athletic injuries post midterm

on-field assessment first priority

primary assessment, assess life (ABC) and limb

on-field assessment step 1

immediately block head/neck, stabilize c-spine

on-field assessment step 2

subjective history: MOI, pain level, location of pain, numbness or tingling of extremities (specifics)

on-field assessment step 3

dermatome/myotome testing: move fingers and toes, feel fingers and toes (unilateral or bilateral), to what level

on-field assessment step 4

palpate cervical spinous processes, look for pain

on-field assessment step 5

rotate neck 45 degrees to each side

stinger/burner injury

nerve traction or compression involving C5 and C6 (brachial plexus)

stinger/burner MOI

shoulder distracted down from head and neck, blow to supraclavicular fossa, forced neck extension and rotation to injured side (pinched root)

stinger/burner signs/symptoms

rarely neck pain - unilateral symptoms, may be transient and heal quickly, sensory changes to C5-C6 distribution, motor changes from C5-C6 (shoulder ABD/ER, elbow flexion, wrist ext)

c-spine injury MOI

axial load-vertical compression (Burst fracture), compression-flexion (anterior compression, posterior elongation)

c-spine injury on-field findings

neck pain, pain on spinous process palpation, bilateral neural findings (dermatomes, myotomes), upper and lower extremity findings, +ve Canadian c-spine rules

articulations of the shoulder complex

glenohumeral (GH) joint, acromioclavicular (AC) joint, sternoclavicular (SC) joint, scapulothoracic joint

on-filed assessment after spinal injury cleared

palpate spine of scapula, tip of acromion, AC joint, coracoid process (1 inch down and in from joint), deltopectoral space (full = anterior/inferior dislocation), along clavicle and pull middle 1/3 (fracture), supraclavicular fossa, SC joint (1 inch over and down - CC ligament)

sideline or clinical assessment (same)

subjective history, objective tests (observation, active, passive resisted movement, special tests, neuro, palpation), assessment (problem list, impression), plan (immediate first aid or rehab)

GH joint flexion/extension normal ROM

flexion 0-180 degrees, extension 0-50 degrees

GH joint abduction normal ROM

0-180 degrees

GH joint ER/IR normal ROM

both 0-90 degrees

clavicle movement with GH ROM

clavicle retracts, elevates, and moves posteriorly as GH joint moves through flexion and abduction

acromioclavicular (AC) joint injuries

damaged in 1/10 of shoulder girdle injuries, more common in adults in their 20s and in males than females

sternoclavicular (SC) joint injuries

very rare, occur in young and active males (high energy MOI)

AC joint static stabilizers

acromioclavicular (AC) ligaments and coracoclavicular (CC) ligaments

acromioclavicular (AC) ligaments

anterior-posterior (AP) stability, 4 bundles (superior, inferior, anterior, posterior), interact with capsule

coracoclavicular (CC) ligaments

vertical stability - conoid (superior) and trapezoid (compression)

AC joint dynamic stabilizers

serratus anterior, deltoid, trapezius: trapezius and SA force-couple to stabilize the joint, AC ligament connects with the trapezius and deltoid fascia to stabilize during stretch

AC joint injury MOI

direct MOI - land on or contact to the shoulder point with arm adducted (most common), indirect - fall on out-stretched hand puts force through the arm (less common)

Rockwood classification of AC injuries

types 1-6: 1-3 are non-surgical in Canada

type 1 AC injury

AC ligament damaged, CC intact, tender but no anatomic changes, full abduction AROM with pain at end range

type 2 AC injury

AC ligament torn, CC ligament damaged, unstable AC joint with direct stress, abduction AROM 45-90 degrees

type 3 AC injury

AC and CC ligaments torn, raised clavicle with depressed acromion (step deformity), abduction AROM less than 45 degrees

type 4 AC injury

AC and CC ligaments torn, posterior clavicle, possible tented trapezius

type 5 AC injury

AC and CC ligaments torn, step deformity + trapezial and deltoid fascia stripped off

type 6 AC injury

AC and CC ligaments torn, downward displacement of clavicle (emergency, brachial plexus)

AC joint test cluster

Paxino’s sign, O’Brien’s test (if Paxino +), Hawkins-Kennedy IR test (if Paxino -)

AC joint low grade management (grade 1, low grade 2)

grade 1 - clinically stable, can return when pain/function permits, remove sling, tape for comfort, goals - keep shoulder moving and regain function ASAP for RTP (can work through some pain, use cryokinetics, pass function test prior to return

goal of cryokinetics

numb injured area to analgesia and work through ROM and gentle functional activities, speeds recovery process by enabling pain-free controlled mobilization earlier

cryokinetics process

using water frozen in a styrofoam cup, rub until numb (7-10 mins, N stage of CBAN), exercise through range beginning with AROM and working to gentle functional exercises, re-numb as needed (for 5 mins every 3-5 mins)

AC joint grade 2-3 management - inflammation phase

POLICE/P&L, stabilize with tape (reproduce function)

AC joint grade 2-3 management - repair phase

gentle AROM or AAROM progressing to full ROM, strengthen scapular stabilizers (rhomboids, traps, SA), start with shoulder isometrics and progress to concentric (deltoid and RC)

AC joint grade 2-3 management - remodelling phase

full strength at shoulder, good scapulothoracic mechanics, full function as per RTP criteria

estimated return time for AC joint injuries

0-10 days for grade 1, 2-3 weeks for grade 2, 4-12 weeks for grade 3, surgery for grade 4-6

criteria to RTP after AC joint injury

medical clearance, full ROM, good functional strength, able to protect themselves, protect joint using donut pad (distribute force)

clavicle function

protects neurovascular bundle, muscle attachments, bony attachment of shoulder

clavicle fracture MOI

one of the most common fractures in sports - any force that brings shoulder to midline (fall on point of shoulder, fall on outstretched arm), direct force from superior or anterior direction

clavicle fracture signs and symptoms

middle 1/3 broken with outer fragment dropped down, pain on palpation and pull, localized tenderness and swelling, may have loss of function, trapezius and/or SCM spasm, arm held to body with shoulder elevated

clavicle fracture immediate first aid

POLIce/PEACE&LOVE, tube/B sling, send for x-rays

clavicle fracture continued management

figure 8 brace for pain relief, shoulder ROM as tolerated (arm movement below 90 degrees), strengthen arm once cleared, usually heals in 4-6 weeks (shortening and bump remains), functional test prior to RTP

sternoclavicular (SC) joint anatomy

only 25% of clavicle surface area in contact with manubrium (least bony stability in the chain), integrity from strong ligament attachment (costoclavicular, sternoclavicular, and interclavicular), shock absorbing disc between bones, clavicle moves forward, back, up, and rotates

SC joint injury MOI

MVA and sports most common, direct blow to clavicle, or indirect injury through arm or shoulder (more common), clavicle usually moves superior or anterior

SC joint most dangerous injury/MOI

clavicle moves posteriorly - send to ER, may compress trachea or esophagus, severe cases - causes shock or pneumothorax

SC joint injury management

if anterior, reduce with lateral traction, for anterior and superior - ice and immobilize, figure 8 brace, taping possibly, high-incidence of reinjury

glenohumeral (GH) joint

ICOM of the GH joint - bony structures maintain articulation, rotator cuff muscles compress and centralize the humeral head, scapular stabilizers position scapula for max stability

posterior and superior shoulder support

spine of scapula and acromion, thick capsule, RC muscles cross posterior joint

anterior shoulder support

minimal bony support - biceps, joint capsule, and ligaments

GH joint bony support

labrum deepens glenoid socket to better fit large head, scapula most coordinate rotation with humeral movement

GH joint static stabilizers

ligaments are thickenings of the shoulder joint capsule - superior (SGHL), middle (MGHL) and inferior (IGHL) - rotate with movement, with abduction and ER the IGHL fans out and rotates anterior/superior to prevent subluxation

anterior dislocation MOI

most common (95% of dislocations), forced ER usually abducted or FOOSH

anterior dislocation signs and symptoms

arm held slightly externally rotated and abducted, restricted ROM, altered shoulder contour

Bankart lesions

damage to the anterior labrum occurs in 8/10 anterior dislocations, usually from 3 o’clock - 6 o’clock, Bony Bankart lesion - anterior glenoid rim fracture (very unstable)

Hill-Sachs lesion

compression fracture of humeral head (posterolateral) occurs in 8/10 anterior dislocations, reverse Hill-Sachs (anterior notch) occurs in posterior dislocations, can be seen on x-ray

posterior dislocation MOI

rare (4%), often from seizure or electric shock, force on hand through arm while arm in flexion and adduction

posterior dislocation signs and symptoms

elbow held at side with hand on stomach, can’t ER or abduct, easily missed on x-ray (majority are)

inferior dislocations

very rare (1%), force through arm while arm is in excessive abduction, similar s/s as anterior dislocation

immediate first aid for anterior dislocations

gently reduce if SURE there is no fracture, Stimson technique with scapular manipulation, check pulses and sensation and test for ability to abduct arm (following any dislocation, axillary nerve check)

Stimson technique with scapular manipulation

lay prone on bed with arm hanging off.down at 90 degrees (can hold weight), add scapular manipulation technique (SMT) - rotate inferior angle medially while rotating superior aspect laterally (high success rate)

apprehension test for anterior instability

elbow and shoulder at 90 degrees, bring to max ER, positive signs = tell you to stop, roll body towards arm, fight movement, pull arm to body

fowler reduction/relocation test for anterior or inferior instability

shoulder and elbow at 90 degrees, superior pressure on GH should centralize the humeral health and take pressure off the anterior/inferior capsule, positive sign = feels better/greater ROM

traumatic anterior dislocations evidence for surgical vs. non-surgical

early surgical repair in young patients (15-25) reduces recurrence rate, non-operative management in those 25-40 and 40+ due to lower re-dislocation rate,

traumatic anterior dislocation research recommended management

immobilize in 10 degrees ER = significantly lower recurrence rate compared to an IR matched group - takes pressure off injured labrum

shoulder dislocation general rehab - inflammatory phase

POLICE/P&L (protect from ER), sling for younger patients, gentle exercise in pain free ROM (avoid ABD/ER for anterior), isometric strengthening of RC and scapular stabilizers, scapula setting exercise, maintain elbow and wrist movement

shoulder dislocation general rehab - repair phase

slowly regain ROM to shoulder height (avoid combined ABD/ER), functional strength training of scapular stabilizers through ROM, proprioception and stabilization exercises (closed chain first), strengthen RC muscles starting from neutral to scapula plane to 90/90 position

shoulder dislocation general rehab - remodelling phase

achieve full ROM, stabilize and strengthen through full ROM, set goals and progress based on functional strength, power, agility, etc. needed for RTP

preparation/wind-up phase of throwing (80%)

establish rhythm, hip and shoulders turn 90 degrees to target, weight transferred from both legs to balance on single stance rear leg, lower body generates forces forward (“controlled fall”), shoulder muscles relatively inactive

cocking phase of throwing (part of preparation)

hands spread apart to EOR ER, body position allows propulsion contribution from all segments, shoulder abducts (horizontal extension, max ER), shoulder loaded with anterior capsule taught (AIGHL), max elastic energy secondary to strain on static restraints

acceleration phase of throwing (2%) - timing

begins when arm moves forward, explosive release of elastic energy from passive restraints, concludes with ball release at ear level

acceleration phase of throwing - muscle function

maximal activity from the subscapularis, pectoralis major, and latissimus dorsi to IR the humerus; RC maintains humeral head in position, biceps contract to oppose valgus stress and elbow hyperextension (tension on superior labrum)

acceleration phase of throwing - injury risk

high velocity switch from ER to IR = highest risk of injury during transition from late cocking to early acceleration, fatigue = decreased coordination and anterior wall support

deceleration/follow-through phase of throwing (18%)

remainder of momentum, forward rotation of body, near max firing of intrinsic and extrinsic shoulder muscles, posterior capsule and RC muscles prevent excessive anterior humeral translation (eccentric pull)

deceleration/follow-through phase - injury risk

high forward force on GH joint as elbow extends, large stress on elbow flexors

general sources of shoulder pain

chronic joint instability, rotator cuff lesions, glenohumeral impingement

shoulder dynamic stabilizers

rotator cuff muscles - subscapularis, supraspinatus, infraspinatus, teres minor

rotator cuff functions

humeral head rotators - position upper extremity, humeral head depressors - stability through concavity/compression, humeral head steerers - control GH joint fulcrum during movement

force-coupling at the GH joint

anterior/posterior: subscapularis = infraspinatus + teres minor; superior/inferior: deltoid = SS + TM + IF + SubS

scapulohumeral rhythm

scapula doesn’t move first 30 degrees (stable base), then moves with the humerus at a 2:1 ratio

scapulothoracic force couple

0-90 degrees of shoulder abduction: upper fibres of traps and SA, 90+ degrees: lower fibres of traps and SA

mild rotator cuff injury MOI

acute overload or fall, minor strain or contusion, tendinitis

mild rotator cuff injury pathology/course

progressive development from mild RC strain to RC tendinosis, to partial-thickness tear, to full-thickness; mild injuries are reversible and respond to rest and rehab

acute rotator cuff tear red flags

recent trauma, pain from the shoulder and/or lateral aspect of arm, inability to abduct arm above shoulder level (not limited by pain is worse); imaging if problems persist 2 weeks post-injury

chronic rotator cuff injuries facts

repetitive microtrauma, uncommon in younger athletes, slow onset, shoulder pain during activity above shoulder, inability to sleep on shoulder, +ve impingement signs (tendinosis), may progress to full thickness tear

shoulder impingements

either external (primary or secondary), or internal; up to 9 specific diagnoses associated

primary external impingement

abnormalities of superior structures enter the subacromial space, obstruction decreases available room - anatomy issue

primary external impingement anatomy

inferior acromion may be too flat, hooked, or curved; either congenital abnormalities or secondary to osteophyte formation

secondary external impingement

stability issue (of the scapular and/or humeral head), more common in younger athletes

secondary external impingement 1st cause

inferior and medial scapular stabilizing muscles fail to limit protraction and anterior rotation, subacromial space is blocked superiorly due by excessive acromion angle; exacerbated by tight pectoralis minor and weak mid/inferior trapezius

secondary external impingement 2nd cause

mismatch between humeral head elevators (deltoids) and stabilizers (RC) leads to humeral head excessive elevation against RC tendon

supraspinatus impingement

superior translation of humeral head balanced by inferior pull of RC muscles, weak muscles = humeral head is pulled too far and pinches the supraspinatus or sub-acromial bursa; painful arc from 60-120 degrees

internal impingement

mainly in overhead athletes during the late cocking phase; hyper-laxity in the anterior direction = RC inferior surface impinged against the posterior/superior glenoid; combination of anterior instability and repetitive microtrauma

impingement causing RC tendinopathy - symptoms

diffuse pain around acromion and over deltoid (or posteriorly/internal), overhead activities increase pain, below 90 degrees is ok

impingement causing RC tendinopathy - signs

posture - anterior humeral head, scapula anteriorly rotated/protracted; AROM - painful arc, poor scapulohumeral rhythm; MMT - strong internal rotators, weak external, weak/poor timing of stabilizers; GH stability - lax anterior structures, tight posterior strucures; special tests - Hawkins Kennedy, Neer, apprehension

Hawkins-Kennedy impingement test

passively flex shoulder and elbow across to the mid-clavicular line, support medial elbow with hand, slowly IR the humerus (pinches supraspinatus tendon between greater tubercle and acromion or coracoacromial ligament); positive = pain in subacromial area or lateral shoulder, limited IR is not positive (tight capsule or humeral ERs, self-inhibition)

Neer impingement sign

sit athlete, stabilize scapula, medially rotated arm in ~ 10 degrees adduction and passively elevate (shoulder flexion = greater tuberosity jammed against anteroinferior acromial surface); positive = pain in subacromial area or lateral shoulder = impinged supraspinatus or biceps long head