Sports Injuries For Shoulder Joint PDF

Sports injuries for shoulder joint Dr. Sahar Mowad Lecture of Orthopedic Physical therapy in Beni-Suef Univerity A ‘sports injury’ can be def ined as an injury that occurs during sporting activities or exercise. This can be broadened to include injuries affecting participation in sports and exercis...

Sports injuries for shoulder joint Dr. Sahar Mowad Lecture of Orthopedic Physical therapy in Beni-Suef Univerity A ‘sports injury’ can be def ined as an injury that occurs during sporting activities or exercise. This can be broadened to include injuries affecting participation in sports and exercise and affecting athletes of all ages and all levels of performance Shoulder injuries  ACROMIO-CLAVICULAR DISLOCATION  ANTERIOR SHOULDER DISLOCATION  BICEPS TENDON RUPTURE  CLAVICLE FRACTURE  EXTERNAL IMPINGEMENT  INTERNAL IMPINGEMENT SYNDROME  MULTI-DIRECTIONAL INSTABILITY ROTATOR CUFF RUPTURE SLAP TEAR SUBSCAPULARIS TENDON RUPTURE THORACO-SCAPULAR INSTABILITY FROZEN SHOULDER PECTORALIS MUSCLE RUPTURE POSTERIOR SHOULDER DISLOCATION  ACROMIO-CLAVICULAR DISLOCATION SYMPTOMS There is acute onset of localised swelling and pain over the acromio-clavicular joint with or without immediate deformation. AETIOLOGY : This injury can occur after a direct trauma or tackle to the shoulder or after a fall on to an outstretched arm. It is common in rugby, ice hockey or riding and cycling A Grade I injury is a partial ligament tear Grade II, one with added slight deformation or lifting of the distal clavicle end and easily reducible; Grade III, a complete tear with signif ic ant lifting, which is still easily reducible; Grades IV–VI, anterior or posterior dislocation that cannot be reduced and possibly a fracture. CLINICAL FINDINGS There is localized tender and f lu ctuating swelling over the acromio-clavicular joint and, depending on the grade, a ‘loose’ clavicle end and typical deformation. Cross-body test is positive. INVESTIGATIONS This is a clinical diagnosis. X-rays should be taken in different planes to rule out fracture and demonstrate the severity of dislocation DIFFERENTIAL DIAGNOSES Fractures must be ruled out, in particular upper rib fractures which can be complicated by pneumo-thorax or sternoclavicle injuries. TREATMENT For Grades I-III this injury usually responds to conservative treatment including cold and compression and an 8-bandage to hold the acromio-clavicular joint in position for three to five weeks. There is seldom any indication for surgery for these grades. Some Grade III injuries and most Grade IV–VI injuries will require surgery. Surgery for this injury may not always be straightforward and should be handled by a shoulder specialist. EVALUATION OF TREATMENT OUTCOMES Return to normal clinical symptoms and signs. Healing usually takes six weeks for Grades I– III but more severe injuries, requiring surgery, may bar a player from contact sports for three to four months. ANTERIOR SHOULDER DISLOCATION SYMPTOMS There is acute onset of localized swelling and pain over the anterior part of the shoulder with deformation, after an excessive external rotation and abduction trauma. This is the most common type of dislocation in sports (85-90 per cent). Movements of the arm cause pain and the patient will protect the arm in the ‘Napoleon position’. CLINICAL FINDINGS A first dislocation in a young athlete usually requires relaxation (under anaesthesia) to be repositioned, unless a team doctor is trained in the specific manoeuvres involved. After reposition, the apprehension test is positive, as well as the reposition test. Apprehension test INVESTIGATIONS This is a clinical diagnosis. X-rays should be taken in different planes to rule out fracture and demonstrate the type of dislocation (to rule out rare cases of posterior dislocation). MRI is usually not required in the acute phase for the diagnosis but may be done in cases i nv o l v i ng gre a t t ra um a , t o i nv e st i ga t e associated injuries. TREATMENT Age and activity level is the most important factor in determining management. A rugby player younger than 25 years old will need surgery, a Bankart repair, followed by four to six months’ rehabilitation, while a 40– year-old runner who has had a fall can most often be treated with stabilizing training guided by a physiotherapist. In older age groups, associated injuries to the rotator EXERCISE PRESCRIPTION Most sports and activities, such as cycling and cross-training, can be maintained but avoid further direct or indirect trauma to the shoulder. Running should initially be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for at least three months, though other water exercises are fine. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco-scapular control after three months, followed by functional training for up to six months, before resuming sports like rugby. BICEPS TENDON RUPTURE SYMPTOMS There is acute onset of pain over the anterior part of the shoulder with a lump typically forming at the mid-biceps from the retracted muscle bulk (the ‘Popeye sign’). Usually the biceps longus tendon, ori gi n ati n g f rom the an teri or superior labrum, ruptures and the short biceps tendon originating at the coracoid is intact. This leaves some biceps function infact AETIOLOGY This injury often occurs in middle aged or elderly athletes or after cortisone injections. The rupture can be partial, causing pain but no lump. If complete, the sudden lump on the mid- biceps is typical. CLINICAL FINDINGS The typical deformation can be seen clearly on resisted elbow flexion. A proximal partial tear or subluxation gives a positive palm-up test TREATMENT Usually this injury is treated without surgery with gradual and progressive rehabilitation. Even though the long head of the biceps, subject to suf ficient length and quality, can be re - i nse r t e d i nto t he hume ral he ad , t he functional improvement may be questionable. However, an associated, SLAP tear is not unusual and may require surgery. EXERCISE PRESCRIPTION Most sports and activities can be maintained, such as cross-training, working-out and running. The specific rehabilitation should aim at a full range of controlled motion, good po st ure and t ho rac o - sc apul ar c o nt ro l , followed by functional training DIFFERENTIAL DIAGNOSES Associated injuries must be ruled out. Due to its origin at the anterior superior labrum, a SLAP tear, with or without impingement, may complicate the situation and require surgery. CLAVICLE FRACTURE SYMPTOMS AETIOLOGY There is acute onset It is common in of localized swelling rugby, ic e ho c key, and pai n o v e r t he riding and cycling. anterior part of the shoulder, with typical deformation, after d i re c t o r i n d i re c t trauma, often in a young athlete. CLINICAL FINDINGS A clavicle fracture is usually easy to diagnose since the patient refers to a ‘crack’and can point to the fracture site where there is bruising, deformation and tenderness on palpation. Vascular complications (wrist pulse) and neurological complications (ref le xes and sensation and power of the hand) TREATMENT An 8-bandage, applied properly, will reduce the pain as well as holding the fracture in the best position for healing, which takes six to eight weeks. Only complicated cases will require surgery. EXERCISE PRESCRIPTION Many sports and activities, such as water exercises and cross-training, can be maintained but avoid further direct or indirect trauma to the shoulder Running should initially be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for around six weeks. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco-scapular control after two months, followed by functional training for up to three months before resuming full sport  EXTERNAL IMPINGEMENT SYMPTOMS There is gradual onset of pain in AETIOLOGY the shoulder on overhead activity involving internal External impingement rotation and abduction. is not a diagnosis but a symptom. Typically, the pain is worst in one specific position or during a certain movement but often the shoulder gradually stiffens up, restricting abduction and It is usually caused by rotation. jamming of a scarred and inf la med bursae It is painful to sleep on that side between the acromion and movement becomes a and the rotator cuff. problem. CLINICAL FINDINGS The range of motion is usually decreased. External impingement is diagnosed by a positive Hawkin’s test. Since an underlying rotator cuff tear can cause the bursitis, Jobe’s test for the rotator cuff is often positive. In chronic cases there is often muscle atrophy. TREATMENT The clue to success is the proper identif ication of the type of impingement and underlying cause. A r th roscopic evalu ation an d su b-acromial decompression , with or with ou t repair of an y underlying rotator cuff problem, is often required and must be followed by rehabilitation. In some cases physiotherapy is sufficient on its own. Cortisone injections should be used with care, since they will not cure a scarred and f ibrotic bursae and can decrease the tensile strength of the rotator cuff, causing further ruptures and reducing the ability to repair. EXERCISE PRESCRIPTION Most sports and activities without an overarm action are possible but secondary symptoms due to compensatory movements are common and must be addressed. Run n i n g shoul d be avoi ded si n ce the shoul der i s sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming is also unsuitable. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco- scapular control after three months, followed by functional training before resuming sports such as rugb  FROZEN SHOULDER SYMPTOMS AETIOLOGY Froze n shoulde r is a There is sudden or capsulitis of unknown origin that make s the shoulde r grad ual o nse t o f freeze because of a gradually shrinking capsule. localized pain and The onset can be dramatic; stiffness in the the patient wakes up with a stiff shoulder having had no shoulder, often in a previous problems. middle-aged athlete, It is sometimes associated with no prec ed ing w ith ge ne ral collage n trauma disorders and diabetes.  FROZEN SHOULDER CLINICAL FINDINGS TREATMENT A frozen shoulder is often said The shoulder is to be incurable but can heal within two years. That is not passively restricted true : phy siothe rapy and in movements in all occa sion a lly a r t h roscopic re le a se ca n im prove the directions. The condition dramatically. condition is very NSAID can help in the initial stages. Each case needs to be painful discusse d individually. Se condary proble ms in the ne ck a nd uppe r ba ck a re almost inevitable and must be addressed. EXERCISE PRESCRIPTION Most sports and activities without an overarm action are possible but secondary symptoms due to compensatory movements are common. Running should be avoided since the shoulder w ill be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming is usually difficult but warm water can be helpful to release the shoulder. The specif ic rehabilitation should aim to achieve over time a full range of controlled motion, good posture and thoraco- scapular control  INTERNAL IMPINGEMENT SYNDROME SYMPTOMS There is sudden or grad ual o nse t o f e x e rc i se - i nd uc e d pain in the shoulder on overhead m o v e m e n t s. Typi c al l y t he pai n occurs in one specif ic position or during one specif ic movement INTERNAL IMPINGEMENT SYNDROME AETIOLOGY Impingement is not a diagnosis but a sy mptom. Inte rnal posterior or anterior primary impinge me nt can have a variety of causes, including loose bodies, partial f la p tears of the rotator cuff or the labrum, sy novitis or de rive from f u n ct ion a l in st a b ilit y a s a se conda ry im pinge m e nt. Primary impingement can lead to micro-instability. CLINICAL FINDINGS Internal impingement is diagnosed from provoking the position that causes the pain in repeated tests – a positive internal impingement test. Since an underlying labrum tear can cause the same symptoms, an apprehension test, Jobe’s test for the rotator cuff, SLAP tests, Gerber’s lift-off test for the sub-scapularis tendon and the palm-up test for the biceps tendon must be evaluated. A clinical test that indicates an underlying multidirectional laxity is the sulcus sign. General joint laxity test should be ruled out. Functional tests such as the ‘press against the wall’ te st and te sts of thoracoscapular control as w e ll as a t h orou g h e x a m in a t ion of t h e ce r v ica l sp in e sh ou ld complement the examination EXERCISE PRESCRIPTION Most sports and activities are possible but secondary symptoms due to compensatory movements and inappropriate muscle activity must be addressed. Running should initially be avoided since the shoulder may be sensitive to this type of impact and cause secondary upper back and neck pain. Swimming should also wait for around three months. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco-scapular control, followed by functional training before resuming overhead sports  MULTI-DIRECTIONAL INSTABILITY SYMPTOMS T here is sudden or gradual onset of localized p ain in th e shoulder, usually during o ve r h e ad ac t i v i t y. Typically, pain occurs in specif ic positions or during different movements. there is a sense of weakness or instability.  MULTI-DIRECTIONAL INSTABILITY AETIOLOGY CLINICAL FINDINGS A positive sulcus sign is the Multi-directional laxity is a most important reflection of hereditary condition caused multi-directional laxity. b y a lo o s e s ho uld er jo int General joint laxity may or capsule. may not co-exist. In many sports, such as ballet, Functional tests, such as the gymnastics and figure-skating, ‘press against the wall test’, t his increas ed laxit y is tests of thoraco-scapular essential for performance. co n t r o l a n d a t h o r o u g h examination of the cervical Some of these athletes may spine should develop instability, which is a complement the examination. subjective problem. EXERCISE PRESCRIPTION Mo st spo r t s and ac t i v i t i e s wi t ho ut an overarm action are possible but secondary symptoms due to compensatory muscle ac tivation are c ommon and must be addressed. Swimming should also wait for a r o u n d t h r e e m o n t h s. T h e s p e c i f ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco- scapular control by three months followed by functional training before resuming overhead sports PECTORALIS MUSCLE RUPTURE Resisted adduction- f le xion will be very w e a k i f t he re i s a c omplete rupture. Pain suggests a partial tear PECTORALIS MUSCLE RUPTURE SYMPTOMS AETIOLOGY Sudden onset of The pectoralis muscle insertion at the upper localized p ain in th e humerus or muscle bulk can an terior par t of th e rupture partially or shoulder and upper arm completely. after excessive abduction and external CLINICAL FINDINGS rotation su ch as in a rugby tackle. There is Clinical tests of resisting an weakness on internal rotation an d forward internal rotation manoeuvre will identify the weakness and flexion pain typical of a rupture. EXERCISE PRESCRIPTION Most general activities are possible but secondary symptoms due to compensation and avoidance of pain are common and must be addressed. Running should initially be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for around three months. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoraco-scapular control by three months followed by functional training for up to six months before resuming sports like rugby.  POSTERIOR SHOULDER DISLOCATION A posterior shoulder islocation is not only dif ficult to diagnose, it is also hard to reposition, and this often requires general naesthetic Post e rior dra w e r t e st is positive if there are injuries to the posterior labrum  SYMPTOMS AETIOLOGY There is acute onset of This injury accounts for localized swelling and fewer than 5 per cent pain over the posterior o f s h o u l d e r part of the shoulder, with disloc ations. It is typical deformation, after uncommon in sport but an e xc e ssiv e trauma. can occur from direct This injury is mo re tackles or falls on an common in o utstre tc he d arm in epileptics and alcoholics rugby o r Ame ric an than in athletes. football. EXERCISE PRESCRIPTION Most sports and activities, such as cycling, cross-training and working-out, can be maintained but avoid further direct or indirect trauma to the shoulder. Running should be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for around three months. The specif ic rehabilitation should aim at a full range of controlled motion, good posture and thoracoscapular control by three months followed by functional training for up to four to six months before resuming sports like rugby.  ROTATOR CUFF RUPTURE SYMPTOMS There is usually exercise- related pain and weakness of the shoulder on abduction and in overhead activities. The player may rel ate that ‘s o m ethi n g snapped’ in the shoulder. In many partial ruptures, the i n i ti al s ym p to m i s secondary impingement or m uscl e atrop hy an d weakness. CLINICAL FINDINGS Since this injury often is associated with other injuries such as shoulder dislocations or SLAP tears, a broad range of clinical tests must be performed. The active range in all directions of shoulder motion should be tested (it is almost always decreased), repeated against manual resistance and compared with the other side Jobe’s test is positive in major or complete ruptures and internal impingement tests are positive in undersurface partial tears. Major tears are usually degenerative, affecting athletes over 40 years of age, while partial tears are common in younger athletes, but a severe tackle in rugby can tear a rotator cuff completely in a young player.  in chronic cases, there is usually a restricted range of motion and muscle atrophy and secondary problems around the upper back and neck. Such rotator cuff tears may well be seen as a post-traumatic stiff shoulder. EXERCISE PRESCRIPTION Most sports and activities are possible but secondary symptoms due to compensatory muscle activation are common and must be addressed. Running and swimming are usually difficult but warm water can be helpful to release the shoulder. The specific rehabilitation should aim to achieve over time a full range of controlled motion, good posture and thoraco-scapular control  SLAP TEAR SYMPTOMS There is sharp impingement-type should er pain and weakness when trying to pe rfo rm spe c i f ic overhead activities, such as throwing a ball or serving in tennis. AETIOLOGY The SLAP ligament (Superior Labrum Anterior to Posterior) is the superior part of the glenoid labrum. Besides stabilizing and centring the humeral head to the glenoid, it stabilizes the long head of the biceps tendon, which originates from the anterior part. When the SLAP ligament is damaged, the gleno humeral joint becomes unstable. SLAP injuries are common in many sports involving overhead activities, like rugby or tennis. It can also be caused by falling on to an outstretched arm. SLAP injuries are often associated with other injuries such as rotator cuff tears or Bankart lesions. EXERCISE PRESCRIPTION This is an injury with which you can undertake virtually all non-overhead activities throughout the healing process Fo r t hi s i nj ur y, a t hre e - to fo ur- m o nt h rehabilitation programm is usually suf fic ient before returning to overhead sport.  SUBSCAPULARIS TENDON RUPTURE SYMPTOMS There is acute or gradual onset of exercise- ind uc ed pain and weakness on internal rotation with the shoulder in a neutral position, and dif fic ulty in reaching the lower back with the hand. AETIOLOGY The onset can be dramatic and relate to an anterior shoulder dislocation caused by heavy tackling, for example in rugby.  SUBSCAPULARIS TENDON RUPTURE CLINICAL FINDINGS Active f orwa rd f le xion a n d externa l rota tion is usua lly painful. Gerber’s lift-off test is positive. There is tenderness o n p a l p a t i o n i n t h e a n t er i o r shoulder joint. Palm-up tests and SLAP tests are usually vaguely positive. Since this injury of ten a f f ects ma ny structures, a thorough clinical examination of these must also be undertaken. EXERCISE PRESCRIPTION Most sports and activities are possible but secondary symptoms due to compensatory movements are common and must be addressed. Swimming is usually difficult. The specific rehabilitation should aim to achieve over time a full range of controlled motion, good posture and thoraco-scapular control.