Shoulder Instability

Report
Shoulder Injuries
Rodney S. Gonzalez, MD
MAJ, MC, USA
Primary Care Sports Medicine Fellow
Overview
• Rotator Cuff (RC)
Syndrome
• Shoulder Instability
• Clavicle Fractures
• Acromioclavicular (AC)
Sprains
• Sternoclavicular (SC)
Sprains
• Biceps Tendonopathy
Rotator Cuff Syndrome
• Mechanism of Injury
– Insidious onset
– Pain with overhead
activities
• Risk Factors
– Extrinsic
– Intrinsic
Rotator Cuff Syndrome
• Clinical Features
–
–
–
–
–
–
Pain location
Painful arc of motion
RC strength testing
Neer’s impingement sign
Neer’s impingement test
Hawkins’ sign
Rotator Cuff Syndrome
• Diagnosis
– X-ray
– MRI
• Treatment
–
–
–
–
–
Activity modification
Pain control
Rehabilitation
Subacromial injections
Surgical intervention
Shoulder Instability
• Types of Instability
– Unidirectional traumatic
– Acquired microinstability
– Atraumatic multi-directional
• Classifications
– Apprehension
– Subluxation
– Dislocation
• Directions
–
–
–
–
Anterior
Posterior
Inferior
Superior
Shoulder Instability
• Mechanism of Injury
– Anterior – Arm abducted,
externally rotated with a
force applied to arm
– Posterior – Arm forward
elevated, internally rotated
and adducted (seizures
and electrocution)
– Acquired microinstability
– repetative stretches of
shoulder ligament due to
overhand throwing
Shoulder Instability
• Risk Factors
– Injury to stabilizers of the
shoulder
• Static – Bone, cartilage,
and ligament
• Dynamic – Rotator cuff,
long head biceps tendon,
and scapular stabilizers
Shoulder Instability
• Diagnosis
– History & Physical
– X-ray
• AP, Scapular-Y, and West
Point views
• Bankart lesions – West
Point view
• Hill-Sachs lesions – Stryker
notch view
– MRI – If labral tear
suspected
Shoulder Instability
• Treatment
– Reduction
– Immobilization
• Sling
• Immobilize at 30° ER
– Rehabilitation
– Bracing
– Surgery
Shoulder Instability
AMBRI
TUBS
Atraumatic
Multidirectional
Bilateral
Rehab
Inferior
Traumatic
Unilateral
Bankart
Surgery
Clavicle Fractures
• Mechanism of Injury
– Fall causing lateral impaction
of acromion
– Fall on outstretched arm
– Direct trauma (i.e. sports with
sticks – hockey & lacrosse)
• Risk Factors
– Contact sports
– Male athletes
– Participation in sports with
sticks
Clavicle Fractures
• Clinical Features
– Report the event; usually
hear a crack and have
immediate pain
– Pain with arm motion
– Self-splinting
– Lump and possible
tenting of the skin
Clavicle Fractures
• Diagnosis
– History & physical
– X-ray – AP & axillary
views, AP with 45° tilt
– CT for proximal clavicle
fractures
• Treatment
– Conservative
– Surgical
Clavicle Fractures
• Conservative
– Rest
– Immobilization (sling or
figure-8 splint)
– Pain control
– No overhead activity for
4-6 wks
– Surgery if fails
Clavicle Fractures
• Surgery
– Open fracture
– Neurovascular
compromise
– Fracture displacement or
shortening of 20mm or
greater
– Healed clavicle lump not
desirable
– Floating shoulder
(concurrent scapular neck
fracture)
AC Sprains
• Mechanism of
Injury
– Fall with arm
adducted
• Risk Factors
– Contact sports
– Male athlete
– Bicycling and
horse riding
(falls)
Acromioclavicular
Trapezoid
Conoid
AC Sprains
• Clinical Features
– Pain with overhead or
cross body motion
– Self-splinting
– Tenderness of AC Joint
– Graded I-VI
AC Sprains
• Diagnosis
– History & physical
– X-ray – bilateral AP and
axillary (no weights)
• Treatment
– I & II – conservative
– III – controversy
• Surgery for backpackers
and parachutists
– IV-VI – surgery
SC Sprains
• Mechanism of Injury
– Direct blow anteriorly to
shoulder or clavicle
– Indirectly by fall on lateral
shoulder
• Risk Factors
– Contact sports such as
football or rugby
SC Sprains
• Clinical Features
– Pain over SC joint
– May present for other
injuries
– Grades:
• I – SC ligament injury
• II – Tear of SC ligament
and costoclavicular
ligament
• III – Dislocation of SC
joint; tear of SC ligament
and costoclavicular
ligament
SC Sprains
• Diagnosis
– X-ray – Chest AP/Lat
– CT scan if posterior
dislocation suspected
• Treatment
– I & II – Rest, ice, sling
– III (Anterior)
• Attempt reduction (unstable)
• Immobilize
– III (Posterior)
• Reduce as soon as possible
• Treat life threatening injuries
Biceps Tendonopathies
• Mechanism of Injury
– Repetitive overhead throwing
and lifting
• Clinical Features
– Pain anterior shoulder
– Possible signs and symptoms
of impingement
– Tenderness over bicipital grove
– Speed’s test
– Yergason’s sign
Biceps Tendonopathies
• Diagnosis
– History & Physical
– X-rays to rule out other
causes of pain
– MR if suspect biceps tear
• Treatment
– Rehabilitate
– Counterforce bracing
– Surgery for tears
Questions

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