Ebook Sports Rehabilitation and Injury Prevention: Part 2

Part 5 Joint specific injuries and pathologies 17 Shoulder injuries in sport Ian Horsley English Institute of Sport This chapter outlines the anatomy of the shoulder girdleanddiscussescommonlypresentingpathology around this area. Common orthopaedic assessment tests are described, together with a presentation of the effectiveness of these tests in assessing for spe-cific diagnoses of commonly presenting pathology, from currently available literature. The role of reha-bilitation is covered with analysis of the function of commonly utilised exercise and the role of clinical reasoning in determining the diagnosis and formu-lating a safe and effective rehabilitation programme. Incidence of shoulder injury Theglenohumeral jointisoneofthemostfrequently injured areas of the upper extremity in competitive sports. Studies indicate that 8–20% of athletic in-juries involve the glenohumeral joint (Hill 1983; Lo et al. 1990; Hutson 1996; Terry and Chopp 2000; Ranson and Gregory 2008). Athletes whose sports require a large amount of time with their arms above the level of the shoulder, such as those playing racquet sports, sports involv-ing throwing (baseball, cricket, American Football and water polo), swimmers and rugby players (due to their arm position within the tackle) commonly report a high incidence of shoulder pain with up to 43.8% reporting shoulder pain (Lo et al. 1990). Hutson (1996) reported that more than 40% of elite swimmers complained of shoulder pain at some point during their careers, and this was related to the fact that 90% of the propulsive force comes from the upper extremity (Counsilman 1977) with the main cause of pain being attributed to glenohumeral joint instability (Weldon and Richardson 2001), due to significantly increased humeral head translation (Tibone et al. 2002). In American Football 15.2% of all injuries in-curred by quarterbacks were shoulder injuries with direct trauma being responsible for 82.3% of the shoulder injuries (Kelly et al. 2004), and in profes-sional cricket 23% of players in one study reported suffering a shoulder injury during one professional season (Ranson and Gregory 2008). The epidemiology of Rugby Union and Rugby League injuries appears to suggest that injury to the shoulder accounts for approximately 12–16% of all injuries, with an incidence of 10–13 per 1000 game hours, with this statistic higher when compared to pre-professionalism incidence rates (Garraway and Macleod 1995; Bird et al. 1998; Gabbet 2000; Chalmers et al. 2001; Lee et al. 2001; Gissane et al. 2003; Junge et al. 2004; Handcock et al. 2005). With regards to Rugby Union, Bathgate et al. (2002) highlighted the upper limb as responsible for 15.4% of injuries, with 6.3% of overall injuries located at the shoulder. Even within non-overhead sports, such as ski-ing, shoulder injuries have been reported as high as 11.4% of all injuries (Kocher 1996). Sports Rehabilitation and Injury Prevention Edited by Paul Comfort and Earle Abrahamson ° 2010 John Wiley & Sons, Ltd 310 SHOULDER INJURIES IN SPORT Table 17.1 Ligament Static stabilisers of the glenohumeral joint Description Action Superior glenohumeral ligament Middle glenohumeral ligament Inferior glenohumeral ligament complex Coracohumeral ligament Glenoid labrum Attaches from the supraglenoid tubercle of the glenoid labrum onto the proximal tip of the lesser tuberosity of the humerus Attaches from the supraglenoid tubercle and anterior aspect of glenoid labrum onto the lesser tuberosity of the humerus, blending with the subscapularis tendon Anterior band: from anterior labrum to the glenoid rim Middle band : is an axillary pouch Posterior band: form the posterior labrum to the glenoid rim. Not found in all patients Lateral aspect of the coracoid process of the scapula onto the upper facet of the greater tuberosity of the humerus, blending with the supraspinatus tendon A fibrocartilaginous rim attached around the margin of the glenoid cavity attached to the circumference of the glenoid, while the free edge is thin and sharp. It is continuous with the tendon of the long head of biceps Resists inferior humeral translation with the arm adducted and in neutral rotation. Limits external rotation in conjunction with the coracohumeral ligament Provides anterior humeral stability from humeral adduction to approximately 45 degrees abduction From 0 to 30 degrees humeral abduction the anterior band is the primary static stabiliser of the glenohumeral joint. It tightens with abduction and moves superiorly with combined external rotation to become the primary anterior humeral stabiliser in this position The primary static stabiliser with the arm in flexion and medial rotation, providing posterior stability. It tightens with abduction and moves superiorly with combined internal rotation Resists posterior and inferior translation of the suspended shoulder, it is an inferior stabiliser and tightens with external rotation It deepens the articular cavity, and protects the edges of the bone Repetitive overhead stress within the overhead athlete challenges the functional, dynamic integrity of the glenohumeral joint within these athletes. As there is little bony contact between the head of the humerusandtheglenoidfossaofthescapula,thereis a great range of mobility at the joint with an inherent instability of the articulation (Armfield et al. 2003). Joint homeostasis is maintained by the harmonious static and dynamic interaction of the muscles, liga-ments and joint capsule. The static stabilisers (Table 17.1) of the joint consist of the labrum, capsule and ligaments, and the dynamic stabilisers of the joint (Table 17.2) are the muscles of the rotator cuff, del-toid and scapular stabilisers (Terry and Chopp 2000; Woodward and Best 2000). Lack of ability to main- tain the humeral head centred within the glenoid fossa during movement is defined as instability (Magarey and Jones 1992). Hess (2000) adapted Panjabi’s model proposed for spinal segmental stability (Panjabi 1992) for the glenohumeral joint, which states that joint stability is based on the interaction between the active, pas-sive and neural control subsystems, with the rotator cuff muscles, activating at different positions, com-pressing the convex humeral head into the concave glenoid,thusresistingtheshearforceexperiencedby the humeral head (Lee et al. 2000). Receptors within the joint capsule contribute to a reflex arc, which will cause activation of the muscles which overlie the joint capsule (Guanche et al. 1995). INCIDENCE OF SHOULDER INJURY 311 Table 17.2 Muscles of the shoulder girdle. Adapted from Horsley (2005) Assessment of shoulders with pain of a non-traumatic origin. Physical Therapy in Sport. 6:6–14 © Elsevier. Muscle Deltoid Supraspinatus Infraspinatus Teres minor Subscapularis Teres major Serratus anterior Pectoralis major Pectoralis minor Trapezius Origin Lateral one-third of clavicle, acromion and spine of scapula Supraspinous fossa of the scapula Infraspinous fossa of the scapula Superior half of the lateral border of the scapula Subscapular fossa of the scapula (anterior surface of scapula) Inferior angle of the scapula Outer surface of ribs 1–8 From the anterior surface of the sternal half of the clavicle; the anterior surface of the sternum; from the cartilages of the first seven ribs From the upper margins and outer surfaces of the third, fourth, and fifth ribs, near their cartilage and from the aponeuroses covering the intercostalis From the external occipital protuberance and the medial third of the superior nuchal line of the skull, from the ligamentum nuchæ, the spinous process of the seventh cervical, and the spinous processes of all the thoracic vertebræ and their supraspinal ligament Insertion Deltoid tuberosity of the humerus Upper facet of the greater tuberocity of the humerus Middle facet of the greater tuberocity of the humerus Lower facet of the greater tuberocity of humerus Lesser tubercle of the humerus Medial lip of bicipital grove of the humerus. Inserts with Latissimus dosi Anterio-medial border of the scapula The fibres converge to a flat tendon, about 5cm broad, which is inserted into the crest of the greater tubercle of the humerus Converges to form a flat tendon, which is inserted into the medial border and upper surface of the coracoid process of the scapula The superior fibres are inserted into the posterior border of the lateral third of the clavicle; the middle fibres into the medial margin of the acromion, and into the superior lip of the posterior border of the spine of the scapula; the inferior fibres are inserted into a tubercle at the medial end of the spine of the scapula Action Abducts the shoulder joint posterior fibres extend and laterally rotate humerus. Anterior fibres flex and medially rotate the humerus Abducts the humerus; stabilizes head of humerus in glenoid cavity. Medially rotates the humerus, draws it forward and down when arm is raised Laterally rotates, adducts, extends the humerus. Stabilises the head of humerus in glenoid cavity. Laterally rotates, adducts, extends the humerus, stabilises the head of humerus in the glenoid cavity Medially rotates humerus, stabilises the head of the humerus in the glenoid cavity Adducts and medially rotates the humerus and draws it back Abducts and upwardly rotates the scapula, holds the scapula against the thoracic wall Clavicular head: flexes and adducts arm. Sternal head: adducts and medially rotates arm. Acts as an accessory muscle for inspiration Depresses, abducts, downwardly rotates (inferior angle of scapula moves towards the spine), and anteriorly tilts the scapula. It also acts as an accessory muscle with inspiration The whole Trapezius retracts the scapula and braces back the shoulder; if the head is fixed, the upper part of the muscle will elevate the point of the shoulder, when the lower fibres contract they assist in depressing the scapula. The middle and lower fibres of the muscle rotate the scapula, causing elevation of the acromion. If the shoulders are fixed, the Trapezii, acting together, will extend the cervical spine; or if only one side acts, the head is rotated to the same side (Continued) ... - tailieumienphi.vn