1. Acute Shoulder injuries
Physical activity injuries
26/01/10
Janis Leach

2. Objectives Recap of anatomy of the shoulder
Identify key clinical features and mechanisms of injury to the shoulder joint.
Complete an assessment of the area
Read through literature on assessment procedures

3. Clinical perspective
Numerous structures can cause shoulder pain. It is helpful if the problem can be narrowed down to one or more of the following 5 categories of shoulder pain:
Rotator cuff muscles
Instability
Stiffness
AC joint
Referred pain
Rot. Cuff – may be acute or chronic! Acute - muscle strain or tear Overuse - tendonopathy / impinge
Instab – sublx / dislocate – can be from ant / post or sup capsule and labrum
AC joint – pain localised! Always check in shoulder ax
Stiffness may be secondary to trauma – following surgery of injury to brachial plexus or c-spine nerve roots – often adhesive capsulitis
Refer – c-spine and upper t-spine

4. Common causes of shoulder pain
Rotator cuff injury
Glenohumeral dislocation / instability
Glenoid labral tears
Clavicle fracture
AC joint sprain

5. Rotator cuff injuries Rotator cuff injury:
Common cause of shoulder pain and impingement. The tendons become swollen and weak
Clinical features:
Pain with overhead activity. Activities at less than 90 degrees abduction – pain-free.
Tenderness over supraspinatus tendon at it’s insertion onto greater tuberosity.
Painful arc between degrees abduction.
Pain with resisted contraction of supraspinatus.
History vitally important – position of arm at time of injury provides useful info!
Tx: 2 parts – 1st treat tendinopathy itself – Rest, ice. No level 2 evidence to support ultrasound or massage.
2nd part – correction of abnorms – GH inst. Muscle weakness / imbalance, soft tissue tightness, impaired scapulohumeral rhythm.
Strengthen rotator cuff – esp external rots as usually weaker

7. Rotator cuff strains / tears
Minor strains:
generally present with sudden onset of pain or ‘twinge’ in shoulder area.
Some limitation of function
Respond quickly to rest, stretching and soft tissue therapy.
Complete and partial tears:
Common in older athletes
Pain during activity
Inability to sleep on affected shoulder
Weakness on supraspinatus tests
MRI can confirm.
If tear is small – cons man. Full tear – surgical repair

8. Dislocation of glenohumeral joint
Anterior dislocation (most common):
One of the most common traumatic sports injuries.
Results from arm being forced into excessive abduction and external rotation.
Most anterior dislocations damage the attachment of the labrum to the anterior glenoid margin (Bankart lesion)
May also be an associated fracture of anterior glenoid rim, disruption of glenohumeral ligaments or a compression fracture of humeral head (Hill-Sachs lesion)

9. Anterior dislocation cont.
Dwayne wade and james tehuna - youtube

10. Anterior dislocation cont.
History:
Acute trauma – either direct or indirect.
Sudden onset of pain
Patient may describe a feeling of ‘popping out’.
Examination reveals:
Prominent humeral head below acromion
Loss of smooth contour compared with non-injured side.
Occasional damage to axillary nerve = impaired sensation on lateral aspect of shoulder.
Ideally shoulder should be x-rayed prior to reduction as a fx may be present. Most cases not practical to x-ray – need to reduce ASAP. Post-reduction image to be taken. Sooner reduced, the easier it is to reduce – muscles not in spasm!
Many complications with reduction – trained practitioners only!
Place arm across chest and stabilise – adduction and int rot! Do not allow abduction and ext rot.
Shoulder dislocation in young athletes – high rate recurrence leading to chronic instability. Arthroscopy should be considered after dislocation in younger athlete

11. Labrum injuries
Labrum is primary attachment site for shoulder capsule and GH ligaments. The superior aspect of labrum serves as attachment site for tendon of long head of biceps muscle.
Injuries to labrum are divided into superior labrum anterior to posterior (SLAP)
SLAP lesions are injuries that extend from anterior of biceps tendon to posterior of biceps tendon.
Glenoid labrum – fibrous tissue attached to glenoid rim – expands size of socket – inc. stab.
SLAP Classed as stable or unstable depending on whether the majority of superior labrum and biceps tendon are still attached to glenoid fossa.

12. Labrum injuries

13. Glenoid labral tears

14. Labrum injuries Mechanism of injury: Clinical features:
Repetitive overhead throwing
Excessive inferior traction (catching a heavy object).
Clinical features:
Poorly localized pain in shoulder aggravated by overhead and behind the back arm motions.
Popping, catching or grinding may be present.
Tenderness over anterior aspect of shoulder.
Pain on resisted biceps contraction.

15. Clavicle fracture Common fracture in sporting activities.
Mechanism of injury:
Fall onto the point of the shoulder (i.e. horse riding or cycling) OR
Direct contact with opponents in sports such as football / rugby.
Most common fracture site – middle third of clavicle.
Lateral end displaces inferiorly and medial end displaces superiorly.
Clinical features:
Very painful
Localised tenderness, deformity, swelling.
Xray to confirm

16. Clavicle fracture

17. Clavicle fracture Management: Provide pain relief
Almost always heal in 4-6 weeks.
The ends often overlap and clavicle is shortened causing a number of functional problems.
A figure of 8 bandage prevents this shortening rather than sling.
Surgery may be required if the clavicle has compromised the skin.

18. Acromioclavicular joint injuries
Grade I: the ligaments are bruised or strained but there is no actual separation at the AC joint.
Grade II: may involve a partial tear in the acromioclavicular ligaments around the joint, the coracoclavicular ligaments are stretched, and there is a slight separation of the shoulder blade from the collarbone. The cartilage in the AC joint may also be injured. A lump may appear at the AC joint.
Grade III: separation occurs when the acromioclavicular ligaments and the coracoclavicular ligaments are torn, the collarbone is no longer attached to the shoulder blade, and a prominent deformity or bump may appear at the joint. Similar to a Grade II injury, the cartilage may also be injured.

19. AC joint injuries cont.
Another common injury in athletes who fall onto point of shoulder.
Clinical features:
Localised tenderness
Pain on movement, especially horizontal adduction.
Palpable step deformity – visual in more severe injury.
Stability of AC joint is provided by, in order of importance – the joint capsule, AC ligs and corococlavicular lig

20. AC joint injury management
Follow the general principles of management of ligamentous injuries:
Initially ice is applied to minimise degree of damage and pain relief.
Injured limb should be immobilised in a sling for up to 2-3 days in type 1 injuries or up to six weeks in severe type 2 or type 3 injuries.
Isometric strengthening exercises can commence once pain permits.
Tape can be applied to AC joint to provide protection on return to sport.
Historically type 3 injuries have been treated surgically, however recently clinicians have discovered that cons man is just as effective.. Surgery should only be considered if con man fails.

21. Review
Normal shoulder function is essential for many popular sports and shoulder dysfunction causes significant impairment of everyday quality of life.
The shoulder is a challenging region for sports medicine practitioners. A sound background knowledge in the functional anatomy is essential in the treatment and management of shoulder injuries.

22. Assessment of Shoulder
Observation
Palpation
Suprasternal notch
Sternoclavicular joint
Clavicle
Acromion
Acromioclavicular joint
Head of the humerus
Spine of the scapula

23. ROM Flexion Extension Abduction Adduction Internal rotation
External rotation
Horizontal abduction
Horizontal adduction
Depression
Elevation
Scapula Retraction
Scapula Protraction

24. Special tests Apprehension test for dislocation Apley scratch
Scapula winging
Empty can test
Lift off test
Drop arm test
AC compression

25. Apprehension test for dislocation

26. Apley scratch
Loss ROM – rotator cuff injury

27. Scapula winging Weak Serratus Anterior muscle
Damage to Long thoracic nerve
Assessed by wall press up

28. Empty can test
Supraspinatus injury

29. Lift off test
Subscapularis

30. Drop arm test Supraspinatus Passively abduct patient’s shoulder
Arm lowered slowly to the waist
Patient may lower the arm until the final part of the movement as deltoid will work at first

31. AC compression AC joint dysfunction Labral tears – clunk sign
Cross over test – forward elevation to 90 degrees, followed by active horizontal adduction
Labral tears – clunk sign
The patient's arm is rotated and loaded (force applied) from extension through to forward flexion. A clunk sound or clicking can indicate a labral tear.

32. Practical Work in pairs to assess the shoulder
Use your notes and discuss the procedures with each other