Shoulder Injuries

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Shoulder Injuries
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Anatomy of the Shoulder

• Ball-and-socket joint
• Relies on muscular strength for stability
• Several bones link up at the shoulder
• Entire bony linkage of the shoulder referred to
  as the shoulder girdle

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Bones

• 3 basic bony components
• Humerus
• Clavicle (aka collarbone)
• Scapula (aka shoulder blade)

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Muscles

• Rotator Cuff
• Consists of 4 muscles (SITS)
• Subscapularis
• Infraspinatus
• Teres Minor
• Supraspinatus
• Responsible for rotating the arm internally and
  externally as well as abduction

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Muscles (contd)

• Deltoid-lies over the head of the humerus.
• Abducts, flexes, and extends shoulder
• Anterior portion of shoulder-pectoralis major and
  pectoralis minor
• Biceps-flexes the elbow
• Triceps-extends the forearm and shoulder.

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Joints

• Shoulder girdle composed of several joints
• Most commonly injured joints of the shoulder are
  
• acromioclavicular joint (Acromion process of
  scapula and the distal end of clavicle
• glenohumeral joint (articulation of the head of
  the humerus and the glenoid fossa)
• articulation-point of contact
• glenoid fossa-saucerlike portion of scapula

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What causes most shoulder injuries?

• Muscle weaknesses
• Postural problems
• Nature of the game

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Addressing muscle weakness

• Out of sight, out of mind-weight training
• Athletes often lift weights only for the muscles
  they can see in the mirror which leads to
  weaknesses in opposing muscles
• Athletes with rounded shoulders, tight pecs, or
  weak posterior shoulder muscles may be
  predisposed to injuries.
• Supraspinatus muscle, nerve, and blood vessel run
  through a very narrow space and narrowing that
  space can cause those tissues to become pinched

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Muscle weakness (contd)

• Using arm continually in one direction
• Ex. Freestyle swimming or throwing
• Need to strengthen the muscles opposing the
  motion in order to prevent injuries.
• Otherwise, it creates a muscle imbalance.
• Ex. A swimmer who swims 300 strokes freestyle
  must swim 300 strokes backstroke to balance the
  strength of the muscles.

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Acromioclavicular Ligament Sprain

• Referred to as a shoulder separation
• Can be injured by impact to the top of the
  shoulder or by falling on an outstreched arm
• Athlete will indicate pain with movement
• More serious sprains cause the clavicle to move
  superiorly

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Acromioclavicular Ligament Sprain (contd)

• 3rd degree separation-large abnormal bump caused
  by excessive upward desplacement of clavicle.
• Unable to move arm and will hold it tight against
  body
• Treatment
• 1st degree-PRICE
• 2nd 3rd PRICE initially and then referred to
  an orthopedist.

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Acromioclavicular Ligament Sprain (contd)

• 2 courses of action to treat 3rd degree tear
• Surgery-joint wired or screwed together
• Harness-straps the clavicle downward in an
  attempt to hold the joint together long enough to
  allow the ligament to heal.

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Glenohumeral Ligament Sprain

• Especially vulnerable when in abduction and
  external rotation.
• If a 3rd degree sprain, subluxation or
  dislocation is likely
• Will have pain with motion
• Treated by PRICE and referred to a physician

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Muscle and Tendon Injuries

• Most muscle and tendon injuries are caused by
  overuse
• Athletes who throw, shoot, or repeat a swim
  stroke prone to overuse injuries
• Require rest, ice application, immobilization,
  and physician referrals

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Rotator Cuff Strain

• Occur from excessive motion beyond the normal
  range
• Supraspinatus is most often injured
• Pain with motion and sometimes when shoulder is
  not moving.
• Pain generally occurs with abduction
• If unable to abduct, complete tear or 3rd degree
  strain is suspected

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Impingement Syndrome

• Develops from repetitive overhead types of
  movement
• Supraspinatus and biceps muscles run together
  through a space beneath acromion process
• If space narrows due to swelling, tendinitis,
  weak posterior muscle strength, or poor posture,
  the muscles become impinged in the space
• Creates pain and discomfort with overhead
  movements.
• Treatment-modified activity, strengthening
  posterior muscles, improving flexibility of tight
  pectoralis muscles.

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Bicipital Tendinitis

• Common in athletes who are constantly raising
  their arms above their heads
• Repetitive nature of the movement causes
  irritation of the tendon in bicipital groove
• Immobilization in a sling will make athlete more
  comfortable
• Physician may prescribe ultrasound therapy and
  anti-inflammatory medication.

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Biceps Tendon Rupture

• Can rupture from a direct blow or severe
  contractional forces
• Unable to flex elbow
• Noticeable change in appearance of muscle (look
  like a golf ball under the skin)
• Arm must be iced and immobilized
• Referred to physician
• Tendon must be surgically repaired

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Clavicular Fractures

• Most often fractured at its weakest point (distal
  3rd)
• Caused by a direct blow or fall on the tip of
  shoulder
• Experience pain and will hold arm close to body
  to prevent movement
• Ice used to decrease swelling and pain
• Sling restricts arm movement
• Physician can set the clavicle in place using a
  harness
• Fracture takes 6 weeks to heal

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Humeral Fracture

• Midshaft fractures easy to locate
• Humeral head fractures sometimes hard to find if
  hidden behind shoulder musculature
• Shoulder sprain can mimic a fracture so its
  important to ensure proper assessment.
• Unable to move arm and will experience pain
• May report feeling or hearing a pop
• Will hold arm against body

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Humeral Fracture (contd)

• Easiest way to determine a fracture palpate
  circumference of bone
• Painful on all sides, most likely a fracture
• Physician referral
• Severity determines treatment-could just be a
  sling or surgery with long arm cast
• Takes at least 6 weeks to heal

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Epiphysis Injury

• Growth plate susceptible to direct and indirect
  blows
• Same signs and symptoms as humeral fractures
• Can cause permanent growth impairment
• Ice, splinting, and a sling-what an ATC should do
• Physician will determine severity of injury and
  treatment.

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Epiphysis Injury (contd)

• Some injuries require surgery to hold the head of
  humerus to the shaft of humerus
• Teenage pitchers prone to epiphyseal injury from
  excessive throwing.
• Limited in number of games allowed to play as
  well as number of pitches thrown

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Avulsion Fractures

• May accompany a glenoumeral or acromioclavicular
  sprain
• Ligament or tendon pulls away a small portion of
  bone
• When humerus is dislocating from glenoid fossa,
  capsular ligament can pull on scapula
• Athlete will experience pain associated with the
  dislocation and avulsion fracture
• Impossible to know if avulsion fracture exists
  ATC must assume until X-ray reveals otherwise

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Glenohumeral Dislocations and Subluxations

• Glenohumeral dislocation means that head of
  humerus is out of its socket
• Subluxation means that head of humerus came out
  of socket and then went back in
• Cause for both is the same excessive abduction
  and external rotation.
• Results are completely different
• Both require attention by ATC and team physician

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Glenohumeral Dislocations and Subluxations
(contd)

• Dislocation sometimes causes the humerus head to
  tear the capsular ligament anteriorly
• Instability of capsular ligament allows the
  humerus head to shift forward (most common type
  of shoulder dislocation)
• Experience pain and inability to use shoulder
• ATC will see a deformity at deltoid muscle
• Shoulder will be flat, not round
• Physician needs to reduce a dislocation

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Glenohumeral Dislocations and Subluxations
(contd)

• For a subluxation, athlete may feel his shoulder
  pop out and then pop back in
• X-ray necessary to determine extent of the
  dislocation or subluxation
• Athlete needs to strengthen the muscles of
  adduction and internal rotation
• If athlete experiences recurrent subluxations or
  dislocations will require surgery to repair
  capsular ligaments.