Shoulder Injuries in Sportsmen
ByAlampallam Venkatachalam
The shoulder joint is one of the five major
areas of the body involved in sports injuries.
Sportsmen who over use the shoulder in throwing
or overhead activities as in cricket bowlers,
volleyball, Javelin throw, after a fall, gymnasts
are all at risk of developing shoulder injuries.
It can be injured to falls on the arm or due
to traction as in some contact sports like
rugby. In this article I shall discuss the
various types of injuries of the shoulder
and its neighboring structures. I present
salient feature of its anatomy for a better
understanding of the various injuries.
Anatomy
The shoulder is the most mobile joint
in the human body, yet is the most insecure.
It is a ball and socket joint formed by
the upper end of the arm bone (humerus)
joining with the shoulder blade (scapula).
It is surrounded by a bag like tissue
called the capsule. A group of tendons
called the rotator cuff are closely related
to the shoulder. They serve as dynamic
restraints. There is a discrepancy between
the radius of curvature of the ball and
its socket which renders the shoulder
potentially unstable. This is akin to
a golf ball perched on a tee. This inherently
unstable joint is rendered stable by soft
tissue restraints, the bony orientation
and a negative suction force between the
components. A great deal of movement is
possible at the shoulder to allow the
arm to be positioned in space.
The price for this great range of movement
is instability which is described below.
Closely related to the joint are important
nerves and blood vessels of the upper
limb in their course downwards from the
chest to the arm.
Types of shoulder injuries
1) Instability-
Shane Warne’s shoulder dislocation a
couple of years is one of the most famous
in recent memory. The ball shaped upper
end of the arm bone slides pops out of
its socket either completely (dislocation)
or partially (subluxation). This occurs
in sports when there is a fall on the
outstretched hand. A frank dislocation
results and sudden pain is felt when the
ball comes out of joint. It predominantly
comes out at the front. The arm held as
if it is paralyzed, until it is set right
by the player or in a hospital. This is
a dramatic event. Once the shoulder has
dislocated, there is a tendency for it
to recurrently dislocate in young sportsmen
less than 25 years of age. This tendency
for recurrent dislocation merits rehabilitation
and surgical treatment. Arthroscopic stabilization
offers these sportsmen a minimally invasive
surgical technique. The results of this
mode of surgery are matching the old "gold
standard" of Open stabilization. Rehabilitation
is faster after an arthroscopic procedure
as the amount of pain is less. It is important
to bear in mind that instability need
not necessarily result only from a fall.
It can also occur in sportsmen who use
their arm to throw in overhead sports
like cricket, Javelin, volley ball. In
these sportsmen, the joint may not dislocate
frankly but there is a dead arm feeling
or pain. The fielder in cricket, who suffers
from pain and has to throw the ball in
from the boundary in an overhead manner,
avoids this and instead throws it in underarm.
Instability commonly occurs in a front
ward direction but can occur to the back
or in more than one direction (multi directional).
These are less common. Instability towards
the front and back needs surgical stabilization
by preferably, arthroscopic means. However
multidirectional instability (in more
than one direction) is best treated by
a rehabilitation process.
2) Tendonitis and impingement-
Tendonitis refers to an inflammation
of tendons surrounding the shoulder. The
rotator cuff or the biceps tendons can
get inflamed due to overload/fatigue,
trauma and age related degenerative changes.
Swelling and crowding of the tendons underneath
the bony arch can lead to a condition
called impingement. In this condition,
pain is felt during overhead activities.
Night pain is present in advanced cases
by lying on the affected shoulder.
Impingement is a phenomenon in which
the rotator cuff (group of tendons) rubs
against the undersurface of the bony acromion
(crow like) projection of the shoulder
blade. Tendons which are weakened by tears
do not function efficiently to stabilize
the arm bone which migrates upwards to
squeeze the already damaged tendons under
the overhead bony arch. It can be due
to weakness of the rotator cuff as above
or be due to instability. In instability
the stretching of the capsule permits
the ball to migrate upward once again
causing impingement. Differentiation between
instability and impingement can be difficult
and clinical acumen is needed. Internal
impingement occurs in baseball pitchers
as in the picture where the arm is cocked
back for throwing.
3) Rotator cuff tears -
In the young patient tears of the rotator
cuff are due to trauma. In the older person,
tears are due to degeneration like grey
hair. Tears result in weakness and pain
during overhead activities. Usually these
tears have poor capacity to heal spontaneously
and need to be repaired particularly in
the young sportsman. In the older patient
a trial of conservative treatment with
analgesics and one or two cortico-steroid
injections may be useful before embarking
on surgery.
4) Acromio - clavicular joint injuries-
This joint is formed at the outer end
of the collar bone as it joins the shoulder
blade. Dislocation results after a fall
on the shoulder. It leads to a separation
of the collar bone from the shoulder blade
and upward prominence of the collar bone.
Pain and deformity result. While the minor
varieties can be treated conservatively,
surgery is necessary for the major types.
5) Labral tears-
The labrum is a circular band of cartilage
attached to the glenoid cavity (socket)
to make it deeper. It can be torn in sportsmen
who use the arm for throwing, serving,
smashing; swimming etc. Pain is felt toward
the front of the shoulder. The other symptoms
may be clicking or locking. There may
be associated instability, rotator cuff
partial tears. Arthroscopic surgery is
the only option. All associated abnormalities
should be addressed simultaneously.
6) Muscle ruptures-
These occur due to their sudden contraction
against an unexpected resistance. The
common muscles ruptured are the Pectoralis
major which is located at the front wall
of the arm pit and the biceps.
7)Nerve injuries-
They may be associated with a shoulder
dislocation, or may occur due to traction
on the brachial plexus, leading to complete
or partial paralysis of the upper extremity.
Brachial plexus injuries in most cases
are temporary injuries, however may need
investigation by an electromyogram.
Diagnosis and management of shoulder
injuries in sportsmen is best done by
an Orthopaedic surgeon treating these
problems and exposed to arthroscopic surgery.
A physiotherapist, rehabilitation expert
and sports psychologist also have their
important role to play to rehabilitate
these sportspersons and make them return
to competitive sport. Such skilled manpower
and equipment exists in India and vast
amounts of money need not be spent on
overseas treatment.
Dr.A.K.Venkatachalam
Consultant orthopaedic surgeon
Venkataeswara hospital
Chennai,India
Tel 00 91 44 24912905, 00 91 9282165002.
http://www.kneeindia.com
http://www.shoulderindia.com
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