Superior labral anterior-posterior (SLAP) lesions occur where the biceps tendon attaches to the superior labrum. The injury occurs as the superior labrum tears off the glenoid attachment. SLAP lesions place strain on the anterior band of the inferior glenohumeral ligament which compromises shoulder stability. In patients under 40, SLAP lesions can develop from repetitive overhead sports or a fall on an outstretched hand that pulls on the biceps anchor on the labrum. SLAP lesions can also occur over time and are generally considered a degenerative condition in patients over 40 years old. An O’Brien’s test, also known as the active compression test, is commonly used to diagnose SLAP tears. The test involves placing the arm in 90 degrees of forward flexion, 20 degrees of horizontal adduction, and internal rotation (thumb pointing down). The patient is then instructed to forward flex the arm against resistance. The test is repeated with the arm internally rotated and then externally rotated. Pain with internal rotation but not external rotation is a positive test. The O’Brien’s test stresses the labrum by tightening the posterior capsule and posteriorly translating the humeral head. This stress causes pain and weakness during the O’Brien’s test when the superior labrum is torn. MRI arthrogram is the diagnostic study of choice for SLAP tears.

References
1. Owen M, Boulter T, Walton M, Funk L, Mackenzie T. Reinterpretation of O’Brien test in posterior labral tears of the shoulder. Int J Shoulder Surg. 2015 Jan-Mar; 9(1): 6–8.
2. Marx R, Camp C. Labral Tears of the Shoulder. Clinical Summary. http://www.JBJS.org. Retreived on 12/20/18.

The symphysis pubis is a fibrocartilaginous joint that connects the left and right superior pubic rami. The symphysis pubis widens during pregnancy as a normal response to child birth. The widening is generally 2-3 mm and rarely exceeds more than 1 cm. Progesterone and relaxin are natural hormones that help the strong supporting ligaments stretch as a normal physiological response to childbirth. Any widening usually regresses after delivery and rarely becomes symptomatic. Symphysis diastasis of over 1 cm represents complete disruption of the joint which is usually symptomatic. Complete disruption may be heard as a popping sound during delivery. A complete disruption causes pain over the symphysis pubis that is made worse with walking.
AP pelvis x-ray is the best study to diagnose symphysis pubis diastasis. A careful physical exam is also necessary to rule out sacroiliac joint (SI) involvement. The SI joint is usually not involved unless the diastasis exceeds 4 cm. Treatment is almost always non-operative. Patients may be weight bearing as tolerated and use a walker for support if needed. Pelvic binders and sleeping in a lateral position can also help with symptoms. Pain usually subsides in 8 weeks but can last as long as 8 months. The diastasis usually reduces over time and becomes asymptomatic. Surgery may be indicated in patients with persistent symptoms and a large diastasis.
References
1. Khorashadi L, Petscavage JM, Richardson ML. Postpartum symphysis pubis diastasis. Radiol Case Rep. 2011; 6(3): 542.
2. Neeta J, Sternberg L. Symphyseal Separation. Obstetrics & Gynecology: May 2005 – Volume 105 – Issue 5 – p 1229-1232.

A herniated cervical disc can compress the nerves roots exiting the neck causing radiating pain to the shoulder and arm, or cervical radiculopathy. The pattern of radiculopathy doesn’t always follow a classic dermatomal pattern and may be confused with pain originating from the shoulder. Confusing things further is the fact that some patients presenting with cervical radiculopathy can also have painful shoulder impingement. A careful review of the patient’s symptoms and physical exam findings is crucial to distinguish between cervical spine and shoulder pathologies. Electromyography and advanced imaging of the shoulder and cervical spine with MRI can ultimately determine the source of pain but are too costly to be used as first line screening tests.
Turning the patient’s neck to the affected side can decrease the space in the neural foramen, which increases nerve root compression and pain. A positive Spurling’s maneuver, performed by gently moving the patient’s neck in extension, leaning the head to the affected side, and placing slight axial compression, is very specific for cervical radiculopathy. However, Spurling’s has a relatively low sensitivity for cervical radiculopathy with one study showing a positive test found in only 30% of patients with positive electromyography (EMG) studies. Abducting the affected arm offers relief of the radicular symptoms by releasing tension off the compressed nerve root, also called the shoulder abduction relief sign. An arm squeeze test involves placing a moderate squeeze to the mid biceps and triceps area on the affected side. The rationale behind the test is that the musculocutaneous, radial, ulnar, and the median nerves are relatively superficial in that area and an arm squeeze stretches the nerve which worsens the compression of the nerve roots from C5-T1. Cervical traction should help relieve radicular symptoms from the neck by opening up the neuroforamen and reducing compression on the nerve root. 1,2

References
1. Tong HC1, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002 Jan 15;27(2):156-9.

2. Gumina S, Carbone S, Albino P, Gurzi M, Postacchini F. Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J. 2013 Jul; 22(7): 1558–1563.

Scaphoid fractures are the most common of all carpal fractures. Injury is often the result of a fall on an outstretched hand with the wrist in extension. Most (80%) of the blood supply to the scaphoid is supplied via branches of the radial artery that start distally and perfuse in a retrograde manner (distal to proximal). Fractures through the scaphoid can interrupt this tenuous blood supply and are prone to slow healing. Because the blood supply to the scaphoid is decreased proximally, fractures are less likely to heal as they occur more proximally. Proximal scaphoid fractures have the highest rate of nonunion. The waist is the most common location for scaphoid fractures to occur, followed by the proximal third, then the distal third. 1
In general non-displaced, or up to 1mm displaced, scaphoid fractures can be treated successfully without surgery. Scaphoid waist fractures are placed in a thumb spica cast for 2-3 months or until the fracture is healed. Healing rates of 90% with cast treatment are equal to the healing rates with surgical treatment and without the increased complication rate of surgery. Indications for surgery include proximal pole and displaced fractures. Without early recognition and treatment of scaphoid fractures patients can go on to develop avascular necrosis of the scaphoid, scapholunate advanced collapse, and wrist arthritis. Any suspected scaphoid fracture with normal x-rays should be either followed closely or evaluated with an MRI to avoid these potential complications. 1,2

References
1. Scaphoid Fractures. http://www.orthobullets.com. Accessed on 7/22/17.
2. Ibrahim T, Qureshi A, Sutton AJ, Dias JJ. Surgical Versus Nonsurgical Treatment of Acute Minimally Displaced and Undisplaced Scaphoid Waist Fractures: Pairwise and Network Meta-Analyses of Randomized Controlled Trials. The Journal of Hand Surgery. Volume 36, Issue 11, November 2011, Pages 1759-1768.

The overhead throwing motion places significant stress on the elbow which can often lead to overuse injury. Determining pathology in the overhead athlete starts with the basic understanding that a valgus force is placed on the elbow during the throwing motion. This causes tensile forces to the medial elbow and compression forces to the lateral elbow. Common sources of medial elbow pain in the throwing athlete are often attributed to a stretch of the medial structures including ulnar collateral ligament tearing, ulnar neuritis, flexor pronator strain, and medial apophysitis. Repetitive compressive forces at the lateral elbow may cause a condition called osteochondritis dissecans (OCD) of the capitellum. 1
OCD of the capitellum occurs when repetitive trauma starts to damage the articular cartilage and subchondral bone of the capitellum. The condition generally occurs between the ages of 11 and 21 and is more common in males. Pain is often described as worse with activities and better with rest, with the occasional catching or locking occurring during throwing motion. On exam tenderness along the radiocapitellar articulation and pain with the lateral compression test is often noted. Radiographs are generally negative early in the disease but may show irregularity to the articular surface as the disease advances. MRI is the most sensitive study for picking up OCD early. Early stable OCD can be treated successfully with 3-6 weeks of rest followed by a gradual return to throwing. Large or unstable OCD lesions often require operative debridement and lesion excision, debridement and bone marrow stimulation, or fragment fixation. (Note: Panner disease occurs almost exclusively in males under 10 years of age and is not associated with trauma.) 1,2
References
1. Patel RM, Lynch TS, Amin NH, Gryzlo S, Schickenantz M. Elbow Injuries in the Throwing Athlete. JBJS Reviews 2014; 2 (11). Pages 1-11.
2. Ruchelsman DE, Hall MP, Youm T. Osteochondritis Dissecans of the Capitellum: Current Concepts. JAAOS 2010; 18: 557-567.