L'épaule du sportif de lancer est une entité reconnue depuis de nombreuses années. Le conflit postéro-supérieur, décrit par Walch, permet de comprendre les lésions découvertes en arthroscopie. Le but de ce travail était d'étudier les différentes lésions mises en évidence et d'analyser les résultats du débridement arthroscopique.

La série se composait de 75 sportifs de lancer présentant des douleurs du bras dominant. Après échec du traitement conservateur, tous les patients ont été traités par arthroscopie. Après un bilan lésionnel précis, nous avons réalisé un débridement des lésions de la coiffe et du bourrelet. Au contrôle, (recul > à 2 ans), les patients ont été revus pour évaluation clinique et radiologique.

Sur les 75 patients, nous avons retrouvé 67 ruptures partielles de la face profonde de la coiffe (89 % des cas) : 40 lésions du supra-épineux, 24 du supra et de l'infra-épineux, et 3 lésions isolées de l'infra-épineux. Le bourrelet était fissuré dans 52 % des cas ; il pouvait avoir un aspect normal (18 %) ou être effrangé (38 %). En cas de fissure du bourrelet, la lésion ne dépassait pas en avant l'insertion du biceps, sauf dans 3 cas, ce qui la différenciait d'une SLAP lesion. L'arthroscopie a montré des lésions de la glène (chondromalacie, abrasion, éculement) ainsi que de la tête humérale (lésion cartilagineuse, lésion en regard de l'insertion du tendon de l'infra-épineux). Au contrôle, 8 patients étaient très satisfaits du débridement, 22 satisfaits et 45 déçus. Seul 12 patients avaient retrouvé le même niveau sportif ; 44 avaient pu reprendre leur sport à un niveau inférieur alors que 18 avaient cessé les sports avec armer du bras et 1 avait renoncé à toute activité sportive. Vingt-deux patients avaient subi une nouvelle intervention (20 ostéotomies de dérotation humérale, 1 stabilisation antérieure, 1 acromioplastie).

La théorie du conflit postéro-supérieur permet de comprendre les lésions découvertes en arthroscopie chez les sportifs de lancer. Il s'agit de lésions partielles de la coiffe, de stade 1 ou 2 selon Snyder dans plus de 80 % des cas et de lésions du bourrelet en arrière de l'insertion du biceps. L'analyse dynamique des lésions que l'arthroscopie permet, montre que le conflit peut se faire entre le supra-épineux (voire l'infra-épineux) et le bourrelet ou le rebord osseux de la glène. Contrairement à d'autres séries, les résultats du débridement arthroscopique chez les sportifs de lancer sont décevants : 60 % des patients sont déçus de l'intervention et seulement 40 % sont satisfaits ou très satisfaits. Dans cette population de sportifs, l'indice de satisfaction dépend du niveau de pratique sportive.

The painful shoulder is a well-recognized clinical entity in throwers although the pathogenic mechanisms involved are still debated. In 1991 Walch then Jobe developed the concept of posterosuperior impingement to explain lesions observed athroscopically. This impingement between the deep aspect of the supraspinatus tendon and the glenoid occurs during loaded arm movements. The purpose of this work was to study the different types of lesions observed arthroscopically and to analyse outcome after arthroscopic debridement.

Our series included 75 thrower athletes who had shoulder pain for loaded arm movements. Pain was situated in the dominant shoulder in all cases. Clinically, the Jobe manipulation provoked pain in 52 patents, expression of a supraspinous disorder. After failure of conservative treatment, the patients underwent arthroscopy for assessment and debridement. At the time of arthroscopy, the patients had suffered pain for two years (mean 22.3 months). All 75 patients were seen for clinical and radiological assessment at least two years after arthroscopy.

Among the 75 arthroscopies, there were 67 (89%) partial tears involving the deep aspect of the cuff, associated in 90% of the cases with a labral lesion. Tears involved the supraspinatus in 40 cases, the supraspinatus and the infraspinatus in 24 and the infraspinatus alone in three. Eight patients were free of tendon lesions at arthroscopy. There were no full thickness tears. The labrum had a meniscal (45%) or non-meniscal aspect (55%) and appeared normal (18%), fringed (38%) or fissured (52%). The very large majority of the labral fissures were found behind the biceps insertion. Fissures of the labrum were found in front of the biceps insertion in only thee cases (slap lesion). Arthroscopy demonstrated glenoid damage (soft cartilage, fissure, abrasion, wear). The humeral head also exhibited lesions of the cartilage facing the insertion of the infraspinatus. At last follow-up (minimum > 2 years), eight patients were very satisfied, 22 were satisfied and 45 were disappointed. Twelve patients had resumed their sports activities at their former level with loaded arm movement and one patient had interrupted all sports activities. At last follow-up, 22 patient had undergone another surgical procedure: 20 derotation osteotomies of the humerus, one anterior stabilization, one acromioplasty.

The notion of posterosuperior impingement is increasingly recognized as the cause of pain in thrower atheletes. Loaded arm movements produce a physiological contact between the posterorsuperior edge of the glenoid cavity and the deep aspect of the rotator cuff. Injury results from repeated loaded arm movements in throwers. In our series, all the patients had at least one lesion, either involving the cuff or the labrum. According to the Snyder classification, 80% of the supraspinatus lesions were grade 1 or grade 2. We did not have any full thickness tears. All patients with a normal cuff were found to have a lesion of the posterosuperior labrum. At arthroscopy, dynamic assessment evidenced an impingement between the supraspinatus (or the infraspinatus) and the labrum or the bony edge of the glenoid cavity. Only three patients had a labral lesion anterior to the biceps insertion that could be considered a type 1 or 2 slap lesion. Unlike earlier reports by others, we had disappointing results after debridement: 60% of the patients were disappointed after the procedure and only 40% were satisfied (22 patients) or very satisfied (8 patients). Patient satisfaction depended greatly on the level of sports activity attained after arthroscopy, the eight very satisfied patients had resumed their former level. None of the professional athletes or those competing at the international level were very satisfied with arthroscopic debridement. There was an inverse relationship between level of competition and patient satisfaction after debridement.