The summer is over and fall sports have started. Gone are the summer sports of swimming and baseball, and the contact sports of hockey and football have started. It sure is a different atmosphere at ?the Sport Medicine Specialists? in the fall. I have already seen several separated shoulders this week when I will see only a few all summer long. There is always a lot of confusion concerning what is a separated shoulder compared to a dislocated shoulder.
As I performed the Toronto Maple Physicals last week, there was barely a player that did not have evidence of a previously separated shoulder. If you read the weekly injury reports in the NHL there is rarely a week when a player is not listed with a separated shoulder. The good news is that it is not a very serious injury and rarely leads to long term problems. The joint that is separated is the joint called the Acromioclavicular joint. I prefer to write it as I can barely say it. This is the joint which attaches the clavicle(collarbone ) to the shoulder.
If you follow your finger along your collarbone it will come to an end and your finger will fall into a divot. That is the Acromioclavicular joint. There is almost no protection to this joint and thus easily injured. This is the only boney connection from the body to the arm. It is attached to the shoulder bone(the acromium) by ligaments across the joint and a set of stronger ligaments going down from the clavicle about one inch before the end. These strong ligaments going down really hold the collarbone down. The joint is most commonly injured by a direct blow to the shoulder.
Classically the player is hit into the boards and the shoulder takes the majority of the impact. The severity of the injury depends on how hard and at what angle the shoulder is hit at. We grade these injuries into three degrees. The most common and the least serious is the first degree. This is merely a bruise to the joint. The athlete will be painful but can play as soon as the pain is diminished enough to allow him to function fully. This will vary from not even missing a shift to a week or so before the pain settles down. The second degree sprain is more serious. It involves partial tearing of the ligaments.
There is more swelling in the joint and usually bruising will appear a few days later. There is a small bump evident where the clavicle is now sitting a bit higher. A sling can be worn for comfort for a few days. Sport therapy is started immediately to maintain range of motion and regain the strength in the shoulder. Again, pain and function will guide the athlete on when they can return to play. the athlete will usually be out 4-6 weeks. The third degree separation involves total tearing of the ligament in the joint. The clavicle is totally out of the joint. In the old days(10-15 years ago) we used to operate on these to put the clavicle back in the joint. Now we treat it the same as a second degree separation, except there is a longer recovery.
We now know that an athlete or a worker for that matter will get back to activity sooner and with more strength if we do NOT operate. I t is the only joint in the body which we will actually leave out of joint once it is injured. The athlete is usually out for 6-8 weeks. The most important thing is to protect the shoulder when they go back to play. We use a special pad under the shoulder pad to protect the joint and probably use a better shoulder pad. Shoulder pads are a lot better now but can be very cumbersome. You would be amazed to see what some of the NHL players use to protect their shoulders. Some of the pads have been worn since bantam hockey. I am now working on design for a better shoulder pad to protect this Acromioclavicular joint. As with any injury I would rather prevent an injury than treat the injury.
The Rotator Cuff
Spring training has now started and although there are only replacement players we are all getting in the baseball mood. We dream about hitting the ball, running the bases, sliding into home, and sore shoulders. Yes, the most common injury in baseball especially the pitchers, the rotator cuff. The rotator cuff has since become a household word. It has almost become an injury of grandiose nature as patients almost seem proud that they too have ""The Rotator Cuff"" injury. With all this hoopla with the rotator cuff you would think that more people would know what it is. The rotator cuff is a group of four muscles that are around the shoulder. Their function is to stabilize this inherently unstable ball and socket joint. The socket is very shallow and thus relies on the surrounding ligaments and muscles to provide the stability. The muscles also function to move the shoulder.
The four muscles are
3. Teres minor
4. Subscapularis The most common muscle in this complex to be injured is the suprapinatus. The cause of problems are multifactorial. Basically you can divide the major causes to athletes below age 35 and those over age 35. In the younger athlete it almost always occurs in the athlete performing overhead activity. Therefore the most common athletes I see are in baseball, tennis, and swimming. The cause of the problem is too much stress on the tendon. The main cause of the stress is subtle instability of the shoulder. With excess high velocity repetitious movement on the shoulder, the shoulder becomes unstable as the tissues are stretched. Eventually the rotator cuff tendon breaks down and becomes inflamed. With each successive use the problem is aggravated until the pain or function limits the athlete from continuing.
In the older age group the major problem is an impingement type problem. The supraspinatus lies in a narrow space within the shoulder. With the shoulder at your side their is a lot of room for the tendon. With the arm raised to the side the tendon becomes impinged under the bone and a ligament in the shoulder. As you get older this space becomes narrower due to degeneration and spur formation. Their is also a problem with the blood supply to the supraspinatus tendon within the shoulder making it more prone to becoming inflamed. The pain occurs not only when doing sports but also with daily activities especially with any overhead activity. The treatment will vary on the etiology of the problem but a lot of the principles are the same.
1. MODIFY Depending on how severe the problem it will depend on how much you have to modify your activity. Not matter what the cause the important thing is to avoid the overhead motions. A tennis player will not serve or do overheads. A swimmer will have to do other strokes or cross train until it is better. A pitcher may have to only throw easy or play another position until it is healed.
2. ICE Ice is important to reduce the inflammation. Ice for 15 minutes twice per day and always after sports.
3. PHYSIOTHERAPY Initially the therapist will use various modalities to reduce the inflammation. The important part of the therapy and the crucial part of the treatment is to correct the underlying problem. In the young athlete the goal is to make the shoulder more stable. The rotator cuff and other muscles around the shoulder are strengthened in a special way to stabilize the shoulder. With this program there will be less movement in the shoulder as it goes through these repetitive high velocity movements. With this dynamic stability their is less stress on the rotator cuff muscle.
4. MEDICATION Anti-inflammatory pills are sometimes used to help reduce the inflammation. Occasionally a cortisone injection is used in resistant cases to potentiate the therapy. This is almost only used in the older population.
5. BIOMECHANICS Often the cause of the problem is in the biomechanics. Swimmers may have to put more roll in their stroke to reduce the impingement. The baseball and tennis players should have their mechanics reviewed to see if any changes will make their motion more efficient and less stress on the shoulder.
6.SURGERY We do not often operate on the shoulder for tendinitis. In the younger population when we can not control the instability we would operate to tighten the capsule around the shoulder. In the older population the objective is to make more room for the tendon. We basically file the bone down on the roof of the bone tunnel where the rotator cuff tendon goes through. This eliminates the impingement.
7.RETURN TO ACTIVITY Once the inflammation is reduced the athlete slowly returns to the offending activities. Start with a good warm up of the shoulder. Initially throw easy and for not very long. On alternate days gradually increase the intensity and length of time you use the arm. The key is treating the rotator cuff early before it turns into a chronic problem and harder to treat. Although it may sound glamorous to have the same rotator cuff injury as Duane Ward, I would think that you would rather be playing pain free. Then, maintain your strength and flexability program achieve top performance.
A couple of months ago I wrote several columns about knee injuries. The first of the series discussed the anatomy of the knee. I will do the same thing here and discuss the anatomy of the shoulder. Future articles will discuss the major injuries to the shoulder. The shoulder complex is actually made up of four separate joints. They are the glen- ohumeral joint, the acromioclavicular joint, the sternoclavicular joint and the scapu- lothoracic joint. For full use of the shoulder all of these joints must be functioning properly. The main joint is the glenohumeral joint. This is the joint that you think of when you think of the shoulder. It is a ball and socket type of joint. The ball is the top of the arm bone(humerus). The socket is formed within the shoulder bone. The socket is very shallow in the shoulder as compared to other ball and socket joints in the body like the hip.
The socket is made a little bit deeper by an extension of the socket by a soft tissue structure called the labrum. This would be like a rubber extension around a metal socket. The socket is still fairly narrow even with the labrum and the ball needs further support to hold it in the socket. This is provided by a thin capsule which connects the ball to the socket. At certain areas around the capsule it is thicker to form a ligament which provides even more support. Nonetheless the joint is still relatively unstable and the most common joint to become dislocated in sports. The Acomioclavicular joint is a common joint to become injured especially in hockey. When this joint is injured it is called a ""separation"" as apposed to the ""dislocation"" to the ball and socket glenohumeral joint.
This is commonly confused by people. The clavicle is attached to a small protrusion off the shoulder blade called the acromium. The collerbone is the only boney attachment from the shoulder to the axial or central skeleton. The clavicle is attached to the shoulder by ligaments. It is further held down by other ligaments which connect the body of the clavicle down to another protrusion off the shoulder blade called the coracoid. A shoulder is ""separated"" when a blow to the shoulder tears all or part of these ligaments which attach the clavicle to the shoulder blade. At the other end of the clavicle it is joined to the sternum(breast- bone) at the Sternoclavicular joint. The last joint in the shoulder is the Scapulothoracic joint. This is not truly a joint as you would think of.
The scapula or shoulder blade moves over the ribs and thus it must be considered a joint as there is movement between bones. It rarely is a major problem by itself in sports. More than the knee the shoulder relies on the surrounding muscles for it's stability. The muscles around the shoulder are much more famous than around the knee. We have all heard about the Rotator Cuff muscles. These are four muscles around the shoulder which provide stability to the shoulder joint. They also provide strength to the shoulder to allow it to function. Powerful muscles connect the shoulder to the neck and back. The deltoid muscle is the big muscle which provide the rounded cap shape to the shoulder. All in all the shoulder is a very complex joint that can move 360 degrees. When functioning at top form it can throw a baseball or serve a tennis ball at well over 100 miles an hour. To be as versatile and functional as that it must give up something and that is stability as we will learn in future articles.
The Shoulder Dislocation
January 8, 1993. The Vancouver Canucks are in Toronto to meet the Leafs. Midway through the second period as the game becomes a little more intense, Cliff Ronning makes his way out of his own end. Just before the blue line he passes the puck up to his teammate. Just as he passes the puck he is hit by a fore checking Leaf. His left shoulder is jammed up against the board. He goes down in pain and Larry the Vancouver team therapist immediately goes out on to the ice to his aid. After a quick analysis he asks for additional help. I go out on to the ice and assess Cliff Ronning. I realize that he has dislocated his shoulder. We carry him off on a stretcher to the medical room. After we take his equipment off I confirm that there is no other injury. I then gently put his shoulder back into the socket. His severe pain was immediately relieved. After many years in the NHL he has suffered his first injury.
In my previous article I discussed the anatomy of the shoulder. The shoulder ball and socket is very mobile but sacrifices in stability. The socket is very shallow making the shoulder so easy to dislocate. The most common age group to dislocate is 16 to 25 but it can happen at any age. When the shoulder is out of joint it is very painful. The sooner it is put back in place the easier it goes back in. There are several methods that the doctor can use to put it back in. They usually consist of some kind of traction and rotation of the arm. The earliest recorded method is the method by the ancient Greek physician Hippocrates. He would place his foot in the armpit and pull and rotate the arm until the spasm relaxed and the arm went back in to place. We now have a little less dramatic ways to put the shoulder back in. In some cases, especially if the shoulder has been out of joint for some time we have to even put the patient asleep with anaesthesia to eliminate the muscle spasm so the shoulder can be put back in to place.
The next question is what to do with the shoulder after the dislocation. Recently at a gathering of Sports Doctors in Toronto there was not a consistent agreement for how long you should immobilize the shoulder. It ranged from not at all to a full six weeks in a sling. I generally put the athlete in a sling for 3 weeks. At that point they are placed in physiotherapy to strengthen the shoulder muscles while still allowing the capsule and ligaments to heal. They can not go back to their sports for 6 to 8 weeks. The athlete is educated on what positions are dangerous to the shoulder to avoid the shoulder popping out again. Depending on the sport we will use a special brace to hold the arm in and help prevent it from dislocating again. This is especially useful for hockey and skiing. Now for the bad news. The shoulder is very prone to coming out again.
Research has shown that there is anywhere from a 60% to 90% chance that the shoulder will come out again once it has happened the first time. Generally the younger you are the higher the risk is for re-injury. As a general rule of thumb three strikes and you are out. So once you have dislocated your shoulder three times the shoulder should be operated on to prevent further dislocations. The surgery is about 90-95% effective. There are several complications that can happen to the shoulder once it has been dislocated. The most common is a nerve injury of the axillary nerve which goes through the shoulder. Not long after the dislocation you will notice that the outside of your arm is numb. There will then be wasting or atrophy of the deltoid muscle which you can see. Fortunately the nerve comes back to life on it's own in 6-8 weeks. The other common complication is a torn shoulder rotator cuff muscle. This is more common in the older athlete. This certainly will prolong the recovery and may even require surgery to repair the muscle. The Vancouver Doctor's tell me that Cliff Ronning is doing well. Hopefully with a strong rehabilitation program which is the most important part of the recovery he will be back playing and not have his shoulder dislocate again.
The Shoulder Separation
The shoulder is the second most common joint injured in hockey. The shoulder is very vulnerable when used to hit a opponent or more commonly being hit by an opponent and the shoulder is smashed against the boards. There has been a rare player in the N.H.L. who has not had at least one shoulder separation in their career. If you read the daily injury report you will see several players who are on the disabled list with the famous separated shoulder. Last spring David Ellett had a complete third degree separation and was out almost six weeks before he returned to lead the Leafs into the playoffs. The Acromioclavicular Joint is the joint in the shoulder where it is separated. This is the joint where the clavicle joins the shoulder. The clavicle is the only boney connection from the body to the arm. It is attached to the shoulder bone in two areas. The end of the clavicle is attached to the shoulder by ligaments which mainly hold the collar bone from moving back and forth. About an inch from the end are two stronger ligaments which hold the collar bone down.
We grade these separations into three degrees. The most minor is the first degree. It is mainly a bruise to the joint. It is painful but not very serious. The player can go back to play as soon as they have full range of motion and strength. This will vary from not missing a shift to being out for a week allowing for the pain to settle down. The second degree separation involves partial tearing of the ligaments that hold the clavicle down. Usually the ligaments at the end of the clavicle are totally torn and the ligaments that hold the clavicle down are partially torn. There is small bump on the top of the shoulder where the collar bone has risen up. This is more painful than the first degree separation. A sling is worn for comfort by the athlete for as long as the athlete needs it for comfort. Sports therapy is started immediately to maintain range of motion and regain the strength of the shoulder as their pain allows. Again the athlete can go back to competition as soon as they have full function of the shoulder. Usually it is 4-6 weeks before they are playing.
The third degree separation is obviously the most severe. There is a greater blow to the shoulder and all the ligaments holding the clavicle down are torn. Last season Dave Ellett had a third degree separation last season. He came off the ice holding his arm. I knew he had a bad injury to his shoulder. I slid my hand under his shoulder pad and could feel a large bump where his clavicle was totally separated from his shoulder. I am sure he knew from my face that he had a bad injury. X-rays confirmed that there was not a fracture, but the x-ray revealed that the collar bone was totally separated from the shoulder. The question now was what to do with this joint which was totally out of joint. It was not long ago that we use to operate on these injuries. We now know that the athlete will get back to playing sooner with more strength and less pain if we do NOT operate. It is the only joint in the body that we will actually leave out of joint and the athlete will function at a high level.
The principles of the treatment is the same as the second degree injury but there is a longer recovery time of 6-8 weeks. There are actually a few situations where we would operate, but these are very few and far between The most important thing for the athlete is to protect the injury by better padding. There has not been great changes in shoulder pads over the years. I am always amazed as I look around the dressing rooms of N.H.L. teams of the variations of quality of the shoulder pads worn by the players. Some of the pads have been worn by the players since junior. I encourage the players to wear better pads but as human nature is, it is often not until an athlete is injured where they will consider wearing better protection. Dave Ellett did extremely well and was back playing in about six weeks in plenty of time for the play-offs. He now wears the characteristic bump on the shoulder that is so common among hockey players.