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Shoulder Injuries

In the athlete, the demands in the shoulder are greater. The overuse injuries that you see in sports often times you will not see in any other setting. There are not too many activities outside of baseball where you are required to throw a 2 ½ pound object a hundred miles an hour 90 times over the course of a baseball game. Those types of demands and stresses we put on the shoulder and elbow are often times unique just to the athlete.

The subsequent demands in the shoulder will be different, so the treatment might vary from the way we might manage say the pedestrian patient who is going back to their desk job, who has a shoulder dislocation versus the high school corner back on the football team who dislocates his shoulder. The treatment and the way we manage those patient’s are different.

We are going to talk about our overuse injuries which is probably going to be the most common type of patient that presents to your office, the overuse of micro-traumatic injury to the shoulder, then we will talk about some common traumatic injuries to the shoulder where there is a fall or blunt trauma to the shoulder, those are our dislocations, fractures, separations, etc. Then finally, we are going to talk about posttraumatic problems where there has been a significant traumatic injury to the shoulder a number of months or years ago, and then we are dealing with the sequelae of that historical traumatic injury to the shoulder or elbow.

We are going to start with overuse injuries of the shoulder. If you don’t remember anything else from my lecture, this is the one point I do want you to remember, that the most common cause of shoulder pain in athletes, actually in your health adult population, is going to be injuries or problems dealing with the rotator cuff, and of course we include the long head of the biceps tendon in that category as well. In the athlete, we often times find a component of laxity in the shoulder.

The pain is pretty characteristic, it’s deep in the shoulder because the rotator cuff is deep, you can’t put your finger on it because you are actually palpating it through the deltoid muscle, so they always describe it as deep, the often times have trouble localizing the pain, they just say, well it’s in there somewhere deep inside my shoulder. The upper arm is a classic place for the pain to be referred, so often times patient’s will come into your office complaining of arm pain, they get it at night when they lie down to go to sleep, so it comes at night. In older patient population, they will be convinced that they have a tumor in their arm and that type of pain is classic for rotator cuff pain. In the older patient you may want to get an x-ray to make sure it is not a tumor.

Another common complaint is patient’s driving into a parking structure, they can’t eve reach out and put the card through the reader because their rotator cuff hurts so much. Pain with abduction and elevation in the classic test which we will cover in our shoulder work shop this afternoon is impingement sign, simple elevation of the shoulder in the plane of the scapula.

Most rotator cuff injuries get better with rest and rehab. The R&R of treatment for rotator cuff problems, you are going to hear through the rest of the shoulder lecture that the rotator cuff really is the key to normal functioning of the shoulder, and particularly true in the athlete, so we are going to hammer this home. Any of you athletes with shoulder problems, even with dislocations and other types of shoulder injuries, the main stay of their rehab or recovery program is to strengthen the rotator cuff.

Here is a good example, this is the supraspinatus muscle, the main part of the rotator cuff and here is it’s tendon, which is nice and black here, it should be attaching to the greater tuberosity, you see it’s torn and pulled back, this is white fluid here, representing a rotator cuff tear, so black is good, white is bad. Refer if no improvement after six or eight weeks, that’s a good general rule of thumb. If you have the patient exercising, and doing his rehab, you pull him out of his sport, six.

Biceps tendinitis, we are talking about the long head of the biceps, we consider that part of the rotator cuff. It sits between the supraspinatus and subscapularis, two of the four parts of the rotator cuff tendons.

Glenoid labral tears are a little more difficult to diagnose, less common, this is the rim of cartilage around the glenoid socket, it helps make that little glenoid into a better socket to hold the ball of the humeral head in the joint, that is the glenoid labrum much like the meniscus in the knee, it’s cartilaginous and it can tear, although it’s not as problematic as a meniscus tear.

Another overuse problem that we see and strictly see in the athletes, is osteolyses of the distal clavicle. This is really a weight lifter’s problem, it’s pain in the shoulder, but they will localize it to that little bump on the top of your shoulder, you AC joint, take your fingers and feel that bump on the top of your shoulder, that’s your acromioclavicular joint, and in 90%.

In my practice, I only see this in guys doing bench press or females doing bench press, but it’s this bench press maneuver, as they bring their arms up and the shoulder comes into adduction and rotation, it rubs the end of the clavicle.

Let’s move on to traumatic injuries. These injuries, the actual trauma is the same type of trauma you are going to see in the pedestrian population, the worker population as well. As we talked about, the sequelae are sometimes different for the athlete. We will start with the AC joint sprain or dislocations, what’s referred to in the lay press as a shoulder separation where the acromion and clavicular separate, the lay press calls it a shoulder separation because the AC joint.

A complete separation where the clavicle misses the acromion completely, those are the bones that are pretty prominent when you see them clinically, you will see one bump here, that bump is very prominent as opposed to the other. I am sure at least one or two of you in the audience must have had an AC joint separation.

In certain circumstances, we will do early surgery on the shoulder. If it’s more than 100% displaced, if the tip of the clavicle is sticking way up and tenting the skin, we call that a grade 4 separation, we might do surgery on that, or if it’s displaced abnormally, instead of just riding up, sometimes it gets trapped in the trapezius muscle, it can even get caught under the coracoid, significant trauma, the distal clavicle gets stuck under the coracoid, and of course those you would to refer to your orthopaedic surgeon. With the standard grade 3 separation, there are a few cases where you might want to do early surgery.

The other situation is in the high performance shoulder athlete, if they are pitcher and that is their dominant arm, you might consider doing an early surgical repair of that AC joint, but in general, in the vast majority of the population, we are going to leave that alone.

Clavicle fractures, like I said, when you fall on your shoulder and you push that shoulder into your axial skeleton, something has to give, if it’s not the AC joint it could be the clavicle. Clavicle fractures are pretty easy to deal with, most are mid shaft, you put them in a sling, you rest them until they heal, they take a couple of months to heal.