Edmund S. Evangelista, MD
The shoulder is made up of two main joints: the glenohumeral joint, which is the “ball and socket,” and the acromioclavicular joint, which is the smaller joint above the glenohumeral joint. All athletes are prone to shoulder injuries from both direct trauma and overuse. Throwing athletes and those performing repetitive overhead motions (e.g., swimmers, volleyball players) are especially prone to shoulder injuries caused by repetitive forces transmitted through the joint. In this chapter we review some of the common shoulder injuries encountered by athletes.
Most shoulder injuries can be treated conservatively. As described throughout the chapter, treatment principles for all shoulder injuries include relative rest and avoidance of the offending activity, decreasing pain and inflammation with ice and anti-inflammatory medications (if appropriate), restoring full pain-free range of motion, and strengthening of the shoulder, especially the rotator cuff muscles, which are the most important dynamic shoulder stabilizers. If an athlete experiences any of the following signs and symptoms after a shoulder injury, medical attention is required:
- Significant or persistent pain or deformity
- Persistent numbness or tingling
- Noticeable weakness or muscle wasting of the shoulder
- Inability to move the arm or shoulder
- Persistent or worsening pain despite conservative treatment
Recurrent Shoulder Dislocation
Acromioclavicular Joint Injury
Rotator Cuff Tear
Biceps Tendon Rupture
Suprascapular Nerve Injury
Deep Vein Thrombosis
Fractures of the collarbone, or clavicle, are among the most common fractures encountered in contact or collision sports such as American football, rugby, lacrosse, wrestling, and hockey. These injuries typically occur following a direct blow to the clavicle during contact or following a fall onto the top of the shoulder.
Following the injury, the athlete will complain of pain at the fracture site and might be unable to move the arm because of pain. Look for swelling and an obvious deformity at the fracture site. Tenting of the skin below the fracture might occur if the displacement is significant (i.e., if one end of the fractured bone moves away from the other end).
If a clavicle fracture is suspected on the field, keep the arm of the injured side against the body and immobilized until the athlete is evaluated by a physician. X-rays will confirm the diagnosis of a clavicle fracture. The majority of clavicle fractures are treated conservatively. Treatment includes immobilization with a figure-of-eight brace or a simple sling. Use ice and over-the-counter pain medications as needed for comfort. After three to four weeks, once healing is noted on a follow-up X-ray, the athlete may begin gentle range-of-motion exercises and eventually progress to light strengthening as pain allows. Most clavicle fractures heal uneventfully with conservative treatment. However, surgery may be considered for fractures where the ends are not aligned or are in multiple fragments. Recent studies suggest that clavicle fractures where the ends are displaced or shortened by more than 0.8 inches (2 cm) may heal better with surgical treatment compared to conservative treatment.
Return to Action
Athletes may usually return to noncontact sports after six to eight weeks if the fracture shows healing on X-rays and if they have full pain-free range of motion and full strength about the shoulder. Avoid contact sports until after 12 weeks. Most will have a residual deformity or bump at the healed fracture site. Use donut padding over the healed fracture site for comfort and protection when returning to contact sports.
Most shoulder dislocations are caused by a forceful blow to the front of the shoulder or arm when the arm is outstretched or overhead. Such a blow can occur during a fall to the ground, during a collision with an object or another player, or during a tackle. Dislocation is common in sports such as American football, rugby, wrestling, and skiing.
When the athlete’s arm is stopped but the rest of the body continues to move forward, tremendous force is created across the shoulder joint. This force can result in the “ball” (humeral head or top of the humerus bone) slipping out of the “socket” (glenoid fossa, which is part of the scapula), resulting in a shoulder dislocation. Athletes with a long history of participation in sports involving repetitive overhead motions or throwing, such as swimming, volleyball, or baseball, are more prone to suffering shoulder dislocation. The repetitive stretching of the shoulder’s capsule and ligaments that occurs over time causes the shoulder to become loose or unstable.
Following a shoulder dislocation, athletes usually complain of immediate pain with inability to move the shoulder or arm. They might report that the shoulder has “popped” out of place. A deformity might be visible, with prominence of the acromion (the upper part of the scapula that forms the roof of the shoulder, sometimes called the point of the shoulder), and there may be a depression in the skin beneath it suggesting a dislocation.
During a shoulder dislocation, the shoulder capsule and glenohumeral ligaments, which hold the shoulder in place, are torn, stretched, or both. There might also be detachment of the labrum (the anchor point for the shoulder capsule and ligaments) from the shoulder socket (glenoid fossa). Occasionally, other structures around the shoulder, such as the rotator cuff muscles or the surrounding nerves, are injured due to the dislocation. Associated fractures can also occur during a shoulder dislocation, especially in older athletes. Greater tuberosity fractures have been reported to occur in up to a third of anterior shoulder dislocations. The vast majority of dislocations are anterior dislocations, in which the humeral head slips out through the front of the shoulder but, depending on the position of the arm at the time of trauma, the humeral head might slip from the socket toward the back, producing a posterior dislocation.
Initial management of an acute shoulder dislocation requires putting the displaced humeral head back into place (placing the humeral head back into the socket), also known as a shoulder reduction. Shoulder reductions can often be done on the field (or court) by an experienced physician or athletic trainer. When the shoulder cannot be reduced on the field, the arm and shoulder must be immobilized while the athlete is transported to an emergency room, where X-rays can rule out an associated fracture and ensure that the shoulder is placed back into normal anatomic position. If you can’t feel the pulse near the wrist on the side of the dislocated shoulder (and you can feel one near the other wrist), this is a medical emergency and the athlete must be transported immediately to a local emergency room.
Once the shoulder dislocation is reduced, all first-time “dislocators” should have their arm and shoulder immobilized in a sling or brace for three to four weeks to allow for adequate healing. A shorter period of immobilization (one to two weeks) is recommended for older athletes (over 40) to prevent joint stiffness and development of an adhesive capsulitis (“frozen shoulder”). For anterior dislocations, research suggests immobilization in braces that keep the arm and shoulder rotated away from the body in order to obtain better healing of the shoulder structures and decrease the likelihood of future dislocations. However, this is somewhat controversial, because a more recent study showed no difference in outcome in patients immobilized in a brace holding the arm and shoulder rotated away from the body compared to patients immobilized in a sling following an anterior dislocation. Hence, determining the most appropriate method of immobilization following a dislocation should be discussed with the athlete’s physician. Associated greater tuberosity fractures are usually treated conservatively with immobilization in a sling for four weeks. However, when a fracture shows significant displacement (greater than 0.2 inches, or 0.5 cm) from its normal anatomic position, surgery may be recommended.
Following an appropriate period of immobilization, the athlete begins physical therapy to restore range of motion and strength in preparation for a return to play. Strengthening the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) is critically important in treating all shoulder disorders, and this is especially true for shoulder instability. These muscles are the dynamic stabilizers of the shoulder joint and help prevent recurrent dislocations by holding the humeral head in place within the socket. Strengthening of the scapular stabilizing muscles (serratus anterior, rhomboids, trapezius, and levator scapulae) is also very important for shoulder stability, because these muscles function to rotate the scapula and glenoid fossa (shoulder socket) in the correct position during shoulder motion. Additionally, the muscles along the spine, the paraspinal muscles, play a role in shoulder function, and strengthening exercises geared toward these muscles such as trunk rotations and prone leg lifts are also recommended.
Return to Action
Athletic arm activity should be restricted until the athlete has attained full pain-free range of motion and full strength of the muscles surrounding the shoulder. Depending on their sport, athletes may usually return to play within 8 to 12 weeks. When returning, they might wear a shoulder brace to protect the shoulder from another dislocation. Unfortunately, these braces work by restricting motion, so performance is affected.
RECURRENT SHOULDER DISLOCATION
Recurrent shoulder dislocations are caused by the same mechanisms as initial shoulder dislocations. However, athletes who have suffered previous dislocations might be prone to recurrent episodes due to only minimal trauma.
A recurrent shoulder dislocation looks about the same as an initial dislocation, but the pain might be less severe, and in some cases, athletes can reduce the dislocation on their own. Many factors contribute to the risk for developing recurrent shoulder dislocations, including age, activity level, and structural abnormalities of the shoulder following an initial dislocation. A traumatic dislocation can lead to permanent stretching of the shoulder capsule and glenohumeral ligaments. There might also be permanent detachment of the glenoid labrum, which is the dense cartilage-like rim surrounding the outer edge of the shoulder socket (glenoid) that serves as the anchor point of the shoulder capsule and ligaments; this detachment is also known as a Bankart lesion. In patients with recurrent shoulder dislocations, an MR arthrogram (magnetic resonance imaging (MRI) with contrast in the joint) is the best imaging study to assess for structural issues in the shoulder, such as a labral detachment, that could be contributing to instability. Athletes involved in repetitive overhead activities might develop stretching of shoulder capsule and ligaments over time, making the shoulder loose or unstable. These structural deficiencies predispose an athlete to recurrent shoulder dislocations or shoulder instability.
Many studies have shown that the likelihood of recurrent dislocations is very high in young athletes, especially those involved in high-risk activities such as collision or contact sports. Researchers believe that failing to properly heal Bankart lesions, in addition to the high activity level in this population, contributes to the high incidence of recurrent dislocation. The inherent laxity or looseness of the shoulder capsule and ligaments, more common in young athletes, might also play a role.
Initial treatment for a recurrent shoulder dislocation involves a period of relative rest, varying from a few days to four weeks, depending on the extent of the injury and the athlete’s symptoms. A prolonged period of immobilization is typically not as necessary as for an acute first-time dislocation because athletes with recurring dislocations often have structural abnormalities that probably will not heal with additional immobilization.
In addition to restoring full pain-free range of motion, three options exist for managing recurrent shoulder instability. First, through diligent exercise, an athlete can try to optimize the strength and condition of the dynamic shoulder stabilizers (i.e., the rotator cuff muscles and scapular stabilizers) to help prevent the shoulder from dislocating. This is especially important in “loose-jointed” athletes who have recurrent instability or dislocations not related to an initial traumatic event. These athletes have a better chance of responding to a prolonged rehabilitation and strengthening program that might take up to six months. Second, the athlete can avoid sports that carry a higher risk for dislocation (collision and contact sports). Doing so can dramatically decrease the risk of a recurrent dislocation.
However, if athletes continue to have dislocations despite conservative measures and still wish to participate in collision or contact sports, a third option is available. They can opt for surgical correction of the injured shoulder structures to prevent further dislocations. Surgery might include reattachment of the detached labrum and tightening of the shoulder capsule.
Return to Action
Following a recurrent shoulder dislocation, athletes may return to play once they have attained full pain-free range of motion and full strength in the muscles surrounding the shoulder. This might take a few days to several weeks depending on the extent of the injury, the athlete’s symptoms, and the sport. Prolonged immobilization is usually not necessary as is the case for first-time dislocations. Athletes might consider using special shoulder braces that prevent arm positions that increase the likelihood of dislocation. As noted previously, however, these braces might not be acceptable to the athlete. If athletes opt for shoulder stabilization surgery, they will usually not return to play for approximately six months, depending on the sport.
Because of the risk of recurrent dislocations, especially in young athletes involved in high-risk sports, the decision to return to play should be seriously considered. Athletes who continue to suffer shoulder dislocations can cause further injury to the structures of the shoulder, including the capsule, ligaments, rotator cuff, cartilage, and even nerves about the shoulder. Over time, repetitive injury to these structures can lead to persistent pain, stiffness, loss of motion, and early arthritis.
A shoulder subluxation occurs when the humeral head slips partially out of the socket, but not completely out as in a shoulder dislocation. Shoulder subluxations are much more common in younger athletes, especially those who are loose jointed. Athletes with a long history of participation in sports involving throwing or repetitive overhead motions such as baseball, softball, volleyball, water polo, or swimming are predisposed because of the repetitive stretching of the shoulder capsule and glenohumeral ligaments that occurs over time. When the shoulder capsule and ligaments become stretched and loose, they can no longer adequately stabilize the joint, especially during overhead sports, which transmit high amounts of forces across the joint. Thus, the humeral head has a higher likelihood of slipping out of the shoulder socket. Collision and contact sports such as American football, rugby, hockey, or wrestling can also lead to shoulder subluxations.
Athletes with shoulder subluxations might have a variety of symptoms. Some might say their shoulder joint feels loose and briefly slips out of place during activity. Others might feel only pain during certain activities. Some have a transient numbness or tingling sensation down the arm (“dead arm syndrome”). Some develop symptoms following an initial traumatic event, but many develop symptoms gradually without any trauma.
Whereas some athletes might have mild instability and subluxations with only minimal or no pain, other athletes can develop pain that inhibits them from playing. Pain results from the repetitive subluxation that leads to irritation and inflammation of the shoulder structures, including the capsule, labrum, bursa, and rotator cuff tendons. As the humeral head slips out of the glenoid, the shoulder structures (especially the bursa and rotator cuff tendons) can get impinged underneath the roof of the shoulder (the acromion), leading to further inflammation and pain.
In cases of an acute first-time shoulder subluxation caused by a traumatic event, immobilization in a sling or brace for up to four weeks might be necessary to allow healing of the injured shoulder structures (shoulder capsule, ligaments). In nontraumatic cases related to repetitive overhead activities or throwing, immobilization is usually not required. In these cases, the athlete should rest and avoid throwing and overhead activities until pain and inflammation subside. Icing, anti-inflammatory medications, and physical therapy can help reduce pain and inflammation and restore full pain-free range of motion.
The next step in managing the injury is a structured rehabilitation program that focuses on correcting muscle imbalances and strengthening the dynamic shoulder stabilizing muscles, specifically the rotator cuff and scapular stabilizing muscles. Optimizing the strength of these muscles can stabilize the joint by helping to hold the humeral head within the glenoid, thus compensating for the loose, stretched shoulder capsule and ligaments commonly found in athletes with subluxations. Many athletes develop muscle imbalances about the shoulder because of repetitive stresses placed across the joint, which allow certain areas to get overly stretched or strong while other areas get tight or weak. Correcting these imbalances can lead to better stabilization across the shoulder joint and decrease the risk of recurrent subluxations. A structured rehabilitation program, which may last up to six months, is often successful in athletes with subluxations, especially those not related to trauma.
Along with focusing on strengthening the shoulder, technique should also be addressed (see Return to Action further on), as should the condition of other areas of the body that might affect the stress and forces transmitted through the shoulder. By correcting technique and correcting deficiencies in other areas of the body used in the sport, the athlete might be able to reduce undue stress across the shoulder.
Athletes who continue to suffer from recurrent shoulder subluxation despite extensive conservative management might need to consider giving up their sport or consider surgery to tighten the ligaments of the shoulder capsule.
Return to Action
Time required before returning to play varies from a few days up to several weeks, depending on the athlete’s symptoms, the extent of injury, and the sport. Because acute first-time shoulder subluxations caused by trauma are usually treated with a period of immobilization followed by gradual range-of-motion and strengthening exercises, it might take 6 to 12 weeks to return to action.
However, athletes who have recurrent nontraumatic subluxations might be able to gradually return to sport sooner once they have attained full pain-free range of motion and full strength in the muscles surrounding the shoulder. Athletes should stop participating if symptoms recur. In some cases, they will need to modify their participation to prevent recurrence of symptoms. For example, a swimmer might eliminate certain strokes or events, a pitcher might limit the number of pitches thrown, and a volleyball player might move to the back line to avoid the repetitive overhead motion. Athletes might also benefit from modifying technique once they return to play. For example, baseball pitchers obtain much of the power in their throw from their hips and trunk. If they lose power in the throw because of deficiencies in technique or an under-reliance on the hips and trunk, they might try to compensate by overloading the shoulder. Improving technique and throwing mechanics can help reduce undue stress across the shoulder joint.
The glenoid labrum is the dense cartilage-like rim that surrounds the shoulder socket (glenoid) and serves as the anchor point for the shoulder capsule and ligaments that help stabilize the shoulder. Injuries to the labrum are common in sports in which the athlete sustains shoulder subluxations and dislocations, such as collision or contact sports (American football or rugby), throwing sports (baseball or softball), sports involving repetitive overhead motions (swimming or volleyball), or sports in which athletes might fall to the ground onto the shoulder or arm. A traction-type injury to the shoulder and arm, such as can occur when holding the rope while water skiing, can also produce an injury to the labrum.
When the humeral head slips partially or completely out of the glenoid, a tearing or detaching of the labrum can result. The long head of the biceps tendon attaches to the superior part of the labrum, and repetitive traction to this area from the throwing motion can cause a strain or detachment of the superior labrum, also known as a SLAP (superior labrum, anterior to posterior) lesion. Detachment of the anterior–inferior portion of the labrum is known as a Bankart lesion and commonly occurs after an anterior shoulder dislocation.
Athletes with labral injuries or tears might complain of deep, ill-defined shoulder pain with an associated painful clicking, popping, or catching sensation. Some might have symptoms that start after an initial traumatic event, but many symptoms occur gradually and might be chronic by the time the athlete seeks professional advice. Pain might be reproduced with the throwing motion or when reaching overhead, which can make a labral tear difficult to distinguish from shoulder impingement symptoms. The diagnosis of a labral tear is made by MRI or during surgery. An MRI with contrast in the shoulder joint (MR arthrogram) is more accurate in identifying a labral tear or detachment, compared to an MRI without contrast. The symptoms from a labral tear are usually caused by the labrum getting caught in the glenohumeral joint during motion. In addition to pain, the athlete might have recurrent subluxations or dislocations caused by more significant labral injuries, such as a Bankart lesion that has not healed.
The management of labral injuries caused by shoulder dislocations, recurrent dislocations, or subluxations follows the same guidelines as prescribed for those injuries (see pp. 106-111). Because pain from a labral injury can be difficult to distinguish from the pain of shoulder impingement, treatment for a possible underlying shoulder impingement should also be considered, including a trial of physical therapy and a possible cortisone injection. An athlete with persistent pain or instability symptoms related to a labral injury or detachment that has been unresponsive to conservative treatment might consider surgery. If a labral tear has not healed initially, it is unlikely to heal over time. If the athlete is unable to live with the symptoms, surgical debridement or repair of the torn labrum should be considered.
Return to Action
For labral injuries resulting from shoulder dislocations, recurrent shoulder dislocations, or shoulder subluxations, see the return-to-action guidelines for these injuries on pages 106-111. For painful labral injuries treated conservatively, gradual return to sport may be initiated once the athlete has attained full pain-free range of motion and full strength about the injured shoulder. Depending on the severity of the injury, degree of symptoms, and the sport, a full return might take a few days up to several weeks. Taping or bracing is usually not helpful for painful labral injuries. Participation in sport might need to be modified to avoid painful motions. For example, a tennis player might avoid a painful overhead serve, or a weightlifter might steer clear of certain exercises at the gym. If a labral tear is continually aggravated or stressed through participation in sports or activities, the injury could become worse, resulting in more painful symptoms and the possibility of surgery.
ACROMIOCLAVICULAR JOINT INJURY
Acromioclavicular (AC) joint injuries are common in contact or collision sports such as American football, rugby, hockey, or lacrosse. The injury typically occurs during a fall directly onto the acromion, or the point of the shoulder. It can also occur when an athlete sustains a direct blow on top of the shoulder when trying to tackle or hit another player.
An AC joint injury is also known as an AC joint sprain, AC joint separation, or shoulder separation. This type of injury involves a disruption to the joint formed between the end of the clavicle (collarbone) and the acromion. The primary ligaments that stabilize the joint, the AC and coracoclavicular (CC) ligaments, are stretched or torn. Athletes with this injury usually have pain and swelling directly over the AC joint and difficulty raising the arm overhead. An obvious deformity might also be present caused by the separation of the acromion and clavicle. This separation is known as a “step-off deformity.”
Acromioclavicular joint injuries can be classified as one of six types depending on the severity of the injury. Type I is a mild sprain of the AC ligaments that does not result in any separation of the clavicle from the acromion. In a type II injury, the AC ligaments are torn and CC ligaments are sprained, which results in partial separation of the clavicle from the acromion. In a type III injury, the AC and CC ligaments are completely torn, resulting in complete separation of the clavicle from the acromion. Type IV through VI injuries are uncommon and involve complete tears of the AC and CC ligaments with more severe displacement of the clavicle in varying locations.
Treatment depends on the degree of the injury. Most AC joint injuries are type I or type II and are treated conservatively. Type III injuries can also be treated conservatively, but surgery may be considered in high-level athletes or if the athlete remains symptomatic despite conservative care. Type IV through VI injuries are treated surgically. When a step-off deformity is present, X-rays can assess the degree of separation and rule out an underlying collarbone fracture. Conservative management includes ice and anti-inflammatory medications, which can help reduce pain and inflammation. Short-term immobilization in a sling can be used for comfort, followed by gentle range-of-motion exercises as pain allows. After AC joint separations, a deformity with a bump at the AC joint often persists even after healing. This deformity is usually cosmetic with no related pain or symptoms.
Return to Action
In general, athletes may return to sport once they have achieved full pain-free range of motion and full strength in the muscles surrounding the shoulder. Athletes with type I injuries can typically return to sport within one to two weeks, and those with type II injuries usually return within two to four weeks. Those with type III injuries take a longer time to recover to allow for healing of the injured ligaments, and may not return to sport for 6 to 12 weeks. Use foam padding or a donut cushion over the AC joint for extra protection and comfort when returning to contact sports. Athletes who have recurring injuries to the AC joint might develop early arthritis in the joint.
ROTATOR CUFF TEAR
The rotator cuff muscles and tendons originate on the scapula and attach onto the humeral head. There are four groups of rotator cuff muscles and tendons, including the supraspinatus on top, the infraspinatus and teres minor in the back, and the subscapularis in the front. The rotator cuff assists with movement of the shoulder and is also critical in helping to stabilize the humeral head within the glenoid. Rotator cuff tears usually occur in athletes over age 40 who have a long history of participation in repetitive overhead sports such as swimming, surfing, volleyball, or throwing sports. A fall or a direct blow to the shoulder during any sport can cause acute tearing or straining of the rotator cuff in such athletes. Several factors are thought to contribute to the development of rotator cuff tears. Many believe they result from repeated episodes of impingement. Over time, repeated inflammation and irritation of the rotator cuff can cause the cuff to tear. Other factors possibly contributing to tearing include repetitive microtrauma and overuse, degeneration of the cuff from aging, poor circulation to the rotator cuff tendon, and acute injury superimposed on chronic cuff degeneration. Rotator cuff tears typically occur in the outer aspect of the tendon near its attachment to the humerus. The supraspinatus tendon of the rotator cuff is the tendon most commonly torn.
Rotator cuff tear symptoms are similar to symptoms of impingement, rotator cuff tendinitis, or bursitis. Athletes have pain in the front or side of the shoulder that is aggravated by reaching or overhead activities. With smaller tears, weakness might not be apparent. With larger tears, weakness can be prominent. With massive tears, the athlete might be unable to elevate the arm from the side. Athletes with rotator cuff tears are typically over age 40 and might have a past history of recurrent episodes of rotator cuff tendinitis or bursitis. Pain might start suddenly after a precipitating event or occur gradually with no obvious cause. Severity of pain varies from minimal to severe. Magnetic resonance imaging is the best imaging study to identify the location and extent of a rotator cuff tear. Studies have shown that some people with rotator cuff tears that show up on MRI may have no symptoms whatsoever, especially adults over the age of 60.
Treatment varies depending on the athlete’s age, level of function, size of the tear, weakness, and pain. Larger tears in younger athletes who are very active might require early surgery. Otherwise, most rotator cuff tears can be treated conservatively. Conservative treatment is identical to the treatment of athletes with shoulder impingement, rotator cuff tendinitis, and bursitis: relative rest, reducing pain and inflammation, restoring full pain-free range of motion, and progressing the athlete to a strengthening program for the rotator cuff and surrounding shoulder muscles. Although spontaneous healing of the rotator cuff tear is unlikely to occur over time, conservative treatment is still very successful in allowing most athletes to return to their sport with minimal or no pain.
Another emerging nonsurgical treatment option for rotator cuff tears is injection into the torn tendon with platelet-rich plasma (PRP). Platelet-rich plasma is a concentrated sample of the athlete’s blood containing a high number of platelets. Platelets are the cells in our blood that contain numerous growth factors that are important for healing. Platelet-rich plasma is created in an office setting after a simple blood draw. The athlete’s blood is placed in a centrifuge to concentrate the platelets, creating PRP. The PRP is then injected directly into the tendon injury or tear to stimulate healing. Typically, ultrasound is used to guide the injection directly into the rotator cuff tear. Studies have shown that PRP can improve pain and function in people with partial rotator cuff tears or tendon injuries.
If symptoms persist despite conservative treatment, surgery might be necessary. Surgery might include repair of the torn rotator cuff tendon and a subacromial decompression to shave off arthritic bone and spurs to allow more room for the rotator cuff to travel.
Return to Action
After treatment, athletes may gradually return to their sport once they have full pain-free range of motion and full strength in the injured shoulder. Return time depends on the size of the tear, the athlete’s symptoms, degree of weakness, and the sport. A full return often takes up to three months. If symptoms recur, stop participation. Taping or bracing is usually unnecessary on return. Athletes might need to adjust their participation or technique to avoid recurring symptoms. Athletes who undergo surgical repair of a torn rotator cuff usually cannot return for at least six months.
Shoulder impingement is common in sports that involve repetitive overhead motions or throwing, such as swimming, surfing, baseball, softball, water polo, and volleyball. During normal shoulder motion, the rotator cuff travels smoothly beneath the acromion in the subacromial space (the space between the acromion and humeral head). Additionally, the subacromial bursa, a small fluid-filled sac that lies on top of the rotator cuff, helps the rotator cuff travel smoothly beneath the acromion and AC joint. In shoulder impingement, however, the rotator cuff and bursa get pinched or impinged underneath the acromion during overhead activities, resulting in pain.
Several factors can contribute to shoulder impingement. Structural or anatomic abnormalities might result in a narrower subacromial space. For example, some people are born with a curved or hook-shaped acromion that narrows the subacromial space. With aging, development of AC joint arthritis and bony spurs underneath the acromion can also narrow the subacromial space. The less room there is for the rotator cuff and bursa to travel, the more likely it is that these structures get pinched during shoulder motion.
A second factor is inflammation. Overuse or repetitive irritation of the rotator cuff underneath the acromion can lead to inflammation and swelling of the rotator cuff tendons and overlying bursa (tendinitis and bursitis). Not only are the inflamed tendons and bursa painful, but pain is aggravated when these inflamed and swollen structures get pinched or impinged underneath the acromion during overhead motions.
A third factor is shoulder instability, especially in young athletes. If the structures of the shoulder are ineffective in stabilizing the humeral head within the socket (glenoid fossa) during overhead motions, the humeral head might migrate upward out of the socket, causing impingement. Underlying shoulder instability is likely a primary cause of impingement symptoms in young athletes.
Shoulder impingement is an extremely common condition that affects athletes of all ages. Athletes typically experience gradual pain in the front or side of the shoulder that is aggravated by reaching or overhead activities. Sometimes the pain radiates down into the upper arm. They might have decreased range of motion and subjective weakness with difficulty raising the arm overhead or behind the back. Night pain and difficulty sleeping on the affected shoulder are also common.
Repeated impingement usually leads to rotator cuff tendinitis (inflammation of the rotator cuff tendons) and bursitis (inflammation of the subacromial bursa that overlies the rotator cuff). Again, these two conditions can aggravate the impingement symptoms.
Athletes can begin treating shoulder impingement at home. They should avoid repetitive overhead activities and other aggravating activities until pain and inflammation subside. Anti-inflammatory medications (e.g., ibuprofen) and ice might also be helpful in reducing pain and inflammation. Early in treatment, athletes should begin range-of-motion exercises to help restore normal pain-free motion, and progress exercise as pain allows.
If symptoms persist despite initial treatment, formal physical therapy might be needed to assist in decreasing inflammation and pain through electrical stimulation, ultrasound, or other modalities. A cortisone injection into the subacromial bursa can be a quick, effective way to reduce pain and inflammation. Eventually, all athletes should begin a shoulder strengthening program with attention to the rotator cuff and scapular stabilizing muscles. This is especially important for younger athletes, in whom impingement symptoms usually involve underlying instability.
Athletes who continue to have disabling symptoms may require surgery to correct underlying structural or anatomic abnormalities causing the impingement. In older athletes, this might involve a subacromial decompression in which arthritic bone and spurs are shaved off the acromion to allow more room for the rotator cuff to travel. In younger athletes, shoulder stabilization surgery might be required to prevent impingement related to underlying instability. If shoulder impingement continues over time, the repeated inflammation and irritation of the rotator cuff might eventually cause the cuff to wear down, degenerate, and tear.
Return to Action
Most athletes improve with conservative treatment and gradually return to sport after attaining full pain-free range of motion and full strength in the muscles surrounding the affected shoulder. Return time varies from a few weeks to a few months, depending on the degree of symptoms, extent of injury, and the sport. Taping or bracing is usually not necessary when returning to play. If symptoms recur, the athlete should stop the sport or painful activity until the sport or activity is no longer painful.
To prevent recurrence of symptoms, athletes might need to limit or avoid certain movements in their sport. They might also benefit from modifying their technique. For example, a thrower might choose to throw sidearm instead of overhead, which might prevent the rotator cuff and bursa from getting impinged underneath the acromion.
BICEPS TENDON RUPTURE
The biceps muscle has two proximal tendons and one distal tendon. By far the most common tendon to be ruptured is the proximal long head of the biceps tendon. This tendon travels up and around the humeral head, through the shoulder joint, and underneath the acromion to attach onto the top of the glenoid (shoulder socket). Rupture of this tendon tends to occur in athletes over 40. It is more common in athletes with a prior history of shoulder impingement or bicipital tendinitis who are involved in repetitive overhead sports such as swimming, surfing, and volleyball or in throwing sports. Ruptures of the proximal biceps tendon usually occur because of its weakening and degeneration over time. Because of its location beneath the acromion (roof of the shoulder), this tendon is predisposed to being pinched during overhead activities, similar to the rotator cuff. Over time, the tendon can get frayed and weak and might eventually tear or rupture.
A biceps tendon can also rupture at its more distal attachment onto the radial tuberosity on the radius of the forearm. But a rupture at this location is far less common than a proximal rupture. Distal biceps tendon ruptures tend to occur in middle-aged “weekend warrior” athletes who are lifting heavy weights.
Typically, athletes with a proximal biceps tendon rupture describe a sudden pain in the shoulder often accompanied by an audible snap or tearing sensation. Within a few days, bruising develops in the biceps area, and a bulge in the lower biceps is apparent. This bulge is accentuated when flexing the biceps muscle (think of Popeye after he’s eaten some spinach). The bulge occurs because the torn biceps tendon and muscle get bunched up into the lower aspect of the upper arm. Sometimes when a proximal biceps tendon rupture occurs acutely, very little pain results, and the injury might even go undetected. Because the other proximal biceps tendon remains attached to the coracoid process in the shoulder, significant weakness is rarely a complaint.
Athletes with a distal biceps tendon rupture might describe a sudden pain in their distal arm and over their elbow. They often say the injury occurred while they were trying to lift a heavy load; they might mention hearing or feeling a snap or pop in their arm. They might also note swelling and bruising at the elbow. Unlike a proximal tendon rupture, a distal rupture usually results in arm weakness.
For most proximal biceps tendon ruptures, treatment is conservative. Because of the intact remaining proximal biceps tendon, and because other muscles assist in flexing the elbow, little loss of function or strength occurs. The cosmetic deformity (loss of the normal biceps muscle contour and the bulge in the lower biceps area) is usually acceptable to most athletes. As needed, over-the-counter anti-inflammatory medications and ice may be used for pain. Range-of-motion exercises followed by gradual strengthening exercises for the shoulder and upper arm may be done as tolerated. Surgical repair of the torn tendon might be considered in younger athletes with high activity levels. Any surgery should be done within a few weeks to prevent retraction of the tendon, making the repair more difficult.
Distal tendon ruptures cause functional impairment. A full-thickness distal tendon biceps rupture almost invariably leads to significant weakness. In active people and athletes wishing to return to sport, surgical repair of the tendon is usually required. If the rupture is incomplete, or if the patient is older and does not need to be physically active, conservative care, including rest, ice, and immobilization, followed by structured physical therapy, is an alternative to surgery.
Return to Action
If treated conservatively, a proximal biceps tendon rupture might allow a return to play within four to six weeks. Before considering a return, athletes should have full pain-free range of motion and close to full strength about the injured shoulder. Taping and bracing are usually not necessary. After a surgically repaired proximal biceps tendon rupture, return to sport takes at least three to six months.
A full-thickness distal biceps tendon rupture, when treated conservatively, makes a return to sport unlikely. If treated surgically, a return can take up to six months. Following surgery, the elbow is typically immobilized for one to two months, followed by two to three months of physical therapy. The athlete should have full pain-free range of motion and close to full strength with elbow flexion and supination before attempting a return to sport.
Bicipital tendinitis (also called biceps tendinitis) is an inflammation of the long head of the biceps tendon as it passes up through the bicipital groove of the humerus (upper-arm bone). Because of its location, the tendon is prone to irritation and inflammation by the same mechanisms that cause shoulder impingement. During overhead motions, the biceps tendon can get pinched or impinged between the humeral head and the acromion, leading to inflammation and pain. This injury is common in sports that involve repetitive overhead motions or throwing, such as swimming, surfing, baseball, softball, water polo, and volleyball. Although most cases of bicipital tendinitis are related to impingement, the inflammation might occasionally be related to primary overuse from repetitive stress placed on the tendon caused by repetitive throwing, overhead hitting, racket sports, or doing arm curls with weights using improper technique.
Athletes with bicipital tendinitis typically complain of gradual pain over the front of the shoulder that might radiate down the biceps muscle. They mention pain with overhead activities and throwing, and they might have pain at night. Activities that stress the biceps tendon might be painful, such as biceps muscle contraction when doing arm curls, lifting objects in front of the body with a straight arm, or turning a doorknob or screwdriver in such a way that the palm faces up (supination). Because bicipital tendinitis most commonly occurs with shoulder impingement, it is common in athletes over 40. However, younger athletes who perform repetitive motions such as throwing can also develop bicipital tendinitis.
Initial treatment includes relative rest and avoiding activities or motions that elicit pain. Icing and anti-inflammatory medications (e.g., ibuprofen) to reduce pain and inflammation may help. Range-of-motion exercises should be started early in the treatment course and progressed as tolerated to restore normal pain-free range of motion. Formal physical therapy may be considered to assist in reducing pain and inflammation through the use of electrical stimulation, ultrasound, or other methods. In refractory cases, a steroid injection (cortisone shot) into the biceps tendon sheath may be considered to eliminate persistent pain and inflammation.
Once pain and inflammation subside, begin strengthening exercises to restore full strength about the shoulder with particular attention to the rotator cuff muscles. This is especially important for younger athletes, who might have impingement and irritation of the bicipital tendon caused by underlying instability.
If the athlete continues to have disabling symptoms despite conservative measures, surgery may be considered. For older athletes, surgery may involve a biceps tenodesis, in which the tendon is transferred to the upper humerus to relieve the repetitive mechanical irritation. A subacromial decompression may also be performed in which arthritic bone and spurs are shaved off the acromion to address the impingement anatomy. In younger athletes, shoulder stabilization surgery could be required to prevent impingement and irritation of the biceps tendon that might be related to underlying instability. If bicipital tendinitis continues over time, the repeated inflammation and irritation of the tendon might eventually cause it to wear down, degenerate, and tear (proximal biceps tendon rupture).
Return to Action
In general, athletes may gradually return to sport once they have attained full pain-free range of motion and full strength in the muscles surrounding the affected shoulder. Return time might vary from a few weeks up to a few months depending on the degree of symptoms, extent of injury, and the sport. Taping or bracing is usually not necessary when returning to play. If symptoms recur, athletes should stop the sport or painful activity. They might need to modify their sport participation to prevent recurrence of symptoms.
SUPRASCAPULAR NERVE INJURY
Suprascapular nerve injury, also known as suprascapular neuropathy, suprascapular nerve entrapment, or suprascapular nerve palsy, is a relatively less common cause of shoulder pain in athletes. The injury tends to occur most often in volleyball players or overhead throwing athletes. The suprascapular nerve might be damaged because of a traction or stretch injury to the nerve caused by the repetitive overhead or throwing motion. The nerve might also be damaged because of compression by a ganglion cyst. Tears of the glenoid labrum are sometimes associated with formation of ganglion cysts that can compress the suprascapular nerve. Sometimes a direct trauma or fracture to the scapula can cause an injury to the suprascapular nerve.
An athlete with a suprascapular nerve injury typically complains of shoulder pain that is deep and poorly localized but often felt more in the back or side of the shoulder. The athlete might describe a feeling of weakness. Eventually, athletes might have wasting (atrophy) of the supraspinatus and infraspinatus muscles, which are the rotator cuff muscles behind the shoulder blade (scapula) that are innervated by the suprascapular nerve. The suprascapular nerve can be damaged at a few points along its course to innervate the supraspinatus and infraspinatus muscles. Depending on where the nerve is damaged, it can affect one or both of these muscles.
With weakening of the rotator cuff muscles, some athletes might develop instability and secondary impingement pain because these muscles can no longer hold the humeral head in its socket (glenoid). In many cases, the athlete might continue to play and function despite the injury and without seeking medical attention. The weakness might be detected incidentally on a preseason physical exam, or sometimes a family member or friend will notice the athlete’s muscle wasting with prominence of the shoulder blade, prompting a visit to the doctor.
The diagnosis of a suprascapular neuropathy is usually made by a physician or other medical professional. Strength testing reveals weakness with shoulder abduction or external rotation. An electromyograph (EMG)–nerve conduction study (test of the muscles and nerves) is usually ordered to confirm the diagnosis and determine the extent of nerve injury. An MRI of the shoulder can help to identify a ganglion cyst compressing the suprascapular nerve.
Treatment for suprascapular neuropathies depends on the cause of the nerve injury. If an obvious ganglion cyst has formed or another lesion is compressing the nerve, surgery might be necessary to remove the compressive lesion and relieve pressure on the nerve. Aspiration of a ganglion cyst using ultrasound guidance may also be recommended to relieve pressure on the nerve without surgery. If the injury is caused by a traction or stretch injury from repetitive throwing or overhead activities, athletes must rest and avoid these activities. Over-the-counter anti-inflammatory or pain medications may be used as needed. Strengthening exercises (especially shoulder abduction and external rotation) are performed to strengthen the weak rotator cuff muscles as well as the surrounding shoulder muscles. In cases in which the athlete fails to improve within three to six months of conservative treatment, surgical exploration may be considered. In severe cases, the athlete might be left with some chronic wasting (atrophy) and mild weakness of the affected muscles.
Return to Action
Return time ranges anywhere from six weeks to several months, depending on the severity of the nerve injury. In general, once the athlete’s pain resolves and strength improves to approximately 80 percent of normal, the athlete can initiate gradual return to play. The athlete should be monitored for any recurrence of weakness and should stop play if weakness or pain recurs. Taping and bracing are usually not necessary when returning to play. In some cases, if weakness and symptoms fail to improve, the athlete might need to consider modifying or changing sport participation to avoid the repetitive overhead motion.
DEEP VEIN THROMBOSIS
Damage to the blood vessels in the arm (as in other parts of the body) may trigger the formation of thrombi (clots) in the blood vessels. When these thrombi form in the deep veins, the condition is known as deep vein thrombosis (DVT). There is a risk that the thrombi will break away from the vessel wall and travel to the lungs or brain, causing serious injury and, in rare cases, death.
When an athlete develops vague shoulder or neck discomfort, swelling of the limb, and possibly a low grade fever, DVT must be considered. If this condition is suspected, the athlete must be referred to a physician immediately.
Depending on the underlying cause, DVTs are generally treated for at least three to six months with anticoagulation therapy. Often, the athlete with a DVT will initially receive an anticoagulating medicine such as heparin, which is given via an IV (intravenously), or low-molecular-weight (LMW) heparin, which is given subcutaneously once or twice daily. The athlete is then transferred over to warfarin (Coumadin), which is given orally. It is important that athletes’ blood be monitored while they are taking warfarin because the levels of this medication in the blood may fluctuate and dosages may need to be adjusted. There are several oral anticoagulant medications now available that may be an alternative to warfarin and do not require blood monitoring. Until adequate anticoagulation is reached (typically in three to seven days), the patient should not use the affected extremity.
Return to Action
Athletes should not return to contact sports until they are finished with anticoagulant therapy. During therapy, there is a significant risk of bleeding from contact. Athletes can usually return to noncontact sports (e.g., running) once their blood is fully anticoagulated (typically within three to seven days of treatment initiation as directed by a physician) and they have pain-free range of motion. Until adequate anticoagulation is reached, the affected extremity should not be used, to reduce the risk of dislodging the clot and sending it to the lung or brain.