Injuries of the Shoulder Joint
Most shoulder injuries are not single-entity injuries. They are composed of a variety of contusions, strains, sprains, and possible fracture. Dislocations, spontaneously reduced dislocations, and subluxations also complicate the picture. Thus, any painful shoulder syndrome requires careful differentiation.
Shoulder Injuries in Sports
The shoulder is at the forefront among high-incidence athletic injuries. Tears of the rotator cuff, usually without humeral displacement, are common in a large number of sports. Most are the result of throwing injuries, falls on the shoulder point, and vertical forces directed along the humerus. Careful evaluation of the soft tissues is necessary. Subclavian and axillary vessel injury may be the result of direct trauma or a sudden and violent shoulder movement. Rarely, just muscular hypertrophy may produce venous insufficiency or thrombosis. Brachial plexus and coracoid injuries are sometimes seen in recoil injuries such as in rifle sports. Epiphyseal injuries of the proximal humerus are rare, heal well, and are usually treated closed.
Throwing Injuries. Throwing includes an initial smooth sequence of elevation, abduction, and external rotation of the upper arm which quickly leads to a sudden, forceful, forward flexion, anterior abduction, and internal rotation of the shoulder associated with elbow, wrist, and finger extension. Crucial to the initial motion is the integrity of the rotator cuff. Unfortunately, the cuff muscles are well beneath overlying muscles, thus difficult to palpate and differentiate. Inasmuch as the path of the ulnar nerve is quite close to the medial epicondyle, strenuous pitching can readily result in traumatic ulnar neuropathy. Cases frequently present paresthesias associated with fragmentation and partial avulsion of the medial epicondyle.
The shoulder girdle is a multiaxial, intricately synchronized joint complex that has considerable power and an extreme range of motion. The anterior, superior, and posterior shoulder muscles provide the great power, and the collateral ligaments do not appreciably limit motion in any plane. Thus, stability must be provided by the musculature: essentially the rotator cuff and subscapularis muscles, which are aided somewhat by the glenohumeral ligaments. Muscle forces must act through four relatively unique joints (glenohumeral, scapulo- thoracic, acromioclavicular, sternoclavicular) to achieve the normally graceful coordination required of shoulder motion. Because of this, alterations of the throwing mechanism about the shoulder produce a clinical picture that is often difficult to diagnosis and effectively treat.
For the purposes of analysis, Tullos/King divide the throwing mechanism into three separate, independent stages, each of which is associated with specific shoulder injuries:
The Cocking Phase. During windup, the shoulder is brought into extreme external rotation, abduction, and extension. The biceps, triceps, and internal and external rotators are highly tensed. For this reason, a professional baseball pitcher will invariably exhibit abnormal external humeral rotation and subnormal internal rotation. Overstress makes the proximal arm vulnerable to biceps tendinitis, triceps tendinitis, and humeral subluxation. See Table 22.2.
The Acceleration Phase. The actual throwing phase is a two-stage process: (A) With the forearm and hand stationary, the shoulder is brought forward, the elbow is placed into extreme valgus strain as the muscular forces multiply on the shaft of the humerus, and the elbow is stabilized by the flexors of the forearm. (B) In the second stage, the forearm is rapidly whipped forward by internal shoulder rotation produced by severe contraction of the pectoralis major and latissimus dorsi. This stage ends when the hand is near ear level and the ball is released. Overstress makes the shoulder complex vulnerable to pectoralis and latissimus tendinitis, along with the effects of the mechanical forces upon the humerus.
The Follow-Through Phase. The last phase begins as the ball is released near head level and ends when the pitch is completed. Its major function is involved with deceleration of the arm and forearm and, usually, some type of ball rotation. Great stress is applied to the glenohumeral joint and its adjacent tissues.
Table 22.2. Typical Throwing Injuries
Especially
Throwing Vulnerable
Phase Structures Clinical Picture
Cocking Biceps, Tendinitis; localized pain in the anterior
long head shoulder and bicipital groove,
aggravated by resisted forearm supination.
Triceps, Tendinitis; pain in the posterior aspect of
long head the shoulder, which radiates to
axilla or deltoid area.
Rotator Impingement syndrome during abduction and
cuff externalrotation, involving entrapment against
either the acromion or coracoacromial ligament.
Humerus Abduction subluxation during internal or
external rotation.
Axillary Occlusion by the pectoralis minor when the arm
artery is brought into hyperabduction, extension, and
extreme external humeral rotation, leading to
intimal damage and subsequent thrombosis.
Subdeltoid Bursitis and the development of fibrous
bursa adhesions.
Acceleration Pectoralis Strain, tendinitis, rupture.
major
Latissimus Strain, tendinitis, rupture.
dorsi
Humerus Fatigue fractures, coracoid process avulsion,
epiphysitis in the young.
Follow- Glenohumer- Posterior capsulitis or tear; traction spurs.
through al joint
Quadrilater- Strain, myositis ossificans; occlusion of
al area theposterior humeral circumflex vessel.
Roentgenographic Considerations. Keep in mind that everything within the film area must be evaluated. This includes rib, thoracic outlet, and pulmonary abnormalities in addition to osseous and soft-tissue structures related to a specific sports injury. Normally, the margins of the glenohumeral joint are parallel arcs. The cartilage space should be clear and uniform.
Anterior abnormalities may be found with the long head of the biceps tendon within the intertuberous groove or the supraspinatus. In rupture of the biceps brachii, a mass of soft tissue may appear at the anterior or anterolateral aspect of the mid or lower humerus. The long head of the triceps originating from the scapula at the infraglenoid tubercle may present an avulsion throwing injury detectable on roentgenography.
Less common throwing injuries include avascular necrosis of the head of the radius; thrombosis of the axillary artery; stress fracture of the olecranon process, the first rib (usually the contralateral midrib), and the front tips of the lower three ribs; and humeral fracture. Fracture of the humerus, a spiral fracture of the mid or lower third of the shaft (sometimes comminuted), appears to be associated with the sudden stopping of the throwing movement by the deltoid. While it is most common in the unconditioned baseball player, it is sometimes seen in softball, javelin, shot put, and handball.
Fracture of the proximal humeral epiphyseal cartilage is sometimes seen in adolescent baseball pitchers. Roentgenography may show irregular ossification of the capitellum, abnormalities of the medial epicondyle, accelerated closure of the epiphyseal cartilage, or fragmentation of the medial epicondylar epiphysis resulting from avulsion injury.
In heavy throwing sports such as shot put, hammer throw, and javelin, tears of the interscapular, scapulocostal, and rotator cuff muscles are often seen. In javelin activity, overstress may lead to elbow abnormalities such as bony-surface irregularities, soft-tissue calcification, para-articular ossification, capitellar erosion, rupture of the collateral ligaments, and intra-articular loose bodies at the lateral epicondyle and olecranon area. Bursal or tendon ossifications are best shown in coned-down views taken during external and internal rotation.
Swimming Injuries. Shoulder pain is a common complaint in swimmers, especially with the freestyle and butterfly strokes and during underwater pushoffs. The symptomatic picture is one of pain and discomfort after activity, tenderness over the supraspinatus or biceps tendon, and a painful arc (often restricted) of shoulder motion. Shoulder subluxation is sometimes seen in backstrokers.
Contusions, Strains and Tears
The pain from strain implies
(1) abnormal strain on a normal joint,
(2) normal strain on an unprepared joint, or
(3) normal strain on an abnormal joint.
SHOULDER "POINTER"
This is a contusion, by a blow from above, in the prominent upper-deltoid area at the tip of the shoulder. It is easily mistaken for an acromioclavicular separation.
Signs and Symptoms. The trapezius medially and the deltoid laterally are simultaneously bruised between the impact force and bone. Acute disability, swelling, and extreme tenderness are exhibited in the trapezius and/or deltoid. The acromioclavicular joint is not lax, nor is tenderness found in the area of the trapezoid, coracoclavicular, or conoid ligaments.
Management. Initial treatment is by cold packs, shoulder-cap strapping, and a sling for support for 48 hr. For the next 3–4 days, moist heat, passive manipulation, and progressively active exercises should be offered. When the player returns to competition, a protection pad should be applied to the area to reduce impact forces for 1–3 weeks.
THE BICIPITAL SYNDROME
In shoulder injury, after possible dislocation and fracture have been eliminated, attention should be given to the bicipital muscle. The biceps is the most powerful flexor of the elbow and a strong supinator. Within the shoulder area, proximal strains and tears along the long head's course within the bicipital groove to the glenoid rim are frequently found.
Background. Acute rupture of the biceps tendon occurs as a result of forceful contraction of the biceps muscle or forceful movement of the arm with the biceps contracted. The injury may be avulsion of the tendon from the muscle belly anywhere along its course or be pulled free from its glenoid attachment. It is often a crippling problem in sports, often accompanied by tenosynovitis. The condition is called "golfer's shoulder" but occurs in almost any sport.
Signs and Symptoms. An acute tendon tear may be felt by the patient as a "snap", followed by swelling, tenderness, and ecchymosis over the bicipital groove and bulging of the biceps near the antecubital fossa at the lower half of the humerus. Pain is usually felt on the anterior shoulder about 2 inches below the humeral head at the site of the thecal tunnel. If the long head is torn, the contracted muscle belly moves distally and bulges even if the short head is intact. This is an important sign in differentiating a proximal biceps problem from other shoulder problems. A hollow in the upper humeral area can be both seen and felt. Flexion and supination, especially against resistance, increases the bulging at the lower half of the upper arm. Strength of forearm supination is decreased.
Yergason's Stability Test: The seated patient flexes the elbow, pronates his forearm, and attempts elbow flexion, forearm supination, and humeral external rotation against the resistance of the examiner. The doctor stabilizes the patient's elbow with one hand while offering resistance to the patient's distal forearm with his other hand during the maneuver. Severe pain in the shoulder is a positive indication of a bicipital tendon lesion, a tear of the transverse humeral ligament, or bicipital tendinitis.
Loose-Tendon Syndrome. In some chronic bicipital disorders, the tendon may appear slack and actually glide from side to side on palpation during repeated adduction and external rotation. To further test this condition, place the patient's affected forearm on your knee. Palpate the bicipital groove with one hand while the other hand moves the patient's elbow laterally and anterior while the patient resists the movement. If the tendon is slack, it will be felt to "jump" during the motion. Injury to the transverse humeral ligament is often involved.
Gilcrest's Sign. The patient is instructed to lift a 5–lb weight (eg, dumbbell) overhead and then to externally rotate the arm and slowly lower it to the lateral horizontal position. Pain and/or reduplication of symptoms during this maneuver (with or without tendon displacement from the groove) is said to indicate instability of the long head of the biceps and probable tenosynovitis.
Hueter's Sign. If pain and/or reduplication of other symptoms appear when the patient's supinated forearm is flexed against resistance, partial rupture of the biceps is suggested.
Management. Bicipital injury with or without tenosynovitis requires careful strain therapy. Rest in an arm sling is necessary until all symptoms subside. Graduated exercises can be initiated once the tissues appear stable to clinical testing. Impatient pitchers must be advised against "testing" throws, as progress may be completely destroyed. Steroid injections are rarely helpful in the athlete, although frequently employed by habit by some medical physicians. Complete tear or rupture requires surgical approximation.
RUPTURE OF THE TRANSVERSE HUMERAL LIGAMENT
An important function of this ligament is to hold the long head of the biceps within its humeral groove. The mechanism of injury is usually heavy lifting, "Indian" arm wrestling, or a slip while carrying a heavy object. Injury occurs, especially in young adults, when the contracted biceps meets an overload.
Signs and Symptoms. Extreme tenderness will be found at the superior aspect of the bicipital groove, with some tenderness along the groove distally. A slack tendon will be found on palpation of the upper groove as the humerus is abducted and internally rotated. A "jumping" sensation from the tendon is felt if the transverse ligament is partially torn. A gliding sensation is felt if the ligament is completely torn.
Management. Mild partial tears will respond to strapping and sling, and the usual physiotherapeutic measures for sprain. Supplementation with 140 mg of manganese glycerophosphate six times daily speeds healing. Severe ruptures require surgical attention.
BICIPITAL TENDON DISLOCATION
A stable tendon may be found to be dislocated or at least partially subluxated from its groove and express symptoms of a bicipital syndrome. This is due to rupture or loosening of the transverse ligament which holds it within the bicipital groove.
Background. The disorder is often a consequence of painful strains, sprains, capsule tears, and contractures. The subluxated tendon will be felt and/or heard to snap as the patient forward flexes and abducts his arm, then returns it to its natural position. The patient is unable to place the ipsilateral hand on the sacrum. As time passes, motion restrictions indicate cuff degeneration. Yergason's test is positive on resisted external rotation.
Abbott-Saunders Test. This is a modification of Yergason's test which forces the biceps tendon against the lesser tuberosity which will stress an instable tendon. Bring the arm of the seated patient into full abduction, rotate it externally, and then lower the arm to the patient's side. A "click" felt or heard, frequently accompanied by pain and a reproduction of symptoms, is a positive sign of subluxation or dislocation of the biceps tendon.
Biceps Stability Test. The seated patient is asked to flex his elbow so that the forearm is held forward and horizontal. As the patient attempts to extenally rotate the arm, the examiner applies resistance. Localized pain indicates an inflammatory instability of the long head of the biceps and/or displacement of the tendon from the bicipital groove.
Lippman's Test. In the relaxed seated position, the seated patient is asked to flex the elbow on the involved side and rest the forearm in the lap. The examiner palpates for the tendon of the long head of the biceps about 3 inches distal from the glenohumeral joint. An attempt is made to displace the tendon laterally or medially from its groove. Pain, reduplication of other symptoms, and a palpable displacement of the tendon from its groove signifies tenosynovitis with instability.
Booth-Marvel's Test. The examiner abducts the patient's arm laterally to the horizontal position, flexes the elbow to a right angle, and deeply palpates the bicipital groove as the humerus is passively rotated internally and externally. If the transverse humeral ligament has been stretched, a painful and palpable snap will be felt and as the tendon of the long head displaces from the bicipital groove.
Adjustment. To re-set, stand behind the sitting patient towards the side of involvement. If the right shoulder is involved, place your left hand over the shoulder cap and grasp the patient's right wrist with your right hand. The patient's arm is allowed to hang loose, the elbow should be flexed about 45°, and the arm should be abducted about 45°. Press the thumb of your left hand against the back of the tendon, and wrap your fingers under the short head of the biceps and coracobrachialis to compress the tendon of the biceps. Advise the patient that the adjustment is not painful and not to resist. With firm contact on the shoulder muscles, quickly bring the patient's flexed arm anterior and medial to internally rotate the humerus. This usually brings immediate relief. If not, a steady lateral (rarely medial) pressure is applied to the slipped tendon while the elbow is drawn posterior and held close to the chest until the limit of motion is reached. Then with continued pressure on the tendon, abduct the elbow, bring it forward, and return it to its original position.
Management. Follow adjustment with traction strapping, sling, and the usual treatment of sprain depending upon the history. Efforts to elongate the tendon with weight exercises following the acute stage are most helpful. If the ligament is severely torn, it will not remain in place; surgery is required for permanent correction.
ROTATOR CUFF INJURIES
Five deep muscles are around the glenohumeral joint. They comprise the rotator cuff. The infraspinatus and teres minor work as external rotators of the humerus. The subscapularis and teres major rotate the humerus medially. The supraspinatus pulls the humerus into the glenoid fossa and abducts the humerus initially (10°–15°) before the deltoid becomes effective. In further abduction, the supraspinatus stabilizes the humerus as the deltoid, during full abduction, tends to displace the humerus from the glenoid. The mechanism of injury may be a fall with outstretched hand, a blow on the shoulder, throwing, or heavy lifting.
Background. In pitching "round house" curves, the tendon is whipped against the outer edge of its groove, initiating an inflammation and degenerative process ("glass arm" syndrome). The injury is essentially a localized tendinitis from intrinsic overload particularly at the subscapularis insertion on the lesser tuberosity. This creates disability on elevation and external rotation of the arm in the early stages of throwing. The cause is found in overstretch of the subscapularis at the end of "draw back" which is instantly interrupted by a sudden force on the tendon as the throw takes place. Examination shows limited motion and pain on abduction and external rotation of the shoulder. Pain is increased when active internal rotation is resisted. Tenderness will be found over the lesser tuberosity.
Stages. Three stages are commonly recognized and related to age:
(1) Edema and hemorrhage resulting from overuse (eg, swimming, tennis, baseball) characteristically seen in young athletes before 25 years but may be seen at any age.
(2) With repeated episodes, the subacromial bursa becomes fibrotic and thickened. The patient is usually 25–40 years old.
(3) Characterized by wearing of the bone and rupture of the tendon in individuals over 40 years, associated with anterior acromial erosion and spurs. However, these stages fail to recognize the effect of a reflex-produced ischemia so often seen in practice.
Supraspinatus tears (full or partial rupture) are characterized by a total loss of initial abduction. The tendon of the supraspinatus may be the site of peritendonitis or ectopic calcification.
Rotator cuff strain can be classified as follows:
Grade I Injury: Minor pain and weakness; tenderness over upper end of humerus, weakness and loss of normal shoulder rhythm on flexion and abduction.
Grade II Injury: Pain with moderate disability; exaggerated signs of Grade I. Unpalpable tear site.
Grade III Injury: Pain at tear site (partial or complete) with severe disability; weakness with inability to actively abduct shoulder. A tear is possibly palpable. Later signs of atrophy appear. A supraspinatus tear is characterized by a dull ache on rest which is aggravated by abduction. It is usually sited in the rotator cuff or common tendinous insertion, rather than within the tendon itself. Complete ruptures are rare in comparison to partial tears.
The degree of injury is determined by the degree of pain or weakness on passive motion or active motion against resistance. Differentiation must be made from bicipital tenosynovitis by a positive Yergason's sign and severe pain on palpation. Roentgenograms are usually negative; but in chronic cases, the anterior edge of the acromion may show spur formation or a displaced fracture of the tuberosity.
Signs and Symptoms. On examinination, the patient's arm is held to the side and cannot be abducted actively without pain; however, nearly a full range of passive movement can be obtained with care. The arc of pain is generally located between 45°–90° as the tuberosity of the humerus passes under the acromion process. Pain may also be noticed during adduction from 120°–170° with subacromial crepitus, varying amounts of weakness, and recurrent "bursitis" episodes. When the patient is asked to raise his arm, the shoulder hunches in support, a short motion may be made, but the arm quickly collapses to the side in pain. While passive motions of the shoulder are unrestricted, pain may be felt when the humeral head presses under the acromial arch. When the shoulder is extended, the front and back of the humerus will be tender but not as acute as at the greater tubercle. Extreme tenderness is found where the cuff inserts into the tuberosities. A superior subluxation of the humerus is often associated.
Subacute Cases. An important sign in 1–2 weeks after injury is an area of thinning or depression at the fossae of the supraspinatous and infraspinatus (especially) muscles. If this is the site of rupture, a "catch" and clicking sound may be felt and heard at the site during passive movements if swelling is minimal.
Arm Drop Test. Hold the patient's arm at 90° abduction and then ask him to hold that position without assistance. If this cannot be done actively for a few moments without pain, it is a positive indication of a torn rotator cuff. In lesser tears, the patient may be able to hold the abduction (a slight tap on the forearm will make it drop) and slowly lower it to his side, but the motion will not be smooth.
Supraspinatus Press Test. With the patient in the relaxed seated position, the examiner applies strong thumb pressure directed toward the midline in the soft tissues located superior to the midpoint of the scapular spine. The production of pain signifies an inflammatory process in the supraspinatus muscle (eg, strain, rupture, tendinitis).
Apley's Scratch Test. This is a two-phase test:
(1) The patient (seated or standing) is asked to raise the arm on the involved side overhead, flex the elbow overhead, and then place the fingers as far down on the opposite shoulder blade as possible.
(2) The patient is then asked to relax his arm at the side, then place the hand behind the back and attempt to touch as far up on the opposite scapula as possible. If either of these manuevers increases shoulder pain, inflammation of one of the rotator cuff's tendons is indicated. The supraspinatus tendon is most commonly involved. Restricted motion without sharp pain points to osteoarthritis or shortened soft tissues.
Shoulder Abduction Stress Test. The seated patient is asked to abduct the arm laterally to the horizontal position with the elbow extended while the examiner applies resistance. If this causes pain in the area of the insertion of the supraspinatus tendon, acute or degenerative tendinitis should be suspected.
Codman's Sign. This is a variation of the shoulder abduction stress test and the arm drop test. If the patient's arm can be passively abducted laterally to about 100* without pain, the examiner then removes support so that the position is held actively by the patient. This produces sudden deltoid contraction. If a rupture of the supraspinatus tendon or strain of the rotator cuff is present, the pain elicited will cause the patient to hunch the shoulder and lower the arm.
Teres' Major Spasm Sign. When the relaxed standing patient is viewed from behind, the arms normally rest so that the palms face the thighs. If the palm faces distinctly backward (toward the examiner) on the involved side, a spastic contraction of the teres major muscle is suggested.
Management. The chief therapy for small tears is rest. Any taping technique should be designed to assist the action of the rotator cuff tendons or the joint capsule. This requires strapping from just above the elbow to the neck. Horizontal strips should be laid "in line" at the base of the neck to cover the entire shoulder to stabilize the clavicle and scapula. Early rehabilitation exercises should emphasize flexion, extension, abduction, and adduction in the later stage. Moderate or large tears usually require surgery.
IMPINGEMENT SYNDROME OF THE SUPRASPINATUS AND/OR BICIPITAL TENDON
Locking Position Test. The patient's arm is extended and internally rotated. If a painful reduplication of the patient's symptoms occurs on this maneuver, an impingement syndrome of the supraspinatus and/or bicipital tendon is suggested.
Impingement Syndrome Test. The patient is placed supine with the arms resting loosely as the sides. The elbow on the involved side is then flexed to a right angle and the arm is rotated internally so that it rests comfortably on the patient's upper abdomen. The examiner places one hand on the patient's shoulder and the other hand on the patient's elbow. A compressive force is then applied, which pushes the humerus against the inferior aspect of the acromion process and the glenohumeral fossa. Pain and/or a reduplication of symptoms indicates an impingement syndrome of the supraspinatus and/or bicipital tendon.
DELTOID CONTUSION AND STRAINS
This powerful abductor is a frequent site of acute and chronic disability. Injury may be intrinsic. Powerful contraction of the deltoid has been known to fracture its attachment from the clavicle or humerus.
Anterior deltoid strain is often seen in football following an attempted one-arm tackle. Symptoms arise slowly, often peaking 6–8 hr after injury. Pain and weakness increase on forward abduction. Evidence of swelling and tenderness appear in the anterior third of the muscle.
Middle deltoid strain follows forceful abduction against resistance in the lateral plane. Symptoms arise slowly. Pain and weakness increase on lateral abduction. Evidence of swelling and tenderness appear in the mid-third of the muscle.
Dorsal deltoid strain is the result of a posteriorly directed strain such as seen in swimmers using the butterfly stroke. Symptoms arise slowly. Pain and weakness increase on posterior abduction. Evidence of swelling and tenderness appear in the posterior third of the muscle.
Management. Cold packs, shoulder-cap strapping, and an arm sling are necessary during the first 2 days, followed by moist heat and passive manipulation. Active exercises should be conducted during a warm shower. Full activity can usually be allowed (with support) in 3–5 days.
BRACHIALIS CONTUSION AND STRAIN
Brachialis strain is common in contact sports. It is continually subjected to bruises in football as it is exposed to contusion just below the epaulettes of the shoulder pad.
Signs and Symptoms. In sprain of the proximal radioulnar joint, there is often a related injury to the brachialis anticus muscle with contracture, or, especially in children, a strip of periosteum may be torn from the anterior aspect of the humerus, followed by callus formation and blocked joint motion. The athlete will present a highly developed muscle belly on the anterolateral aspect of the upper arm which is easily found between the deltoid and the lateral head of the triceps.
Management. Treat for acute sprain with ice, pressure, and follow with typical physiotherapeutic procedures such as heat and progressive exercises.
POSTTRAUMATIC TRIGGER POINTS
The source of many shoulder pains sited in the front of the shoulder will be found at the insertion of the infraspinatus muscle at the scapula. In other cases, a localized trigger point may be found in the anterior deltoid with pain referred to the subdeltoid bursa. Other common trigger-point sites in shoulder pain include the lesser tuberosity at the insertion of the subscapularis, the greater tuberosity at the insertion of the supraspinatus tendon, at the glenohumeral joint space, within the bicipital groove, at the acromioclavicular joint, or at the sternoclavicular joint. The levator scapulae, scaleni, pectoralis major and minor, sternalis, and seratus anterior are less common sites.
MUSCLE TECHNIQUE
No physical therapy will strengthen a muscle or shorten a lax muscle. Only exercise will do that. Various techniques may be applied to relax a muscle, but only active or passive stretching exercises will lengthen a shortened muscle.
After a muscle has been strained, Goodheart's research found that heavy pressure over the origin or insertion of the affected muscle will elicit a normalization response in the comparatively weakened muscle. This state of weakness after strain appears to be the result of a microavulsion of the tendoperiosteal connection. The following technique is essentially used on weak hypertonic muscles created by overstretch injuries:
Test the isolated muscle, and note comparative weakness, hypertonia, and/or shortening.
If strain to the tendoperiosteal site has occurred, the muscular origin and insertion will be tender. Select the site which appears to be the most tender, origin or insertion. Apply the pads of two or three fingers on the muscle's tendon or point of attachment. Direct pressure from the muscle towards the point of origin or insertion. If partial rupture has occurred, it may be necessary to strap the muscle somewhat prior to therapy. If relaxation of a reactive muscle is desired, apply pressure gently at first, and slowly increase it to just below the patient's tolerance (2–3 lb). Initial heavy pressure can be extremely painful and tends to increase spasm. The pressure utilizes the Golgi tendon receptor reflex to induce muscle relaxation. Maintain pressure for several (30–60) seconds until the muscle relaxes and allows lengthening, then for approximately 10 sec after the muscle has relaxed.
Re-examine the muscle unless severity prohibits retesting. In some cases, small sensitive nodules noted on palpation near the affected muscle's origin and/or insertion usually disappear within 24 hr after successful treatment. When normalized, conclude by giving the patient instructions in proper stretching exercises.
SPASM MANAGEMENT
The benefits of vertebral and rib adjustments are well known within the chiropractic profession. To relieve muscle spasm, heat is helpful, but cold and vapocoolant sprays have shown to be as effective. The effects of cervical traction are often dramatic but sometimes shortlived if a herniated disc is involved.
Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys the beneficial reflexes. For example in rhomboid spasm, have the prone patient place his hand on the involved side behind his back to "wing" the scapula. This slightly stretches the muscle fibers by pulling the scapula from the midline. It may be assisted by the doctor offering a slight tug upward on the scapular angle. The muscle should relax within 2–3 min. Thumb pressure, placed on a trigger area, is then directed towards the muscle's attachment and held for a few moments until relaxation is complete. When pain has subsided, good home progressive exercises are gravity-assisted pendulum exercises holding a weight or iron while prone and holding a broom stick in front with both hands and doing elevations.
Other methods may prove helpful. Peripheral inhibitory afferent impulses can be generated to partially close the presynaptic gate by acupressure, acupuncture, or transcutaneous nerve stimulation. Isotonic exercises are useful in improving circulation and inducing the stretch reflex when done supine to reduce exteroceptive influences on the central nervous system. An acid-base imbalance from muscle hypoxia and acidosis may be prevented by supplemental alkalinization. In chronic cases, relaxation training and biofeedback therapy are helpful.
General Sprains
Overtreating an upper humeral fracture or sprain is a common pitfall according to some orthopedic authorities.
Background. The symptoms of sprain of the shoulder are pain, tenderness on pressure, and, rarely, swelling. Passive motion is comparatively painless, but active motion induces severe pain. Differentiation must always be made from rupture of the supraspinatus tendon, subdeltoid bursitis, fracture, and inflammation of other bursae about the shoulder.
Management. During the acute hyperemic stage, structural alignment, cold, compression, strapping, positive galvanism, ultrasound, and rest are indicated. An application of hyaluronidase is helpful to reduce tissue swelling and edema, especially if it is "driven in" with iontophoresis or phonophoresis. After 48 hr, passive congestion may be managed by contrast baths, light massage, gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of motion exercise initiated. Immobilization may be required if effusion and swelling persists. Vitamin C and 140 mg of manganese glycerophosphate six times daily may prove helpful throughout care. During the stage of consolidation, local moderate heat, moderate active exercise, moderate range of motion manipulation, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise, negative galvanism, ultrasound, and active joint manipulation speed recovery and inhibit postinjury effects.
Subluxations
Shoulder subluxations may be primary conditions after injury, or they may occur weeks or months after reduction of a primary dislocation. Thus, in cases of chronic shoulder pain, probe the history for possible shoulder dislocation and reduction. Most shoulder subluxations are not acute, exhibit little or no swelling, but they present chronic (often episodic) pain, movement stiffness or "blocks", and other signs of local tissue fibrosis and joint "gluing". Mild to moderate local muscle weakness and possible atrophy are characteristic. Postural distortions of the lower cervical and upper dorsal spine and musculoskeletal abnormalities of some aspect of the shoulder girdle are invariably related.
During correction of a shoulder subluxation, dynamic thrusts should be reserved for nonacute, fixated situations. When subluxation accompanies an acute sprain, attempts at correction should be more in line with gentle traction pressures after musculature has been relaxed. Obviously, the probability of fracture fragments or osteoporosis must be eliminated prior to any form of manipulation.
SEVERE SUBLUXATION OF THE HUMERAL HEAD
This acute condition is probably a dislocation which has partially reduced itself spontaneously.
Background. It occurs when the greater tuberosity has been displaced upward as a whole to lie between the humeral head and the glenoid. The capital part is rotated to a degree but has not completely escaped from its capsular envelope. The outer border of the shaft is impacted firmly into the cancellous tissue of the head of the humerus.
Management. The chief obstacle in obtaining reduction is in the difficulty of removing the tuberosity from within the joint and overcoming the very firm impaction of the two main fragments. It is rarely possible to overcome these obstacles by manipulation, especially without anesthesia, thus immediate referral should be made for orthopedic attention.
SUPERIOR HUMERUS SUBLUXATION
Because of its bony arch, the humerus cannot dislocate much superiorly unless there is severe fraction involved. However, several authorities believe that superior subluxation can often be demonstrated on bilateral roentgenography.
Background. Schultz feels this is the most common shoulder subluxation seen. This writer, however, believes the term to be a misnomer as the suprahumeral joint is not an articulation in the true sense of the word but is a structure that serves as a protective and supportive mechanism. Most likely what is referred to as a superior humeral subluxation is the result of contractures within the superior humeral area which prevent the greater tuberosity from gliding smoothly under the coracoacromial ligament during abduction. The result is chronic compression and irritation of the enclosed tissues. Keep in mind that the acromioclavicular meniscus progressively thins with age. It is quite thick in the young and may be completely gone by the sixth decade.
Adjustment. Determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The doctor sits on the affected side facing the head of a supine patient. A shoeless foot is placed in the patient's axilla for counterpressure and stabilization of the shoulder girdle. Straight axial traction is then applied with both hands on the patient's arm. The traction is towards the inferior and slightly lateral. After a few seconds and with steady traction, the patient's arm is rotated internally (usually) or externally as need be, and a short tug is applied inferiorly towards the doctor's body to correct any rotational deficiency present. Strapping is sometimes, but not always, necessary for a few days to rest the joint. Follow with therapy for chronic sprain, frequent mobilization, and progressive stretching exercises. Evaluate the integrity of the pectoralis major and the latissimus dorsi for associated dysfunction.
Alternative Adjustment Procedure. Determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The patient is placed supine if there is any internal rotation; prone if there is any external rotation. The doctor sits relatively perpendicular to the patient's affected side. The patient's elbow is flexed 90°, and his shoulder abducted 90°. The doctor takes contact with the web of his cephalad hand on the lateral proximal humerus (cephalad aspect) and with the web of his caudad hand on the medial distal humerus (caudad aspect). Pressure is made against the proximal humerus in a caudal direction, and a thrust is made while the doctor's caudad hand stabilizes the distal humerus.
ANTERIOR HUMERUS SUBLUXATION
This is also a frequently seen shoulder subluxation. The mechanism of injury is that similar to anterior humeral dislocation.
Background. There is difficulty in raising the arm overhead. Fullness will be noted on the upper anterior arm that will be tender on palpation. The deltoid will feel taut and stringy. A sensitive coracoid process will be found higher than the head of the humerus. Signs of acute or chronic sprain will be found depending upon the history. Check infraspinatus, teres minor, and rhomboid major for possible strain.
Adjustment of Externally Rotated Anterior Humerus. Stand behind the patient sitting on a low stool. Instruct the patient to place his hand on his opposite shoulder near his neck to internally rotate his humerus. The elbow will be fully flexed and the arm will be almost horizontal to the floor. Reach around the patient with both arms and clasp your fingers over the patient's elbow. Brace your chest against the patient's dorsal spine for counterpressure. Ask the patient to relax, and as this is done, lift the elbow slightly and apply pressure followed by a short quick thrust (pull) posterior and slightly inferior towards yourself. Follow with sprain therapy and rehabilitation measures to assure against joint looseness or restrictions.
Adjustment of Internally Rotated Anterior Humerus. The procedure is essentially the same except that prior to the adjustment, the patient is instructed to grasp the back of his neck on the ipsilateral side with the palm of his hand on the affected side to externally rotate his humerus.
INTERNAL HUMERUS SUBLUXATION
Background. This type of malposition is frequently associated with a fixation that restricts external rotation of the humerus. Rotator cuff tendinitis and inferior humerus subluxation may be associated.
Adjustment. The patient is placed supine on the adjusting table and the doctor stands facing the patient's shoulder on the side of involvement. The patient's elbow is flexed and the arm is allowed to rotate externally somewhat by its own weight. The doctor's contact hand grasps the patient's proximal humerus firmly, just below the acromion process, and the other (lateral) hand is slide under the patient to stabilize the patient's scapula. It is helpful if a thumb contact can also be made with the clavicle. A deep, but not severe, rotary thrust is made, and the line of correction is directed to produce external rotation of the humerus.
INFERIOR HUMERUS SUBLUXATION
Background. A slight hollowness may be found at the joint space, indicating that the humeral head has dropped from its normal position. The deltoid will often feel firm and stringy, indicating a chronic disorder. Evaluate the integrity of the supraspinatus, long head of the triceps, deltoid, coracobrachialis, and clavicular division of the pectoralis major. Signs are often vague and should be confirmed by bilateral roentgenography.
Adjustment. Determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The patient is placed supine if there is any internal rotation, prone if there is any external rotation. The doctor sits relatively perpendicular to the patient's affected side. The doctor takes contact on the patient's medial proximal humerus (caudad aspect) with the web of his caudad hand and on the patient's lateral distal humerus (cephalad aspect) with the web of his cephalad hand. Pressure is made cephally, and then a short thrust is made with the doctor's contact hand while his cephalad hand stabilizes the patient's humerus.
Alternative Adjustment Procedure. Correction is by abduction, moderate traction, and then superior pressure. The patient is placed supine and the doctor sits perpendicular to the affected side. The patient's flexed elbow of the affected extremity is placed in the doctor's axilla for control. The doctor grasps the humerus high with both hands and pulls the head of humerus first laterally towards himself and then cephally in one smooth quick movement. Counterpressure is applied by the doctor's knee against a pillow placed in the patient's axilla. This is a "reseating" procedure which must be followed by temporary immobilization to encourage the lax tissues to tighten and then rehabilitation procedures to strengthen weakened musculature and lax supporting tissues.
POSTERIOR HUMERUS SUBLUXATION
Background. Physical signs of this rare disorder are usually negative; bilateral roentgenography is required for confirmation. In a few cases, the posterior area may feel fuller than the unaffected side. An unusually prominent coracoid process may be felt, and a slight hollow may be felt above the humerus. Signs of taut tissues on the posterior aspect of the humeral head and lax tissues on the anterior aspect are often found. Evaluate the integrity of the pectoralis major.
Adjustment. Correction can be made in the same doctor-patient position as for the alternative adjustment procedure of an inferior humeral subluxation by applying humeral traction first laterally towards yourself and then anteriorly towards the ceiling. A slow steady lateral pull should be concluded with an anterior tug to stretch the contracted tissues and "reseat" the humeral head in its normal position. Follow with standard therapy for acute or chronic sprain, depending upon the history.
Alternative Adjustment Procedure. The patient is placed prone with the involved extremity at his side. The doctor stands on the side of involvement facing the patient's shoulder. A pisiform contact is made on the patient's posterior proximal humerus, as far cephally as possible, with the doctor's medial hand. The doctor's lateral hand stabilizes his contact hand. Pressure is made toward the floor, followed by a short thrust.
EXTERNAL HUMERUS SUBLUXATION
Background. This type of subluxation is often related to restricted internal rotation of the humerus. Supraspinous tendinitis, bicipital tendinitis, tendon displacement from the bicipital groove, and inferior humerus subluxation are common complications.
Adjustment. The patient is placed prone on the adjusting table and the doctor stands facing the patient's shoulder on the side of involvement. The patients elbow is flexed and the supinated hand is placed under the patient so that the palm comfortably rests against the patient's chest and the back of the hand is in contact with the table. This "sling position" will allow some internal rotation tension that will assist the forthcoming adjustment. The doctor's indifferent hand cups the shoulder so that the heel of the stabilizing hand holds the patient's clavicle while the fingers stabilize the patient's scapula. The doctor's contact hand firmly grasps the humerus just below the acromion process. A deep, but not severe, rotary thrust is made that is directed to produce internal rotation of the humerus.
Dislocations
Falls and collisions causing shoulder dislocation are frequent in contact athletics, representing about 50% of all major joint dislocations and the most common dislocation area of the body. Incidence is highest in high jumping, pole vaulting, gymnastics, horseback riding, and water polo. The typical mechanism is an extension force against an abducted arm that is externally rotated.
Most dislocations are anterior dislocations of the glenohumeral joint (85%), followed by acromioclavicular dislocations (10%), sternoclavicular dislocations (3%), and posterior dislocations (2%). True dislocations must be differentiated from pseudo-subluxations where the humerus is displaced inferiorly by hemarthrosis. Poor muscle tone is usually related in the occasional athlete.
The glenoid cavity covers only a small part of the head of the humerus. In extreme degrees of abduction, extension, and flexion, any force transmitted through the humeral shaft is applied obliquely in the body surface and directly on the capsule of the joint, through which the head of the bone is then forced. In fracture dislocations, the humeral fracture is invariably displaced with the articular surface outside the joint.
Apprehension Test. If chronic shoulder dislocation is suspected, begin to slowly and gently abduct and externally rotate the patient's arm with the elbow flexed toward a point where the shoulder might easily dislocate. If shoulder dislocation exists, the patient will become quite apprehensive, symptoms may be reproduced, and the maneuver is resisted as you attempt further motion.
Dugas' Test. The patient places his hand on his opposite shoulder and attempts to touch his chest wall with his elbow and then raise his elbow to chin level. If it is impossible to touch the chest with the elbow or to raise the elbow to chin level, it is a positive sign of a dislocated shoulder.
Calloway's Sign. The circumference of the proximal arm of a seated patient is measured at the shoulder tip when the patient's arm is laterally abducted. This measurement is compared to that of the noninvolved side. An increase in the circumference on the affected side suggests a dislocated shoulder.
Bryant's Sign. A posttraumatic ipsilateral lowering of the axillary folds (anterior and posterior pillars of the armpit), but level shoulders, is indicative of dislocation of the glenohumeral articulation.
Hamilton's Ruler Sign. Normally, a straight edge (eg, a yardstick) held against the lateral aspect of the arm cannot be placed simultaneously on the tip of the acromion process and the lateral epicondyle. If these two points do touch the straight edge, it signifies a dislocated shoulder.
VARIETIES
In primary dislocation, symptoms may be severe even if the soft-tissues and capsule are not greatly damaged. Heroic on-field reductions should be avoided. Four types may be classified according to the direction in which the humeral head leaves the socket, and these can be subclassed according to the point at which the head of the humerus comes to rest or according to limb position:
Anterior Dislocations. Subcoracoid (most common), intracoracoid, and subclavicular types may be found. The typical mechanism involves a combination of abduction, extension, and external rotation of the shoulder. The common means are
(a) a fall on the outstretched arm where the trauma drives the humeral head forward against the anterior capsule;
(b) abduction with the humerus in internal rotation or forward flexion with the humerus in external rotation, limited by the acromial arch --if forceful elevation is applied when this point of impingement is reached, the arch is used as a fulcum to dislocate the proximal head anterior and inferior; and
(c) a fall or blow to the lateral shoulder from the rear.
In subcoracoid luxation, the head of the humerus lies under the coracoid process, either in contact with it or at a finger's breadth distance at most below it. The head may be displaced inward until three-fourth's of its diameter lies to the medial side of the process or be simply balanced on the anterior edge of the glenoid fossa. The humeral axis passes to the medial side of the fossa. The elbow hangs away from the side, the lateral deltoid bulge is flat, and the acromion is prominent. The glenoid cavity is empty. Palpation reveals the absence of the usual bony resistance below the lateral aspect of the acromion and the presence of abnormal resistance below the coracoid process or in the axilla. Voluntary movement is lost, and assisted abduction is strongly resisted by the patient. Dugas' test is positive. The arm can be passively adducted but not to the degree that the elbow can touch the chest with the fingers resting on the opposite shoulder. Measurement in abduction shows shortening.
In intracoracoid dislocations, the humeral head is displaced further medially. The symptoms and signs are those of the subcoracoid type except that the head of the humerus is felt further displaced and the shoulder is more flattened. The arm may be fixed in horizontal abduction. Severe capsule laceration is usually involved which allows for the greater displacement.
Complications of Anterior Dislocations. When the humerus dislocates anteriorly, its posterolateral margin is often forced against the rim of the glenoid to produce a compression fracture (Hill-Sachs deformity). The malpositioned humerus frequently tears the cartilaginous labrum and capsule from the glenoid rim (Bankhart lesion) with an avulsed fragment of bone. If there is fracture of the anatomical neck, the humeral head (if it can be felt) will not participate in passive movement of the shaft, and crepitus can usually be felt. Fracture of the greater tuberosity, tears of the rotator cuff, and recurrent dislocation are common complications. Anterior fracture dislocations are usually related with displacement of the greater tuberosity, but the capsule is not displaced. Any anterior luxation can do great harm to the brachial artery, vein, or nerves. Circulation must always be checked before reduction is attempted.
Inferior Dislocations. Subglenoid and luxatio erecta types are infrequently seen in which the humeral head lies below the glenoid fossa. The typical cause is forcible abduction followed by rotation or impulsion. The mechanism of injury is usually a leverage force on an abducted arm such as in an arm tackle. There is severe pain and disability. The arm is fixed at about 45° in abduction. A hollowness will be found at the joint space, with the humeral head inferior to its normal position and often palable within the axilla. The deltoid is flattened and extremely spastic. In subglenoid luxation, the symptoms are those of subcoracoid flattening, but abduction and flattening of the shoulder are more marked. The upper part of the greater tuberosity is usually torn. In rare instances of luxatio erecta, forcible elevation of the arm causes the head of the humerus to be displaced far downward so that the extremity remains in an erect position.
Posterior Dislocations. This is often a diagnostic challenge in the young well-muscled athlete because all joint motions may be unrestricted, yet disability is acute. Two types are seen which differ only in the extent of displacement; ie, subacromial and subspinous types. The cause is direct pressure lateral and posterior, or pressure has been exerted in the same direction along a flexed, adducted, and internally rotated humerus. It is sometimes produced during a convulsive attack. The patient's arm is abducted and rotated internally, and the elbow is directed slightly forward. The shoulder is flat in front and full behind, where the head of the humerus may be felt. The coracoid is prominent. The head of the humerus lies on the outer edge of the glenoid fossa or further posterior under the scapular spine or on the infraspinatus. These features are not as obvious as those of anterior dislocation. Passive abduction and external rotation motions are restricted. In severe cases, the lateral side of the capsule is usually torn, and there may be associated cuff tear or an avulsion fracture of the greater tuberosity resulting in persistent pain. The internal and external scapular muscles are usually quite lacerated or contain fragments of the torn tuberosities.
Superior Dislocations. A supraglenoid luxation is very rare except in sports. A routine A-P view may show narrowing of the space between the head of the humerus and the acromion, indicating a tear. In many cases, arthrography must be recommended. Take care not to confuse the growth plate of the proximal humerus with that of a fracture line.
ROENTGENOGRAPHIC CONSIDERATIONS
Careful evaluation of the glenohumeral articulation is necessary to judge alignment congruity. An axillary (bird's eye) view to clearly expose the glenohumeral relationship is often quite helpful. A tangential view of the scapula may be helpful to elicit a fracture of the coracoid process or glenoid margin or to find evidence of defects in the humeral articular margin following chronic dislocation. In approximately 20% of cases of shoulder dislocation, fractures of the glenoid are related. Lesser tuberosity fractures are often related to a posterior dislocation of the shoulder. Vigorous contractions of the triceps muscle, as seen in throwing, may produce avulsion injuries to the inferior aspect of the glenoid. Roentgenography is required to analyze possible complications prior to any considered reduction.
SUBCORACOID DISLOCATION REDUCTION TECHNIQUES
Before any reduction technique is utilized, the integrity of the circumflex nerve should be established by checking the dermatome (C5) with a pin or pinwheel, and signs of possible fracture should be sought. As a rule, early reduction of a shoulder dislocation may not require an anesthetic except in the highly apprehensive patient. Reassurance, warmth, and a quiet area help to augment relaxation. Occurrence and reduction should always be confimed by x-ray.
Kocher's method is to
(1) apply gentle downward traction to the flexed elbow, and press it closely to the patient's side;
(2) most carefully, ease the arm into full possible external rotation by moving the patient's arm away from the trunk (a sudden motion may fracture the humerus);
(3) While maintaining the external rotation, carry the elbow well anterior and superior as to gently adduct the elbow across the patient's chest; then
(4) reduction can be felt (and often heard) when adduction is complete. The arm is then rotated internally so as the patient's hand rests on his opposite shoulder. The elbow is simultaneously lowered. If this method fails, the classic method may be attempted. Keep in mind, however, that failure in reduction may indicate a complicating fracture which would make further attempts contraindicated.
The classic (Hippocratic) method is for the sitting doctor to place a shoeless foot in the supine patient's axilla for counterpressure and apply straight axial traction with both hands on the patient's arm. The gentle pull is towards the inferior and slightly lateral, never upward and outward as there is danger of lacerating vessels. After a long steady pull (never a jerk), the muscles may yield and allow the head of the humerus to slip back into the socket as the arm is slowly internally rotated. If successful, relief is immediate. During traction, some doctors attempt to push the humeral head into the socket with the ball of the stockinged foot. If replacement is not complete, remove your foot from the patient's axilla, and flex the patient's elbow. Stabilize the elbow with one hand while applying gently pressure downward on the forearm to cause slight internal rotation of the humeral head to complete the reduction. Place the flexed arm over the patient's chest and instruct him to hold it there until the joint can be secured with tape.
Note: Muscle spasm may be difficult to overcome in the highly musculatured athlete. Regardless, never use severe leverage against the chest as it will undoubtedly break a rib if the thorax is used as a fulcrum. However, some are skilled at applying forceful adduction over a closed padded fist in the axilla.
Stimson's method, a gentle alternative, is to place the patient prone on a cot or table with the affected limb hanging towards the floor. Fix a 10–lb weight to the wrist with tape. Frequently, this gentle continuous traction will reduce the dislocation within 20 min. It works best with the patient not presenting highly developed musculature.
Techniques for long-duration dislocation requiring anesthesia are orthopedic procedures rather than emergency sports-related techniques.
INTRACORACOID OR SUBCLAVICULAR DISLOCATION REDUCTION TECHNIQUE
Outward traction usually has no difficulty in reduction unless the subscapularis or torn capsule intervenes. If this is the case, surgery is the only recourse. Angelvin's method is to place the hand of the dislocated extremity about your neck. With your hands, direct the head of the humerus in intracoracoid luxation by applying extension, counterextension, and lateral traction as need be. In subclavicular dislocation, the same forces applied more energetically force the head of the humerus into the socket.
INFERIOR DISLOCATION REDUCTION TECHNIQUES
In subglenoid dislocation, treatment is by moderate abduction with direct pressure. This is a most difficult type of dislocation to reduce without anesthesia, and usually requires an orthopedist. To reduce mild to moderate displacements, the patient is placed supine and the doctor sits perpendicular to the affected side. If possible, place the patient's flexed elbow in your axilla for stabilization. The head of humerus must be first pulled laterally towards you and then cephally in one smooth movement. Counterpressure is applied by the doctor's knee against a pillow placed in the patient's lower axilla. Any degree of luxatio erecta is reduced by upward traction until the head of the humerus slips into place.
POSTERIOR AND SUPERIOR DISLOCATION REDUCTION TECHNIQUES
In uncomplicated cases of posterior luxation, reduction can usually be accomplished by inferior and lateral traction and direct pressure forward. Unreduced dislocations exhibit an unusual amount of disability. When viewed from the lateral, the posterior area may appear fuller than the unaffected side. An unusually prominent coracoid process may be felt, and a hollow may be felt above the humerus. Avulsion of the subscapularis makes recurrence probable. Superior dislocation may be reduced by direct inferior traction via the classic method.
MANAGEMENT OF SHOULDER DISLOCATIONS
Some feel that, if possible, reduction should be made within 10 min after injury when local numbness is present and severe spasm has not occurred. A firm gentle manipulation will usually result in reduction. If not, avoid persistent attempts and refer to an orthopedist. Other authorities feel that prior x-rays should always be taken before attempting reduction to avoid possible problems associated with a fracture. There is always a great danger of forcing a bone clip into the joint which would require surgery. Thus, a decision must be made to either offer immediate relief with some risk by making one good attempt or leaving the patient in severe pain until films can be taken, processed, and analyzed. The longer reduction is delayed, the greater the muscle spasm which makes reduction difficult.
Following reduction, a sling should be used to rest the joint and a harness employed to restrict shoulder abduction. Such a sling should have a controlling swath around the thorax to stabilize the joint such as incorporated within a modified Velpeau bandage. Local soreness will subside within a few days as the soft tissues heal. Cold can be applied initially to reduce pain and swelling, followed by the usual treatment for severe sprain. The typical athlete is overly anxious to have the sling removed. Professional opinion differs as to the length of immobilization. Some feel prolonged immobilization over 3 weeks produces more harm (atrophy) than good, while many others feel that at least 6 weeks are necessary to avoid recurring problems. Regardless, the shoulder should be allowed to heal solidly before progressive exercises are initiated. However, the fingers and wrist should be actively exercised early during immobilization.
The older patient is more prone to later stiffness problems than recurrence problems. Mild circumduction exercises may be initiated after about 4 days and progressive range-of-motion regimens after 3 weeks. Full external rotation and abduction should be avoided for 6 weeks in older patients, 9 weeks in younger patients. Isometric exercises of all involved muscle groups are always recommended while the shoulder is immobilized.
RECURRING DISLOCATIONS
Several factors influence recurrent dislocation. The younger the patient in glenoid-rim fracture, the size of the capsular deformity (Hill-Sachs deformity), and the range of normal lateral motion all increase the chances for recurrent dislocation. If the humeral head is driven directly forward during injury, the cartilaginous labrum glenoidale is torn from its anterior attachment which leaves a potential cavity into which the head can repeatedly slip. Another cause is too early mobilization following a primary dislocation. Incidence is highest in males 20–40 years of age. In the nonathlete, recurrences appear in over 90% of patients under the age of 20 after a primary dislocation. This rate drops to about 12% in patients over 40 years old. However, proper treatment can reduce this rate in any age group.
Recurring dislocations, almost always of the subcoracoid type, are a different problem from that of a primary dislocation. Posterior dislocations are usually not as painful and may be of the snapping variety. The dislocating force is usually mild and reduction is easy in comparison. Pain is severe and unrelieved until reduction is made. After reduction, symptoms disappear in 1 or 2 days whereupon progressive exercises can be initiated. Prolonged immobilization is ill-advised.
In some cases of a permanently loose joint, surgical fixation may be the only solution --an orthopedic decision. Regardless, the decision should be based on what is in the athlete's long-term best interests and not what procedure will return him to competition the fastest. Sports which may subject the shoulder to constant severe stress must also be put into the prognosis puzzle.
THE LAX JOINT
Repeated subluxations without clinical dislocation often produce a loose joint. The history will reveal frequent episodes of mild trauma, each incorporating a period of pain and limited motion, followed by an audible "click" as the head of the humerus slips painfully back into the fossa. After reduction, examination reveals little except residual tenderness and a lax capsule.
Lax Capsule Test. To determine a lax capsule, have the patient clasp his fingers behind his head and laterally abduct his elbows. Palpate high in the axilla over the glenohumeral capsule while applying posterior force on the patient's flexed elbow. While laxity of the anterior capsule can always be demonstrated by this maneuver, care must be taken not to dislocate the humerus within its loose capsule. If episodes are frequent, some form of external support should be provided, and the patient should be advised of the risks involved in repeated subluxation.
Fractures
Fractures of the proximal humerus are not common in athletics; they are most common clinically in mature women with a degree of osteoporosis.
Background. The mechanism is usually a fall on the outstretched pronated upper extremity. About 85% of these fractures are simple, usually involving the surgical neck and greater tuberosity of the humerus. A scapula fracture may be associated. In any case within athletics, early mobilization, without compromising long-term effects, is a necessity.
Roentgenographic Considerations. Fragments are usually displaced less than 1 cm, are angulated less than 45°, and are held in place by an intact rotator cuff and periosteum. Displacement of the greater tuberosity of more than 1 cm indicates a torn rotator cuff. Fractures through the surgical neck, frequently associated with brachial plexus injuries, are usually displaced anteriorly and medially due to the pull of the pectoralis major. Fractures through the head or anatomic neck of the humerus are rare, but they do have a high incidence of avascular necrosis.
As in the elbow joint, the epiphyseal lines in the shoulder make interpretation difficult unless contralateral views are taken. Note that the epiphysis for the lateral end of the acromion process does not unite until about 20 years of age. In young baseball pitchers, the upper humeral epiphysis may be damaged from throwing overuse (Little League shoulder).
In the area of the subacromial or subdeltoid bursae, calcification may simulate a fracture of the greater tuberosity. A calcification shadow appears more dense and irregular than that of bone and is not trabeculated.
Tendinitis and Tenosynovitis
Tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because tendons are relatively avascular, they are subject to chronic trauma, microtears, slow repair, and aging degeneration in the shoulder. Overuse is the common cause, both within and outside of sports. The initial inflammatory reparative process is often associated with the deposition of calcium salts which may evade an overlying bursa. Abduction is quite painful against resistance in tendinitis.
SUPRASPINATUS TENDINITIS
Inflammation of paratendonous supraspinatus tissues is often a part of subdeltoid or subacromial bursitis. This is frequently a part of rotator cuff injury and a complication of severe supraspinatus strain.
Signs and Symptoms. An ache is present on rest which is aggravated by abduction. Pain may be referred as far distal as the deltoid insertion. The distinguishing feature is that pain is restricted to movement only within a certain point of the arc (painful arc syndrome). This is because the acromion process affects the tendon area only during part of its excursion. Point tenderness will be found over the site of inflammation. The patient will complain that it is painful to sleep on the affected side. Treatment is similar to that of bicipital tendinitis.
BICIPITAL TENDINITIS
The synovia of the biciptal groove is a common site of chronic peritendonous inflammation. It is frequently a complication of bicipital rupture (long head) or subluxation of the tendon from the groove.
Signs and Symptoms. Pain is aggravated on abduction and extension, and tenderness is localized over the inflammed tendon. Symptoms mimic supraspinatus tendinitis, but the pain is referred distally in the area of the biceps insertion to the radius. Tenderness is found along the anterior shoulder in the bicipital groove. Pain is increased if the patient abducts, flexes, and internally rotates the shoulder. When the patient flexes his arm and supinates his wrist against resistance, a positive sign is pain within the anterior medial upper humerus area.
Management. Check for lower cervical, 1st rib, and upper dorsal subluxations. A trigger point is frequently found over the scapula. Supraspinatus and infraspinatus muscle spasms are often associated. In the acute stage, cold rather than heat is indicated. Ultrasound combined with pulsating high-voltage galvanism is especially beneficial in degenerative tendinitis. Apply strapping for 3–5 days. An arm sling should be used for relieving the tendon of weight for 7–10 days from injury. Progressive exercises may begin at home as soon as symptoms subside such as circumduction, and lateral and front finger-wall walking. Generally treat as a severe sprain.
Bursitis and Calcifications
The shoulder tendons are wide bands of collagen fibers. If stress roughens a tendon, its tensile strength decreases. This leads to fibrinoid degeneration in and between the collagen fibers and later fibrosis. With necrosis, the local tissues become alkaline which induces precipitation of calcium salts.
SUBDELTOID BURSITIS
Of the 140 bursae of the body, none receive the attention in sports as much as the subdeltoid bursa.
Background. Anterior, middle, or posterior deltoid strain can easily be associated with acute subdeltoid bursitis, but the clinical picture is quite different. Degenerative changes in the rotator cuff (floor of the subdeltoid bursa) lead to calcific deposits resulting in acute inflammation of the bursa. When a calcium deposit breaks into a bursa, it absorbs water which enlarges the bursal space, resulting in increased pressure. This causes severe pain and some warmth and redness of the overlying skin.
Signs and Symptoms. The patient presents acute, severe, deep-seated local pain and weakness with shoulder movement in any plane but especially on abduction. The entire bursa and peritendinous tissues will be swollen and readily palpable. This swelling prevents the greater tuberosity from sliding under the acromion during abduction. Dysfunction of the rotator, bicipital, and subscapularis tendons (which pass through the bursa) will be demonstrated. The initial attacks are localized in the vicinity of the greater tubercle. The chronic stage is characterized by subdeltoid tenderness, restricted motion in abduction and external rotation, and associated capsular contraction and adhesions. Keep in mind that bursitis is rarely a primary condition.
Management. A common pitfall is overtreatment of bursitis. When acute, treat with cold, pressure, and complete rest in an arm sling for 2–3 days. In severe cases where strapping is necessary, apply the direction of pull in the direction that affords the greatest relief to the bursa involved. When symptoms subside, a most gradual program of active exercise, traction, positive galvanism, and diathermy can usually begin in 4–7 days with careful monitoring. Most cases will respond well to ultrasound, swimming, vitamins C and E, manganese glycerophosphate, and acid calcium to diffuse the calcareous deposit. It is common to find a ipsilateral sacroiliac subluxation associated as well as C2, C3, and C5 subluxations. A good stretching and mobilization exercise is to have the patient flex the trunk and swing the arm anterior and posterior holding an iron or weight for three or four bouts daily. Reduce activity on the first signs of recurring local symptoms. Referral for aspiration and steroids may be necessary in stubborn cases, but the results of immediate injections in acute athletic injuries are not as good as that of more conservative care.
ROTATOR CUFF CALCIFICATION
An example of calcification in tendons is commonly found in the supraspinatus tendon near its insertion to the greater tuberosity of the humerus. In the well-developed athlete, symptoms from calcification may not appear for many months after injury. Deposits may appear in shoulder tendons, ligaments, or aponeuroses, and especially within the rotator cuff. They may be chronic, silent, or extremely acute. Spontaneous absorption may occur relatively fast.
Background. A hypovascular area has been identified in the area of the supraspinatus tendon. This is referred to as the "critical zone," and it occurs between the anastomosis of the vascular supply from the humeral tuberosity and the longitudinally directed vessels arriving from the muscle's belly. Tullos/Bennett report that this relatively avascular area of the supraspinous corresponds to the most common site of rotator cuff tendinitis, calcification, and spontaneous rupture.
Two other "critical zones" of hypovascular phenomena are found at the insertion of the infraspinatus tendon and at the intracapsular aspect of the biceps tendon. These areas of avascularity seem to expand with age, enhancing the potential for tendon rupture. Other factors can be added to this. For example, prolonged abduction such as seen in the common side-lying sleeping posture also produces compression or impingement under the acromion process or coracoacromial ligament. In the early stages, this leads to an inflammatory response and scar tissue development. Later, reports Brewer, the avascularity leads to a breakdown of the tendon and encourages rotator cuff rupture in the middle-aged athlete.
Signs and Symptoms. Symptoms appear suddenly. Pain is usually severe and aggravated by shoulder movement, but the pain is less severe and movements more tolerated than in supraspinatus tendinitis. Tenderness is localized over the bursa. A painful arc syndrome may be noted, similar to that seen in supraspinatus tendinitis. It is viewed in roentgenography as a large dense opacity above the outer head of the humerus and most frequently related to middle age with no definite history of trauma. It is occasionally seen in the young athlete. Associated bursitis may be present, which is responsible for acute symptoms.
Adjunctive Management. Therapy often includes iontophoresis of .25 g methacholine in 100 cc of water. Ionization is also frequently helpful with a cloth soaked with magnesium sulphate (4 oz/qt of water) over the deposit. The negative pad is on the cloth over the deposit; the positive pad is placed on the arm. Once pain subsides, ultrasound should follow for a few visits.
SUBACROMIAL BURSITIS
A painful, faltering abduction arc is also characteristic of subacromial bursitis. To differentiate, palpate the coracoid process under the pectoralis major. It is easily found by circumducting the humerus and is normally tender. Once the process is isolated, slide your finger slightly lateral and superior until it reaches a portion of the subacromial bursa. If the same palpation pressure here causes greater tenderness than at the process, it is a positive sign of subacromial bursitis. Still holding pressure, abduct the patient's arm above the horizontal. An inflammed bursa is exposed to palpation when the arm is relaxed but not when the arm is abducted beyond a right angle (Dawbarn's test).
Subacromial Button Sign. The examiner stands behind the seated patient, cups a palm over the involved shoulder, and applies finger pressure over the subacromial bursa. If this produces pain or unusual tenderness, subacromial bursitis is suggested.
Dawbarn's Test. With the patient seated, the examiner stands behind the patient and deeply palpates the area just below the acromion process to determine symptoms of focal tenderness or referred pain. Then, while still maintaining this palpatory pressure to patient tolerance, the examiner grasps the wrist of the patient with the other hand and brings the arm to the lateral extended position so that it is abducted to about 100*. If subacromial bursitis exists, the pain elicited on initial palpation should decrease substantially when the arm is raised because the deltoid will cover the spot below the acromion during abduction. If the pain remains unaltered or is increased by this abduction maneuver, subacromial bursitis can usually be ruled out.
TRICEPS BRACHII CALCIFICATION
Repetitive stretching of the posterior elements of the shoulder in baseball pitchers frequently causes an inflammation of the posterior capsule tissues of the shoulder. This may result in an osteotendinous calcification at the infraglenoid area where the long head of the triceps originates. Once calcification forms, the pitching follow-through is most painful to accomplish. Adjunctive management is similar to that of supraspinatus calcification.
Other Painful Shoulder Syndromes
Excessive postinjury immobilization leads to muscle atrophy and loss of capsular elasticity, a predisposing factor to capsulitis and periarthrits. Lack of joint movement fosters retention of metabolites, edema, venous stasis, and ischemia leading to fibrous adhesions and trigger-point development.
CAPSULITIS
Shoulder capsulitis is often the result of a sprain attended by a spontaneously reduced subluxation or of prolonged overuse. Joint pain is aggravated by movement. Tenderness and other symptoms are generalized within the whole joint area rather than being localized. Motion limitation may be considerable in adhesive capsulitis (frozen shoulder) where the head of the humerus is "glued" to the glenoid cavity.
FROZEN SHOULDER (PERIARTHRITIS)
Frozen shoulder (Duplay's syndrome) is often a challenge because it is usually near the terminal stage when the patient is first seen. Usually a combination of several chronic, diffuse, degenerative shoulder disorders are involved. Roentgenography is often negative with the exception of an obliterated joint space. Loss of scapulohumeral rhythm is a characteristic feature. This is readily noted when viewed from the posterior. During the early stage, shoulder motion stiffens at the extreme ranges of abduction and internal rotation. Differentiation must be made from the early stage of capsulitis.
Signs and Symptoms. Humeral motion restriction is exhibited in all planes, but adduction and rotation are especially affected. Scapulothoracic motion will be normal. Atrophy is readily noted and proportionate to the chronicity of the condition. Tenderness is diffuse throughout the upper arm with the possible exception of the posterior and medial aspects. The capsule becomes thick and contracted, which contributes to motion limitation. The rotator cuff also becomes thick and inelastic. The tendon becomes cemented within the groove. In time, all adhesions and soft tissues thicken and become tightly fixed, binding capsule to bone. As the joint cavity "drys", the head of the humerus is pulled tightly against the glenoid fossa. Arm use aggravates the condition, thus symptoms are more acute at night after a day's activity. Rest offers relief, thus improvement is seen in the morning. The accessory muscles overwork in an attempt to compensate for primary shoulder muscle deficiency, causing aching posterior shoulder and neck muscles. A superiorly subluxated 1st rib is a common contributing factor.
Management. Unless the instigating factor is removed, a meaningless course of treatments results with progressing deterioration. Rugged "shotgun" manipulation under anesthesia as practiced by some overly enthusiastic surgeons is strongly contraindicated. Specific conservative ajustments, progressive passive manipulation with and without traction and countertraction, graduated pendulum stretching exercises, circumduction manipulations against patient resistance, sine-wave stimulation to the shoulder muscles, ultrasound, and heat will provide a high percentage of relief even in severe cases. In most cases, adhesions must be released of the humerus, clavicle, and scapula in several planes if movement is restricted. As in any case of capsulitis, early care and prevention is the best therapy.
TRAUMATIC ARTHRITIS
True osteoarthritis of the shoulder is seen more in literature than in actual practice. Usually, it is a periarthritis where degenerative changes occur within the soft tissues. Differentiation must be made from supraspinatus rupture, subdeltoid bursitis, and inflammation of other bursae about the shoulder.
Signs and Symptoms. Characteristic symptoms are pain, tenderness on pressure, and swelling (rarely). Passive motion is comparatively painless, but active motion induces severe pain.
Management. When effusion and swelling persist, cold and immobilization are advised. The lower cervical area and shoulder girdle should be checked for chronic subluxations and trigger points. In mild cases, heat, ultrasound, and massage may be sufficient adjuncts.
Nerve Injuries
Contusion of the axillary nerve or brachial plexus is often seen in sports. Occassionally, scapular "winging" is found. If nerve damage is suspected, a thorough neurologic assessment should be conducted.
Contusion of the Axillary Nerve
Contusions of the axillary (circumflex) nerve commonly result from blows suffered along the nerve's course between the coracoid and head of the humerus.
It is not an infrequent complication of the common anterior dislocation of the shoulder (10%).
Signs and Symptoms. The major sign in severe cases is loss of abduction from inadequate deltoid function. An area of anesthesia about the size of a silver dollar will be exhibited on the lateral aspect of the arm at the distal insertion of the deltoid: an important sign. In minor contusions, numbness and tingling may occur over the sensory area of the axillary nerve in the upper deltoid area only during strenuous activity. Weakness may be difficult to determine, but swelling and tenderness can usually be found high and deep within the posterior axilla.
Management. Treat as any nerve contusion. Ice massage is helpful initially. Rest the deltoid by using an arm sling. Measures to reduce spasm and intrinsic muscle swelling will relieve tenderness and paresthesias. Initiate progressive exercises when local symptoms subside. Electrical stimulation is helpful in strengthening the muscle. In severe contusions, fibrous tissue and neuroma usually form which require surgical care.
Brachial Plexus Injury
The branches of the brachial plexus of the shoulder lie just anterior to the glenohumeral joint. The axillary nerve is just below the joint. In brachial plexus trauma, the entire plexus or any of its fibers may be injured. These injuries may be divided into three general types: total-arm palsies, upper-arm palsies (most common), and lower-arm palsies. Motor involvement is the main feature, sensory loss being obscured by overlapping innervation.
Background. Stretching requires special mention. As the roots of the plexus are relatively fixed at their origin in the spinal cord, any sudden or severe traction of the upper extremity may avulse roots from the cord or stretch the plexus to the point of tearing. During avulsion, the spinal cord itself is damaged and contralateral cord symptoms are found. If the lesion is due to stretching, contusion, or partial tearing, the prognosis is good and complete recovery may usually be anticipated.
Management. Treatment measures include support in the functional position, initial cold followed by massage, electric stimulation, progressive exercises, and acupuncture. Suture is required in complete tears, and some improvement can be hoped for. The prognosis is usually hopeless in avulsion from the cord. Fortunately, most injuries are a neurapraxia, and full recovery can be anticipated in time.
Scapular “Winging”
Injury to the long thoracic nerve of Bell (C5–7) can result in paralysis of the serratus anterior muscle. This is a purely motor nerve without sensory fibers. Its winding course under the brachial plexus varies considerably from person to person making localization difficult.
Signs and Symptoms. Rarely seen outside of athletics, this disorder features vague pains referred to the shoulder, a degree of abduction weakness, and visible scapula rotation when the arm is abducted laterally against resistance. Early diagnosis is important, yet there is rarely a complaint until marked atrophy has occurred. Seek the slightest sign of winging while the hands "wall walk" or while doing demanding pushups. Winging in the well-developed athlete is often disguised by heavy trapezius, latissimus, and rhomboid muscles.
Scapular winging is often associated in postural faults, which refer pain to the shoulder but not the joint itself, as a result of imbalanced function of the suspensory muscles of the shoulder girdle. A functional dorsal kyphosis may be found with alterations in scapulohumeral rhythm. A primary subluxation, which may have been present since childhood, may be found near the cervicothoracic transition or the apex of the thoracic curve. Secondary (sometimes primary) costovertebral fixations may also be found.
Management. Treat as a peripheral nerve contusion. Discontinue strenuous work until symptoms subside. This is an absolute which will probably meet patient resistance. Check for lower cervical subluxations and scapula fixations and trigger points. Faradic stimulation of the nerve 3–5 times a week during the early stage of rehabilitation is necessary to prevent atrophy while regeneration is in progress. Later, progressive exercises can be initiated; eg, shoulder shrugging against resistance, overhead weights and springs, and pushups.
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