Labral Tear! • Partial Cuff Tear!
  • 37. Timing of Surgery • Early Surgery: – ‘Major’ lesions – Late in Season – Unable to Return • Rehab & Return: – ‘Minor’ lesions – Early season
  • 38. Types of Surgery • Mostly Arthroscopic Direct Repairs • Latarjet for High-Risk/Revision
  • 39. • Anterior Instability – Revision surgery (even without bone loss) – Chronic Bony Bankart (> 3months) – Any Bony Glenoid Loss – True dislocation in Front Row forward (Rugby Union) – Higher level of sports Latarjet in Athletes
  • 40. • Player-specific - tailored to suit the player’s age, position, requirements, surgeon and therapists. • Not ‘accelerated’ or ‘aggressive’ or ‘time specific’. • Surgery-specific - dependent on the quality and type of fixation achieved. • Protocol is a ‘guide’ and not a prescription. • Phase Progression - when the patient is able to perform all of the exercises in the previous phase without any discomfort or apprehension. Each phase is introduced progressively. Ben Macdonald, Mike Lancaster, Meiron Jones, Doug Jones, 
 Christine Holmes, Kathleen Tatlow, Lennard Funk - 2004 Sports Specific Rehab lenfunk@shoulderdoc.co.uk
  • 41. Sports Specific - Javelin http://kellybram.wordpress.com/
  • 44. Rugby Results ‘03-’05 Pain Satisfaction (%) Playing at previous level Pre-op 5 11% 0% 3 months 10 87% 89% 6 months 12 93% 94% L Funk , K Roney, 
 CJSM, 2007
  • 45. Time to return to play L Funk , K Roney, 
 CJSM, 2007
  • 46. Return to Play Repair! Months-post.op! SLAP! 2.6! Ant.*&*SLAP! 3! Post.*&*SLAP! 4! Ant.*Post.*&*SLAP! 5.5! L Funk , K Roney, 
 CJSM, 2007
  • 47. Arthroscopic Stabilisations 0" 1" 2" 3" 4" 5" Ant" Post" Both" Time"(months)" Fourie & Funk, 2009
  • 48. Return to play by time of 0" 1" 2" 3" 4" 5" Begin" Mid" End" Out" Time"(months)" 63% of all operations took place in the last three months or out of season Fourie & Funk, 2009
  • 51. Recurrences & Revisions • 8/143 = 5.6% at 2 years • All recurrent trauma • 4 treated with Latarjet Procedures
  • 52. 1. High demand; High forces; Fatigue 2. Increased Injuries & recurrence risk 3. Understand 4. Recognise 5. Appropriate imaging 6. Customised Surgery 7. Timing of Surgery 8. Sports-specific Rehabilitation Athlete’s Shoulder