Shoulder Injuries. Why Bother? QAS Injury Prevalence. Screening Injury 29.2% 12 month cumulative injury prevalence. Dr Simon Locke
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1 Shoulder Injuries Dr Simon Locke Why Bother? Are shoulder and upper limb injuries common? Some anatomy What, where, what sports? How do they happen? Treatment, advances? QAS Injury Prevalence Screening Injury 29.2% 12 month cumulative injury prevalence First injury 66.7% Second injury 22%
2 QAS Screening injury Prevalence Figure 4: Proportion of QAS athletes with current injuries by anatomical site 47.5% 28.7% 23.8% Head, neck and spine Shoulder girdle and upper limb Pelvis, hip and lower limb QAS Cumulative Injury Prevalence Figure 5: Number of first injuries by anatomical site Number of injuries reported Shoulder/clavicle Neck/spine/torso Upper arm/elbow Wrist/hand Knee/leg/thigh Pelvis/hip Ankle/ foot QAS Initial and Second Injuries Figure 6: Proportion of injuries sustained during the preceding year by anatomical site % First injury Second injury Neck, Spine, Torso Upper limb Lower limb
3 QAS Upper Limb Injuries Most common injury hand and wrist Traumatic Fracture 12% Ligament 5% Tendon Injury 6.8% QAS Shoulder Injuries Cumulative prevalence >50% Gymnastics, Rugby League, Water polo, Swimming, Tennis Site Rotator Cuff Injuries 6.8% Dislocation (16) Subluxation (16) Instability (34) Shoulder Injuries Rotator Cuff: Supraspinatus Infraspinatus Teres Minor Subscapularis
4 Shoulder Injuries in elite College Football (NFL) Shoulder Injury AC separation Injury (%) 41 Surgery (%,Y) 12 Anterior Instability RC tendon Clavicle # 4 0 Posterior Instability 4 78 SLAP 2 40 RC tear SC separation 2 0 MD Instability 2 50 Kaplan AJSM 2005 Injury Risk Previous shoulder injury Increasing player experience Athletes have multiple injuries 1.3 per injured player* *Kaplan AJSM 2005 Shoulder Anatomy Acromion AC Joint Clavicle Ligaments Subscapularis Tendon Biceps Tendon Coracoid Shoulder Joint
5 Shoulder Injuries Rotator Cuff: Supraspinatus Infraspinatus Teres Minor Subscapularis Clavicle Conoid Trapezoid AC Capsule Coracoacromial Shoulder Instability Injuries Anterior Inferior Posterior Multidirectional Instability (MDI)
6 Anterior Dislocation Arm forced into extension, abduction and external rotation Ant. capsule stretched torn Humeral head slips anteriorly Acute Injury - Intense pain / Paraesthesia Chronic Injury - Recurrent dislocation Subluxation Anterior Dislocation Sharp contour of shoulder joint Prominent acromion Anterior Dislocation Anterior displacement of humerus Defect of humeral head Chip fracture of inferior rim of glenoid Glenoid Labrum tear on MRI
7 Natural History Anterior Dislocation Recurrence 85-90% recurrence young adults Age 90% <20 65% (Hovelius) 30% >30 (Simonet & Coldfield) Sport High risk Anterior Dislocation Treatment Reduction Analgesia ice, analgesics Immobilization ER Surgery Rehabilitation Acute Dislocation Treatment Decisions Reduction anterior Immobilisation (Recurrence rate) Yes (90%) versus No IR (45%) versus ER (0%)* Surgery, Risk Factors Age, Sport *McCarty Clin Sports Med23,2004
8 Treatment Options Conservative Surgical anterior instability Open versus arthroscopy Quality of life post treatment Prospective studies of Recurrence rates Surgery rates 4-15% Non Operation recurrence 27-80% Immobilisation In ER Basic Science Cadaver study, MR Coaptation zone adduction +IR to 30º ER MR Bankart lesion & glenoid closer in ER Clinical Study Recurrence** Immobilisation 3/52 Follow-Up 15.9 mths All (40 yrs) IR (30%), ER (0%) Young (<29 yrs) IR (45%), ER (0%) Apprehension Sign +ve IR (14%), ER (5%) *Itoi JBJS 1999,2001 **Itoi Am Acad OS 2003 Return To Play No Surgery* Is a safe return possible? Is there a risk of further injury? Can the athlete protect themselves? Do they meet return to play criteria? No Pain Normal ROM Normal Strength, Function, Sports, Skills *McCarty Clin Sports Med23,2004
9 Anterior Instability Laxity Apprehension Inferior Dislocation Rare as an isolated pure injury Humeral head slips inferiorly Stretches inferior capsule and inferior glenohumeral ligament Inferior instability X-ray - Inferior displacement Treatment similar to anterior dislocation Posterior Dislocation and Instability Unusual injury Anterior blow to upper extremity Fall on outstretched hand with shoulder in internal rotation and adduction Examination Arm across chest with loss or ER Flattening of anterior shoulder when viewed from side
10 Multidirectional Instability Generalised laxity of capsule Origin intrinsic, Trauma or overuse Pain and Instability Examination Positive apprehension test +ve sulcus sign Capsular laxity Multidirectional Instability Treatment 1. Scapula Strength 2. Rotator cuff strength 3. Complex strength 4. Duration 6 months 5. Surgery Shoulder Impingement Syndromes Rotator cuff tendinosis Supraspinatus* Impingement Syndrome Supraspinatus long head of biceps acromion and coracoacromial ligament Overuse - Tendons and Bursa Trauma partial thickness tears Is instability involved?
11 Impingement Syndromes Predisposing Factors Overuse, age Previous injury Upper limb tightness especially posterior capsule (IR) Instability Fatigue Impingement Examination Positive impingement signs Rotator cuff and biceps weakness Painful Arc ( deg) Atrophy of shoulder muscles Scapula dysfunction Investigation X-Ray bony changes acromion, type of acromion US evidence of tears Impingement Syndromes 1. Ice 2. Symptom resolution Sports training, competition? Analgesics (NSAIDS?no) Nitrates Corticosteroid injections 3. Restrict range of movement 4. Scapular stabilisation exercises 5. Rotator Cuff strength isolated, complex 6. Surgery
12 Rotator cuff tears Usually Supraspinatus Partial (athlete) and complete Acute - indirect force (abducted arm) Chronic - tendonitis & degeneration - over 45 - persistent & night-time pain Rotator Cuff Tear Positive impingement signs Rotator cuff and biceps weakness Painful Arc ( deg) Tenderness at insertion of supraspinatus tendon Complete Tear - unable to adduct arm against resistance Rotator Cuff Tear Treatment Ice, NSAIDs Corticosteroid injection Rehabilitation Reverse functional deficits: IR, IR +ER, ROM Scapula strengthening Isolated RC strength Complex strength Surgery timing is a function of sport, competition, injury
13 AC Dislocation Acromioclavicular Joint Injuries Allman grades Grade 1 - partial tear of A-C joint capsule 2. Grade 2 - More extensive tear of capsule and stretching of coracoclavicular ligs and subluxation of joint 3. Grade 3 - Complete tear of AC joint and coracoclavicular ligaments Rockwood - grade 1-6 A.C. Joint Injuries History Fall on outstretched arm Direct blow to lateral aspect of shoulder Examination Distal clavicle may ride above acromion Pain and swelling of joint Downward pressure on distal clavicle causes pain
14 A.C. Joint Injuries Treatment Grade 1 & 2 - conservative - RICE - Physiotherapy Grade 3 - Conservative unless lots of overarm activity Grade 4, 5, 6 - Surgery Fractures Clavicle Middle third Fall on outstretched hand Examination Visible and palpable deformity Marked swelling and pain Examine for pneumothorax and neurovascular injuries Fractures Clavicle X-Ray - Fracture Treatment Collar and cuff Surgery for: non-union elite sport (?)
15 Fractures Rare 1. Scapula 2. Coracoid 3. Humerus
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