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2 – Shoulder Injuries

One of the top ten sporting injuries!

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Introduction

About 20% of sports injuries involve the shoulder. Shoulder injuries are most common in tennis, swimming, weightlifting, baseball, and volleyball — basically, any sport that involves a lot of overhead movement. Most common are

  • ROTATOR CUFF INJURIES
  • SHOULDER IMPINGEMENT 
  • SHOULDER DISLOCATION & INSTABILITY

ROTATOR CUFF INJURIES

Typical symptoms; General shoulder pain that increases with raising your arm or even sleeping on affected shoulder.

Rotator cuff tears in the shoulder are a common issue in any sports that involve throwing, pushing, pulling or lifting. The humerus (upper arm bone) has a rounded head that forms a ball and socket joint with the scapula (or shoulder blade). An analogy would be like a golf ball sitting on a shallow tee, this allows great natural movement with the trade-off being stability.

golf ball on a tee

The rotator cuff solves this dilemma as it makes a network of four muscles whose tendons coalesce to cover the head of the humerus therefore serving to ‘strap the golf ball on the tee’. The rotator cuff muscles consist of the supraspinatous (runs across the top of the head of the humerus) and the subscapularis (runs across the front) and the infrapsinatous and teres minor muscles (run across the back). These muscles are also very important in rotating or lifting your arm.

Rotator-Cuff muscles

 

If you have suffered an injury to your rotator cuff, you may experience pain or weakness when lifting your arm. The pain is usually over the deltoid region (on the outside of your upper arm). Typically rotator cuff injuries may cause difficulty with basic functional tasks like lifting, reaching, or sleeping.

Problems start when one or more of these tendons (most often the supraspinatous) are damaged or torn completely (full thickness tear) and no longer attach to the head of the humerus. Most often this is seen in the dominant shoulder and can be the result of repetitive stress motions seen in sports such as tennis, rowing or cricket or falling on an outstretched arm. Blood supply to the rotator cuff tendons does also diminish with age and this can impair healing. With age we can also develop bony spurs in the shoulder that rub on the rotator cuff tendons and the tendons themselves can also become calcified due to long standing inflammation.

Typical symptoms start with an acute onset of pain particularly on any movement of the shoulder (especially overhead movements). Treatment involves analgesia and ant-inflammatory medications (under advise from your GP), physical therapy and rehabilitation in order to maintain strength and flexibility. Cortisone injections can help reduce pain and inflammation although repeated injections may serve to further weaken the tendon. If the shoulder does not improve and there is a larger or complete tear surgery may be the best option to reattach or repair the tendon

 

SHOULDER IMPINGEMENT

Typical symptoms; General shoulder pain more commonly as we age. Gradual onset, increased pain when active or at rest and sleeping on affected shoulder.

Impingement syndrome occurs in people who engage in physical activities that require repeated overhead arm movements, such as tennis, golf, swimming, weight lifting, or throwing a ball. Occupations that require repeated overhead lifting or work at or above shoulder height are also at risk.

Rotator cuff tendons are protected as they pass into the shoulder by bones (mainly the acromion) and ligaments that form a protective arch. As the tendons pass through the arch there is a protective lubricating sack called a bursa (subaromial bursa) that forms a smooth friction free surface to allow the tendons to slide over one another and avoid rubbing on bony surfaces. The main bone that forms the protective arch (the acromium)  can develop bony spurs as we grow older. This is illustrated in the diagram below. This narrows the space and can rub on either the rotator cuff tendons or bursa resulting in tendinopathy or bursitis. 

Shoulder Impingement (3)

 

SHOULDER DISLOCATION & INSTABILITY

Traumatic dislocations are most common. The shoulder tends to dislocate forwards and down in 96% of cases (this is know as an anterior dislocation and is illustrated below). This is usually associated with a sports related injury in young people or falling with an outstretched arm for older people. Other types of dislocations which are rare are is when the shoulder is displayed backwards (4%) or downwards (one in 200 cases).

dislocation

Some people are also inherently more mobile than others. This occur for various different reasons. Some of us are just naturally hyermobile. In fact there a scoring system based on hypermobility called Beightons Hypermobility Index that uses a 9 point index for joint laxity with 6 points or more being an indicator of hypermobility. In such cases we often see multidirectional instability with the head of the humerus being unstable in all directions and this is obviously allied with a capacity to dislocate. These people are often what we term as ‘double jointed’.

Other people can also have joint laxity because of repetitive overhead movements that are typical in many sports such as cricket, swimming and tennis or in jobs which require regular and repetitive overhead motions. Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Chronic shoulder instability is the persistent inability of these tissues to keep the arm centred in the shoulder socket.

Shoulder instability therefore  is often generally classified into two large groups by orthopaedic surgeons

TUBS stands for

•Traumatic

•Unilateral (one shoulder)

•Bankart and Hill-Sachs Lesions (bony injuries that I will discuss later)

•Surgery

AMBRI stands for

•Atraumatic (no trauma)

•Multidirectional (loose in d different movements)

•Bilateral (both shoulder affected)

•Rehabilitation (generally responds well to rehabilitation)

•Inferior capsular shift (if rehab fails)

This model is quite simplistic and surgeons now often use the Stanmore Triangle which classifies a third group of patients that have reoccurent dislocations because of loss of shoulder integrity.

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