Call 281-633-8600 for an appointment. In this post, Doctor J. Michael Bennett talks about shoulder injuries and treatments for shoulder injuries. This presentation was given to the Houston Texas Caduceus Society. This is the second portion of Dr. Bennett’s talk to Houston’s Caduceus Society during the Grand Rounds lecture series on July 17, 2012, and it covers shoulder injuries and treatments.
Doctor Bennett specializes in treating issues of the shoulders, elbows, knees, hands and wrists. He’s a Fellowship Trained Sports Medicine Physician and a Board Certified Orthopedic Surgeon with offices in Sugar Land and near the Houston Galleria.
Doctor Bennett’s office accepts medical health insurance from Aetna, Cigna, and United Healthcare, plus most other medical insurance providers. Call our office at 281-633-8600 to schedule an appointment or click the Book an Appointment button in the right hand column to schedule an appointment online.
This is a transcript of Doctor Bennett’s presentation. The slide titles are indicated in brackets.
[Incidence of Shoulder Injuries] This is an old statistic here. I’m sure it’s a lot more than it was at that time. Eight to 13 percent of all athletic injuries are shoulder injuries. It’s
|Dislocated shoulder (Photo credit: garyowen)|
probably about 25 percent now.
[Types of shoulder injuries] Like I mentioned before, there are chronic injuries and there are traumatic injuries, so that’s why it’s key to find out the mechanism of the injury and how it happened. Soseparations, dislocations, labral tears, and rotator cuff tears can all be traumatic. Some of these will be chronic as well, but they’re mostly traumatic.
[AC separation] AC joint separations: I usually see these in football players that come in, and anybody that lands directly on their shoulder. I’ve seen this in patients from car wrecks, actually, when their shoulder hit the dashboard or the seatbelt and caused an AC joint injury. I’ve seen this in bicyclists, especially if they’re mountain biking or outdoors riding around and they hit something and flip over their rails and land on their shoulder. That’s typically what you’re going to find with the mechanism of injury with these patients.
[AC separation 2] There are different types of AC joint sprains – not like I’ve confused you guys enough with the seven different SLAP tears and now I’m going to throw at you six different AC joint separations. The key here is to really recognize what they look like in the patients: were they painful? Do they have a deformity in the shoulder? You can have a type one AC joint sprain, which is just a typical injury (you see a lot of these), they’re just tender here and it means the AC joint got irritated. You can treat this easily in a sling. Just rest and let it heal. Type two is down here. The AC joint can be disrupted but the CC ligaments are intact here; that clavicle is still located. So it’s still in alignment and actually still looks good but they’re hurting, tender, and swollen. Still use the same treatment: sling, anti-inflammatories, do nothing. Type three is where the debate comes in on whether or not to fix it. I base this on activity level and expectations of the patient. It when you basically disrupt all of the CC ligaments here, and you have a dislocation of the clavicle. Type four, five, and six are more serious. Four is when it actually pops through the trapezius posteriorly. It’s stuck in the musculature; you have to fix this. It’s got to be pulled out and reattached. Type five is when you have double the displacement, it’s completely unstable, and it needs to be addressed because all of the soft tissue here has been disrupted. Type six – I’ve never seen it, but I’ve read about it and tested on it – is when the clavicle actually dislocates and goes underneath the coracoid and gets stuck over here. That can actually cause some nerve issues. This is just something you have to be aware of.
[Treatment of AC Separation] Like I mentioned before, type one and two are conservative, type three is controversial, and type four through six are surgical.
[Type III AC separation] This is basically a type three, and this was a football player. He had been treated non-operatively, but continued to have pain and he was at the point where he had developed significant weakness. He couldn’t play or lift as much as he wanted to, so he opted to proceed with the reconstruction. This is what it looks like; a type five is where it’s twice as high as that. It’s pretty obvious.
[Type III AC separation] This is what it looks like on x-ray. This is a type three; with type one and two, you wont see any step-off here. This is your scapular wide view, and you can see here that the clavicle and the acromion are not aligned and you can see the overlap. This, I’d say, is probably a type two acromion. I always tell residents that are with me and looking at x-rays to put their pen or whatever they have up against this acromion on a scapular wide view, and if you see a little bit of a hook, it’s probably a type two. If you see a big hook or divot, it’s probably a type three. If you see nothing and it’s lined up with your pen, then it’s a type one.
[Shoulder dislocations] Shoulder dislocations, or dislocations of the glenohumeral joint usually occurs in athletics, but it can occur from trauma, from a fall, or from a car wreck. 96 percent of shoulder dislocations occur from forceful collisions like football tackling, falling on outstretched extremities, or sudden wrenching movements. I’ve seen some wrestlers who got pinned or pulled and their arm dislocated. In basketball, arms can get tangled up going up for a shot or trying to rebound, so there are a number of different ways you can have a shoulder dislocated.
[Shoulder dislocations 2] Classification of shoulder dislocations with acute versus chronic. Like I mentioned before, these are differences between dislocators and we’ll talk about that in a minute here. As far as the direction of dislocation, anterior is going to be the most common dislocation you’ll see. This is why you want to get more than one view of the shoulder. Obviously, that doesn’t look normal, but sometimes it’s not going to be as obvious. You can see here that theis down below the glenoid. This is an attempt at a scapular wide, and here’s the glenoid and this is the humeral head, and it’s anterior-inferior, so that confirms that we have a dislocation. Posterior is usually seen in patients that have seizures or have been shocked or electrocuted, but other than that, you’re not going to see a lot of posterior dislocations. Inferior – I’ve never seen this. I’ve been tested on it, but never seen it. It’s the luxatio erectae. This is a patient who will walk into your office with their arm stuck in the air, and they can’t move it because the humeral head is jammed underneath the glenoid and the coracoid, but I’ve never seen it happen.
[Anterior Dislocation] Anterior dislocation, like we mentioned before, we talked about the labrum structure and the glenoid. Bone is glenoid, labrum is the bumper around. You have an anterior-inferior dislocation when the shoulder knocks off a portion of that glenoid. Like I mentioned before, the golf ball/golf tee analogy. If that golf tee is chipped, that ball is going to roll out anteriorly-inferiorly. This is what we fix; this is the soft tissue, the labrum, that we bring up and reattach to the bone. This gives back the conformity of the cuff. This is a bony bankhart. Bankhart just means a detachment of the anterior-inferior labrum, and a bony bankhart means that they have a small fragment of bone with it. Hill-Sachs lesion, like I mentioned before, if you have a dislocation of the humeral head, this little divot of the glenoid embeds itself in the humeral head and creates an indention in the humeral head, and that’s a Hill-Sachs lesion.
[Treatment] So what do you do? You want to immediately reduce the patient. As far as what to expect from the patients that are dislocators,if they are under 20, they have about a 75-95 percent risk of recurrence. So with the patients that think they’re never going to dislocate again, if they’re under 20, it’s very rare that they will stop dislocating because they definitely recur. It may have to do with their ligamentous structure or the ligament laxity, but they usually recur. The most common complication axillary nerve palsy because they stretched out the axillary nerve, which is inferior. If they’re greater than age 40, there’s a high incidence of rotator cuff tears. So if I have a patient that dislocates their shoulder that’s my age, I’m thinking that they tore a tendon. If it’s a high school student that comes in, then it’s more likely a labrel tear or something along those lines.
[Surgical Management] Repair of the labrum. These are just some basic pictures of what it looks like arthroscopically. This is the glenoid here, this white cartilage. This is the labrum here, you can see where it’s detached. So basically what we do is pull it off and repair it. So this is what it looks like. This is bone here and the labrum here, and you want to reattach that to that. This is just an MRI showing a labral tear. Like I mentioned before with treatment, arthroscopic Bankart repair is becoming the standard care regarding recurring instability in the shoulder with labral defect. Open Bankart repairs are still done for patients that failed with arthroscopic, or there are still guys that want to do capsular shifts. More and more guys are doing arthroscopic Bankart repair.
[Rotator cuff tear] Rotator injuries usually result from high forces, and like Adam mentioned before, its always during the deceleration phase of throwing. I think he mentioned the biceps getting injured with that and also the tendon, the supraspinatus, the rotator cuff tendon. That’s when it’s going to be more prone to injury: during that phase of throwing.
[Treatment] Treatment of rotator cuff tears. If you look at these tears, usually we’re going to treat these with non-operative measures like therapy, injection, or PRP, like Adam had mentioned. But if they fail that, then we have to look at the tendon, and sometimes we’ll see some partial tears. A partial tear is less than 50 percent, and these patients will actually get better if you just debride it and leave it alone; you don’t have to fix it necessarily. You just have to remove some of that degenerative tissue and see if there are any pathologies such as acromial spurs or bursitis that you need to take care of. You can actually have pretty good results with that. If it’s greater than 50 percent torn, we’ll actually repair these because the likelihood of it progressing to a full tear if it’s greater than 50 percent is high, so you’ll want to go ahead and take care of that while you’re there.
[Types of shoulder injuries] Nontraumatic types of injuries are instability, cuff tendonopathy, and impingement. These all occur a lot of times from chronic issues. Multidirectional instability is what we just talked about a second ago. It’s common in swimmers, volleyball players, and rowers because this gives them a mechanical advantage to get that arm backward and get that extra velocity in their stroke or in their throwing. Anterior and posterior laxity is what it means with multidirectional instability. It mean’s they’re loose in all directions.
[Atraumatic shoulder instability] This is laxity in other joints. This is like what Adam mentioned before with the Marfans, it basically means these patients are prone to instability in all of their joints because their ligaments are so lax. They can bend their elbow back 45 degrees or they can bend their thumb back to touch their forearm. They’re going to be prone to shoulder dislocations and instability. These are patients in which strengthening is so key, and they just have to understand that. There’s no quick fix for this; they really just have to work on the musculature and the balancing act of the body.
[Treatment] Like I said before, rehab emphasizing rotator cuff and scapular stabilizing exercises. That’s definitely for the shoulder to help balance out the shoulder.
[Cuff Tendonopathy] Adam did a good job describing the difference between tendonitis and tendonopathy. Most of the problems we see are tendonopathy. Tendonitis may just be the acute phase of it, while tendonopathy is kind of a long-term result of degeneration within the tendon itself. It’s common in athletes with multidirectional instability. Think about it: these athletes have these shoulders that are unstable. Their muscles are working overtime, the tendons are constantly getting stressed, so they’re going to develop a tendonopathy. They’re going to be at higher risk for that. Rotator cuff and biceps tendon are dynamic stabilizers of the shoulder, and usually these are the places where you’re going to see most of your injuries regarding the tendonopathy. Secondary to tensile failure, like I mentioned before, these muscles are working overtime trying to stabilize that shoulder because of the laxity that they’re compensating for, so they’re going to fail because of tensile failure and overworking.
[Cuff tendonopathy] This is what you look for with cuff tendonopathy: pain with overhead activity, weakness with external rotation, pain with internal rotation at 90 degree abduction, proximal biceps tenderness, and scapular winging due to atrophy. So always remember to look at the scapula and the balancing of the shoulder to make sure they’re strong in every plane.
[Treatment] Cuff stabilizing program, strengthening that rotator cuff. Working on the scapular stabilizers and working on the parascapular musculature and scapular-thoracic junction. Anti-inflammatory injections. The majority of these are non-operative, and we get very good success rates just sticking with this program. The problem is that a lot of people don’t want to do all of this stuff. They want the quick fix, but unfortunately you just have to explain to them and educate them that they have to work at it and that you’re working with them from a preventative aspect; you’re helping prevent them from getting injured in the future.
[Primary impingement] This is basically secondary to compressive mechanisms underneath the rotator cuff and under the coracoacromial arch, which is that CA ligament I mentioned to you before in that anatomy picture I showed to you in the beginning. This is that again. Here’s the coracoid, here’s the acromion, and this is the ligament up here, so when they reach back and externally rotate and abduct the arm, that’s right underneath there. So sometimes if you have any kind of spurs or anything like that or any kind of injury in that CA ligament (or fraying in that CA ligament), you can cause a bursitis or an irritation of the rotator cuff tendon.
[Impingement] Entrapment of the rotator cuff or labrum during late cocking or early acceleration phase. This is internal impingement, what Adam mentioned before as well. What happens with internal impingement is when you have this imbalance in the shoulder because of the tightness in the posterior capsule and laxity of the anterior capsule, over time the body just kind of gets used to it. So if I look at a pitcher and they put their arms out side by side, the pitching arm is going to have external rotation like this and their other arm is going to be at 90. Then they’re going to go into internal rotation, and the internal rotation on their left arm is going to be about here, and their pitching arm is going to be right here. That’s an imbalance in the shoulder. That means that that posterior capsule is incredibly tight and the anterior capsule is incredibly weak, so your job is to balance that out. Make sure you stretch out that posterior capsule. Work on the sleeper stretch that I mentioned before. Have them lie on a table, bring their arm up to their side, and push on their arm, and that actually helps stretch out that posterior capsule and it’s a great stretch that they can work on, especially in the throwers. Arthroscopic debridement and anterior capsulorraphy – I think that this is kind of falling out of favor nowadays. Some recent studies are showing that patients are doing much better with actually rehabilitating this and balancing out the shoulder. We’re only doing this in really extreme cases.
If you have any questions about this information or if you’re facing a medical problem related to orthopedics or sports medicine, please call our office for an appointment at 281-633-8600.