Injuries to the athletic shoulder

Dr.H.SaremiOrthopaedic surgeon, Hand & Shoulder fellowshipHamedan university of medical sciencesBesat Hospital

Sport injuriesSport specific injuriesRegional Injuries

Shoulder4jointsThe least stable joint

Injuries to the athletic shoulderInstabilityImpingement and rotator cuff problemsBiceps labral complex injuriesAc joint injuriesS.c joint injuriesFracturesNeurovascular injuries

InstabilityUnique anatomy for Mobility and StabilitySports that stress the static and dynamic stabilizers beyond their physiological limit(repeatative overhead maneuvers)

InstabilityPainFeeling that the shoulder is loosePainfull giving way associated with dead arm syndromDislocation

InstabilityPost traumatic anterior SX or DXPost traumatic posterior SX or DXAtraumatic Anterior SX or DXAtraumatic posterior SX or DXMultidirectional SX or DX

InstabilityDescription of arm position when symptoms occurIs it completely involuntary

Traumatic anterior DX98% of shoulder dislocationsExcessive abduction and Ex rotationDirect blow from the behindPain ,decreased ROM ,guardingAn immediate reduction may be attempted on the playing field,if unsuccessful another attemp can be made in the locker room

Simple reduction manuvere

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

Traumatic anterior DXThe criteria for returning to sport are based on a FULL ROM and FULL strength

Traumatic anterior DXIf repeated or sustained instability symptoms and signs ARTHROSCOPIC REPAIR

LABRAL DETACHMENT

GLENOID DEFECT

Posterior traumatic sx or dxLess commonDirect blow to the anterior shoulderDirect forces with the arm I flx, Add, int rotAxillary view is critical40y---2-3w

Atramatic anterior shoulder instabilitySign and symptoms of instability without significant initial traumaRepetitive over head activityThrawers in acceleration phase Swimmers during the backsroke or turnsPain may be posterior

Atramatic anterior shoulder instabilitySling and antiinflamatory medicationVigorous physical therapyArthroscopic repair

Atraumatic posterior shoulder instabilityUnlike posterior dislocation ,is relatively commonAthlete usually complain of pain rather than instabilityFollow through in pitching, pull through phase in swimming ,serving motions or backhand in tennis

PH.EX

Atraumatic posterior shoulder instabilitySling and antiinflamatoryPhysiotherapyArthroscopic repair

Multidirectional instabilityInstability occurring in more than one plan(antero inferior,posteroinferior,or three directionsMay have generalized ligamentous laxity(beighton hypermobility score)Physical therapy

Multidirectional instabilityThe athlete may return to activity at a low level during therapy as long as the specific activities that couse that symptoms are avoidedTherapy should progress until the patient can return to activities without symptomsArthroscopic repair and capsular shift

A

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

Rotator cuff

DEPRESSION effect

ImpingementOutlet impingementNon outlet impingementAn unstable head that subluxes anteriorly due ro capsular laxity may displace upward against the acromionStabilize the shoulder

Secondary impingement is the most common type of impingement in young athletesStabilize the shoulder

Impingement syndrom

ACROMIO Humeral distance

CUFF ARTHROPATHY

Impingement syndromPainful arc signPositive howkins sign and jobe testNon operative treatment Operative treatment(arthroscopic)

Internal Glenoid impingement

Rotator cuff tearRepetitive microtrama ,occasionally single traumatic eventProgressive pain and weaknessRestriction of ROMMay be an aging process(30-50% cadavr)Partial or fullthicknessNon operative treatment operative treatment(arthroscopic)Rotator cuff arthropathy

Non operative treatmentPhysio therapyNASAIDCorticoid injection

Non operative TreatmentSTEP 1 :Avoid repeated injuryWorkSport

Non operative treatmentSTEP 2: Restore normal flexibilityStretch out all the direction of tightnessspecially posterior Most effective by the patientGentle stretched five times a day by patient

To the point of pull of tightness not to the point of painEach stretche for 1 min----30 min a dayObvious improvement---1 m may be 3 m full recovery

Non operative treatmentSTEP 3: Restore normal strenthWhen near normal passive flexibility of the shoulder is restoredInternal and external strenthening excersiseswith the arm at the sideBy the patient

Non operative treatmentDeltoid strengthing is added when it can be performed comfortably

Scapular motors

Non operative treatmentSTEP 4:Perform aerobic exerciseTo get back in shape and improve the sense of well being5 days a week,sweaty ex 30 min

Non operative treatmentSTEP5: Modify work or sportReviewe the technique of sportModifiy the job

Operative treatmentSub acromial decompressionRotator cuff repair (Arthroscopic)

Post opp Rehabilitation

Post opp Rehabilitation

Closed chain passive EX

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

Frozen shoulder(adhessive capsulitis)Restricted active and passive motionIdiopathic(DM,IHD,cervical discopathyimmmobilizationhyperthyroidism,stroke,MiSecondary(trauma,shoulder surgery)Pain and restrictedROM(Int .R,Flex,ext.Rot)Pain,Stiffness,ThawingNon operative treatmentOperative treatment(arthroscopic release)

Calcific tendinitisSite of diminished blood suply(1.5-2 cm to insertion of supraspinatus)>30y/oW>MPrecalcification stageCalcification stagePhase of formationResting phaseResorptive phasePost calcification phase

Calcific tendinitisNon operative treatmentOperative treatment(arthroscopic)

Biceps tendinitis

Biceps tendinitis>30-40 yearsPain during flx and supination of elbowNon operative treatmentOperative treatmentRUPTURE

Trauma to shoulderFx of the clavicleMost common fx in childrenmechanism

N.V damageOpenSkin irritation1/3 distal>2cm over ridingFliale shoulder

FX of clavicleComplicationsN.V damageNon unionmalunion

AC dislocationMechanismClassificationtreatment

Ac dislocation

Sc dislocationAnteriorposterior

Scapular fxGlenoidBody

Glenohumeral dislocationMore than 90% anteriorAbd,ext.RotPH.exComplicationTreatmentPost opp

Posterior dislocationNot obvious in Ap viewAbd,Int.rotFollowing seizure

Posterior dislocation

Fx arround the shoulderGreater tuberositySurgical neckshaft

AP_LAT scapular view

Axillary view

Neer classification

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