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SHOULDER INJURIES

Shoulder Problems

The shoulder is a very muscular joint that is frequently injured during athletics but it is also susceptible to inflammatory conditions. The most common athletic injuries include dislocation or subluxation of the joint, shoulder separations, and clavicle and humerus fractures.

Because of the very shallow shoulder socket, the humeral head is susceptible to "going out of place." Patients who present with a history that their shoulder "popped out and then went back in," probably subluxated the joint which means the head slipped out onto the rim of the socket and then reduced back into place on its own.

But when the humeral head comes completely out of socket, it's virtually impossible for the acutely injured patient to reduce the dislocation themselves or with friends and medical assistance is required. This predicament can be extremely painful. Treatment of subluxations or dislocations require ice, two to three weeks immobilization, and follow-up therapy to get the shoulder back to its normal motion and strength. Patients are warned that this injury often recurs and may later require surgical invention that must address the incompetent capsule that is suppose to hold the humeral head in the socket.

Shoulder, or Acromioclavicular (AC) separations, usually result from a fall on the tip of the shoulder. The patient presents with point tenderness over this area and frequently notices a bump. Range of motion and strength can be compromised secondary to pain and x-rays will only show evidence of the more severe (Grade Three) separation. Treatment is conservative with short term immobilization, ice, physical therapy and exercise. There are very few indications for surgical intervention. In fact, multiple studies have shown that conservative and surgically treated patients with this problem one year after injury have essentially the same result.

Proximal humerus fractures are usually seen in more elderly patients. Examination of the area often reveals pain, severe limitation of motion, and an unsightly black and blue area. X-rays are useful and confirm the diagnosis. Short term immobilization is used for pain control but early mobilization is paramount to prevent stiffness. Surgical intervention is occasionally used for severely comminuted (broken in several pieces) fractures or severely arthritic joints. Unfortunately, the results of these procedures can be disappointing and the patient needs to understand all the risks. The surgery is quite extensive and associated with considerable pain and lengthy rehabilitation.

Shoulder bursitis is very common and frequently no cause or injury is obvious, although in the athletic population, people get associated impingement syndrome from participating in sports that involve the overhead throwing motion or swimming. The pain is often widespread about the shoulder and some range of motion can be quite painful and limited.

X-rays are usually negative but can show other conditions with similar clinical presentations, such as a calcium deposit.

Although conservative treatment of ice, exercises,  NSAIM and   physical therapy may be of some help, a cortisone injection is often required. Contrary to popular belief, this does not have to hurt excessively if the docter is gentle and experienced in doing this procedure.

However, this injection should not be done more than two to three times. If a patient doesn't improve, more studies, such as magnetic resonance imaging (MRI), should be done to rule out other possibly, more serious conditions such as a rotator cuff tear, which can be worsened by repeated cortisone shots. Unfortunately, rotator cuff tears, which usually occur in more elderly patients, carry with it a very guarded prognosis. Even with surgical intervention, this injury almost never results in full strength and range of motion, although the pain may improve.

Finally, arthroscopic surgery for the shoulder has become more popular with orthopedic surgeons and has usefulness in patients who haven't responded to conservative treatment for chronic bursitic conditions, calcium deposits, impingement syndrome, lesions inside the socket and subluxation/dislocation. Although this procedure is done as an out-patient with very little risk, it has not been as successful for rotator cuff problems.

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