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Shoulder Injury: A Surgical Perspective


An orthopedic surgeon explains why shoulders go wrong and what can be done to repair them. Shoulder chiropractor, Dr. Alexander Jimenez gets into the discussion.

The shoulder joint is frequently injured in the throwing athlete since it has a greater range of movement than any other joint in the body, and because its stability is dependent upon complete muscles and ligaments rather than supporting bone structures.

Phases Of Throwing

The five phases of throwing are wind-up, cocking, acceleration, deceleration and follow-through. The forces generated during those phases are significant and the subsequent pressures generated around the shoulder joint make it more likely to severe and chronic inflammatory conditions and injuries. A poor throwing technique will exacerbate the possibility of chronic inflammatory shoulder conditions.

A fantastic throwing technique requires the athlete to use his body weight as well as the big muscle groups of the legs, back and trunk to generate kinetic energy across the shoulder in the path of the thrown object. After the object is thrown, then the retained energy in the throwing arm has to be dissipated back to the large muscles which then absorb it. Poor mechanics throughout the wind-up and cocking stages require the shoulder muscles to generate extra energy to propel the object being thrown. This also contributes to exhaustion of the shoulder muscles, and can ultimately result in injuries.

When the object is thrown, a poor follow-through will lead to excess energy being retained in the delicate tissues of the shoulder, rather than returning to be consumed by the large muscles described previously, causing local tissue damage. Dynamic electromyographic analysis has substantiated a lot of the theory(2,3,4).

Simple Anatomy & Biomechanics

The shoulder (glenohumeral) joint is a ball (the humeral head) and socket (the glenoid fossa of the scapula) joint that's supported by the glenohumeral ligaments and labrum. The glenohumeral ligaments (inferior, middle and superior) are different capsular thickenings that restrict excessive rotation and translation of the humeral head. From the overhead throwing athlete, the more inferior glenohumeral ligament is the key anterior stabilizer when the arm is abducted beyond 90 degrees and externally rotated. The labrum is a thickening surrounding the glenoid which functions to deepen the glenoid cavity (the socket).

The shoulder is stabilized by both static and dynamic restraints. Static restraints include the articular anatomy, the labrum, the glenohumeral ligaments as well as also the negative pressure inside the joint. Dynamic restraints incorporate joint compression and also the steering effect of the rotator-cuff muscles (the very important small muscles around the shoulder).

The rotator-cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. The subscapularis is an internal rotator of the glenohumeral joint, whereas the infraspinatus and teres minor muscles are outside rotators. The rotator cuff as a whole functions to center the humeral head in the glenoid for stability and to allow maximal leverage during shoulder movements.

Shoulder Injuries In The Throwing Athlete

One of those dynamic or static restraint mechanisms could possibly be ruined by the throwing actions of this athlete, and there's a considerable overlap of injuries. Furthermore, an untreated or unrecognized injury may progress to additional injuries within the shoulder.

Common acute overuse injuries include rotator-cuff tendinitis and biceps tendinitis. Common chronic accidents include impingement syndrome, rotator-cuff tears, glenoid- labrum tears and shoulder instability.

The athlete will usually complain of anterior shoulder pain that is worst when trying to increase the speed or power of their throw.

Primary Instability & Secondary Impingement

Most athletes with anterior shoulder pain have favorable impingement signs and before a couple of years ago it was considered that they all had primary impingement. They subsequently underwent anterior acromioplasty (removal of the anterior part of the acromion process -- the acromion is a bony plate which juts up from the shoulder blade to supply a sort of protective roof over the shoulder joint) using rotator-cuff repair as necessary and the results of surgery proved to be inconsistent(5). It's currently known that symptomatic throwing athletes frequently have a primary instability of the shoulder with secondary impingement(6,7). Anterior acromioplasty with excision of the coracoacromial ligament in these people may actually raise shoulder instability and magnify symptoms.

Anterior instability can develop after a high-energy injury but in the throwing athlete it starts as an overuse injury. Chronic overuse can stretch the static stabilizers of the shoulder, resulting in instability. The scapular and rotator-cuff muscles act out of synchrony with each other placing an increased strain on the rotator cuff to maintain the head of the humerus at the center of the glenoid. As the rotator-cuff muscles weaken, the head subluxes anteriorly (moves forward) when the arm is abducted and externally rotated. This lateral subluxation causes a secondary impingement (compressing against) of the rotator cuff on the acromion and the coracoacromial ligaments, causing pain.

Clinical Examination

Active and passive array of motion, shoulder strength and regions of tenderness ought to be elicited. Most athletes with shoulder pain have favorable impingement signs. Pain during forward flexion while the examiner stabilizes the scapula is the principal impingement sign. Pain during active abduction of this internally rotated arm is your secondary impingement sign.

Examination of shoulder stability is significant and also the signals may be subtle. The apprehension test may be utilized to detect anterior instability and entails abduction of the shoulder to approximately 90 degrees followed by external rotation. As the outside rotation is increased, the athlete with anterior instability will feel as though the shoulder will 'pop out' or sublux forward. He/she will attempt to guard against further external rotation and eventually become very apprehensive.

The movement evaluation is done in a similar manner with the patient lying supine (on his/her back) and applying lateral pressure into the posterior aspect of the humeral head when abducting and externally rotating the arm. When there's anterior instability, this may be painful, but by employing a posteriorly directed force into the humeral head, the pain will ease because the humeral head is put in the anatomic position.

The existence of posterior capsular stimulation may be modulated by the presence of decreased internal rotation of the shoulder.

Imaging

Recent studies suggest that MRI is superior to ultrasound and CT scanning in assessing shoulder pain caused by rotator-cuff tears, subacromial impingement and osteoarthritis of the glenohumeral and acromioclavicular joints(8,9,10). Ultrasound evaluation in the hands of a good musculoskeletal radiologist is much cheaper, however, and allows dynamic evaluation. With a good history and evaluation, however, such imaging might not be required from the great majority of instances.

Plain radiographs should be taken to exclude bony pathology such as fractures, calcific tendinitis, metastatic disease and osteoarthritis. Axillary views may demonstrate signs of instability, namely spurring or erosion of the anterior glenoid or even a Hill-Sachs lesion (osteochondral depression on the anterior humeral head brought on by impaction of the dislocated humeral head on the glenoid rim).

Other Diagnostic Tools

Selective local anesthetic shots can help pinpoint the painful area in the shoulder.

Diagnostic arthroscopy allows excellent visualization of the glenohumeral joint and the subacromial space with little soft- tissue destruction and brief rehab period. Whilst the individual is anesthetised, the existence, level and management of this shoulder instability might be evaluated(11). Of course, it is likely to proceed to fix or fix many of the pathological conditions in the shoulder arthroscopically.

Non-Operative Treatment

The mainstay of initial treatment for primary instability and secondary impingement is non-operative(12). A huge analysis of non-operative management for subacromial impingement syndrome demonstrated that non steroidal anti inflammatory drugs with specific rehabilitation programs gave sufficient results in 67% from 616 patients and that just 28% needed a subacromial decompression(13). There ought to be a period of 'comparative remainder' where overhead activity is avoided(14).

An individualized chiropractic program should then be initiated. Stretching of tight muscle groups whilst avoiding stretching the anterior muscles and capsule in a patient with anterior instability should be followed by strengthening exercises for the scapular rotators and rotator-cuff muscles. This should last for six to 12 months under supervision. If now it's still not possible due to pain, a surgical procedure to address the problem with the anterior capsule and labrum should be sought. Athletes with recorded rotator-cuff tears, labral lesions or loose bodies should have these lesions repaired or debrided.

Operative Treatment

The athlete with chronic shoulder instability whose ligaments are excruciating, resulting in capsular laxity, must have a surgical alteration to the ligament tension in order to restore ligament equilibrium if non-operative measures have failed. Such processes are termed capsulorrhaphies or capsular changes (that they efficiently demand a tightening of the capsule to stop unwanted movement). The adjustment is made medially, inferiorly or laterally in the capsule(15,16). Other processes are described but are contentious as they work by limiting the selection of motion so that the end-range laxity isn't challenged. That is obviously not ideal for the athlete. Recent work has been printed on laser-assisted capsulorrhaphy(17) andthermal-assisted capsular shrinkage (18) --that the jury is still out on those techniques.

Primary or secondary impingement could be surgically treated by open or arthroscopic acromioplasty. Care has to be taken to avoid elimination of the lateral acromion, to stop deltoid detachment and to eliminate just enough bone. The aim is that by removing the source of mechanical abrasion of the supraspinatus tendon of the rotator cuff, progression of impingement to partial and full thickness tears will probably be ceased. But, inadequate vasculature, tendon nutrition, established fibrosis and makeup changes in the tendon imply that the practice of degenerative disease and cuff tearing continues despite relief of painful symptoms(19).

The anticipated outcome after acromioplasty for impingement syndrome, whether performed within an open or arthroscopic procedure, is comparable(20). Roughly 80% of individuals will experience sufficient pain relief(21,22). There are, however, a lack of some standardized tests, so an accurate comparison between studies is not actually possible.

Post-operative rehabilitation originally requires the recovery of a pain-free passive array of motion and then the growth of active strength. The results of surgery frequently seem poor for the first three months but tend to improve over the first year.

The principal benefits of arthroscopic surgery include the shorter hospital stay, less anesthetic morbidity and reaching rehabilitation landmarks quicker(23). Sadly, some studies suggest poorer results where patients have been involved in compensation claims(24).

Referred neck pain pathology should always be excluded. Repetitive pressure may also injure the acromioclavicular and sternoclavicular joints. Finally, bear in mind the less common causes of shoulder pain in the throwing athlete. These include quadrilateral space syndrome, suprascapular nerve entrapment, axillary artery occlusion, axillary vein thrombosis, lateral capsule laxity and glenoid spurs. These investigations lie in the domain of the professional shoulder surgeon.

References

1. Review of Sports Medicine and Arthroscopy, Philadelphia, pp123, 1995
2. Annals of Cases on Information Technology, Vol 70(20, pp220-226, 1998
3. Journal of Shoulder & Elbow Surgery, Vol 7(6), pp610-615, 1998
4. American Journal of Sports Medicine, Vol 12(3), pp218-220, 1984
5. Clinical Orthop & Related Research, Vol 198, pp134-140,1985
6. Knee Surgery, Sports Traumatology, Arthroscopy, Vol 1(2), pp97-99, 1993
7. Journal of Orthopaedic & Sports Physical Therapy, Vol 18(2), pp427-43, 1993
8. Manual Therapy Vol 4(1), pp11-18, 1999
9. Radiographics, Vol 17(3), pp657-673, 1997
10. European Journal of Radiology, Vol 35(2), pp126-135, 2000
11. American Journal of Sports Medicine, Vol 18(5),pp480-483,1990
12. Medicine & Science in Sports & Exercise, Vol 30(4), pp18-25, 1985
13. Journal of Bone and Joint Surgery, Vol 79(5), pp732-737, 1997
14. Clinics in Sports Medicine, Vol 8(4), pp657-689, 1989
15. Acta Orthop Scand, Vol 68(5), pp447-450, 1997
16. American Journal of Sports Medicine, Vol 22(5), pp578-584, 1994
17. Arthroscopy, Vol 17(1), pp25-30, 2001
18. Instructional Course Lectures, Vol 50, pp17-21, 2001
19. Journal of Bone and Joint Surgery, Vol 80(5), pp813-816, 1998
20. Arthroscopy, Vol 11(3), pp301-306, 1995
21. American Journal of Sports Medicine, Vol 18(3), pp235-244, 1990
22. Arthroscopy, Vol 14(4), pp382-388, 1998
23. Arthroscopy, Vol 10(3), pp248-254, 1994
24. Journal of Bone and Joint Surgery, Vol 70(5), pp795-797, 1988

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