77SHOULDER INJURIES IN SPORT

DAVID S. MUCKLE, F.R.C.S.,

Nuffield Orthopaedic Centre.Shoulder injuries account for one half of serious

injuries to the upper limbs in association football(personal series) with dislocations of the shoulder andthe acromio-clavicular joint predominating. Fracturesinvolving the shaft of the clavicle and greater tuberosityof the humerus are also frequent. Overuse injuries andperiarthritis of the glenohumeral joint may severelylimit athletic activity especially in throwing events,while prolonged control by the deltoid and rotatormuscles in swimming and bowling puts considerablepressures on the subjacent sub-achromial bursa.

plentw fclitkastrain latera ligament ankle

Fig. 1. Some of the stresses on joints due to a specific sportingactivity - bowling at cricket.

Dislocation of the shoulder, classically seen in ahands-off at rugby football when the arm is abducted,extended and externally rotated, produces an anteriordislocation with avulsion of the capsule and usually atearing or detachment of the glenoid labrum. This formof anterior dislocation differs from the pure abductiondislocation found in the elderly, when the head of thehumerus is thrust downwards through the weakest partof the capsule (its inferior margin). Although an an-terior dislocation can be readily reduced, recurrencemay follow trivial injuries if the anterior glenoid frag-ment is extensively damaged or if the humeral defect (aflattening of the head seen on the postero-lateralsector) is marked. External rotation of the forearm, ifcombined with elevation of the limb as in a high smashat tennis, can easily cause a re-dislocation. Once recur-rent shoulder dislocation is established, then a limit-ation of external rotation by shortening the sub-

scapularis muscle (Putti-Platt operation) combined witha repair of the defect in the glenoid labrum (Bankartrepair) will produce a stable shoulder; but the limit-ation of external rotation severely affects athleticability.

About two per cent of all shoulder dislocationsoccur in a posterior direction, and the injury, althoughunusual in athletes, has been reported following a blowto the anterior aspect of the shoulder in boxing.Posterior displacement is uncommon because nearly allinjuries to which the shoulder is subjected, includingmost falls on the outstretched hand and all externalrotation and extension strains, drive the humeral headforwards. Difficulty in diagnosis of a posterior dis-location is often encountered for the outline of theshoulder may appear normal, but one important sign isundue prominence of the coracoid process. After re-duction the limb must be immobilised in externalrotation.

Fractures of the humeral neck occasionally occurwith dislocations, and a precautionary X-Ray shouldprecede reduction in all but the most recurrent ofdislocations. Damage to the axillary (circumflex) nervecan produce weakness of the deltoid muscle, but a casedemonstrating permanent paralysis of the anterior two-thirds of deltoid after a rugby injury revealed that themuscle weakness did not prevent the person fromrowing for his College at Cambridge, the supraspinatusmuscle compensating for the weak deltoid. (Watson-Jones, 1955). Simultaneous tears of the rotator cuff,especially the supraspinatus muscle, may causeshoulder stiffness and painful movements sufficient tolimit athletic ability once the dislocation has beenreduced.

Acromioclavicular dislocation with over-riding ofthe clavicle on the acromion may indicate rupture ofthe trapezoid and conoid ligaments. Many sportsmencan carry out first class activities - including goal-keeping up to county standards - providing there issufficient clavicular rotation at the point of dislocationnot to hamper shoulder mobility. Adhesions limitingclavicular movement can be divided and the acromio-clavicular joint arthrodesed using metal pins or screws,although redislocation is frequent. In extreme cases thelateral two centimetres of the clavicle can be excised.

Fractures of the clavicle usually heal rapidly in theconventional figure of eight bandage and goalkeepers,being amongst the most unfortunate in this respect, are

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78often back in full activity withm six to eight weeks ofthe injury.

brachial plexus

Illuton hing frecuee of body of Osuse

FYg. 2. Common sites on injury to the clavicle and scapula.

Periarthritis of the shoulder and subacromial bursitisrespond to heat, general physiotherapy and steroidinjections combined with anti-inflammatory tablets,although a recent review at Oxford tends to indicatethat the natural outcome of the disease is little affectedif treatment is not commenced early. The painful stiffshoulder is amongst the most refractory of jointailments, and requires energetic physiotherapy and, incertain instances, manipulation under anaesthesia. Themore common rotator cuff injury, especially the supra-spinatus tear with limited abduction and externalrotation, is commonly missed and operative inter-vention undertaken too late. Studies on the micro-circulation of the tendons and muscles around theshoulder joint (Rathbun et al, 1970) have shownrelatively avascular areas in the supraspinatus andbiceps tendons due to compression of the tendonsagainst the humeral head. The authors suggest thatthese -avascular areas may be the site of subsequenttears due to degeneration of the collagen fibres. Directsurgical intervention in chronic supraspinatus tendinitishas been advocated, with complete acromionectomy(Hammond, 1962) or osteotomy through the neck ofthe scapula to relieve pressure on the inflamed tendonby increasing the distance between the humeral headahd acromion (Symp. Surgical Legions, 1962). The

importance of arthrography in detecting tears in therotator muscles has been emphasised (Neviaser, 1962).Calcified deposits within the supraspinatus tendons canbe excised, but such lesions are rare in sportsmen.Subachromial bursitis, per se, may be a manifestationof gout or other rheumatoid diseases and the appro-

bwgromial burn

deltoid(*"A*d*-** ~ fied nodule (fromX..1|lt depneration of muscle)

humeruscalcified nodule in asprapinatusmuscle, has caused-by friction-aswlling of the subecromial burn

Fig. 3. Calcified nodule in supraspinatus muscle has caused - byfriction - a swelling of the subacromial bursa.

priate biochemical investigations performed.Pain on the anterior aspect of the shoulder with

tenderness in the bicipital groove indicates tendinitis ofthe long head of biceps (although it has been statedthat many tendons of the body are tender on deeppalpation without concurrent pathology) commonlycalled golfer's shoulder. Treatment is by anti-inflam-matory agents and physiotherapy. Rupture of thetendon requires operative repair in the athlete; usuallythe tendon being sutured to the humerus in thebicipital groove.

The enormous range of movement in the shouldercompared to other joints, and the strong compensatoryadaptations of small muscles to act as ligaments, arevital in athletic activity. Unfortunately a reduction inmobility after injury can be a serious barrier toregaining peak performance. The ubiquity of shoulderdislocations or clavicular fractures should not detractfrom their potential seriousness as far as future sportingactivity is concerned, and shoulder injuries requireprompt and planned therapy to restore mobility, ex-tensibility and power.

* illustration from 'Sports Injuries', D. S Muckle, Oriel Press 1971

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79REFERENCES

1. HAMMOND, G., 'Journ. Bone and Joint Surg.', 44A, p. 494, 1962

2. MUCKLE, D. S., 'Sports Injuries', Oriel Press, 19713. NEVIASER, J. S., 'Journ. Bone and Joint Surg.', 44A, p. 1321, 1962

4. RATHBUN, J. B., MACNAB, I., 'Journ. Bone and Joint Surg.', 52B, p. 540, 1970

5. SYMPOSIUM OF SURGICAL LESIONS OF THE SHOULDER, 'Journ. Bone and Joint Surg.', 44A, p. 977, 1962

6. WATSON-JONES, R., 'Fractures and Joint Injuries', Livingstone, 1955

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doi: 10.1136/bjsm.6.2.77 1972 6: 77-79Br J Sports Med

David S. Muckle

Shoulder injuries in Sport

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