Injuries in Athletes

Fig. 6.1

Illustrations of (a) a Bankart tear and Hill-Sachs lesion with shoulder dislocation viewed from above (b) Bony Bankart lesion (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

The physical examination reveals protrusion of the humeral head on the anterior aspect of the shoulder and sunken skin just below acromion. It is may be accompanied by an axillary nerve injury which is easily diagnosed by assessing paresthesia over the lateral deltoid skin area.

Before reducing the dislocation, plain radiographs should be taken to ensure an accurate diagnosis (Fig. 6.2). A prompt reduction is easier and non-steroidal anti-inflammatory drugs (NSAIDs) or muscle relaxants can be prescribed to make patients more comfortable. There are a number of described reduction techniques. Our preference is the Stimson manoeuvre [4] which is considered a safe reduction method (Fig. 6.3).

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Anterior shoulder dislocation on plain radiograph

../images/473070_1_En_6_Chapter/473070_1_En_6_Fig3_HTML.jpg — Fig. 6.3

Stimson manoeuvre (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

Once reduction is achieved, an arm sling is applied for comfort for 2–3 weeks. Although controversial, some papers report that internal rotation of the arm can aggravate a Bankart lesion, so we feel that an arm sling is beneficial after reducing the shoulder dislocation.

Anterior dislocation of the shoulder can be treated in several ways. However, most physicians start with immediate isometric exercises to strengthen internal rotation. After 3 weeks, the patient is allowed to perform active external rotation, while abduction is not permitted until 6 weeks.

Editor’s Note

The longitudinal studies by Hovelius et al. [5] found that sling immobilisation did not alter the outcome of non-operatively managed dislocations and so many surgeons would advocate early movement and rehabilitation of dynamic stabilisation with specialist physiotherapy.

Young athletes in their teens and twenties have a greater tendency to re-dislocate after a first traumatic dislocation. Therefore, surgery can be considered in young athletes. The surgical treatment of choice is an arthroscopic Bankart repair. Twenty-four hours postoperatively, pendulum exercises are allowed and an abduction sling is applied for 4–6 weeks. To minimise anterior capsule contracture, the sling is applied with the shoulder in slight abduction and external rotation. After 6 weeks, active muscle strengthening is allowed; minor sports activities can be started at 3–4 months. The athlete can return to full activities at 6 months.

6.3 Anterior Instability (Recurrent Anterior Dislocation)

Anterior instability implies that there has been damage to the anteroinferior glenohumeral ligament, leading to dislocation or subluxation. A good analogy is to consider the shoulder as a golf ball on a tee; it is easily knocked off (or dislocated) with trauma. Anterior instability usually arises from acute dislocation and its prevalence is high in people in their teens and twenties. Most of the instability occurs within 2 years of a traumatic dislocation [6], and arm abduction, external rotation, and extension position can lead to dislocation. With frequent dislocation, some patients can reduce their shoulder themselves by using traction and rotation.

Bankart (anteroinferior glenoid labral tear) and Hill–Sachs lesions are common pathologies in anterior instability of the shoulder.

A detailed description of the first dislocation event is essential, including the nature of the trauma, the arm position during the trauma, and the method of reduction and rehabilitation protocol. With anterior instability, patients fear anterior dislocation on abduction and external rotation, which makes the physical examination difficult. It is important to identify generalised hyperlaxity. The Beighton score metacarpophalangeal dorsiflexion, the distance from the thumb to the forearm with wrist flexion, elbow hyperflexion, and genu recurvatum must be measured [7]. The findings should be compared with those of the contralateral side.

6.3.1 Examination

Differential shoulder laxity can be assessed with the drawer tests and sulcus test.

Drawer Test

With the patient sitting and resting, the surgeon holds the scapula with one hand and the humerus head and neck with the other. Then, the surgeon moves the humerus anteriorly (Fig. 6.4): Grade 0 is no translation; Grade 1 is translation just before the glenoid rim; Grade 2 is translation on the glenoid rim; and Grade 3 is translation past the glenoid rim.

../images/473070_1_En_6_Chapter/473070_1_En_6_Fig4_HTML.png — Fig. 6.4

Anterior drawer test (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

Sulcus Test

With the patient sitting and the arm in internal rotation, traction is applied to the arm (Fig. 6.5). Sunken skin between the acromion and humeral head is a positive sign. In a non-pathological shoulder, with the arm in external rotation, the sulcus sign disappears. A positive sulcus sign means that there is laxity of rotator interval: 1+ means subluxation <1 cm; 2+ means subluxation of 1–2 cm; and 3+ means subluxation >2 cm.

../images/473070_1_En_6_Chapter/473070_1_En_6_Fig5_HTML.png — Fig. 6.5

Sulcus test (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

Several apprehension tests are used to diagnose anterior instability of the shoulder.

Crank Test

With the patient sitting and resting, the surgeon holds the scapula with one hand and the arm with the other. Then, the arm is slowly abducted, externally rotated, and extended (Fig. 6.6). If the patient suffers pain or fears dislocation, the test is positive. This is called the fulcrum test when performed with the patient in the supine position.

../images/473070_1_En_6_Chapter/473070_1_En_6_Fig6_HTML.jpg — Fig. 6.6

Crank test (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

Relocation Test

After the fulcrum test, press the humerus back into the glenoid. If the patient’s pain and anxiety are relieved, the sign is positive.

6.3.2 Imaging

Bony Bankart and Hill–Sachs lesions may be seen on plain radiographs. True anteroposterior (AP), apico-oblique, axillary lateral, West Point, and Stryker notch views should be obtained. The West Point and apico-oblique views reveal glenoid rim erosion, bone defects, and bony Bankart lesions; the Stryker notch view reveals Hill–Sachs lesions; and the axillary lateral view reveals the relationship between the glenoid and humeral head and articular surface. More detailed imaging such as magnetic resonance (MR) arthrogram or CT arthrogram will give a better representation of soft tissue injuries, particularly labral tears. Bony lesions are better visualized on CT.

There are several types of glenoid labrum lesions (Fig. 6.7):

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Variants of labral tears (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

6.3.3 Treatment

Although there is some controversy over the use of surgical treatment for dislocation in young athletes, non-active patients are managed conservatively. There is no relationship between prolonged immobilisation and recurrent dislocation. Typically, after 3 months of isometric exercise, active muscle strengthening exercises are started. At 6 months, all sports activities are allowed.

If pain, loss of range of motion, and high recurrent dislocation rates persist with non-operative rehabilitation, surgeons should consider operative treatment. The arthroscopic Bankart repair (Fig. 6.8) is the gold standard for treating anterior instability and the reported outcome is similar to that of open surgery [8]. After a Bankart repair, if laxity of the inferior capsule is present, then an inferior capsular shift should be performed. For a large bony Bankart lesion or a large glenoid rim defect, the bone transfer Latarjet) procedure is done [9]. Recent studies show that while a small Hill–Sachs lesion requires no direct treatment, a large Hill–Sachs lesion requires a remplissage procedure [10]. Postoperatively, minor sports activity starts at 3 months and a return to full competition is allowed at 6 months.