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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