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Injuries to the athletic shoulder Injuries to the athletic shoulder Dr.H.Saremi Orthopaedic surgeon, Hand & Shoulder fellowship Hamedan university of medical sciences Besat Hospital

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Sport injuries Sport specific injuriesSport specific injuries Regional InjuriesRegional Injuries

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Shoulder 4joints4joints The least stable jointThe least stable joint

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Injuries to the athletic shoulder InstabilityInstability Impingement and rotator cuff problemsImpingement and rotator cuff problems Biceps labral complex injuriesBiceps labral complex injuries Ac joint injuriesAc joint injuries S.c joint injuriesS.c joint injuries FracturesFractures Neurovascular injuriesNeurovascular injuries

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Instability Unique anatomy for Mobility and StabilityUnique anatomy for Mobility and Stability Sports that stress the static and dynamic stabilizers beyond their physiological limit(repeatative overhead maneuvers)Sports that stress the static and dynamic stabilizers beyond their physiological limit(repeatative overhead maneuvers)

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Instability PainPain Feeling that the shoulder is looseFeeling that the shoulder is loose Painfull giving way associated with dead arm syndromPainfull giving way associated with dead arm syndrom DislocationDislocation

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Instability Post traumatic anterior SX or DXPost traumatic anterior SX or DX Post traumatic posterior SX or DXPost traumatic posterior SX or DX Atraumatic Anterior SX or DXAtraumatic Anterior SX or DX Atraumatic posterior SX or DXAtraumatic posterior SX or DX Multidirectional SX or DXMultidirectional SX or DX

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Instability Description of arm position when symptoms occurDescription of arm position when symptoms occur Is it completely involuntaryIs it completely involuntary

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Traumatic anterior DX 98% of shoulder dislocations98% of shoulder dislocations Excessive abduction and Ex rotationExcessive abduction and Ex rotation Direct blow from the behindDirect blow from the behind Pain,decreased ROM,guardingPain,decreased ROM,guarding An immediate reduction may be attempted on the playing field,if unsuccessful another attemp can be made in the locker roomAn immediate reduction may be attempted on the playing field,if unsuccessful another attemp can be made in the locker room

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Simple reduction manuvere

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Traumatic anterior DX Immobilization?Immobilization? 6w(>40 y 7-10 days)6w(>40 y 7-10 days) Internal or ex rotation?Internal or ex rotation? Recurrency?Recurrency?

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Traumatic anterior DX The criteria for returning to sport are based on a FULL ROM and FULL strengthThe criteria for returning to sport are based on a FULL ROM and FULL strength

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Traumatic anterior DX If repeated or sustained instability symptoms and signs ARTHROSCOPIC REPAIRIf repeated or sustained instability symptoms and signs ARTHROSCOPIC REPAIR

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LABRAL DETACHMENT

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GLENOID DEFECT

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Posterior traumatic sx or dx Less commonLess common Direct blow to the anterior shoulderDirect blow to the anterior shoulder Direct forces with the arm I flx, Add, int rotDirect forces with the arm I flx, Add, int rot Axillary view is criticalAxillary view is critical 40y---2-3w 40y---2-3w

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Atramatic anterior shoulder instability Sign and symptoms of instability without significant initial traumaSign and symptoms of instability without significant initial trauma Repetitive over head activityRepetitive over head activity Thrawers in acceleration phaseThrawers in acceleration phase Swimmers during the backsroke or turnsSwimmers during the backsroke or turns Pain may be posteriorPain may be posterior

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Atramatic anterior shoulder instability Sling and antiinflamatory medicationSling and antiinflamatory medication Vigorous physical therapyVigorous physical therapy Arthroscopic repairArthroscopic repair

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Atraumatic posterior shoulder instability Unlike posterior dislocation,is relatively commonUnlike posterior dislocation,is relatively common Athlete usually complain of pain rather than instabilityAthlete usually complain of pain rather than instability Follow through in pitching, pull through phase in swimming,serving motions or backhand in tennisFollow through in pitching, pull through phase in swimming,serving motions or backhand in tennis

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PH.EX

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Atraumatic posterior shoulder instability Sling and antiinflamatorySling and antiinflamatory PhysiotherapyPhysiotherapy Arthroscopic repairArthroscopic repair

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Multidirectional instability Instability occurring in more than one plan(antero inferior,posteroinferior,or three directionsInstability occurring in more than one plan(antero inferior,posteroinferior,or three directions May have generalized ligamentous laxity(beighton hypermobility score)May have generalized ligamentous laxity(beighton hypermobility score) Physical therapyPhysical therapy

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Multidirectional instability The athlete may return to activity at a low level during therapy as long as the specific activities that couse that symptoms are avoidedThe athlete may return to activity at a low level during therapy as long as the specific activities that couse that symptoms are avoided Therapy should progress until the patient can return to activities without symptomsTherapy should progress until the patient can return to activities without symptoms Arthroscopic repair and capsular shiftArthroscopic repair and capsular shift

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A

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Impingement and rotator cuff problems Subacromial impingement is one of the most common couse s of shoulder pain in athletesSubacromial impingement is one of the most common couse s of shoulder pain in athletes

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Rotator cuff

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DEPRESSION effect

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Impingement Outlet impingementOutlet impingement Non outlet impingementNon outlet impingement An unstable head that subluxes anteriorly due ro capsular laxity may displace upward against the acromionAn unstable head that subluxes anteriorly due ro capsular laxity may displace upward against the acromion Stabilize the shoulderStabilize the shoulder Secondary impingement is the most common type of impingement in young athletes Stabilize the shoulder

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Impingement syndrom

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ACROMIO Humeral distance

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CUFF ARTHROPATHY

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Impingement syndrom Painful arc signPainful arc sign Positive howkins sign and jobe testPositive howkins sign and jobe test Non operative treatmentNon operative treatment Operative treatment(arthroscopic)Operative treatment(arthroscopic)

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Internal Glenoid impingement

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Rotator cuff tear Repetitive microtrama,occasionally single traumatic eventRepetitive microtrama,occasionally single traumatic event Progressive pain and weaknessProgressive pain and weakness Restriction of ROMRestriction of ROM May be an aging process(30-50% cadavr)May be an aging process(30-50% cadavr) Partial or fullthicknessPartial or fullthickness Non operative treatmentNon operative treatment operative treatment(arthroscopic)operative treatment(arthroscopic) Rotator cuff arthropathyRotator cuff arthropathy

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Non operative treatment Physio therapyPhysio therapy NASAIDNASAID Corticoid injectionCorticoid injection

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Non operative Treatment STEP 1 :Avoid repeated injurySTEP 1 :Avoid repeated injury WorkWork SportSport

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Non operative treatment STEP 2: Restore normal flexibilitySTEP 2: Restore normal flexibility Stretch out all the direction of tightnessspecially posteriorStretch out all the direction of tightnessspecially posterior Most effective by the patientMost effective by the patient Gentle stretched five times a day by patientGentle stretched five times a day by patient To the point of pull of tightness not to the point of pain Each stretche for 1 min----30 min a day Obvious improvement---1 m may be 3 m full recovery

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Non operative treatment STEP 3: Restore normal strenthSTEP 3: Restore normal strenth When near normal passive flexibility of the shoulder is restoredWhen near normal passive flexibility of the shoulder is restored Internal and external strenthening excersiseswith the arm at the sideInternal and external strenthening excersiseswith the arm at the side By the patientBy the patient

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Non operative treatment Deltoid strengthing is added when it can be performed comfortablyDeltoid strengthing is added when it can be performed comfortably

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Scapular motorsScapular motors

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Non operative treatment STEP 4:Perform aerobic exerciseSTEP 4:Perform aerobic exercise To get back in shape and improve the sense of well beingTo get back in shape and improve the sense of well being 5 days a week,sweaty ex 30 min5 days a week,sweaty ex 30 min

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Non operative treatment STEP5: Modify work or sportSTEP5: Modify work or sport Reviewe the technique of sportReviewe the technique of sport Modifiy the jobModifiy the job

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Operative treatment Sub acromial decompressionSub acromial decompression Rotator cuff repair (Arthroscopic)Rotator cuff repair (Arthroscopic)

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Post opp Rehabilitation

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Closed chain passive EX

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A hundred times every day,I remained myself that my inner and outer life are based on the labors of other men living and dead,and that I must exert myself in order to give in the same measure as I have received. ALBERT EINSTEIN

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Frozen shoulder(adhessive capsulitis) Restricted active and passive motionRestricted active and passive motion Idiopathic(DM,IHD,cervical discopathyimmmobilizationhyperthyroidism,stro ke,MiIdiopathic(DM,IHD,cervical discopathyimmmobilizationhyperthyroidism,stro ke,Mi Secondary(trauma,shoulder surgery)Secondary(trauma,shoulder surgery) Pain and restrictedROM(Int.R,Flex,ext.Rot)Pain and restrictedROM(Int.R,Flex,ext.Rot) Pain,Stiffness,ThawingPain,Stiffness,Thawing Non operative treatmentNon operative treatment Operative treatment(arthroscopic release)Operative treatment(arthroscopic release)

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Calcific tendinitis Site of diminished blood suply(1.5-2 cm to insertion of supraspinatus)Site of diminished blood suply(1.5-2 cm to insertion of supraspinatus) >30y/o>30y/o W>MW>M Precalcification stagePrecalcification stage Calcification stageCalcification stage Phase of formation Resting phase Resorptive phase Post calcification phase Post calcification phase

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Calcific tendinitis Non operative treatmentNon operative treatment Operative treatment(arthroscopic)Operative treatment(arthroscopic)

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Biceps tendinitis

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>30-40 years>30-40 years Pain during flx and supination of elbowPain during flx and supination of elbow Non operative treatmentNon operative treatment Operative treatmentOperative treatment RUPTURERUPTURE

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Trauma to shoulder Fx of the clavicle Most common fx in children mechanism N.V damage Open Skin irritation 1/3 distal >2cm over riding Fliale shoulder

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FX of clavicle Complications N.V damage Non union malunion

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AC dislocation MechanismMechanism ClassificationClassification treatmenttreatment

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Ac dislocation

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Sc dislocation AnteriorAnterior posteriorposterior

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Scapular fx GlenoidGlenoid BodyBody

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Glenohumeral dislocation More than 90% anteriorMore than 90% anterior Abd,ext.RotAbd,ext.Rot PH.exPH.ex ComplicationComplication TreatmentTreatment Post oppPost opp

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Posterior dislocation Not obvious in Ap viewNot obvious in Ap view Abd,Int.rotAbd,Int.rot Following seizureFollowing seizure

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Posterior dislocation

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Fx arround the shoulder Greater tuberosityGreater tuberosity Surgical neckSurgical neck shaftshaft

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AP_LAT scapular view

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Axillary view

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Neer classification

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