Shoulder Injuries

updated through subacromial bursitis

Sternoclavicular Joint Sprains

MOI: longitudinal force on the clavicle, FOOSH, traction (possible)

S/S: pain with movement

Tx:

anterior separation: treat symptomatically, most will NOT reduce and stay reduced, surgery not needed

posterior separation: EMERGENT, need to reduce immediately before damage to mediastinal vessels occurs

epiphyseal injury: “pseudo dislocation” fx of medial epiphysis, must be ruled out in patients under 25

Acromioclavicular Joint Sprains — rupture of AC or coracoclavicular ligaments

MOI: direct blow to AC joint, FOOSH, overuse

S/S: pain over distal clavicle, AC joint, anterolateral neck, superior scapula and lateral deltoid, deformity

Tx: 6 types of sprains

type 1&2: conservative management, local corticosteroid injections

type 3&higher: surgical and conservative

Conservative Management

-immobilization for pain relief

-local modalities

-ROM exercises

-strengthening

Type 1 AC

-slight or partial damage of AC ligament and capsule

-point tenderness over AC joint

-no laxity or deformity

Type 2 AC

-rupture of AC ligament and partial damage to coracoclavicular ligament

-slight laxity and deformity of AC joint

-slight step deformity

Type 3 AC

-complete tearing of AC and coracoclavicular ligament

-tearing of deltoid and trapezius fascia

-obvious dislocation of distal end of clavicle from the acromion process

Type 4 AC

-complete tearing of the AC and coracoacromial ligaments

-tearing of deltoid and trapezius fascia

-posterior clavicular displacement into insertion of upper fibers of trapezius

Type 5 AC

-complete tearing of AC and coracoclavicular ligaments

-tearing of deltoid trapezius fascia

-displacement of involved clavicle from acromion 100% to 300%

-clavicle posteriorly displaced with stripping away of the deltoid-trapezius aponeurosis

Type 6 AC

-complete tearing of AC and coracoclavicular ligaments

-tearing of deltoid and trapezius fascia

-displacement of clavicle inferiorly under coracoid (possible involvement of brachial plexus)

Anterior Glenohumeral Instability

-laxity of anterior stabilizing structures such as middle GH ligament and anterior band of the inferior GH ligament

-superior and middle GH ligaments and large tears or weakness of the rotator cuff musculature may also contribute to anterior GH instability

MOI: excessive rotation and abduction of the humerus

Complications: bankart lesion and Hill Sachs lesion

Bankart Lesion

inferior GH ligament avulses labrum and part of fossa which may result in fx of glenoid

Hill-Sachs Lesion

small defect in the posterior humeral head’s articular cartilage caused by the impact of the humeral head on the glenoid fossa as the humerus attempts to relocate

Posterior Glenohumeral Instability

MOI: humerus is flexed and internally rotated while a longitudinal posterior force is placed on the humerus

-may occur as a result of accumulated micro trauma such as repeated blows on a forward-flexed arm (blocking during football)

-result from weakness in subscapularis muscle

Complications: reverse hill Sachs lesion

Reverse Hill Sachs Lesion

on the anterior portion of the humeral head after a posterior dislocation

Inferior Glenohumeral Instability

-primary restraint against inferior translation of the GH joint depends on the position of the humerus

(a) neutral - superior GH ligament

(a) abducted to 45 - anterior portion of the inferior GH ligament

(a) abducted to 90 - entire inferior GH ligament

-rotator cuff tears or weakness also increase inferior GH laxity

Multidirectional GH Instability

-combination of two more unidirectional instabilities

-important to differentiate between unidirectional and multidirectional instabilities

Rotator Cuff Tendinitis Stages

1) pain following activity

2) pain during activity

3) constant pain

Rotator Cuff Impingement (stages)

1) edema and hemorrhage

2) repeated inflammation

3) rotator cuff tears, biceps rupture/labrum tear, bony changes (may require surgical repair)

2 Categories of Tendinitis and Impingement

Under 35 (age): most commonly athlete in overhead sport

Over 35 (age): a result of degenerative aging process

Rotator Cuff Impingement

reducing in space below coracoacromial arch (rotator cuff muscles, long head of biceps, subacromial bursa, GH joint capsule, and head of humerus)

-anatomical variation in coracoacromial arch

-fatigue from overuse

-decreased strength of the rotator cuff — possibly due to poor scapular biomechanics

S/S: pain during overhead movements and a painful arc

Rotator Cuff Tendinitis

typically presents with a slow onset of symptoms

MOI: decreased muscle balance between internal and external rotators, capsular laxity, poor scapular control, and impingement syndrome

tendons are poorly vascularized, hinders healing process

-supraspinatus has poorest blood supply

Type I RC Inflammation

acromion is flat

Type II RC Inflammation

acromion process is gently curved with the potential to compress the underlying tissues

Type III RC Inflammation

acromion process is sharply “beaked” or hooked and has a higher potential to cause rotator cuff pathology

Type IV RC Inflammation

acromion process has spurs projecting off its inferior surface and has the highest potential for causing rotator cuff pathology

Internal Impingement

associated with GIRD and anterior instability

S/S: posterior shoulder pain that worsens with activity, loss of control and velocity with throwing

Tx: conservative — improper scapular control, thoracic extension, reduce GIRD, improve GH dynamic control

Rotator Cuff Tears

result from single traumatic force, or more commonly from the accumulation of micro trauma

partial tears: short, longitudinal lesions in the tendon, if they go untreated they can develop full thickness tears

Tx: debridement

complete tears: repair

Subacromial Bursitis

chronic impingement and/or rotator cuff tears, if untreated, can lead to inflammation of the subacromial bursa