Athletic injuries POST midterm

3 questions for the on field assessment

• is the athlete at risk of life or limb

• is the area stable

• how do i get them off the court

Stinger burner injury

• nerve traction or compression involving C5/C6

Stinger/Burner mechanisms

• shoulder distracted down from head and neck

• blow to supraclavicular fossa

• forced neck extension and rotation to injured side

Signs/Symptoms of stinger/burner

• not true neck pain

• unilateral symptoms

• may be transient

• sensory and motor changes c5/6

• heals quickly

motor changes C5/6

shoulder abd/er

elbow flexion

C-spine mechanisms

• Axial load-vertical compression

• compression-flexion injury

axial-load vertical compression

burst fracture

compression-flexion injury

anterior portion compresses, and posterior portion elongates

on feild findings for c-spine injury

• neck pain

• pain on central palpation

• bilateral neural findings

• upper and lower extremity findings

• +ve canadian c-spine rules

Glenohumeral ROM causes the clavicle

to move check slides or something

The AC

Articulation between the distal clavicle and scapula

• adults in 20s more often men

Support at the AC joint

• Acromioclavicular ligaments

• capsule

• coracoclavicular ligament

Acromioclavicular ligaments

• superior, inferior, anterior posterior

coracoclavicular ligaments

• superior - conoid

• compression - trapezoid

Dynamic stabilizers of the shoulder

• serratus anterior, deltoid and trap muscles

SA + traps

• force couple

• stabilizes the AC via the scapula

fasical support ac

fibers from superior ac LIG BLEND WITH THE FASCIA OF THE TRAPS AND DELTOID MUSCLES

• stability to the jt with contraction and stretching

Direct AC injury

• land on contact point of shoulder with arm adducted

• most common

indirect AC injury

• indirect

• less common

• FOOSH

Clinical tests for AC seperation

• cross flexion

• scarf test

• obriens

• paxion’s sign

if paxions sign is positive

obriens

if paxion’s sign is negative

hawkin-kennedy and int rot

Rockwood classification grade 1

Rockwood classification grade 2

Rockwood classification grade 3

Rockwood classification grade 4

Rockwood classification grade 5

Rockwood classification grade 6

facts on the SC joint

• clavicle articulates with manubrium to form the SC joint

• stability comes from strong ligament attachment

• can move freely fwd, back and rotate

MOI for SC injury direct

blow to clavicle

indirect sc

through arm and shoulder

posterior sc

dangerous

• may copress the trachea or esophagus

• dyspnea, choking, difficulty swallowing, tight throat

• shock/pneumothorax

Management grade one ac

• clinically stable

• play asap

• get out of sling

• tape for comfort

• goal: keep moving

• cyrokinetics

• function test

G2 AC management

inflammatory phase

• police/peace and love

• tape

Repair

• gentle arom, aarom, full rom

• scap strengthening

• shoulder iso

Remodelling

full strength at shoulder

good scapulothoracic mech.

return to play criteria

goal for cyrokinetics

numb area to the poitn of analgesia and work thorugh rom

how does cyrokinetics work

speeds recovery by enabling patients to do pain-free mobilization sooner than normal

return to play AC

1- 0-10 days

2 -2-3 weeks

c3 4-12 weeks

g4/6- surgical

return to play criteria ac

• medical clearance

• full rom

• good functional strength

• protect themselves

• protect the joint

Clavicle function

• s-shaped bone

• protects neurovascular bundle, muscle and bony attachment

• common

MOI clavice injury

• force bringing shoulder to the midline (fall on pt of shoulder, FOOSH)

• Direct force from superior/anterior direction

Clavicle injury signs and symptoms

• middle 1/3, outer fragment dropping down

• pain +++++

• tenderness/swelling

• loss of fx, spasm of traps/scm/arm held to the body with the shoulder elevated

clavicle injury management first aid

• police/peacelove

• tube sling

• xray

management clavicle long term

• figure 8 brace

• 4-6 weeks healing

• shoulder ROM as tolerated

• strengthen once cleared

• fx test

Glenohumeral joint structure

• allows for great mobility fue to articular surfaces with minimal bony congruity

• musculature and ligaments/capsule maintaion ICOM

ICOM

• bony structures keep articulation in contact

• rotator cuff muscles compress and centralize humeral head

• scapula helps position for max stability

Shoulder support — post and superiorly

• spine of scapular and acromion

• thick capsule

• RC muscles crossing posterior joint

Anterior shoulder support

• minimal bony support

• Biceps

• Joint capsule and ligaments

Bony Support of GH joint

• labrum deepends socket

• scapula rotates under to support the humerus

Static stabilizers of shoulder

• capsule has thickenings (superior, inferior, middle ligaments)

• in abduction and er the AIGHL rotates anteriorly and superiorly to prevent subluxation of the shoulder

Anterior shoulder dislocation MOI

• 95%

• Forced ER — Adducted or FOOSH

Anterior shoulder dislocation Signs/Symptoms

• arm held sligtly er and abducted

• restricted rom

• altered contour of shoulder

Bankart Lesion

Damage to anterior labrum with anterior dislocation

3-6:00

Bony Bankart

with fracture of the anterior gleniod rim

Hill Sachs

• compression fracture of the humeral head

• Posterlateral aspect of the humeral head with traumatic anterior instability

Reverse Hill sachs

• post dislocation

• can be seen on the xray

First Aid — anterior dislocation

• gently reduce if you’res ure there is no fracture

• Stimson Technique

• following any dislocations: test for ability to abduct the arm (nerve damage)

• check pulse and sensation

Tests for anterior shoulder dislocation

• Apprehension test

• fowler reduction/relocation (feels better = positive sign)

Surgical intervention in traumatic Anterior Dislocation

• early surgical repair in younger patients decreases recurrance rate

• 40+ manage non op

throwing — goal

• forces and kinetic energy from the feet to the upper arm

poor mechanism of the wind up and acceleration

upper extremity injuries

Preparation/Wind-up steps (80%)

1. Hip and shoulder turn 90 degrees to targer

2. weight transferred from both legs to end up in a balanced single leg stance on the rear leg

3. lower body generates forces for forward “controlled fall”

4. shoulder muscles relativley inactive

Cocking phase (stage 2)

• hands apart to EOR external rotation

• positions the body to allow all segments to contribute to propulsion

• shoulder abduction via horizontal extension and max er = loaded tight ant capsule

• Max elastic energy 2 degrees to strain on static restraint

Acceleration of throwing

• arm moves forward

• energy releases from static restraings

• subscap, pec major, lat dorsi achieve max activity during acceleration — internally rotating the humerus

• RC stab hum head

• Biceps contracts to oppose valgus + hyperextension at elbow (leading to extreme tendion on sup labrum)

• ball release

greatest forces and angular velcoities in throwing happen when

• during the transition from late cocking to early acceleration

• Highest risk injury

fatigue during acceleration

• decrease coordination and anterior wall support

• increases valgus at elbow

Deceleration in throwing phase

• high force pulls forward on GH joint as elbow extends

• helped by forward rotation of the body

• intrinsic/extrinsic msk fires near max (post capsule and RC contraction prevents anterior humeral translation + eccenteric pull by RC and scap stabilizers)

• large stress on elbow flexors

Dynamic stabilizers of the RC

Subscapularis

Supraspinatus

Infraspinatus

Teres minor

dynamic stabilizers, what do they do?

• humeral head rotators ,position the UE

• humeral head decompressors impact stability thorugh concavity-compression

• humeral head steerers (activley control fulcrum of GH joint during motion

Force couples and scapulohumeral rhythym

Minor RC injury MOI

acute overload or fall and/or twinge in shoulder

initial presentation of mild RC

• limitation in fx

• STTT findings

• graded 1-3

mild RC injuries are

reversible and respond quickly to rehab and rest

mild RC injuries in the overhead arise from

a progressiond evelopment of pathology from mild RC strain tendinosis to partial-full thickness rc tear

Red Flags of Acute Rotator cuff tear

• recent trauma

• pain in the shoulder/lateral aspect of arm

• inability to raise arm in abduction above shoulder level

Chronic RC injuires primarily due to

repetitive microtrauma

Chronic RC injuires signs/symptoms

uncommon in younger athletes

• slow onset

• shoulder pain during activity above shoulder

• inability to sleep on shoulder

• +ve impingement signs, tendinosis

• progress to full thickness tear

Types of Shoulder Impingement

External

• primary

• secondary

Internal

Primary impingement

• external

• caused by abnormalities of the superior structures, leading to encroachment of subacromial space

anatomy of primary impingement

• underside of acromion may be flat/curved/hooked/beaked

• congenital deformity or secondary to osteophyte formation

• decreased SA space due to outlet obstruction

Secondary External impingement types

1. Encroachment into the subacromial space from above as a result of excessive angulation of acromion due to poor muscular stabilization of the scapula

2. excessive elevation of the humeral head as a result of musculature imbalance

1. Encroachment into the subacromial space from above as a result of excessive angulation of acromion due to poor muscular stabilization of the scapula occurs due to

• breakdown of scapular force couples **

• weak inferior and medial musculature fail to limit protraction and anterior rotation

• exacerbated by tightness of pec min weakness of inferior and med traps

1. excessive elevation of the humeral head as a result of musculature imbalance

impingement occurs

• mismatch between the humeral head elevator (deltoid) and stabilizers (RC)

• leads to humeral head butting up against undersurface of rc tendion

• ***: Breakdown of a superior/inferior humeral head force couple

Muscular imbalance due to excessive elevation of the humeral head as a result of musculature imbalance impingement

• deltoid cannot initiate abduction because line of pull is paralell to humerus

• supraspinatus can initiate abduction as it is perpendicular

• once started, deltoid has a strong superior pull on the humerus within the glenoid

If Acute RC tear symptoms persist 2 wks past injury

patient should be referred to shoulder clinical with soft tissue imaging

Supraspinatus impingement

• superior translation of the humeral head pinches the supraspinatus or sub-acromial bursa

Supraspinatus impingement muscles

• superior translation of the humeral head is balanced by inferior pull of RC muscles

• weakness of these muscles reduces the effectiveness of centralization of the humeral head

Supraspinatus impingement test

painful arc from 60-120

Internal Impingement occurs

in overhead athletes during late cocking phase

what is internal impingement

• impingement of the undersurface of the RC against posterior/superior glenoid

• result of hyperlaxity in anterior directionIm

Impingement causing RC tendinits/tendionpathy symptoms

• diffuse pain around acromion and over deltoid or posteriorly (internal)

• overhead activities increase pain

• ok below 90degrees

Impingement causing RC tendinits/tendionpathy signs—observation

• Posture

• humeral head displaced anteriorly and superiorly

• scapula anteriorly rotated and/or protracted

Impingement causing RC tendinits/tendionpathy signs—AROM

• painful arc

• ok below 60-70

• poor scapulohumeral rhythym

Impingement causing RC tendinitis/tendinopathy signs—manual muscle testing

• strong +++ internal rotation

• weak external rotators

• anterior humeral head

• weak/poor timing of scapular stabilizers/movers

Impingement causing RC tendinits/tendionpathy signs—GH stability-

• laxity of anterior structures

• tight posterior structures

Impingement causing RC tendinits/tendionpathy special tests

• Hawkins-kennedy

• neers

• apprehension

internal impingement is a breakdown of

anterior/posterior force couple

Bottom line — primary external

• Outlet obstruction issue, due to anatomy

Bottom line — Secondary external

• stability issue

• scapular/humeral head

Bottom line — Internal impingement

• combination of anterior instability and repetitive microtrauma

Hawkins—Kennedy

• Positive test: pain in the subacrom area indicates impingement of supraspinatus

• movement pinches supraspinatus tendon between greater tubercle and acromion/coracoacromial ligament