Posterior instability
Posterior dislocation is uncommon (4% of all dislocations). Occurs from a fall; or violent muscle contractions as in an electrocution or grand mal convulsion. The diagnosis is often delayed or missed. There is pain and the arm is locked in internal rotation. The (antero-posterior) X-ray may look normal but beware check the axillary view (is diagnostic). If there is any doubt then a CT scan should be performed.]
Posterior subluxation
Posterior subluxation can occur from sports such as baseball. Suspect when the athlete experiences symptoms with the arm in front of the trunk. May then be associated with multidirectional instability. Clinical examination may reveal increased posterior glide, and symptoms reproduced on posterior load of the shoulder in 90 degrees forward flexion (Fig. ). The X-rays are often normal. If there is a ‘locked posterior dislocation’, early recognition and reduction is essential. If the dislocation is long standing or a large portion of the humeral head damaged then open reduction with surgical reconstruction of the humeral head defect (by autograft, allograft or tuberosity transfer) is required. Where chondral damage has occurred, total shoulder replacement may be necessary.
In patients with posterior subluxations and associated multidirectional laxity, an intensive physiotherapy rehabilitation programme is required. Most patients will respond to this. If stability continues then surgical reconstruction is necessary (performed from an anterior or posterior approach). Anterior surgery consists of an inferior capsular shift and tightening of the superior glenohumeral ligament. Posterior reconstruction undertakes an inferior capsular shift only. In both cases the patient is immobilized in a neutral rotation brace for 6-8 weeks then placed on a graded rehabilitation programme extending over twelve months. No return to sports at least twelve months.
Tendinitis and impingement
The supraspinatus is vulnerable to inflammation as it passes under the coraco-acromial arch in the crowded space between the arch and the greater tuberosity. Tendinitis of the rotator cuff may occur from overload/fatigue of the cuff tendons, trauma, age related degenerative changes. The acromion may have a shape which increases the crowding of the cuff tendons here which leads to impingement Note: Tendinitis may occur in patients with very lax shoulders (the muscles are overworked to stabilize the humeral head). Therefore, it is important to beware of tendinitis in these patients (younger than 25 years) as this may be secondary to subtle (unrecognized) instability.
Typically there is pain over the anterior aspect of the shoulder with radiation into the deltoid (minimal at rest and rarely radiates down the arm or into the neck; aggravated with overhead and rotation activities). Night pain with waking indicates severe cases. Examination, tenderness is located over the greater tuberosity. Impingement signs are present (Fig 6 ). Biceps (tendinitis) provocation test may also be positive (Speeds test-pain with resisted forward elevation of strength arm; Yergason’s- pain with resisted supination of the flexed elbow). The Acromioclavicular joint may be involved. Range of motion and strength are often normal, wasting does occur early. There is pain on loading the rotator cuff muscles. Weakness is due to inhibition from pain. Exclude cervical conditions which may refer pain into the shoulder; (where cervical irritation the shoulder posture is in a depressed or elevated position.)
The diagnosis of tendinitis is a clinical diagnosis. A plain X-ray is essential (include a supraspinatus outlet view) Next investigation is the impingement test. (5-10 mL of lignocaine is injected into the subacromial bursa, wait five minutes, there is then a significant decrease in pain on forward elevation of the arm to perform the impingement sign (Fig. 6). Ultrasound (in experienced hands) accurate in diagnosing full-thickness tears and impingement. Note all shoulders which are stiff, as in adhesive capsulitis, will show impingement on ultrasound due to tightness of the posterior capsule limiting the inferior glide to the humeral head, therefore, investigations should be considered in their clinical context. Arthrography will show cuff tears.
Treatment includes activity modification, NSAIDs and physiotherapy (consisting of stretching and strengthening of the rotator and scapular muscles). Most cases respond. If pain persists inject corticosteroid and local anaesthetic (½ ampoule celestone with 5mls 0.5% marcaine plain) into the subacromial space both diagnostic, and therapeutic. If conservative treatment doesn’t help after 6 months, then acromioplasty (open or arthroscopic) is successful in 90% (Fig. 26).
Rotator cuff tears
Normal tendons seldom tear. For young patients if required a violent injury (instability of direct trauma) to tear the cuff. For older patient there is underlying degenerative changes in the rotator cuff so less trauma is required to disrupt it. With repetitive overhead use of the arm, (tennis or baseball), micro damage to the cuff can progress to a full-thickness tear.
The symptoms are similar to tendinitis. Pain is worsened by overhead activities, and at night. Weakness is present (however with full-thickness tears often there is a normal active range of motion). Only massive rotator cuff tears lose active range of motion. The long head of biceps may be torn as well.
Perform x-rays (may show an acromial spur and narrowing of the acromiohumeral gap where the tear is large) may need an arthrogram, ultrasound or MRI to confirm the diagnosis, extent of damage, atrophy of muscles and associated joint disease (note ultrasound is usually sufficient and cost effective).
Treatment in the young patients (less than 50 years) surgery (with acromioplasty and rotator cuff repair) is required as there is a risk of increase in tear size and deterioration of shoulder function. In older patients a short trial of activity modification, NSAIDs, physiotherapy and corticosteroid injection is reasonable. If pain then surgery with acromioplasty and rotator cuff repair is indicated.
Internal derangements within the glenohumeral joint -
Labral Tears, SLAP (Superior Labral Antero/Posterior) lesions, loose bodies.
Caused by trauma, direct or in association with instability. The labrum, most developed in the upper part of the shoulder joint tears here and may extend into the biceps anchor. Known as SLAP (Superior Labral Anterior Posterior) lesions, four types (frayed labrum / also detached biceps / detached superior labrum / also into biceps anchor). Loose bodies arise from trauma or synovial disease (synovial chondrometaplasia).
There is pain with sudden motion, clicking or catching (with rotation). Pain is worse with resisted elevation of the arm while forward flexed (90 degrees and slightly adducted with the hand in internal rotation. When the hand is externally rotated in the same position then the pain decreases. There may also be associated features of instability.
Diagnoses is difficult1 and requires investigation. (Such as MRI with gadolinium enhancement, or arthroscopy). The treatment is often arthroscopic with either resection or repair of the torn labrum and removal of loose bodies. Also important to treat the underlying cause (such as instability).
1 C A Rockwood, F R Lyons 1993. Shoulder impingement syndrome: diagnoses, radiographic evaluation and treatment with a modified Need acromioplasty. JBJS 75A 409 - 424.
Acromioclavicular joint injuries
The acromioclavicular joint (ACJ) commonly injured from a fall onto the point of the shoulder. 1 The injury is chondral or meniscal. More severe injuries result in subluxation or dislocation of the joint. Classified as sprain, subluxed (coraco-clavicular lig. intact),or dislocated (coraco-clavicular ligament torn).
On examination, localized tenderness and swelling is seen. In dislocations the outer clavicle appears superiorly displaced, (actually the shoulder that sags below the clavicle). Forced cross body adduction provokes discomfort.
X-rays of the joint should include standing weighted views of the ACJ with the weight to the wrists of the patient .
For undisplaced injury ice, rest and then gradual return to activity over a 2-6 week period is required (note that seemingly minor ACJ injuries may give rise to grumbling discomfort for up to six months). Major dislocations may require surgical stabilization in athletes if their dominant arm is involved, and if they participate in upper limb sports or awe workers who use their arms overhead.
Clavicle fractures
Common injury occurs from a fall onto the outstretched hand. Fractures occurs in the mid-shaft, (also medial or lateral possible). There is pain, swelling and deformity over the site of the fracture. Neurological lesions are rare (brachial plexus) as are vascular injuries.
The majority will go on to union with little morbidity, even when moderate shortening or angulation (the bone ends only need to be on the same room). Some may develop symptoms with cross body actions if the clavicle is too shortened. (If the fractures are lateral and involve the Coracoclavicular ligaments or AC joint, treatment may require surgical fixation of the outer clavicle). Most fractures are treated with a sling for elbow support. Clavicle rings to pull shoulders back may help and stabilize the fracture ends). Take care to avoid skin pressure problems and axillary neurovascular compression. With marked displacement or shortening, early open reduction and internal fixation may be considered (but rarely).
Outer clavicular osteolysis2
Occurs from a direct blow or fall, may develop in athletes who work out in the gymnasium on overhead machines or in overhead sports. Probable pathology is a chondral or minor osteochondral fracture which triggers an inflammatory response, leading to resorption of the outer clavicle.
There is pain over the AC joint (radiates to the deltoid or base of neck). Examination reveals localized tenderness and swelling over the AC joint, advanced cases a palpable gap is present at the AC joint. X-rays show irregularity of the outer clavicle with osteolysis (‘suck-candy’ appearance). A bone scan, (not always necessary) will be hot.
Treatment is rest, activity modification and NSAIDs. If the pain is severe then surgical excision of the outer clavicle is required.
1 R R Richards 1993 Acromioclavicular joint injuries. Instr. Course Lect. 42,259-269.
2 M Scarenius, B F Iverson 1992. Non traumatic clavicular osteolysis in weight lifters. Am J Sports Med. 29 463 - 467
Medical Clavicular Sclerosis (Osteitis Condensans)
A rare disorder where there is osteosclerosis of the medial end of the clavicle. Aetiology is unknown, (low grade osteonecrosis or osteomyelitis proposed, but never proven). Occurs in middle aged females with a long insidious onset of pain and discomfort (with elevating the arm).
X-rays show mild enlargement and sclerosis of the medial end of the clavicle (no bone destruction or periosteal reaction). Confirmation by CT scan (though MRI useful).
Treatment is non-operative (analgesics and NSAIDs). May be symptomatic for many years. Condition is rarely painful enough to warrant surgical excision.
Sternoclavicular dislocation
Although limited ligamentous support of the inner end of the clavicle exists, dislocations are rare. May be anterior or posterior. Usually occurs from a fall onto the side and from compression of the shoulder from another player falling on top.
Anterior dislocation displays a painful prominence of the medial end of the clavicle. Reduce closed in the acute situation (many surgeons prefer to leave the dislocation and treat the patient symptomatically). The diagnosis is confirmed with a CT scan as X-rays of this region are difficult to read.
A posterior dislocation may cause pressure on vital structures in the neck with dysphagia, dyspnoea or great vessel compression. A surgical emergency. Posterior dislocations should be reduced urgently if there is compromise of the thoracic outlet mediastinal structures. Place a bolster between the shoulder blades and apply posterior pressure to the shoulders. If the clavicle doesn’t so reduce around the clavicle and pulled forward to reduce hook a sterile surgical towel clip.
Muscle ruptures
A number of muscles may rupture about the shoulder, including pectoralis major; long head of biceps and subscapularis. A muscle tears when there is contraction against an unexpected resistance. Weight lifters (bench pressing large weights) incur such injuries. When the arm is in 90 degrees of abduction and in extension the subscapularis may tear.
There is severe pain and a tearing sensation (at the time of rupture), followed by swelling and bruising. The torn Pectoralis Major bunches on contraction. Long head of biceps rupture may be associated with rotator cuff disease. Subscapularis rupture is to pick (Note: weakness on the posterior lift-off test not able to move back of hand off sacrum).
For the ruptured pectoralis muscle surgical repair is necessary, as the athlete will notice deformity and weakness. A subscapularis tear there may cause term changes in rotator cuff balance and function; so repair is recommended.
1 B L Berson 1979. Surgical repair of the pectoralis major rupture in an athlete. AMJ Sports Med. 7, 348-351.
Biceps tendon injuries
The biceps may be injured with anterior instability or inflamed with impingement and rotator cuff tears. 95% biceps tendonitis secondary.
There is pain over the anterior shoulder. Examination pinpoints tenderness in the biceps groove. A click from subluxation of the tendon may occur with rotation of the arm.
Treatment is rest NSAIDs and steroid injections in the biceps groove. If pain persists or there is dislocation of the biceps then surgical tenodesis is required. If the long head of biceps ruptures the pain often subsides. The rupture is treated symptomatically and surgery rarely required.
Nerve injuries
Nerve injuries about the shoulder occur from direct trauma, traction, compression or instability. The nerves may sustain a neuropraxia or division. Nerves involved include the axillary, suprascapular, musculocutaneous, long thoracic (in swimmers scapulas winging, thoraco-lumbar brace with scapular pad may help) and radial nerve. A brachial plexus palsy (partial or complete) occur with high energy trauma (burners/stingers, transient, foot ball; root avulsions carry poor prognosis). Thoracic outlet is compression of nerves/vessels between scaleres and first rib. Abnormal scaleres or cervical rib. C8-T1 signs. Wright test (Arm is extended/abducted/externally rotated; head turned away; postpone where symptoms / no pulse. Improve posture rarely surgery.
There is pain related to the injury and weakness. Careful neurological examination is required to localize the injury.
Usually the injury is a neuropraxia and will recover. EMG studies may ascertain whether the lesion is complete and /or recovering. Exploration and repair of the nerves is indicated if the lesion does not recover within six months. If suprascapular nerve compression is evident then an MRI scan may reveal a spino-glenoid notch ganglion cyst pressing on the nerve. (Surgical excision / release transverse suprascapular ligament).
Other conditions
Scrapping scapula - from irritation of periscapular bursae, maybe voluntary, difficult to treat, NSAIDs, inject or partial distal scapular resection.
Adhesive capsulitis (frozen shoulder synovitis with capsular contraction), painful should with global ROM (end stage inflammation; exclude post dislocation shoulder / OA neck), autoimmune problem, after trauma or immobilization onset in stages, x-ray shows osteopaenia. Needs NSAIDs. physiotherapy, steroid injection and MUA.
Calcific tendinitis - deposition of calcium (toothpaste) in supraspinatus tendon in middle-aged women, pain in the resorptive phase, localized deposit on x-ray, may benefit from needling/steroid injection or surgical excision (including bursoscopy).
Prevention of injury to the shoulder
Very important to have a general condition programme. In upper limb activity sports the programme includes muscle strengthening and stretching about the shoulder and scapula. Such appropriate strength and muscle length allows for optimal muscle function.
Prior to exercising warm-up is the first step. Stretching of the rotator cuff and posterior capsule and then gentle strengthening exercises focused on the rotator cuff and scapular stabilizers is important.
Technique of throwing needs to be carefully developed under supervision to optimize performance without excessive undue strain on the shoulder capsule or muscles. At the first sign of fatigue or discomfort the athlete should rest to prevent any injury progressing to a more serious level. After activity the athlete should cool down the affected area and then reinstate a gentle stretching programme before rest.
It is important to realize that high level performance at sport places an extreme demand on the bodies tissues and the off season is critical in allowing micro damage to heal itself (appropriate complementary exercises are important in the off season). Such exercise should not place the same strains on the tissues but should be directed at maintaining aerobic fitness in preparation for the next season.
Following this all athletes should be able to enjoy their sports for many seasons with a minimal risk of injury.
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