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Common sports-related shoulder injuries S houlder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presen- tation, assessment and management of these conditions in general practice. The GP curriculum and common sports-related shoulder injuries Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In particular, GPs are expected to be able to: . Communicate health information effectively to promote better outcomes . Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as barriers to recovery . Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness . Agree treatment goals and facilitate supported self-management, particularly around pain, function and physical activity . Assess the importance and meaning of the following presenting features: . pain: nature, location, severity, history of trauma . variation of symptoms over time . loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or occupation . Understand that reducing pain and disability rather than achieving a complete cure could be the goal of treatment . Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans . Diagnose common, regional soft-tissue problems that can be managed in primary care . Understand the challenge that many musculoskeletal conditions might be better and more confidently managed by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills during their training . Refer those conditions which may benefit from early referral to an orthopaedic surgeon The four most common categories of shoulder pain seen in primary care are (Mitchell, Adebajo, Hay, & Carr, 2005): . Rotator cuff disorders (85% tendinopathy) . Glenohumeral disorders . Acromioclavicular joint disease, and . Referred neck pain. There are many different types of sports that can cause acute or chronic shoulder injuries. In professional English Rugby Union, for example, the most common match injury is of the acromioclavicular joint (32% overall) and the most severe injury requiring the longest time off (mean of 81 days) is shoulder dislocation (Headey, Brooks, & Kemp, 2007). Shoulder injuries can also occur in non-contact sports, such as golf, tennis, swimming and weightlifting. Although shoulder injuries may be more common in con- tact sports, the injury may have a larger impact on the performance of individuals playing non-contact sports. For example, golfers require very precise manoeuvres of their dominant.

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Common sports-related shoulder injuries S houlder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presen- tation, assessment and management of these conditions in general practice. The GP curriculum and common sports-related shoulder injuries Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In particular, GPs are expected to be able to: . Communicate health information effectively to promote better outcomes . Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as barriers to recovery . Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness . Agree treatment goals and facilitate supported self- management, particularly around pain, function and physical
activity . Assess the importance and meaning of the following presenting features: . pain: nature, location, severity, history of trauma . variation of symptoms over time . loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or occupation . Understand that reducing pain and disability rather than achieving a complete cure could be the goal of treatment . Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans . Diagnose common, regional soft-tissue problems that can be managed in primary care . Understand the challenge that many musculoskeletal conditions might be better and more confidently managed by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills during their training . Refer those conditions which may benefit from early referral to an orthopaedic surgeon The four most common categories of shoulder pain seen in primary care are (Mitchell, Adebajo, Hay, &
Carr, 2005): . Rotator cuff disorders (85% tendinopathy) . Glenohumeral disorders . Acromioclavicular joint disease, and . Referred neck pain. There are many different types of sports that can cause acute or chronic shoulder injuries. In professional English Rugby Union, for example, the most common match injury is of the acromioclavicular joint (32% overall) and the most severe injury requiring the longest time off (mean of 81 days) is shoulder dislocation (Headey, Brooks, & Kemp, 2007). Shoulder injuries can also occur in non-contact sports, such as golf, tennis, swimming and weightlifting. Although shoulder injuries may be more common in con- tact sports, the injury may have a larger impact on the performance of individuals playing non-contact sports. For example, golfers require very precise manoeuvres of their dominant shoulder to swing a golf club with accuracy... .. ..
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30 ................... InnovAiT, 10(1), 30–38 DOI: 10.1177/1755738016678436 ............................................................................................... ............................................................................................... ............ http://crossmark.crossref.org/dialog/?doi=10.1177%2F17557380 16678436&domain=pdf&date_stamp=2016-11-22 Anatomy ........................................................... The shoulder complex (Fig. 1) consists of the glenohumeral joint, the acromioclavicular joint and the sternoclavicular joint. These work collectively with the scapulothoracic joint to achieve normal shoulder girdle movements. The glenohumeral joint is a ball-and-socket joint that con- sists of the glenoid cavity, glenoid labrum, glenohumeral ligaments and the joint capsule. These components all articulate with the head of the humerus and the scapula. Four muscles form the rotator cuff that controls move- ments of the glenohumeral joint. The deltoid muscle and the muscles that control the scapula also provide move- ment and stability of the shoulder. These muscles and their primary actions are summarised in Table 1. History ........................................................... In general practice, a history of the shoulder problem is probably your most helpful tool when trying to formulate
a diagnosis. Establish the nature, location, duration, and the exact mechanisms of injury. When asking about the shoulder pain, enquire about locking, clicking, catching, popping, stiffness, swelling, redness, warmth, giving way, night pain, weakness, and paraesthesia. A training history to include frequency, intensity and any changes to training routine may also be relevant. Ask about any referred pain, and do not forget possible gastrointestinal or cardiac causes of shoulder pain. Look out for other more sinister features, such as night sweats, fevers, weight loss and history of cancer. Common shoulder sports injuries ........................................................... Rotator cuff disorders Rotator cuff tendinopathy is an overuse condition whereby the rotator cuff tendons at a microscopic level demonstrate hypercellularity, neovascularisation and col- lagen matrix disruption. The tendons are typically swol- len, but have minimal or absent inflammation (Rees, Maffulli, & Cook, 2009). They mainly occur in sports that involve overhead movements of the shoulder and patients may report a history of overuse, such as an increase in training intensity for a competition. Figure 1. The acromioclavicular joint and associated structures. Reproduced from Brukner P., Khan, K. (2012). Brukner &
Khan’s Clinical Sports Medicine (4th ed.), with permission from McGraw-Hill Education. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. . Table 1. The primary action of the muscles around the scapula and shoulder. Shoulder muscles Primary actions Rotator cuff muscles Supraspinatus Abduction of humerus Infraspinatus External rotation of humerus Teres minor External rotation of humerus Subscapularis Internal rotation of humerus Other muscles Deltoid Abduction, flexion and extension of humerus Trapezius Retracts, elevates, rotates and stabilises scapula Serratus anterior Protracts and laterally rotates scapula Rhomboids Retracts and medially rotates scapula Levator scapulae Elevates scapula
Pectoralis minor Protracts, medially rotates scapula 31 .................... InnovAiT ..................................................................................... .......... ............................................................................................... ............ Patients typically present with a gradual onset dull shoul- der pain exacerbated by overhead activities or reaching above the shoulder level. They may get symptoms from reaching behind the back and with lifting movements. Night pain can also be a feature, and weakness can develop in late stages (Factor & Dale, 2014). The rotator cuff muscles or tendons can also tear, espe- cially in older patients. Tears can be partial or full thick- ness, and may present acutely or develop gradually. Other symptoms include night pain, stiffness, weakness and clicking sensations. Glenoid labral injuries The glenoid labrum is a ring of fibrocartilaginous tissue attached to the rim of the glenoid cavity, it allows the cavity size to be expanded and therefore provide more stability to the joint (Brukner & Khan, 2012). The long head of the biceps brachii tendon attaches to the labrum. Patients with labral injuries present with pain usually in the posterior aspect of the shoulder exacerbated by overhead activities with associated features of shoulder
weakness, popping, catching, and grinding sensations. Mechanisms of labral injuries include a single traumatic event, such as a direct blow or fall onto the shoulder, a forceful or excessive traction on the labrum, such as drop- ping then catching a heavy object, or repeated micro- trauma to the labrum, such as from cocking the shoulder in throwing sports (Wilk et al., 2005). It is always important to consider a diagnosis of labral injury, as early referral to a shoulder specialist is indicated for best results. Shoulder instability and dislocation Shoulder instability refers to symptomatic laxity within the glenohumeral joint that can be caused by over- stretched or torn shoulder ligaments, muscles, tendons or labrum. Dislocation occurs when the humeral head no longer sits within the glenoid cavity (i.e. a complete dis- ruption to the joint). A partial disruption to the joint is termed subluxation. The causes of subluxation or dislocation can be traumatic or atraumatic. Traumatic dislocation is common in ath- letes, and approximately 95% of first time shoulder dis- locations result from a forceful collision, a fall onto an outstretched arm or a sudden twisting movement: 98% of traumatic dislocations occur in an anterior direction. Approximately 5% of dislocations overall are atraumatic in nature, and these individuals may have altered muscle control of the shoulder, capsular laxity, or both (Hayes, Callanan, Walton, Paxinos, & Murrell, 2002). Patients present with anterior or posterior shoulder pain, visible deformity, popping or catching sensations, weak- ness, unstable feeling and night pains. They may have a history of recurrent dislocations and be involved in
specific high-risk activities, for example, throwing a jav- elin, being a pitcher in baseball or swimming. Clavicle fracture Clavicle fractures, particularly the mid-third of the clav- icle, are the most common acute shoulder injuries and account for one in twenty adult fractures. Fractures located more laterally can disrupt the acromioclavicular joint. Over 80% of clavicle fractures can be managed conservatively (Quillen, Wuchner, & Hatch, 2004). These injuries usually occur from a fall onto the clavicle or, less frequently, a direct blow to the clavicle. Patients may be involved with contact sports or other at- risk sports such as horse-riding and cycling. They present with acute localised pain with swelling and sometimes visible deformity. Acute injuries are more likely to present to the hospital Accident & Emergency Department than primary care. Acromioclavicular joint injury Acute acromioclavicular joint (ACJ) injuries can occur due to a direct force to the acromion typically with the shoul- der adducted, or from an indirect force elsewhere in the body, for example, a fall onto an outstretched arm (Simovitch, Sanders, Ozbaydar, Lavery, & Warner, 2009). Patients present with acute localised pain, swelling and sometimes redness. Injuries can range from a simple acromioclavicular ligament sprain that can be managed conservatively, to ligament tears with ACJ displacement that often require surgery. Chronic ACJ pain can occur following acute ACJ injuries or from repeated irritation to the joint that can develop into osteolysis or osteoarthritis. These chronic changes can be caused by sports that involve throwing or lifting
weights. The symptoms will be similar to acute ACJ, but the pain develops insidiously. Biceps tendinopathy The biceps brachii muscle has both a short head and a long head. The short head originates from the coracoid process of the scapula, whereas the long head originates from the supraglenoid tubercle of the scapula where it attaches to the superior aspect of the glenoid labrum. The long head of the biceps (LHB) tendon exits the glenohumeral joint and travels through the bicipital groove between the greater and lesser tuberosities. Biceps tendinopathy usually refers to an overuse injury of the LHB tendon. It has a close relationship with the glenoid labrum and the insertion sites of the rotator cuff tendons. An accurate diagnosis of LHB tendinopathy can therefore be difficult; and other shoulder injuries, such as rotator cuff disease, labral lesions, and shoulder instability, may co-exist (Krupp, Kevern, Gaines, Kotara, & Singleton, 2009). The typical features are gradual onset dull anterior.. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 32 ................... ............................................................................................... ............................................................................................... ................................ shoulder pain in someone with risk factors for biceps over- use such as weightlifters and bench pressers.
Examination ........................................................... Have a system for examining joints. Several exist; how- ever, the ‘Look, Feel, Move’ system is perhaps the sim- plest. Start by inspecting the shoulder from the front, side and back, looking for any swelling, asymmetry, deformity, skin changes and scarring. Palpate from the sternoclavicular joint, move laterally to the ACJ, then across the spine of the scapula and along the border of the scapula. It is also important to feel the corac- oid process, humeral head, bicipital groove and surround- ing shoulder musculature for any swelling or tenderness. It is important to test the range of both passive and active movements of the shoulder in all directions. Table 2 sum- marises ‘normal’ range of shoulder movement (ROM), how- ever, in reality, normal range varies between individuals and it is therefore better to compare ROM with the unaffected side for patients with unilateral shoulder injuries. Special tests ........................................................... BLISS is a helpful mnemonic to remember which condi- tions to examine for using special tests. It stands for: . B – Biceps tendon . L – Labral . I – ‘Impingement’ . S – ‘Scarf’ (referring to the ACJ), and . S – Stability tests A systematic review of 45 studies evaluating specific shoulder tests, demonstrated that the diagnostic accuracy for many of these tests is limited (Hegedus et al., 2008). Therefore, special tests should only be used to provide supporting evidence for or against a shoulder injury sus-
pected on the basis of history and general examination. Biceps tendon tests The Yergason’s test and Speed’s test are the two com- monly used tests for biceps tendon pathology. They may also be positive in labral lesions, as the LHB tendon is attached to the labrum. They have low sensitivities (43% and 32%, respectively), but are moderately specific (79% and 75%, respectively). The positive predictive value (PPV) of Yergason’s test and that of Speed’s test is 60% and 50%, respectively, compared with shoulder arthros- copy (Holtby & Razmjou, 2004). Yergason’s test is performed with the patient’s elbow flexed to the side at 90� with forearm pronated. The patient is then asked to actively supinate the forearm against the examiner’s resistance. A positive test will elicit pain in the bicipital groove. Speed’s test is performed with the patient’s elbow extended and forearm supinated. The patient is then asked to elevate (forward flex) their humerus against the examiner’s resistance. A positive test will elicit pain in the bicipital groove. Labral pathology tests There are a variety of special tests for labral lesions, but a test called ‘Biceps Load 2’ (Fig. 2) has the highest sensi- tivity (89.7%) and specificity (96.9%) with a PPV of 92.1% (Kim, Ha, Ahn, & Choi, 2001). The test is performed with the patient supine, arm abducted to 120� and max- imally externally rotated with elbow flexed at 90� and forearm supinated. The patient is then asked to actively flex his or her elbow against the examiner’s resistance. In a positive test, this manoeuvre should increase or repro-
duce the shoulder pain. Impingement tests Impingement itself is actually a syndrome or clinical sign rather than a specific diagnosis. It is usually due to narrow- ing of the subacromial space, and causes include rotator cuff tendinopathy, rotator cuff calcification, bony spurs under the acromion, and subacromial bursal pathology. With impingement syndrome, a ‘painful arc’ can be detected when assessing ROM for abduction whereby pain occurs between 60� and 120� degrees of abduction and eases above 120�. The Hawkins–Kennedy test and Neer’s sign are two other tests for impingement that have moderate sensitivities of 79%, and lower specifici- ties of 59% and 53%, respectively (Hegedus et al., 2008). Table 2. Types of shoulder movement and their ’normal’ range of movement Types of shoulder movement ‘Normal’ range of movement (degrees) Forward flexion 180 Extension 50 Abduction 180 Adduction 30 Internal rotation with elbows
at the side flexed at 90� 70 External rotation with elbows at the side flexed at 90� 90 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. . 33 .................... InnovAiT ............................................................................................... ............................................................................................... ............ The Hawkins–Kennedy test is performed by the exam- iner taking the patient’s arm into 90� of forward flexion then flexing the patient’s elbow to 90� followed by pas- sive internal rotation of the humerus. A positive test occurs when symptoms are reproduced on passive inter- nal rotation. Neer’s sign is performed with the examiner stabilising the patient’s scapula, internally rotating the patient’s arm, and passively forward flexing the patient’s arm. A posi- tive test occurs when symptoms are reproduced on pas- sive forward flexion of the arm. ACJ tests
The ‘Scarf’ test, also known as the cross-body adduction test, has a sensitivity of 77%, but only a 20% PPV, for chronic ACJ pathology (Chronopoulos, Kim, Park, Ashenbrenner, & McFarland, 2004). The test is per- formed with the patient’s arm and elbow flexed and then forcibly adducted by the examiner across the chest. A positive test will reproduce pain in the ACJ. There is, however, a far simpler ACJ test. ACJ tenderness on palpation has a sensitivity of 96% and a 52% PPV for chronic ACJ pathology (Walton et al., 2004). Stability tests The ‘apprehension test’ for anterior shoulder instability has shown sensitivities between 53 and 72% and specifi- cities between 96 and 99% (Biederwolf, 2013). The test is best performed with the patient supine with arm pos- itioned in 90� abduction with external rotation. The examiner gradually applies more external rotation while observing the patient for apprehension (not just pain alone). Care must be taken when performing this test, as there is a risk of acutely dislocating an unstable shoulder. A test of postero-inferior instability can be performed with the ‘Jerk’s test’ that has a sensitivity of 73% and specificity of 98% (Biederwolf, 2013). The test is performed with the patient’s arm abducted to 90� with internal rotation while the examiner stabilises the patient’s scapula with one hand and grasps the elbow with the other. The examiner then proceeds to apply an axial load to the humerus while horizontally adducting the patient’s arm across the body (Fig. 3). A positive test is indicated by reproduction of pain, or reproduction of a click or clunk. Clinical examination
findings ........................................................... The clinical signs for each of the common causes of sports-related shoulder pain are summarised in Table 3. It is important to understand that clinical signs may over- lap in different conditions, as the structures within the shoulder are so closely associated with each other. There may also be more than one pathological process occur- ring in the shoulder simultaneously... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Figure 2. Biceps load 2 test with patient lying supine. 34 ...................
............................................................................................... ............................................................................................... ................................ Investigations ........................................................... There are potentially three radiological investigations that can be requested from general practice, although direct access does vary from area to area in the UK. These are X-rays, ultrasound scans, and magnetic resonance ima- ging (MRI). X-rays In the context of sporting injuries, X-rays are primarily indicated for detecting any bony fractures or disloca- tions. If there is any suspicion of these injuries then the patient needs to be referred for immediate X-ray or, if this is not available, to the local emergency or minor injuries unit. For rotator cuff disorders, an X-ray is not indicated, but it may reveal calcified tendons. X-ray can be helpful for chronic ACJ injuries as it may show osteoarthritic changes and osteolytic lesions suggestive of a stress fracture. Ultrasound A meta-analysis of five studies (311 shoulders) that used an ultrasound scan (USS) to diagnose rotator cuff dis- orders found a sensitivity level of 79% and a specificity of 94% (Roy et al., 2015). Ultrasound scanning is, there- fore, a very valuable investigation for rotator cuff disorders.
An USS can also identify pathologies in and around the subacromial space, which is useful if patients have impingement signs. However, before requesting a shoul- der USS, the age of the patient needs to be taken into consideration, as the incidence of asymptomatic rotator cuff tears increases after the age of 40 (Oschman, Janse van Rensburg, Maritz, Boraine, & Owen, 2007). MRI MRI can be used to evaluate both soft tissue and bony injuries in detail. It is unclear whether MRI is more accur- ate at detecting rotator cuff tendinopathy compared with USS, but both are equally effective in detecting partial or full thickness tears (Gazzola & Bleakney, 2011). Labral injuries can be detected with MRI, but a meta-analysis revealed that magnetic resonance arthrography is super- ior to MRI (Smith, Hilton, Toms, Donell, & Hing, 2011). The cost implications of referring patients for a shoulder MRI need to be carefully considered in general practice, and onward referral to a specialist rather than requesting a MRI maybe a better management option in some cases. Management ........................................................... Rotator cuff disorder In rotator cuff tendinopathy, it is important to counsel patients about relative rest from the sport or the specific activities that trigger the pain. Non-steroidal anti-inflam- matory drugs (NSAIDs) and application of ice can pro- vide symptomatic relief. Subacromial corticosteroid injections do result in a reduction in pain symptoms, but multiple injections over a short period of time and injection into the tendon itself increases the risk of tendon rupture (Gomoll, Katz, Warner, & Millett, 2004).
Referral to physiotherapy for rotator cuff muscle strengthening and scapulohumeral work is recom- mended for all patients. The treatment of a tear in a rotator cuff is similar to rotator cuff tendinopathy, with the exception that young sports-people with a full thick- ness rotator cuff tear normally require referral for surgical repair (Brukner & Khan, 2012). Figure 3. Jerk’s test viewed from the side. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. .. .. 35 .................... InnovAiT ............................................................................................... ............................................................................................... ............ Glenoid labral injuries Conservative management of glenoid labral injuries is usu- ally unsuccessful (Brukner & Khan, 2012). These injuries need to be referred to an orthopaedic shoulder specialist for an arthroscopic repair (reattachment) of the labrum, or, if the labral injury is stable, arthroscopic debridement. Post- operative physiotherapy input is needed to gradually rehabilitate and restore normal shoulder function. Shoulder instability and dislocation In non-acute atraumatic shoulder instability, physiother-
apy referral is required to provide progressive scapular stabilisation exercises, strengthen the rotator cuff mus- cles, and control the glenohumeral translation (Hayes et al., 2002). If physiotherapy is unsuccessful, then cap- sular surgery can be considered. In acute or traumatic shoulder dislocation, the patient should be referred to the local Accident & Emergency Department for diagnostic X-rays, reduction of the shoul- der with appropriate analgesia, and post-reduction X-rays. Clavicle fractures Patients with a clavicle fracture need analgesia and prompt referral to the Accident & Emergency Department for X-rays. If there is low risk of clavicle foreshortening then a broad arm sling (or figure-of- eight bandage) is usually applied, and the fracture grad- ually heals over a month or so. Surgical intervention is indicated if there is a risk of clavicle foreshortening, delayed union, or non-union. ACJ injuries In acute ACJ injuries, patients should be given analgesia and a sling for immobilisation if available. If an ACJ sprain is suspected, then it may be reasonable to treat with ice, analgesia, and immobilisation followed by a review 48 hours after the acute episode. If the ACJ appears deformed, the pain is difficult to control, or there is uncer- tainty about the degree of ACJ injury, then referral to the Accident & Emergency Department or to the on-call Table 3. Sports-related shoulder conditions and their possible clinical signs. Condition Possible clinical signs
Rotator cuff tendinopathy . Asymmetry and muscle wasting . Palpation tenderness at the greater tubercle (insertion sites of three rotator cuff muscles) . Reduced active ROM . Passive ROM intact . Reduced power on resisted movements . Impingement signs Rotator cuff tears . Shoulder shrug appearance . Partial or no active ROM . Passive ROM often intact . Reduced power on resisted movements . Drop-arm sign in complete tears if arm cannot be actively maintained at 90� abduction . Impingement signs
Glenoid labral injury . Palpation tenderness in the anterior shoulder structures . Swelling if acute . Reduced external rotation and or abduction ROM . Reduced power on resisted movements . Biceps load 2 test positive if superior labrum anterior posterior (SLAP) tear . Speed’s test positive if SLAP . Yergason’s test positive if SLAP . Jerk’s test positive if postero- inferior labral injury Shoulder instability and dislocation . Prominent humeral head if anter- ior dislocation . Swelling if acute . Reduced active and passive ROM
if dislocated . Increased active or passive ROM if instability with laxity . Apprehension test positive if anterior dislocation . Jerk’s test positive if postero- inferior dislocation . Upper arm axillary nerve sensa- tion can be reduced in anterior dislocations Clavicle fracture . Localised swelling with deformity . Clavicle shortened or angulated . Localised bony tenderness (continued) Table 3. Continued. Condition Possible clinical signs ACJ injury . Step deformity and swelling if acute . Localised ACJ tenderness . Scarf test positive
. Impingement signs if chronic Biceps tendinopathy . Bicipital groove tenderness . Speed’s test positive . Yergason’s test positive .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. .. .. .. 36 ................... ............................................................................................... ............................................................................................... ................................ orthopaedic team is appropriate. Surgery is indicated for tears in both the acromioclavicular and coracoclavicular ligaments with displacement of the clavicle (Tauber, 2013). The management of chronic ACJ injuries requires relative rest and activity modification, such as reducing the weight load when bench pressing. NSAIDs and cortico- steroid injections into the ACJ can have therapeutic benefits, particularly in younger patients (Hossain, Ayekoloye, Odumala, & Jacobs, 2003). Referral to physiotherapy for range of motion and strength training can aid recovery. In chronic persistent ACJ pain, ortho-
paedic referral for consideration of surgical excision of the distal clavicle may be necessary. Biceps tendinopathy Initial treatment of biceps tendinopathy involves a period of relative rest, withdrawal from exacerbating activities, ice and NSAIDs. The next step is referral for physiother- apy rehabilitation that involves restoration of passive biceps ROM, followed by active biceps ROM exercises, and then finally rotator cuff strengthening. If symptoms fail to respond after 6–8 weeks of conservative measures then corticosteroid injections into the subacromial space can be beneficial, and in resistant cases, injections into the biceps tendon sheath can be tried (Krupp et al., 2009). There are a variety of surgical options for biceps tendinopathy, such as decompression, debridement, ten- otomy and tendon transfer, but choice of procedure is a specialist decision. Specialist referral ........................................................... Patients presenting acutely with sports-related injuries who have severe pain, and/or symptoms in keeping with acute bony injury or joint dislocation should be referred for immediate Accident & Emergency Department review. Most other sports-related shoulder injuries can be man- aged in primary care with rest, ice, analgesia, physiother- apy and possible local steroid injection. Specialist sports physiotherapy input can be helpful if available and may be particularly useful in helping patients to avoid repeat injury when they return to their sport. Consider specialist orthopaedic referral if: . No clear cause of the patient’s pain can be found –
this referral should be urgent if the patient has a past history of cancer, the pain is worsening, or the pain is associated with any constitutional symptoms such as night sweats or raised erythrocyte sedimentation rate . Pain is not resolving despite conservative measures in primary care . The patient is young (under 40 years) and is found to have a full thickness rotator cuff tear on imaging . The patient has a glenoid labral tear Key points . Sports-related shoulder injuries are common and can cause both acute and chronic symptoms . A concise history and a targeted examination is essential for initial diagnosis of sports-related shoulder injuries in primary care . Special tests in the examination of sports-related shoulder injuries are useful only to provide sup- porting evidence for a specific suspected injury . X-ray, USS and MRI may all be useful in further evaluation of patients with sports-related shoulder pain depending on local availability . The majority of patients with sports-related shoul- der injuries can be managed in primary care; some acute injuries will require prompt referral to the Accident and Emergency Department for further imaging and immediate management
. Refer to an orthopaedic shoulder specialist if the diagnosis is unclear, the symptoms fail to settle with primary care management, if the patient is young and has a full-thickness rotator cuff tear, or if the patient has a glenoid labral tear References and further information . Biederwolf, N. E. (2013). A proposed evidence- based shoulder special testing examination algo- rithm: Clinical utility based on a systematic review of the literature. International Journal of Sports Physical Therapy, 8(4), 427–440. Retrieved from www.ncbi.nlm.nih.gov/pmc/arti cles/PMC3812837/ . Brukner, P., & Khan, K. (2012). Brukner & Khan’s clinical sports medicine, fourth edition. New York: McGraw-Hill Medical . Chronopoulos, E., Kim, T. K., Park, H. B., Ashenbrenner, D., & McFarland, E. G. (2004). Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. American Journal of Sports Medicine, 32(3), 655–661. doi: 10.1177/0363546503261723 . Factor, D., & Dale, B. (2014). Current concepts of rotator cuff tendinopathy. International Journal of Sports Physical Therapy, 9(2), 274–288. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/ PMC4004132/ . Gazzola, S., & Bleakney, R. R. (2011). Current ima- ging of the rotator cuff. Sports Medicine and
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treatment. Journal of Orthopaedic Sports Physical Therapy, 39(2), 55–70. doi: 10.2519/ jospt.2009.2802 . Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: Diagnosis and management in primary care. British Medical Journal, 331(7525), 1124–1128. doi: 10.1136/bmj.331.7525.1124 . Oschman, Z., Janse van Rensburg, C., Maritz, N., Borain, H., & Owen, R. (2007). Ultrasound study of the asymptomatic shoulder in patients with a con- firmed rotator cuff tear in the opposite shoulder. South African Journal of Sports Medicine, 19(1), 23–28. doi: 10.17159/2413-3108/2007/v19i1a272 . Quillen, D. M., Wuchner, M., & Hatch, R. L. (2004). Acute shoulder injuries. American Family Physician, 70(10), 1947–1954. Retrieved from: www.aafp.org/afp/2004/1115/p1947.html . RCGP. Clinical module 3.20: Care of people with musculoskeletal problems. Retrieved from www. rcgp.org.uk/training-exams/gp-curriculum-over- view/online-curriculum/applying-clinical-knowl- edge-section-2/3-20-musculoskeletal-problems. aspx . Rees, J. D., Maffulli, N., & Cook, J. (2009). Management of tendinopathy. American Journal of Sports Medicine, 37(9), 1855–1867. doi: 10.1177/0363546508324283 . Roy, J. S., Braën, C., Leblond, J., Desmeules, F., Dionne, C. E., MacDermid, J. C., . . . Frémont, P.
(2015). Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(20), 1316–1328. doi: 10.1136/bjsports-2014- 094148 . Simovitch, R., Sanders, B., Ozbaydar, M., Lavery, K., & Warner, J. J. (2009). Acromioclavicular joint injuries: Diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons, 17(4), 207–219. doi: 10.5435/00124635- 200904000-00002 . Smith, T. O., Hilton, G., Toms, A. P., Donell, S. T., & Hing, C. B. (2011). The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: A meta-analysis. European Radiology, 21(4), 863–874. doi: 10.1007/s00330-010-1956-7 . Tauber, M. (2013). Management of acute acromio- clavicular joint dislocations: Current concepts. Archives of Orthopaedic and Trauma Surgery, 7(133), 985–995. doi: 10.1007/s00402-013-1748-z . Walton, J., Mahajan, S., Paxinos, A., Marshall, J., Bryant, C., Shnier, R., & Murrell, G. A. (2004). Diagnostic values of tests for acromioclavicular joint pain. Journal of Bone and Joint Surgery. American volume, 86A(4), 807–812. Retrieved from www.jbjs.org/content/86/4/807 . Wilk, K. E., Reinold, M. M., Dugas, J. R., Arrigo, C. A., Moser, M. W., & Andrews, J. R. (2005). Current concepts in the recognition and treatment
of superior labral (SLAP) lesions. Journal of Orthopaedic Sports Physical Therapy, 35(5), 273–291. doi: 10.2519/jospt.2005.35.5.273 Dr Raymond Leung Freelance Locum GP, Sutton United Football Club Doctor, MSc student in Sports and Exercise Medicine, London Email: [email protected] .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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.. .. .. .. .. .. .. .. .. .. .. .. .. . 38 ................... ............................................................................................... ............................................................................................... ................................ www.bjjprocs.boneandjoint.org.uk/content/85-B/SUPP_I/72.4 www.bjjprocs.boneandjoint.org.uk/content/85-B/SUPP_I/72.4 www.aafp.org/afp/2004/1115/p1947.html www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum-
overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.jbjs.org/content/86/4/807 Review article Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 Received: 30 November 2017 Accepted: 29 January 2018 Published online: 19 February 2018 © The Author(s) 2018. This article is an open access publication. Jonas Pogorzelski1,2 · Erik M. Fritz1 · Jonathan A. Godin1,3 · Andreas B. Imhoff2 · Peter J. Millett1,3 1 Steadman Philippon Research Institute, Vail, USA 2 Department of Orthopedic Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany 3 The Steadman Clinic, Vail, USA Nonoperative treatment of five
common shoulder injuries A critical analysis Introduction Shoulderpainisoneofthemostcommon musculoskeletal complaints accounting for at least 4.5 million patient visits an- nually in the United States [43, 55] and occurring in as many as 51% of indi- viduals in a lifetime [64]. Moreover, the economic burden of shoulder pathology is vast with annual direct costs for treat- ment of shoulder dysfunction totaling at least $7 billion in the United States, mostly due to operative treatment [47]. InGermanythepercentageofaffectedpa- tients and associated costs are expected to be similar. Moreover, with an aging and increasingly active patient popula- tion in the Western world, the absolute number of shoulder pathologies is likely to grow, further increasing costs. These economic implications high- light the critical need for appropriate diagnosisandtreatmentofvariousshoul- der pathologies, as under-diagnosis and under-treatment can result in increased costs to society with disability and lost production. On the other hand, aggres- sive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, the purpose of this review
is to distinguish the indications between operative and nonoperative management for five common shoulder pathologies, ResearchperformedattheSteadmanPhilippon ResearchInstitute,Vail,CO,USAandtheDepart- ment of Orthopedic Sports Medicine,Technical UniversityofMunich,Munich,Germany. including rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular (AC) joint, and proximal humeral fractures. Moreover, we aim to provide a short overview of the nonoperative manage- ment of each of these pathologies. Rotator cuff tears Indications for nonoperative treatment of symptomatic full- thickness rotator cuff tears Although symptomatic rotator cuff tears are common and affect between 4% and 32% of the general population, the most appropriate therapy is still debatable [59, 75]. While there is agreement that traumatic rotator cuff tears should be treated operatively, the treatment choice for atraumatic rotator cuff tears remains unclear [38, 39]. This is mainly due to the fact that the radiological failure rate following rotator cuff repair surgery can be as high as 70% depending on the patient cohort, thus leading to the
assumption that nonoperative treatment may be equivalent [5, 8, 24, 41]. This conjecture is further strengthened by the fact that pain relief and improvement of symptoms do not necessarily go hand in hand with structural healing of the tendon [59]. However, when taking a closer look at published outcomes in the literature, nonsurgical treatment appears to have limitations. While multiple studies with short-term follow-up of nonsurgical treatment show promising results with good clinical outcomes, studies with mid-term follow-up are more disillu- sioning [10, 22, 38, 39, 50]. This could be explained by the fact that smaller tears may not affect the force couples in the shoulder, thus a reasonable degree of shoulder function may be maintained [42]. As there is strong evidence that the natural history of nonoperatively treated rotator cuff tears leads to tear progression over time, nonoperative outcomes studies with longer follow-up may include more patients whose tears have progressed to the point of destroyed force couples [80]. Kukkonen et al. [38, 39] published a randomized controlled trial for the treatment of supraspinatus tendon tears in patients older than 55 years. A total of 180 shoulders with supraspinatus tendon
tears were randomly allocated into one of three treatment groups: 1. Isolated physiotherapy 2. Acromioplasty and physiotherapy 3. Rotator cuff repair with acromio- plasty and physiotherapy After 1 year of follow-up, no statistically significant differences in outcomes were detected, thus leading to the conclusion that surgical therapy is not superior in these patients [38]. Later, with an addi- tional year of follow-up, the groups still did not differ significantly in outcomes; however, tear progression measured with magnetic resonance imaging (MRI) sug- gested thatonlypatients withlowerphys- ical demands should be treated nonoper- Obere Extremität 2 · 2018 89 https://doi.org/10.1007/s11678-018-0449-1 http://crossmark.crossref.org/dialog/?doi=10.1007/s11678-018- 0449-1&domain=pdf http://orcid.org/0000-0002-6178-4940 Review article Fig. 1 8 Axial T2-weightedmagnetic res- onance imaging sequence of a 36-year-old patient aftera first-timeshoulderdislocation. Givenhisageandtheabsenceofanyrotatorcuff tearorotherconcomitant pathology,he was deemedlow risk forre-dislocation.Therefore,
nonoperative treatment was pursued,which was successful withno recurrent subluxation or dislocation atively and patient counseling is critical [39]. In another randomized controlled trial of 103 patients, which compared rotator cuff repair with nonoperative physiotherapy for tears not exceeding 3cm, Moosmayer et al. [50] found sev- eral additional factors that may influence the outcome. With a minimum follow- up of 5 years, the results for the group of patients who had immediate tendon repair were generally superior to those of patients who underwent physiotherapy as primary treatment and decided later to progress with surgery. Furthermore, treatment failed in almost 24% of the patients who received physiotherapy as primary therapy, and they underwent subsequent rotator cuff repair. In 37% of patients who did not undergo surgery, the tear size increased more than 5mm over 5 years with associated inferior outcomes [50]. SimilarresultswerereportedbySafran et al. [68], who followed up 51 patients younger than 60 years with full-thick- ness rotator cuff tears in a longitudinal study. In this particularly young patient cohort, almost half of the tears increased after a mean follow-up of 29 months.
Moreover, the authors found a signifi- cant association between the size of the rotator cuff tear and pain, which led to theconclusionthatyoungpatientsinpar- ticular benefit from surgery [68]. Treatment While multiple rehabilitation protocols for the postoperative treatment follow- ing rotator cuff repair have been pro- posed, there are only a few published studies focusing on treatment protocols for primary nonoperative management of rotator cuff tears [37, 48, 59, 75]. In general, conservative treatment options include 3–6 months of activity modifica- tion, physical therapy such as strength- ening and stretching ofthe muscles ofthe shouldergirdle, andinjectionororalanti- inflammatory and pain-relieving medi- cation [37, 48, 59]. A prospective multicenter study pub- lished in 2013 by the MOON shoulder group of 452 patients treated with a stan- dardized physical therapy program for atraumatic full-thickness rotator cuff tears revealed a 75% satisfaction rate in patients after 2 years of follow-up. Phys- ical therapy included daily postural and stretching exercising as well as strength- ening of the rotator cuff three times a week. If needed, patients were seen by aphysicaltherapist, especiallyformanual mobilization of the glenohumeral joint.
Although less than a quarter of patients underwent surgery in the short-term follow-up period, the lack of imaging follow-up raises doubts about the long- term success. In summary, careful patient selection is necessary when nonoperative treat- ment for full-thickness rotator cuff tears is chosen. The best possible outcomes are generally achieved in patients pre- senting with pain as the primary symp- tom, those having largely intact coronal and axial force couples, and patients who are willing to trade functional deficits of their shoulder to avoid surgical risks. However, as there is no evidence that the torn tendon actually heals without surgi- cal re-fixation, patient counseling about tear size progression is indicated. This includes the progression from an initially reparable tear to an irreparable tear, as wellasinferiorpostoperativeoutcomesof chronictearscomparedwithacutelyfixed tears. If treated nonoperatively, a combi- nation of activity modification, stretch- ing and strengthening of the periscapular muscles and the deltoid should be per- formed. MRI of a known rotator cuff tear can be performed on patients who want to progress with surgical refixation of the tear and those who wish to monitor tear progression to consider surgery at some future time point.
Anterior shoulder instability Indications for nonoperative treatment of anterior shoulder instability There is consensus in the literature that a detailed analysis of individual risk fac- tors for recurrent instability should be madeforeachpatientpresentingwithan- terior instability to determine the most appropriate treatment [3, 61]. In gen- eral, knownfactorsassociatedwithahigh risk of recurrent instability when treated nonoperatively are young age, an active lifestyle, bone loss of more than 20% of the glenoid surface, and engaging or off- track Hill–Sachs lesions[3, 9, 11, 44, 61, 65, 73]. In patients younger than 30 years of age, the risk of re-dislocation when treated nonoperatively is between 70 and 90% compared with up to 25% when treated operatively [9, 30, 71]. When nonoperative treatment is ap- plied to overhead athletes and active patients, the re-dislocation rate is even higher [3, 61]. However, with increasing age, the re-dislocation rate in patients treated nonoperatively decreases sub- stantially making nonoperative treat- ment an option [12]. In general, patients without structural
lesions of the glenohumeral joint can be treated nonoperatively, especially when older than 35 years (. Fig. 1). However, the treating physician must ensure that concomitant injuries such as rotator cuff tears, Hill–Sachs lesions of more than 25% of the humeral surface, or glenoid bone loss are excluded as those would need surgical intervention [3, 11, 44, 66]. The “critical” amount of glenoid bone loss is typically defined as a loss of more than 20% of the glenoid surface [11, 44]. Another risk factor for recurrent insta- bility is engaging or off-track Hill–Sachs lesions, as reported in recent literature 90 Obere Extremität 2 · 2018 Hier steht eine Anzeige. K recommending operative treatment [57, 73]. Furthermore, the injury pattern should be taken into account. High- energy trauma often results in a locked dislocation or displaced fracture of the glenoid or the humeral head and is generally best approached with surgical treatment. Finally, patients who have
the ability to voluntarily dislocate their shoulder without discomfort should be treated nonsurgically in most cases, as these patients likely suffer not from structural instability but rather from functional instability, which can be due to a pathological functional activation pattern [27, 33] and may respond better to functional conservative treatments [70] or even electrical muscle stimu- lation in some therapy-resistant cases [51]. Treatment In order to manage shoulder instability without surgical intervention, a combi- nation of immobilization and physical therapy is often used before the patient can return to activity [12, 35, 36, 54]. Physicaltherapyprotocolsmayeitherfol- low a period of immobilization of about 3 weeks in internal or external rotation of the shoulder or be initiated immedi- ately. The overall goal of physical ther- apy is to progress through glenohumeral strengthening and stabilization, thus re- ducing the probability of recurrent in- stability. Return to full activity is mostly allowedwhenthereissymmetricalshoul- der strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [12, 57]. More recently, several studies have fo- cused on the position of the arm during
immobilization after a traumatic anterior shoulder dislocation. In an MRI study by Itoi et al. [31], immobilization with the arm in external rotation resulted in reductionoftheBankartlesionaftertrau- maticshoulderdislocation, thussupport- ing the hypothesis thatimmobilizationin external rotation may be superior to im- mobilization in internal rotation. How- ever, published clinical trials have not been able to demonstrate similar efficacy of external rotation immobilization for Abstract · Zusammenfassung Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 © The Author(s) 2018. This article is an open access publication. J. Pogorzelski · E. M. Fritz · J. A. Godin · A. B. Imhoff · P. J. Millett Nonoperative treatment of five common shoulder injuries. A critical analysis Abstract Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under- diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore,
it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals. Keywords Rotator cuff tears · Shoulder injuries · Tendinitis · Acromioclavicular joint · Humeral fractures, proximal Konservative Therapie von 5 häufigen Schulterläsionen. Eine kritische Analyse Zusammenfassung Der zunehmende Kostendruck in der Medizin verstärkt die Notwendigkeit einer rasch zielführenden Diagnose und Therapie verschiedener pathologischer Veränderungen im Bereich der Schulter. Unterversorgte Patienten erhöhen die Kosten für die Gemeinschaft durch längere Ausfallzeiten und damit erniedrigte Produktion, während überzogene Therapien die bereits ausufern- den Kosten in der medizinischen Versorgung weiter erhöhen und den Patienten sogar potenziell schädigen können. Deshalb ist es
unabdingbar, die Indikationen für operative und konservative Therapien zu kennen und anzuwenden, besonders im Hinblick auf häufige pathologische Veränderungen wie Rotatorenmanschettenläsionen, vordere Schulterinstabilität,Bizepssehnentendinitis, Akromioklavikular Gelenkluxationen und pro- ximale Humerusfrakturen. Grundsätzlich ist es dabei wichtig, individuelle Risikofaktoren für ein Therapieversagen zu erkennen, den Erwartungshorizont des Patienten bezüglich funktionaler Ansprüche und Langzeitziele abzuklären und auch das Verletzungsmuster zu analysieren, um so letztendlich die Therapie individuell an den jeweiligen Patienten anpassen zu können. Schlüsselwörter Rotatorenmanschettenläsionen · Schulterverletzungen · Tendinitis · Akromioklavikulargelenk · Proximale Humerusfrakturen preventing recurrent shoulder instability [20, 78], including a recent randomized controlled multicenter trial published in 2014 [78]. Additionally, the conclusion that “immobilization in internal or exter- nal rotation does not change recurrence rates after traumatic anterior shoulder dislocation” was confirmed in a 2014 sys- tematic review of the literature [76] and a 2016 meta-analysis of randomized con- trolled trials [77]. Of note, immobiliza- tion in external rotation is reported to be
veryuncomfortable and, therefore, could reduce patient compliance. Overall, careful consideration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonopera- tive vs. operative intervention. Patients younger than 35 years of age should rarely be treated nonoperatively as the recurrence rate is unacceptably high. If treated nonoperatively, immobilization in internal rotation seems to be more comfortable and shows equal outcomes to immobilization in external rotation 92 Obere Extremität 2 · 2018 https://doi.org/10.1007/s11678penalty @M -hskip [email protected] 018penalty @M -hskip [email protected] 0449penalty @M -hskip [email protected] 1 Fig. 2 8 Images of a 46-year-oldman with right- sidedbicepstendonitis,diagnosedvia history,phys- icalexamination,andaT2- weightedmagneticresonanceimagingwithaclearhalosign(yellow circle) aroundthe long headof the biceps tendon indicating inflammation.The patient was treatedconser- vatively with physical therapyandNSAIDs butcontinuedto experiencesymptoms 6months later.He thusunderwentoperativemanagementasseeninbwiththelongheadof thebicepstendon(BT)and biceps reflection pulley visualizedthrough the
standardposteriorviewing portal.HH humeral head and thus should be preferred, according to current literature findings. Biceps tendinitis Indications for nonoperative treatment of long head biceps tendinitis Inflammation of the long head biceps tendon (LHBT) can lead to damage and weakening of surrounding supporting structures, thereby causing LHBT in- stability. In turn, instability can place increased stresses on the LHBT, which subsequently increase inflammation. This cycle can predispose the LHBT to rupture. Given the potential success of non- operative management for most LHBT tendinopathies, a management strategy involving medications and physical ther- apy should be the first step in treating these conditions. After progressing a pa- tient through physical therapy, a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or injections, it is impor- tanttore-evaluatethepatientforprogres- sion of pain, weakness, and mechanical symptoms. At that time, continuation of a home exercise program vs. consider- ation of additional interventions will be discussed based on symptom progres-
sion. Ifapatientprogressesthroughallnon- operative treatment options and notes no improvement of pain or weakness, he or she should progress to surgical evalua- tion (. Fig. 2). This is also the case for patients suffering from biceps reflection pulley lesions because these lesions do nothealandsymptomsworsenovertime. In general, patients suitable for surgical evaluation include the following: young, highly motivated patients with instabil- ity or complete LHBT rupture; man- ual laborers with significant instability or complete LHBT rupture; elite-level ath- letes with instability or complete LHBT rupture; any individual with a complete LHBT rupture who is not agreeable to a potential loss of elbow flexion or fore- arm supination strength and long-stand- ing “Popeye” deformity; and any individ- ual whohas progressed throughall stages of nonoperative treatment and continues to have symptoms of pain and/or weak- ness that affects their quality of life. Treatment After identification of the underlying pathologic condition of the LHBT, treat- ment generally begins with activity modification, NSAIDs, and/or cortico- steroid injections [1, 53]. NSAIDs can provide short-term benefit for swelling
and pain control. However, there is little evidence that they are efficacious in treating chronic tendon injuries [13]. Useofcorticosteroidinjectionsshould follow a similar treatment protocol to NSAIDs. Multiple case reports discuss the risk of tendon rupture with steroid injections, and caution should be exer- cised when injecting steroid around the LHBT [2, 13]. Corticosteroid injections alone will likely provide short-term anti- inflammatory effects for most LHBT dis- orders. However, they should be used for short-term pain relief and as an adjunct for the patient to initiate and tolerate a physical therapy program, rather than as a long-term treatment option. Be- cause these injections have the potential toreachtheglenohumeraljoint, theanes- theticofchoice, usedincombinationwith corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than bupivacaine [62]. Theinitiationofa3–6-monthphysical therapy program allows for progressive increase in muscle strength while pro- viding protection against further LHBT and associated structure injury during rehabilitation [1, 4, 19, 53, 67]. Other evolving nonoperative treat- mentoptionsforLHBTdisordersinclude prolotherapy (dextrose solution, sodium
morrhuate), platelet-rich plasma (dif- fering concentrations of platelets, white blood cells, red blood cells, and activated and inactivated platelets), and stem cells (circulating stem cells, adipose-derived, bone marrow aspirate, bone marrow aspirate concentrate, amniotic mem- brane-derived). The choice to utilize one of these treatment options varies from patienttopatientand conditiontocondi- tion, and current research is beginning to thoroughly evaluate these interventions and to standardize treatment protocols [21, 23, 45, 46, 49]. Indications for these injections include pain impairing athletic performance, connective tissue laxity impairing athletic performance, and pain impairing rest and quality of life [49]. Future research is needed to de- termine which LHBT disorders respond best to, and what patient populations are the most suitable candidates for, such procedures. Acromioclavicular joint injuries Indications for nonoperative treatment of acromioclavicular joint injury Injuryclassificationisthesinglemostim- portant factor in determining the most appropriate treatment of acromioclavic- ular (AC) joint injuries. In 1989, Rock- wood and colleagues developed the clas-
Obere Extremität 2 · 2018 93 Review article Fig. 3 8 Radiographs of a 26-year-oldmale patientafteradirectfallonto his rightshoulder.a Panoramic view after in- jury showing a probable Rockwoodtype II injury.b However,the Alexanderview demonstratestheclavicleoverriding the acromion, thus indicating horizontal instabilityanddefining thisasa RockwoodtypeIVinjury.Accordingly,the patient un- derwentoperativetherapywithtwodog- bonesinsteadofoneinordertobetteraddressthehorizontalinstability ,aspictured in c, the postoperative panoramicradiograph.d Postoperatively, the horizontal instability wasresolvedasdemonstratedon the Alexanderview 6 weeks aftersurgery sification system that is most widely used for AC joint injuries today [79]. No- tably, this system, which is based on the work of Tossy et al. [74], recognizes the importance of the coracoclavicular (CC) ligaments in joint stability [79]. Rockwood type I injuries are charac- terized by a sprain without rupture of the AC ligaments with no anatomic dis- location and intact trapezius and deltoid fascia. Type II injuries involve rupture of the AC joint ligaments but are otherwise similar to type I. Type III injuries are characterized by rupture of both the AC andCCligamentswithsuperiordisplace-
ment of the clavicle of 25–100% com- pared with the contralateral shoulder; notably, the trapezius and deltoid fascia are disrupted with this injury. Type IV injuries generally present with additional horizontal instability (. Fig. 3). Type V injuries are similar to type-III injuries, but the clavicle is superiorly displaced more than 100% compared with the con- tralateral side. Type-VI injuries, which are rarely seen, involve rupture of both AC and CC ligaments with inferior dis- placement of the distal clavicle under- neath the acromion; the trapezius and deltoid fascia are disrupted [74, 79]. Although high-level studies are rare inthe orthopedic literature todefinitively guide optimal treatment, there is a com- mon consensus regarding the most ap- propriatetreatmentsbasedonRockwood type [6]. It is generally agreed that type I and II injuries should undergo initial nonop- erative treatment while types IV–VI re- quire surgery [6]. Optimal management of type III injuries has been controver- sial. In the highest-level study to date, the Canadian Orthopedic Trauma Soci- ety [16] recently completed a prospective randomized trial of 83 patients compar- ing nonoperative treatment of grade III, IV, or V AC joint injuries with operative intervention using a hook plate. Out- come scores at short-term follow-up as
far as 2 years demonstrated no signifi- cant difference between the groups with the exception of superior radiographic results in the operative group [16]. Moreover, Petri and colleagues re- viewed 41 patients with Rockwood grade III AC joint injuries who were initially treated nonoperatively [60]. Nonoperative management consisted of formalphysicaltherapytwotothreetimes per week for at least 6 weeks using a pha- sic approach with progression dictated by patient tolerance and evidence of improved scapulohumeral kinematics. Nonoperative treatment failed in 12 pa- tients, who ultimately required surgery. Reasons cited for nonoperative failure included unremitting pain, weakness, instability, and dysfunction in spite of physical therapy. At a mean follow-up of 3.3 years, patient-reported outcome scores—including the American Shoul- der and Elbow Surgeons score (ASES), Quick Disabilities of the Arm, Shoul- der, and Hand score (QuickDASH), Single Assessment Numeric Evalua- tion score (SANE), and Short Form 12 Physical Component Summary (SF- 12 PCS)—did not significantly differ be- tween those who successfully completed nonoperative therapy and those who required eventual surgery [60]. In general, there is consensus that
the horizontal stability of the clavicle is considered a potential key factor for a successful postoperative outcome. It is hypothesized that an unstable clavi- cle causes pain and functional deficits. Therefore, the ISAKOS shoulder com- mittee [7] recently proposed a modifica- tion to the classic Rockwood classifica- tion in which type III injuries may be fur- ther subdivided into types IIIA and IIIB; 94 Obere Extremität 2 · 2018 type IIIA injuries are horizontally stable and may respond well to conservative management, but type IIIB injuries are unstable and should therefore be treated surgically [7]. Treatment Typical nonoperative treatment consists of primary immobilization and subse- quent active rehabilitation [15]. How- ever, evidence to support the efficacy of specificrehabilitationprotocolsislimited [15]. Gladstoneetal. [25]publishedaphys- icaltherapyregimenforthenonoperative treatment of AC joint injuries types I, II, andIIIinathletes. Phase1lasts3–10days and focuses on elimination of pain and sling immobilization to protect the AC
joint. Range-of-motion exercises begin in phase 2 with gradual progression of isotonic exercise for strengthening. Phase 3 involves advanced strengthen- ing, and phase 4 involves sports-specific training before full returntoactivity[25]. The total length of rehabilitation can last 3–6 months. Moreover, it is important to check on the scapula movement since a significant number of patients suffering from AC joint injuries also present with scapula dyskinesis. Overall, the general consensus re- garding management of AC joint in- juries is fairly straightforward: initial nonoperative treatment for Rockwood grades I–II, and operative intervention for grades IV–VI. For patients with grade III lesions, a closer look con- cerning the stability of the clavicle is necessary. Proximal humeral fracture Indications for nonoperative treatment of proximal humeral fractures The number of bone parts and concomi- tant displacement mainly influences the treatment strategy of proximal humeral fractures. Nonoperative treatment of two-part fractures with early rehabil- itation has been found to be at least as efficacious as surgical treatment in
injuries with minimal displacement [29]. Betteroutcomesmaybeachievedwith surgical fixation in cases with signifi- cant displacement, a bony avulsion of the supraspinatus tendon, a block to range of motion, andinvolvementoftheanatomic neck. However, well-designed compar- ative studies of operative vs. nonoper- ative management of two-part fractures are lacking [26]. Some authors have found that greater tuberosity fractures with >5mm of dis- placement may benefit from surgical fix- ation to reduce the risk of subacromial impingement [58, 63]. Lesser tuberosity fractures with internal rotation impinge- ment may also benefit from surgery if nonoperative management fails [52]. In contrast to other parts of the proximal humerus, the anatomic neck is devoid of soft-tissue attachments and has a tenu- ous blood supply, which may result in an increased risk of osteonecrosis. Court-Brown et al. recommend 2 weeks of sling immobilization followed byphysical therapyforpatients with two- part surgical neck fractures and valgus- impacted fractures [17, 18]. Two-part proximal humeral fractures with >66% translation were treated with either sling immobilization or with internal fixation with flexible intramedullary nailing and tension-band wires [17, 18]. No statis-
tical difference was reported between the groups with regard to Neer score, return to activities of daily living, and union rates [17, 18]. The data demon- strate that the Constant score diminishes with advancing age and degree of dis- placement. However, when calculated based on age-adjusted Constant score, the older patients actually had better scores than the younger patients [14, 17, 18, 34]. Therefore, sling immobilization is an appropriate treatment option for patients older than age 60 years with valgus-impacted, two-part surgical neck or two-part tuberosity fractures. Although three-part and four-part fractures often require surgical fixation, nonoperative management can be con- sidered for patients with poor baseline function and/or an inability to toler- ate surgery. In select three-part and four-part fractures, particularly valgus- impacted fractures with <1cm of dis- placement of the tuberosities in relation to the head fragment, nonsurgical treat- ment may yield good-to-excellent results [17]. Although surgical treatment of com- plex fracture patterns is generally advo- cated, theefficacyofoperativevs. nonop- erativemanagementremainstobeclearly delineated. In a study of 60 elderly pa- tients with a displaced three-part frac-
ture of the proximal humerus, Olerud et al. found that surgical management with a locking plate resulted in better functional outcomes and health-related quality of life than did nonsurgical treat- ment, butatacostofadditionalsurgeryin 30% of patients [56]. By contrast, a meta- analysis of randomized controlled trials did not find improved functional out- comes with open reduction and internal fixation (ORIF) compared with nonsur- gical treatment in elderly patients with displaced three-part or four-part prox- imal humeral fractures [40]. The study concluded that these results must be con- sidered in the context of variable patient demographics. A systematic review supported the use of nonsurgical treatment of proximal humeral fractures and noted a 2% rate of osteonecrosis mainly associated with three-part and four-part fractures, high rates of radiographic union, and modest complication rates [32]. Ultimately, the patient’s baseline physiology and func- tion may help to quantify the potential advantages of nonsurgical management, even in the setting of complex fracture patterns. Treatment A number of proximal humeral fractures may be treated nonoperatively. However, patients must understand the expecta-
tions with this treatment approach and comply with the accompanying restric- tions. In general, excellent results have been achieved with short-term immobi- lization (<2 weeks) in a sling and early physical therapy [28, 63, 72]. While the literature supports early mobilization, it is important to ensure that further frac- ture displacement does not occur. Sling immobilization with or without closed reduction also has a role in the man- Obere Extremität 2 · 2018 95 Review article agement of displaced proximal humeral fractures [69]. Practical conclusion 4 For rotator cuff tears, the best pos- sible outcomes with nonoperative therapyaregenerallyachievedforpa- tients presenting pain as the primary symptom of an atraumatic rotator cuff tear, largely intact coronal and axial force couples, and a willingness to trade functional deficits to avoid surgical risks. 4 In patients suffering from anterior shoulder instability, careful consid- eration of the injury mechanism,
patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonoperative vs. opera- tive intervention. Patients <35 years should rarely be treated nonopera- tively. 4 For tendinitis of the LHBT, treatment generally begins with a nonoperative treatment protocol including activity modification and NSAIDs. In patients with structural instability of the biceps tendon complex, or in any individual who continues to have symptoms of pain after nonoperative treatment, surgery is favored. 4 The general consensus regarding management of AC joint injuries sug- gests initial nonoperative treatment for Rockwood types I–II, and oper- ative intervention for types IV–VI. For patients with type III lesions, a pathologic instability of the clav- icle potentially requiring surgical stabilization should be considered. 4 Tuberosity fractures with >5mm of displacement may benefit from surgical fixation to reduce the risk of subacromial impingement as well as displaced multifragment fractures in young and active patients. Corresponding address
P. J. Millett, M.D., M.Sc. The Steadman Clinic 181 West Meadow Drive suite 400, 81657 Vail, CO, USA [email protected] thesteadmanclinic.com Compliance with ethical guidelines Conflict of interest. A.B. Imhoffservesasaboardor committeememberforAGA,servesontheeditorial boardofArchives of Orthopaedic and Trauma Surgery, isapaidconsultantandreceivesroyaltiesandresearch supportfromArthrex, Inc.,servesontheeditorial boardofArthroskopie, isapaidconsultantandreceives royaltiesfromArthrosurface,servesasaboardor committeememberforDGOOC,servesasaboardor committeememberforDGOU,servesasaboardor committeememberforISAKOS,servesontheeditorial boardofKSSTA, isapaidconsultantformedi-bayreuth, servesontheeditorialboardofOOTR,andreceives royaltiesandfinancialsupportfromSpringerand Thieme. P.J.Millett isapaidconsultantforArthrex, Inc., receivesroyaltiesfromArthrex, Inc.,Medbridge, andSpringerPublishing,ownsstockorstockoptions inGameReadyandVuMedi,andreceivesresearch supportfromArthrex, Inc.,Ossur,Siemens,andSmith andNephew. J.Pogorzelski,E.M.Fritz,andJ.A.Godin declarethattheyhavenocompetinginterests. Thisarticledoesnotcontainanystudieswithhuman participantsoranimalsperformedbyanyoftheau- thors.
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dislocation: a meta-analysis of randomized controlledtrials.AmJSportsMed44:521–532 78. Whelan DB, Litchfield R, Wambolt E et al (2014) External rotation immobilization for primary shoulder dislocation: a randomized controlled trial.ClinOrthopRelatRes472:2380–2386 79. Williams G, Nguyen V, Rockwood C (1989) Classifi- cationandradiographicanalysisofacromioclavic- ulardislocations.ApplRadiol18:29–34 80. Yamaguchi K, Tetro AM, Blam O et al (2001) Naturalhistoryofasymptomaticrotatorcufftears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 10:199–203 Obere Extremität 2 · 2018 97 Nonoperative treatment of five common shoulder injuriesAbstractZusammenfassungIntroductionRotator cuff tearsIndications for nonoperative treatment of symptomatic full- thickness rotator cuff tearsTreatmentAnterior shoulder instabilityIndications for nonoperative treatment of anterior shoulder instabilityTreatmentBiceps tendinitisIndications for nonoperative treatment of long head biceps tendinitisTreatmentAcromioclavicular joint injuriesIndications for nonoperative treatment of acromioclavicular joint injuryTreatmentProximal humeral fractureIndications for nonoperative treatment of proximal humeral fracturesTreatmentPractical conclusionReferences
Common sports-relatedshoulder injuriesShoulder pain is.docx

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  • 1. Common sports-related shoulder injuries S houlder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presen- tation, assessment and management of these conditions in general practice. The GP curriculum and common sports-related shoulder injuries Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In particular, GPs are expected to be able to: . Communicate health information effectively to promote better outcomes . Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as barriers to recovery . Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness . Agree treatment goals and facilitate supported self- management, particularly around pain, function and physical
  • 2. activity . Assess the importance and meaning of the following presenting features: . pain: nature, location, severity, history of trauma . variation of symptoms over time . loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or occupation . Understand that reducing pain and disability rather than achieving a complete cure could be the goal of treatment . Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans . Diagnose common, regional soft-tissue problems that can be managed in primary care . Understand the challenge that many musculoskeletal conditions might be better and more confidently managed by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills during their training . Refer those conditions which may benefit from early referral to an orthopaedic surgeon The four most common categories of shoulder pain seen in primary care are (Mitchell, Adebajo, Hay, &
  • 3. Carr, 2005): . Rotator cuff disorders (85% tendinopathy) . Glenohumeral disorders . Acromioclavicular joint disease, and . Referred neck pain. There are many different types of sports that can cause acute or chronic shoulder injuries. In professional English Rugby Union, for example, the most common match injury is of the acromioclavicular joint (32% overall) and the most severe injury requiring the longest time off (mean of 81 days) is shoulder dislocation (Headey, Brooks, & Kemp, 2007). Shoulder injuries can also occur in non-contact sports, such as golf, tennis, swimming and weightlifting. Although shoulder injuries may be more common in con- tact sports, the injury may have a larger impact on the performance of individuals playing non-contact sports. For example, golfers require very precise manoeuvres of their dominant shoulder to swing a golf club with accuracy... .. ..
  • 4. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ! The Author(s) 2016. Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
  • 5. 30 ................... InnovAiT, 10(1), 30–38 DOI: 10.1177/1755738016678436 ............................................................................................... ............................................................................................... ............ http://crossmark.crossref.org/dialog/?doi=10.1177%2F17557380 16678436&domain=pdf&date_stamp=2016-11-22 Anatomy ........................................................... The shoulder complex (Fig. 1) consists of the glenohumeral joint, the acromioclavicular joint and the sternoclavicular joint. These work collectively with the scapulothoracic joint to achieve normal shoulder girdle movements. The glenohumeral joint is a ball-and-socket joint that con- sists of the glenoid cavity, glenoid labrum, glenohumeral ligaments and the joint capsule. These components all articulate with the head of the humerus and the scapula. Four muscles form the rotator cuff that controls move- ments of the glenohumeral joint. The deltoid muscle and the muscles that control the scapula also provide move- ment and stability of the shoulder. These muscles and their primary actions are summarised in Table 1. History ........................................................... In general practice, a history of the shoulder problem is probably your most helpful tool when trying to formulate
  • 6. a diagnosis. Establish the nature, location, duration, and the exact mechanisms of injury. When asking about the shoulder pain, enquire about locking, clicking, catching, popping, stiffness, swelling, redness, warmth, giving way, night pain, weakness, and paraesthesia. A training history to include frequency, intensity and any changes to training routine may also be relevant. Ask about any referred pain, and do not forget possible gastrointestinal or cardiac causes of shoulder pain. Look out for other more sinister features, such as night sweats, fevers, weight loss and history of cancer. Common shoulder sports injuries ........................................................... Rotator cuff disorders Rotator cuff tendinopathy is an overuse condition whereby the rotator cuff tendons at a microscopic level demonstrate hypercellularity, neovascularisation and col- lagen matrix disruption. The tendons are typically swol- len, but have minimal or absent inflammation (Rees, Maffulli, & Cook, 2009). They mainly occur in sports that involve overhead movements of the shoulder and patients may report a history of overuse, such as an increase in training intensity for a competition. Figure 1. The acromioclavicular joint and associated structures. Reproduced from Brukner P., Khan, K. (2012). Brukner &
  • 7. Khan’s Clinical Sports Medicine (4th ed.), with permission from McGraw-Hill Education. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 12. .. .. . Table 1. The primary action of the muscles around the scapula and shoulder. Shoulder muscles Primary actions Rotator cuff muscles Supraspinatus Abduction of humerus Infraspinatus External rotation of humerus Teres minor External rotation of humerus Subscapularis Internal rotation of humerus Other muscles Deltoid Abduction, flexion and extension of humerus Trapezius Retracts, elevates, rotates and stabilises scapula Serratus anterior Protracts and laterally rotates scapula Rhomboids Retracts and medially rotates scapula Levator scapulae Elevates scapula
  • 13. Pectoralis minor Protracts, medially rotates scapula 31 .................... InnovAiT ..................................................................................... .......... ............................................................................................... ............ Patients typically present with a gradual onset dull shoul- der pain exacerbated by overhead activities or reaching above the shoulder level. They may get symptoms from reaching behind the back and with lifting movements. Night pain can also be a feature, and weakness can develop in late stages (Factor & Dale, 2014). The rotator cuff muscles or tendons can also tear, espe- cially in older patients. Tears can be partial or full thick- ness, and may present acutely or develop gradually. Other symptoms include night pain, stiffness, weakness and clicking sensations. Glenoid labral injuries The glenoid labrum is a ring of fibrocartilaginous tissue attached to the rim of the glenoid cavity, it allows the cavity size to be expanded and therefore provide more stability to the joint (Brukner & Khan, 2012). The long head of the biceps brachii tendon attaches to the labrum. Patients with labral injuries present with pain usually in the posterior aspect of the shoulder exacerbated by overhead activities with associated features of shoulder
  • 14. weakness, popping, catching, and grinding sensations. Mechanisms of labral injuries include a single traumatic event, such as a direct blow or fall onto the shoulder, a forceful or excessive traction on the labrum, such as drop- ping then catching a heavy object, or repeated micro- trauma to the labrum, such as from cocking the shoulder in throwing sports (Wilk et al., 2005). It is always important to consider a diagnosis of labral injury, as early referral to a shoulder specialist is indicated for best results. Shoulder instability and dislocation Shoulder instability refers to symptomatic laxity within the glenohumeral joint that can be caused by over- stretched or torn shoulder ligaments, muscles, tendons or labrum. Dislocation occurs when the humeral head no longer sits within the glenoid cavity (i.e. a complete dis- ruption to the joint). A partial disruption to the joint is termed subluxation. The causes of subluxation or dislocation can be traumatic or atraumatic. Traumatic dislocation is common in ath- letes, and approximately 95% of first time shoulder dis- locations result from a forceful collision, a fall onto an outstretched arm or a sudden twisting movement: 98% of traumatic dislocations occur in an anterior direction. Approximately 5% of dislocations overall are atraumatic in nature, and these individuals may have altered muscle control of the shoulder, capsular laxity, or both (Hayes, Callanan, Walton, Paxinos, & Murrell, 2002). Patients present with anterior or posterior shoulder pain, visible deformity, popping or catching sensations, weak- ness, unstable feeling and night pains. They may have a history of recurrent dislocations and be involved in
  • 15. specific high-risk activities, for example, throwing a jav- elin, being a pitcher in baseball or swimming. Clavicle fracture Clavicle fractures, particularly the mid-third of the clav- icle, are the most common acute shoulder injuries and account for one in twenty adult fractures. Fractures located more laterally can disrupt the acromioclavicular joint. Over 80% of clavicle fractures can be managed conservatively (Quillen, Wuchner, & Hatch, 2004). These injuries usually occur from a fall onto the clavicle or, less frequently, a direct blow to the clavicle. Patients may be involved with contact sports or other at- risk sports such as horse-riding and cycling. They present with acute localised pain with swelling and sometimes visible deformity. Acute injuries are more likely to present to the hospital Accident & Emergency Department than primary care. Acromioclavicular joint injury Acute acromioclavicular joint (ACJ) injuries can occur due to a direct force to the acromion typically with the shoul- der adducted, or from an indirect force elsewhere in the body, for example, a fall onto an outstretched arm (Simovitch, Sanders, Ozbaydar, Lavery, & Warner, 2009). Patients present with acute localised pain, swelling and sometimes redness. Injuries can range from a simple acromioclavicular ligament sprain that can be managed conservatively, to ligament tears with ACJ displacement that often require surgery. Chronic ACJ pain can occur following acute ACJ injuries or from repeated irritation to the joint that can develop into osteolysis or osteoarthritis. These chronic changes can be caused by sports that involve throwing or lifting
  • 16. weights. The symptoms will be similar to acute ACJ, but the pain develops insidiously. Biceps tendinopathy The biceps brachii muscle has both a short head and a long head. The short head originates from the coracoid process of the scapula, whereas the long head originates from the supraglenoid tubercle of the scapula where it attaches to the superior aspect of the glenoid labrum. The long head of the biceps (LHB) tendon exits the glenohumeral joint and travels through the bicipital groove between the greater and lesser tuberosities. Biceps tendinopathy usually refers to an overuse injury of the LHB tendon. It has a close relationship with the glenoid labrum and the insertion sites of the rotator cuff tendons. An accurate diagnosis of LHB tendinopathy can therefore be difficult; and other shoulder injuries, such as rotator cuff disease, labral lesions, and shoulder instability, may co-exist (Krupp, Kevern, Gaines, Kotara, & Singleton, 2009). The typical features are gradual onset dull anterior.. .. .. .. .. .. .. .. .. .. ..
  • 22. Examination ........................................................... Have a system for examining joints. Several exist; how- ever, the ‘Look, Feel, Move’ system is perhaps the sim- plest. Start by inspecting the shoulder from the front, side and back, looking for any swelling, asymmetry, deformity, skin changes and scarring. Palpate from the sternoclavicular joint, move laterally to the ACJ, then across the spine of the scapula and along the border of the scapula. It is also important to feel the corac- oid process, humeral head, bicipital groove and surround- ing shoulder musculature for any swelling or tenderness. It is important to test the range of both passive and active movements of the shoulder in all directions. Table 2 sum- marises ‘normal’ range of shoulder movement (ROM), how- ever, in reality, normal range varies between individuals and it is therefore better to compare ROM with the unaffected side for patients with unilateral shoulder injuries. Special tests ........................................................... BLISS is a helpful mnemonic to remember which condi- tions to examine for using special tests. It stands for: . B – Biceps tendon . L – Labral . I – ‘Impingement’ . S – ‘Scarf’ (referring to the ACJ), and . S – Stability tests A systematic review of 45 studies evaluating specific shoulder tests, demonstrated that the diagnostic accuracy for many of these tests is limited (Hegedus et al., 2008). Therefore, special tests should only be used to provide supporting evidence for or against a shoulder injury sus-
  • 23. pected on the basis of history and general examination. Biceps tendon tests The Yergason’s test and Speed’s test are the two com- monly used tests for biceps tendon pathology. They may also be positive in labral lesions, as the LHB tendon is attached to the labrum. They have low sensitivities (43% and 32%, respectively), but are moderately specific (79% and 75%, respectively). The positive predictive value (PPV) of Yergason’s test and that of Speed’s test is 60% and 50%, respectively, compared with shoulder arthros- copy (Holtby & Razmjou, 2004). Yergason’s test is performed with the patient’s elbow flexed to the side at 90� with forearm pronated. The patient is then asked to actively supinate the forearm against the examiner’s resistance. A positive test will elicit pain in the bicipital groove. Speed’s test is performed with the patient’s elbow extended and forearm supinated. The patient is then asked to elevate (forward flex) their humerus against the examiner’s resistance. A positive test will elicit pain in the bicipital groove. Labral pathology tests There are a variety of special tests for labral lesions, but a test called ‘Biceps Load 2’ (Fig. 2) has the highest sensi- tivity (89.7%) and specificity (96.9%) with a PPV of 92.1% (Kim, Ha, Ahn, & Choi, 2001). The test is performed with the patient supine, arm abducted to 120� and max- imally externally rotated with elbow flexed at 90� and forearm supinated. The patient is then asked to actively flex his or her elbow against the examiner’s resistance. In a positive test, this manoeuvre should increase or repro-
  • 24. duce the shoulder pain. Impingement tests Impingement itself is actually a syndrome or clinical sign rather than a specific diagnosis. It is usually due to narrow- ing of the subacromial space, and causes include rotator cuff tendinopathy, rotator cuff calcification, bony spurs under the acromion, and subacromial bursal pathology. With impingement syndrome, a ‘painful arc’ can be detected when assessing ROM for abduction whereby pain occurs between 60� and 120� degrees of abduction and eases above 120�. The Hawkins–Kennedy test and Neer’s sign are two other tests for impingement that have moderate sensitivities of 79%, and lower specifici- ties of 59% and 53%, respectively (Hegedus et al., 2008). Table 2. Types of shoulder movement and their ’normal’ range of movement Types of shoulder movement ‘Normal’ range of movement (degrees) Forward flexion 180 Extension 50 Abduction 180 Adduction 30 Internal rotation with elbows
  • 25. at the side flexed at 90� 70 External rotation with elbows at the side flexed at 90� 90 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 30. .. .. .. .. .. .. .. . 33 .................... InnovAiT ............................................................................................... ............................................................................................... ............ The Hawkins–Kennedy test is performed by the exam- iner taking the patient’s arm into 90� of forward flexion then flexing the patient’s elbow to 90� followed by pas- sive internal rotation of the humerus. A positive test occurs when symptoms are reproduced on passive inter- nal rotation. Neer’s sign is performed with the examiner stabilising the patient’s scapula, internally rotating the patient’s arm, and passively forward flexing the patient’s arm. A posi- tive test occurs when symptoms are reproduced on pas- sive forward flexion of the arm. ACJ tests
  • 31. The ‘Scarf’ test, also known as the cross-body adduction test, has a sensitivity of 77%, but only a 20% PPV, for chronic ACJ pathology (Chronopoulos, Kim, Park, Ashenbrenner, & McFarland, 2004). The test is per- formed with the patient’s arm and elbow flexed and then forcibly adducted by the examiner across the chest. A positive test will reproduce pain in the ACJ. There is, however, a far simpler ACJ test. ACJ tenderness on palpation has a sensitivity of 96% and a 52% PPV for chronic ACJ pathology (Walton et al., 2004). Stability tests The ‘apprehension test’ for anterior shoulder instability has shown sensitivities between 53 and 72% and specifi- cities between 96 and 99% (Biederwolf, 2013). The test is best performed with the patient supine with arm pos- itioned in 90� abduction with external rotation. The examiner gradually applies more external rotation while observing the patient for apprehension (not just pain alone). Care must be taken when performing this test, as there is a risk of acutely dislocating an unstable shoulder. A test of postero-inferior instability can be performed with the ‘Jerk’s test’ that has a sensitivity of 73% and specificity of 98% (Biederwolf, 2013). The test is performed with the patient’s arm abducted to 90� with internal rotation while the examiner stabilises the patient’s scapula with one hand and grasps the elbow with the other. The examiner then proceeds to apply an axial load to the humerus while horizontally adducting the patient’s arm across the body (Fig. 3). A positive test is indicated by reproduction of pain, or reproduction of a click or clunk. Clinical examination
  • 32. findings ........................................................... The clinical signs for each of the common causes of sports-related shoulder pain are summarised in Table 3. It is important to understand that clinical signs may over- lap in different conditions, as the structures within the shoulder are so closely associated with each other. There may also be more than one pathological process occur- ring in the shoulder simultaneously... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 34. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Figure 2. Biceps load 2 test with patient lying supine. 34 ...................
  • 35. ............................................................................................... ............................................................................................... ................................ Investigations ........................................................... There are potentially three radiological investigations that can be requested from general practice, although direct access does vary from area to area in the UK. These are X-rays, ultrasound scans, and magnetic resonance ima- ging (MRI). X-rays In the context of sporting injuries, X-rays are primarily indicated for detecting any bony fractures or disloca- tions. If there is any suspicion of these injuries then the patient needs to be referred for immediate X-ray or, if this is not available, to the local emergency or minor injuries unit. For rotator cuff disorders, an X-ray is not indicated, but it may reveal calcified tendons. X-ray can be helpful for chronic ACJ injuries as it may show osteoarthritic changes and osteolytic lesions suggestive of a stress fracture. Ultrasound A meta-analysis of five studies (311 shoulders) that used an ultrasound scan (USS) to diagnose rotator cuff dis- orders found a sensitivity level of 79% and a specificity of 94% (Roy et al., 2015). Ultrasound scanning is, there- fore, a very valuable investigation for rotator cuff disorders.
  • 36. An USS can also identify pathologies in and around the subacromial space, which is useful if patients have impingement signs. However, before requesting a shoul- der USS, the age of the patient needs to be taken into consideration, as the incidence of asymptomatic rotator cuff tears increases after the age of 40 (Oschman, Janse van Rensburg, Maritz, Boraine, & Owen, 2007). MRI MRI can be used to evaluate both soft tissue and bony injuries in detail. It is unclear whether MRI is more accur- ate at detecting rotator cuff tendinopathy compared with USS, but both are equally effective in detecting partial or full thickness tears (Gazzola & Bleakney, 2011). Labral injuries can be detected with MRI, but a meta-analysis revealed that magnetic resonance arthrography is super- ior to MRI (Smith, Hilton, Toms, Donell, & Hing, 2011). The cost implications of referring patients for a shoulder MRI need to be carefully considered in general practice, and onward referral to a specialist rather than requesting a MRI maybe a better management option in some cases. Management ........................................................... Rotator cuff disorder In rotator cuff tendinopathy, it is important to counsel patients about relative rest from the sport or the specific activities that trigger the pain. Non-steroidal anti-inflam- matory drugs (NSAIDs) and application of ice can pro- vide symptomatic relief. Subacromial corticosteroid injections do result in a reduction in pain symptoms, but multiple injections over a short period of time and injection into the tendon itself increases the risk of tendon rupture (Gomoll, Katz, Warner, & Millett, 2004).
  • 37. Referral to physiotherapy for rotator cuff muscle strengthening and scapulohumeral work is recom- mended for all patients. The treatment of a tear in a rotator cuff is similar to rotator cuff tendinopathy, with the exception that young sports-people with a full thick- ness rotator cuff tear normally require referral for surgical repair (Brukner & Khan, 2012). Figure 3. Jerk’s test viewed from the side. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 40. .. .. .. .. .. .. .. .. .. 35 .................... InnovAiT ............................................................................................... ............................................................................................... ............ Glenoid labral injuries Conservative management of glenoid labral injuries is usu- ally unsuccessful (Brukner & Khan, 2012). These injuries need to be referred to an orthopaedic shoulder specialist for an arthroscopic repair (reattachment) of the labrum, or, if the labral injury is stable, arthroscopic debridement. Post- operative physiotherapy input is needed to gradually rehabilitate and restore normal shoulder function. Shoulder instability and dislocation In non-acute atraumatic shoulder instability, physiother-
  • 41. apy referral is required to provide progressive scapular stabilisation exercises, strengthen the rotator cuff mus- cles, and control the glenohumeral translation (Hayes et al., 2002). If physiotherapy is unsuccessful, then cap- sular surgery can be considered. In acute or traumatic shoulder dislocation, the patient should be referred to the local Accident & Emergency Department for diagnostic X-rays, reduction of the shoul- der with appropriate analgesia, and post-reduction X-rays. Clavicle fractures Patients with a clavicle fracture need analgesia and prompt referral to the Accident & Emergency Department for X-rays. If there is low risk of clavicle foreshortening then a broad arm sling (or figure-of- eight bandage) is usually applied, and the fracture grad- ually heals over a month or so. Surgical intervention is indicated if there is a risk of clavicle foreshortening, delayed union, or non-union. ACJ injuries In acute ACJ injuries, patients should be given analgesia and a sling for immobilisation if available. If an ACJ sprain is suspected, then it may be reasonable to treat with ice, analgesia, and immobilisation followed by a review 48 hours after the acute episode. If the ACJ appears deformed, the pain is difficult to control, or there is uncer- tainty about the degree of ACJ injury, then referral to the Accident & Emergency Department or to the on-call Table 3. Sports-related shoulder conditions and their possible clinical signs. Condition Possible clinical signs
  • 42. Rotator cuff tendinopathy . Asymmetry and muscle wasting . Palpation tenderness at the greater tubercle (insertion sites of three rotator cuff muscles) . Reduced active ROM . Passive ROM intact . Reduced power on resisted movements . Impingement signs Rotator cuff tears . Shoulder shrug appearance . Partial or no active ROM . Passive ROM often intact . Reduced power on resisted movements . Drop-arm sign in complete tears if arm cannot be actively maintained at 90� abduction . Impingement signs
  • 43. Glenoid labral injury . Palpation tenderness in the anterior shoulder structures . Swelling if acute . Reduced external rotation and or abduction ROM . Reduced power on resisted movements . Biceps load 2 test positive if superior labrum anterior posterior (SLAP) tear . Speed’s test positive if SLAP . Yergason’s test positive if SLAP . Jerk’s test positive if postero- inferior labral injury Shoulder instability and dislocation . Prominent humeral head if anter- ior dislocation . Swelling if acute . Reduced active and passive ROM
  • 44. if dislocated . Increased active or passive ROM if instability with laxity . Apprehension test positive if anterior dislocation . Jerk’s test positive if postero- inferior dislocation . Upper arm axillary nerve sensa- tion can be reduced in anterior dislocations Clavicle fracture . Localised swelling with deformity . Clavicle shortened or angulated . Localised bony tenderness (continued) Table 3. Continued. Condition Possible clinical signs ACJ injury . Step deformity and swelling if acute . Localised ACJ tenderness . Scarf test positive
  • 45. . Impingement signs if chronic Biceps tendinopathy . Bicipital groove tenderness . Speed’s test positive . Yergason’s test positive .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 50. .. .. .. .. .. .. .. .. .. .. 36 ................... ............................................................................................... ............................................................................................... ................................ orthopaedic team is appropriate. Surgery is indicated for tears in both the acromioclavicular and coracoclavicular ligaments with displacement of the clavicle (Tauber, 2013). The management of chronic ACJ injuries requires relative rest and activity modification, such as reducing the weight load when bench pressing. NSAIDs and cortico- steroid injections into the ACJ can have therapeutic benefits, particularly in younger patients (Hossain, Ayekoloye, Odumala, & Jacobs, 2003). Referral to physiotherapy for range of motion and strength training can aid recovery. In chronic persistent ACJ pain, ortho-
  • 51. paedic referral for consideration of surgical excision of the distal clavicle may be necessary. Biceps tendinopathy Initial treatment of biceps tendinopathy involves a period of relative rest, withdrawal from exacerbating activities, ice and NSAIDs. The next step is referral for physiother- apy rehabilitation that involves restoration of passive biceps ROM, followed by active biceps ROM exercises, and then finally rotator cuff strengthening. If symptoms fail to respond after 6–8 weeks of conservative measures then corticosteroid injections into the subacromial space can be beneficial, and in resistant cases, injections into the biceps tendon sheath can be tried (Krupp et al., 2009). There are a variety of surgical options for biceps tendinopathy, such as decompression, debridement, ten- otomy and tendon transfer, but choice of procedure is a specialist decision. Specialist referral ........................................................... Patients presenting acutely with sports-related injuries who have severe pain, and/or symptoms in keeping with acute bony injury or joint dislocation should be referred for immediate Accident & Emergency Department review. Most other sports-related shoulder injuries can be man- aged in primary care with rest, ice, analgesia, physiother- apy and possible local steroid injection. Specialist sports physiotherapy input can be helpful if available and may be particularly useful in helping patients to avoid repeat injury when they return to their sport. Consider specialist orthopaedic referral if: . No clear cause of the patient’s pain can be found –
  • 52. this referral should be urgent if the patient has a past history of cancer, the pain is worsening, or the pain is associated with any constitutional symptoms such as night sweats or raised erythrocyte sedimentation rate . Pain is not resolving despite conservative measures in primary care . The patient is young (under 40 years) and is found to have a full thickness rotator cuff tear on imaging . The patient has a glenoid labral tear Key points . Sports-related shoulder injuries are common and can cause both acute and chronic symptoms . A concise history and a targeted examination is essential for initial diagnosis of sports-related shoulder injuries in primary care . Special tests in the examination of sports-related shoulder injuries are useful only to provide sup- porting evidence for a specific suspected injury . X-ray, USS and MRI may all be useful in further evaluation of patients with sports-related shoulder pain depending on local availability . The majority of patients with sports-related shoul- der injuries can be managed in primary care; some acute injuries will require prompt referral to the Accident and Emergency Department for further imaging and immediate management
  • 53. . Refer to an orthopaedic shoulder specialist if the diagnosis is unclear, the symptoms fail to settle with primary care management, if the patient is young and has a full-thickness rotator cuff tear, or if the patient has a glenoid labral tear References and further information . Biederwolf, N. E. (2013). A proposed evidence- based shoulder special testing examination algo- rithm: Clinical utility based on a systematic review of the literature. International Journal of Sports Physical Therapy, 8(4), 427–440. Retrieved from www.ncbi.nlm.nih.gov/pmc/arti cles/PMC3812837/ . Brukner, P., & Khan, K. (2012). Brukner & Khan’s clinical sports medicine, fourth edition. New York: McGraw-Hill Medical . Chronopoulos, E., Kim, T. K., Park, H. B., Ashenbrenner, D., & McFarland, E. G. (2004). Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. American Journal of Sports Medicine, 32(3), 655–661. doi: 10.1177/0363546503261723 . Factor, D., & Dale, B. (2014). Current concepts of rotator cuff tendinopathy. International Journal of Sports Physical Therapy, 9(2), 274–288. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/ PMC4004132/ . Gazzola, S., & Bleakney, R. R. (2011). Current ima- ging of the rotator cuff. Sports Medicine and
  • 54. Arthroscopy Review, 19(3), 300–309. doi: 10.1097/JSA.0b013e3182189468 . Gladstone, J. N., & Rosen, A. L. (1999). Disorders of the acromioclavicular joint. Current Opinion in Orthopaedics, 10(4), 316–321. doi: 10.1097/ 00001433-199908000-00011 . Gomoll, A. H., Katz, J. N., Warner, J. J., & Millett, P. J. (2004). Rotator cuff disorders: Recognition and management among patients with shoulder pain. Arthritis and Rheumatism, 50(12), 3751–3761. doi: 10.1002/art.20668.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 60. . Headey, J., Brooks, J. H., & Kemp, S. P. (2007). The epidemiology of shoulder injuries in English professional rugby union. American Journal of Sports Medicine, 35(9), 1537–1543. doi: 10.1177/0363546507300691 . Hegedus, E. J., Goode, A., Campbell, S., Morin, A., Tamaddoni, M., Moorman, C. T., & Cook, C. (2008). Physical examination tests of the shoulder: A systematic review with meta-analysis of individ- ual tests. British Journal of Sports Medicine, 42(2), 80–92. discussion p. 92. doi: 10.1136/bjsm.2007. 038406 . Holtby, R., & Razmjou, H. (2004). Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: Comparison with arthroscopic findings. Arthroscopy, 20(3), 231–236. doi: 10.1016/j.arthro.2004.01.008 . Hossain, S., Ayekoloye, C., Odumala, O., & Jacobs, L. (2003). Intra-articular steroid injection in the treatment of primary acromioclavicular arthritis. An assessment of therapeutic effectiveness. Orthopaedic Proceedings, 85B, 72. Retrieved from www.bjjprocs.boneandjoint.org.uk/content/ 85-B/SUPP_I/72.4 . Kim, S. H., Ha, K. I., Ahn, J. H., & Choi, H. J. (2001). Biceps load test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy, 17(2), 160–164. doi: B10.1053/jars.2001.20665 . Krupp, R. J., Kevern, M. A., Gaines, M. D., Kotara, S., & Singleton, S. B. (2009). Long head of the biceps tendon pain: Differential diagnosis and
  • 61. treatment. Journal of Orthopaedic Sports Physical Therapy, 39(2), 55–70. doi: 10.2519/ jospt.2009.2802 . Mitchell, C., Adebajo, A., Hay, E., & Carr, A. (2005). Shoulder pain: Diagnosis and management in primary care. British Medical Journal, 331(7525), 1124–1128. doi: 10.1136/bmj.331.7525.1124 . Oschman, Z., Janse van Rensburg, C., Maritz, N., Borain, H., & Owen, R. (2007). Ultrasound study of the asymptomatic shoulder in patients with a con- firmed rotator cuff tear in the opposite shoulder. South African Journal of Sports Medicine, 19(1), 23–28. doi: 10.17159/2413-3108/2007/v19i1a272 . Quillen, D. M., Wuchner, M., & Hatch, R. L. (2004). Acute shoulder injuries. American Family Physician, 70(10), 1947–1954. Retrieved from: www.aafp.org/afp/2004/1115/p1947.html . RCGP. Clinical module 3.20: Care of people with musculoskeletal problems. Retrieved from www. rcgp.org.uk/training-exams/gp-curriculum-over- view/online-curriculum/applying-clinical-knowl- edge-section-2/3-20-musculoskeletal-problems. aspx . Rees, J. D., Maffulli, N., & Cook, J. (2009). Management of tendinopathy. American Journal of Sports Medicine, 37(9), 1855–1867. doi: 10.1177/0363546508324283 . Roy, J. S., Braën, C., Leblond, J., Desmeules, F., Dionne, C. E., MacDermid, J. C., . . . Frémont, P.
  • 62. (2015). Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(20), 1316–1328. doi: 10.1136/bjsports-2014- 094148 . Simovitch, R., Sanders, B., Ozbaydar, M., Lavery, K., & Warner, J. J. (2009). Acromioclavicular joint injuries: Diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons, 17(4), 207–219. doi: 10.5435/00124635- 200904000-00002 . Smith, T. O., Hilton, G., Toms, A. P., Donell, S. T., & Hing, C. B. (2011). The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: A meta-analysis. European Radiology, 21(4), 863–874. doi: 10.1007/s00330-010-1956-7 . Tauber, M. (2013). Management of acute acromio- clavicular joint dislocations: Current concepts. Archives of Orthopaedic and Trauma Surgery, 7(133), 985–995. doi: 10.1007/s00402-013-1748-z . Walton, J., Mahajan, S., Paxinos, A., Marshall, J., Bryant, C., Shnier, R., & Murrell, G. A. (2004). Diagnostic values of tests for acromioclavicular joint pain. Journal of Bone and Joint Surgery. American volume, 86A(4), 807–812. Retrieved from www.jbjs.org/content/86/4/807 . Wilk, K. E., Reinold, M. M., Dugas, J. R., Arrigo, C. A., Moser, M. W., & Andrews, J. R. (2005). Current concepts in the recognition and treatment
  • 63. of superior labral (SLAP) lesions. Journal of Orthopaedic Sports Physical Therapy, 35(5), 273–291. doi: 10.2519/jospt.2005.35.5.273 Dr Raymond Leung Freelance Locum GP, Sutton United Football Club Doctor, MSc student in Sports and Exercise Medicine, London Email: [email protected] .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
  • 68. overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.rcgp.org.uk/training-exams/gp-curriculum- overview/online-curriculum/applying-clinical-knowledge- section-2/3-20-musculoskeletal-problems.aspx www.jbjs.org/content/86/4/807 Review article Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 Received: 30 November 2017 Accepted: 29 January 2018 Published online: 19 February 2018 © The Author(s) 2018. This article is an open access publication. Jonas Pogorzelski1,2 · Erik M. Fritz1 · Jonathan A. Godin1,3 · Andreas B. Imhoff2 · Peter J. Millett1,3 1 Steadman Philippon Research Institute, Vail, USA 2 Department of Orthopedic Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany 3 The Steadman Clinic, Vail, USA Nonoperative treatment of five
  • 69. common shoulder injuries A critical analysis Introduction Shoulderpainisoneofthemostcommon musculoskeletal complaints accounting for at least 4.5 million patient visits an- nually in the United States [43, 55] and occurring in as many as 51% of indi- viduals in a lifetime [64]. Moreover, the economic burden of shoulder pathology is vast with annual direct costs for treat- ment of shoulder dysfunction totaling at least $7 billion in the United States, mostly due to operative treatment [47]. InGermanythepercentageofaffectedpa- tients and associated costs are expected to be similar. Moreover, with an aging and increasingly active patient popula- tion in the Western world, the absolute number of shoulder pathologies is likely to grow, further increasing costs. These economic implications high- light the critical need for appropriate diagnosisandtreatmentofvariousshoul- der pathologies, as under-diagnosis and under-treatment can result in increased costs to society with disability and lost production. On the other hand, aggres- sive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, the purpose of this review
  • 70. is to distinguish the indications between operative and nonoperative management for five common shoulder pathologies, ResearchperformedattheSteadmanPhilippon ResearchInstitute,Vail,CO,USAandtheDepart- ment of Orthopedic Sports Medicine,Technical UniversityofMunich,Munich,Germany. including rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular (AC) joint, and proximal humeral fractures. Moreover, we aim to provide a short overview of the nonoperative manage- ment of each of these pathologies. Rotator cuff tears Indications for nonoperative treatment of symptomatic full- thickness rotator cuff tears Although symptomatic rotator cuff tears are common and affect between 4% and 32% of the general population, the most appropriate therapy is still debatable [59, 75]. While there is agreement that traumatic rotator cuff tears should be treated operatively, the treatment choice for atraumatic rotator cuff tears remains unclear [38, 39]. This is mainly due to the fact that the radiological failure rate following rotator cuff repair surgery can be as high as 70% depending on the patient cohort, thus leading to the
  • 71. assumption that nonoperative treatment may be equivalent [5, 8, 24, 41]. This conjecture is further strengthened by the fact that pain relief and improvement of symptoms do not necessarily go hand in hand with structural healing of the tendon [59]. However, when taking a closer look at published outcomes in the literature, nonsurgical treatment appears to have limitations. While multiple studies with short-term follow-up of nonsurgical treatment show promising results with good clinical outcomes, studies with mid-term follow-up are more disillu- sioning [10, 22, 38, 39, 50]. This could be explained by the fact that smaller tears may not affect the force couples in the shoulder, thus a reasonable degree of shoulder function may be maintained [42]. As there is strong evidence that the natural history of nonoperatively treated rotator cuff tears leads to tear progression over time, nonoperative outcomes studies with longer follow-up may include more patients whose tears have progressed to the point of destroyed force couples [80]. Kukkonen et al. [38, 39] published a randomized controlled trial for the treatment of supraspinatus tendon tears in patients older than 55 years. A total of 180 shoulders with supraspinatus tendon
  • 72. tears were randomly allocated into one of three treatment groups: 1. Isolated physiotherapy 2. Acromioplasty and physiotherapy 3. Rotator cuff repair with acromio- plasty and physiotherapy After 1 year of follow-up, no statistically significant differences in outcomes were detected, thus leading to the conclusion that surgical therapy is not superior in these patients [38]. Later, with an addi- tional year of follow-up, the groups still did not differ significantly in outcomes; however, tear progression measured with magnetic resonance imaging (MRI) sug- gested thatonlypatients withlowerphys- ical demands should be treated nonoper- Obere Extremität 2 · 2018 89 https://doi.org/10.1007/s11678-018-0449-1 http://crossmark.crossref.org/dialog/?doi=10.1007/s11678-018- 0449-1&domain=pdf http://orcid.org/0000-0002-6178-4940 Review article Fig. 1 8 Axial T2-weightedmagnetic res- onance imaging sequence of a 36-year-old patient aftera first-timeshoulderdislocation. Givenhisageandtheabsenceofanyrotatorcuff tearorotherconcomitant pathology,he was deemedlow risk forre-dislocation.Therefore,
  • 73. nonoperative treatment was pursued,which was successful withno recurrent subluxation or dislocation atively and patient counseling is critical [39]. In another randomized controlled trial of 103 patients, which compared rotator cuff repair with nonoperative physiotherapy for tears not exceeding 3cm, Moosmayer et al. [50] found sev- eral additional factors that may influence the outcome. With a minimum follow- up of 5 years, the results for the group of patients who had immediate tendon repair were generally superior to those of patients who underwent physiotherapy as primary treatment and decided later to progress with surgery. Furthermore, treatment failed in almost 24% of the patients who received physiotherapy as primary therapy, and they underwent subsequent rotator cuff repair. In 37% of patients who did not undergo surgery, the tear size increased more than 5mm over 5 years with associated inferior outcomes [50]. SimilarresultswerereportedbySafran et al. [68], who followed up 51 patients younger than 60 years with full-thick- ness rotator cuff tears in a longitudinal study. In this particularly young patient cohort, almost half of the tears increased after a mean follow-up of 29 months.
  • 74. Moreover, the authors found a signifi- cant association between the size of the rotator cuff tear and pain, which led to theconclusionthatyoungpatientsinpar- ticular benefit from surgery [68]. Treatment While multiple rehabilitation protocols for the postoperative treatment follow- ing rotator cuff repair have been pro- posed, there are only a few published studies focusing on treatment protocols for primary nonoperative management of rotator cuff tears [37, 48, 59, 75]. In general, conservative treatment options include 3–6 months of activity modifica- tion, physical therapy such as strength- ening and stretching ofthe muscles ofthe shouldergirdle, andinjectionororalanti- inflammatory and pain-relieving medi- cation [37, 48, 59]. A prospective multicenter study pub- lished in 2013 by the MOON shoulder group of 452 patients treated with a stan- dardized physical therapy program for atraumatic full-thickness rotator cuff tears revealed a 75% satisfaction rate in patients after 2 years of follow-up. Phys- ical therapy included daily postural and stretching exercising as well as strength- ening of the rotator cuff three times a week. If needed, patients were seen by aphysicaltherapist, especiallyformanual mobilization of the glenohumeral joint.
  • 75. Although less than a quarter of patients underwent surgery in the short-term follow-up period, the lack of imaging follow-up raises doubts about the long- term success. In summary, careful patient selection is necessary when nonoperative treat- ment for full-thickness rotator cuff tears is chosen. The best possible outcomes are generally achieved in patients pre- senting with pain as the primary symp- tom, those having largely intact coronal and axial force couples, and patients who are willing to trade functional deficits of their shoulder to avoid surgical risks. However, as there is no evidence that the torn tendon actually heals without surgi- cal re-fixation, patient counseling about tear size progression is indicated. This includes the progression from an initially reparable tear to an irreparable tear, as wellasinferiorpostoperativeoutcomesof chronictearscomparedwithacutelyfixed tears. If treated nonoperatively, a combi- nation of activity modification, stretch- ing and strengthening of the periscapular muscles and the deltoid should be per- formed. MRI of a known rotator cuff tear can be performed on patients who want to progress with surgical refixation of the tear and those who wish to monitor tear progression to consider surgery at some future time point.
  • 76. Anterior shoulder instability Indications for nonoperative treatment of anterior shoulder instability There is consensus in the literature that a detailed analysis of individual risk fac- tors for recurrent instability should be madeforeachpatientpresentingwithan- terior instability to determine the most appropriate treatment [3, 61]. In gen- eral, knownfactorsassociatedwithahigh risk of recurrent instability when treated nonoperatively are young age, an active lifestyle, bone loss of more than 20% of the glenoid surface, and engaging or off- track Hill–Sachs lesions[3, 9, 11, 44, 61, 65, 73]. In patients younger than 30 years of age, the risk of re-dislocation when treated nonoperatively is between 70 and 90% compared with up to 25% when treated operatively [9, 30, 71]. When nonoperative treatment is ap- plied to overhead athletes and active patients, the re-dislocation rate is even higher [3, 61]. However, with increasing age, the re-dislocation rate in patients treated nonoperatively decreases sub- stantially making nonoperative treat- ment an option [12]. In general, patients without structural
  • 77. lesions of the glenohumeral joint can be treated nonoperatively, especially when older than 35 years (. Fig. 1). However, the treating physician must ensure that concomitant injuries such as rotator cuff tears, Hill–Sachs lesions of more than 25% of the humeral surface, or glenoid bone loss are excluded as those would need surgical intervention [3, 11, 44, 66]. The “critical” amount of glenoid bone loss is typically defined as a loss of more than 20% of the glenoid surface [11, 44]. Another risk factor for recurrent insta- bility is engaging or off-track Hill–Sachs lesions, as reported in recent literature 90 Obere Extremität 2 · 2018 Hier steht eine Anzeige. K recommending operative treatment [57, 73]. Furthermore, the injury pattern should be taken into account. High- energy trauma often results in a locked dislocation or displaced fracture of the glenoid or the humeral head and is generally best approached with surgical treatment. Finally, patients who have
  • 78. the ability to voluntarily dislocate their shoulder without discomfort should be treated nonsurgically in most cases, as these patients likely suffer not from structural instability but rather from functional instability, which can be due to a pathological functional activation pattern [27, 33] and may respond better to functional conservative treatments [70] or even electrical muscle stimu- lation in some therapy-resistant cases [51]. Treatment In order to manage shoulder instability without surgical intervention, a combi- nation of immobilization and physical therapy is often used before the patient can return to activity [12, 35, 36, 54]. Physicaltherapyprotocolsmayeitherfol- low a period of immobilization of about 3 weeks in internal or external rotation of the shoulder or be initiated immedi- ately. The overall goal of physical ther- apy is to progress through glenohumeral strengthening and stabilization, thus re- ducing the probability of recurrent in- stability. Return to full activity is mostly allowedwhenthereissymmetricalshoul- der strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [12, 57]. More recently, several studies have fo- cused on the position of the arm during
  • 79. immobilization after a traumatic anterior shoulder dislocation. In an MRI study by Itoi et al. [31], immobilization with the arm in external rotation resulted in reductionoftheBankartlesionaftertrau- maticshoulderdislocation, thussupport- ing the hypothesis thatimmobilizationin external rotation may be superior to im- mobilization in internal rotation. How- ever, published clinical trials have not been able to demonstrate similar efficacy of external rotation immobilization for Abstract · Zusammenfassung Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 © The Author(s) 2018. This article is an open access publication. J. Pogorzelski · E. M. Fritz · J. A. Godin · A. B. Imhoff · P. J. Millett Nonoperative treatment of five common shoulder injuries. A critical analysis Abstract Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under- diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore,
  • 80. it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals. Keywords Rotator cuff tears · Shoulder injuries · Tendinitis · Acromioclavicular joint · Humeral fractures, proximal Konservative Therapie von 5 häufigen Schulterläsionen. Eine kritische Analyse Zusammenfassung Der zunehmende Kostendruck in der Medizin verstärkt die Notwendigkeit einer rasch zielführenden Diagnose und Therapie verschiedener pathologischer Veränderungen im Bereich der Schulter. Unterversorgte Patienten erhöhen die Kosten für die Gemeinschaft durch längere Ausfallzeiten und damit erniedrigte Produktion, während überzogene Therapien die bereits ausufern- den Kosten in der medizinischen Versorgung weiter erhöhen und den Patienten sogar potenziell schädigen können. Deshalb ist es
  • 81. unabdingbar, die Indikationen für operative und konservative Therapien zu kennen und anzuwenden, besonders im Hinblick auf häufige pathologische Veränderungen wie Rotatorenmanschettenläsionen, vordere Schulterinstabilität,Bizepssehnentendinitis, Akromioklavikular Gelenkluxationen und pro- ximale Humerusfrakturen. Grundsätzlich ist es dabei wichtig, individuelle Risikofaktoren für ein Therapieversagen zu erkennen, den Erwartungshorizont des Patienten bezüglich funktionaler Ansprüche und Langzeitziele abzuklären und auch das Verletzungsmuster zu analysieren, um so letztendlich die Therapie individuell an den jeweiligen Patienten anpassen zu können. Schlüsselwörter Rotatorenmanschettenläsionen · Schulterverletzungen · Tendinitis · Akromioklavikulargelenk · Proximale Humerusfrakturen preventing recurrent shoulder instability [20, 78], including a recent randomized controlled multicenter trial published in 2014 [78]. Additionally, the conclusion that “immobilization in internal or exter- nal rotation does not change recurrence rates after traumatic anterior shoulder dislocation” was confirmed in a 2014 sys- tematic review of the literature [76] and a 2016 meta-analysis of randomized con- trolled trials [77]. Of note, immobiliza- tion in external rotation is reported to be
  • 82. veryuncomfortable and, therefore, could reduce patient compliance. Overall, careful consideration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonopera- tive vs. operative intervention. Patients younger than 35 years of age should rarely be treated nonoperatively as the recurrence rate is unacceptably high. If treated nonoperatively, immobilization in internal rotation seems to be more comfortable and shows equal outcomes to immobilization in external rotation 92 Obere Extremität 2 · 2018 https://doi.org/10.1007/s11678penalty @M -hskip [email protected] 018penalty @M -hskip [email protected] 0449penalty @M -hskip [email protected] 1 Fig. 2 8 Images of a 46-year-oldman with right- sidedbicepstendonitis,diagnosedvia history,phys- icalexamination,andaT2- weightedmagneticresonanceimagingwithaclearhalosign(yellow circle) aroundthe long headof the biceps tendon indicating inflammation.The patient was treatedconser- vatively with physical therapyandNSAIDs butcontinuedto experiencesymptoms 6months later.He thusunderwentoperativemanagementasseeninbwiththelongheadof thebicepstendon(BT)and biceps reflection pulley visualizedthrough the
  • 83. standardposteriorviewing portal.HH humeral head and thus should be preferred, according to current literature findings. Biceps tendinitis Indications for nonoperative treatment of long head biceps tendinitis Inflammation of the long head biceps tendon (LHBT) can lead to damage and weakening of surrounding supporting structures, thereby causing LHBT in- stability. In turn, instability can place increased stresses on the LHBT, which subsequently increase inflammation. This cycle can predispose the LHBT to rupture. Given the potential success of non- operative management for most LHBT tendinopathies, a management strategy involving medications and physical ther- apy should be the first step in treating these conditions. After progressing a pa- tient through physical therapy, a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or injections, it is impor- tanttore-evaluatethepatientforprogres- sion of pain, weakness, and mechanical symptoms. At that time, continuation of a home exercise program vs. consider- ation of additional interventions will be discussed based on symptom progres-
  • 84. sion. Ifapatientprogressesthroughallnon- operative treatment options and notes no improvement of pain or weakness, he or she should progress to surgical evalua- tion (. Fig. 2). This is also the case for patients suffering from biceps reflection pulley lesions because these lesions do nothealandsymptomsworsenovertime. In general, patients suitable for surgical evaluation include the following: young, highly motivated patients with instabil- ity or complete LHBT rupture; man- ual laborers with significant instability or complete LHBT rupture; elite-level ath- letes with instability or complete LHBT rupture; any individual with a complete LHBT rupture who is not agreeable to a potential loss of elbow flexion or fore- arm supination strength and long-stand- ing “Popeye” deformity; and any individ- ual whohas progressed throughall stages of nonoperative treatment and continues to have symptoms of pain and/or weak- ness that affects their quality of life. Treatment After identification of the underlying pathologic condition of the LHBT, treat- ment generally begins with activity modification, NSAIDs, and/or cortico- steroid injections [1, 53]. NSAIDs can provide short-term benefit for swelling
  • 85. and pain control. However, there is little evidence that they are efficacious in treating chronic tendon injuries [13]. Useofcorticosteroidinjectionsshould follow a similar treatment protocol to NSAIDs. Multiple case reports discuss the risk of tendon rupture with steroid injections, and caution should be exer- cised when injecting steroid around the LHBT [2, 13]. Corticosteroid injections alone will likely provide short-term anti- inflammatory effects for most LHBT dis- orders. However, they should be used for short-term pain relief and as an adjunct for the patient to initiate and tolerate a physical therapy program, rather than as a long-term treatment option. Be- cause these injections have the potential toreachtheglenohumeraljoint, theanes- theticofchoice, usedincombinationwith corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than bupivacaine [62]. Theinitiationofa3–6-monthphysical therapy program allows for progressive increase in muscle strength while pro- viding protection against further LHBT and associated structure injury during rehabilitation [1, 4, 19, 53, 67]. Other evolving nonoperative treat- mentoptionsforLHBTdisordersinclude prolotherapy (dextrose solution, sodium
  • 86. morrhuate), platelet-rich plasma (dif- fering concentrations of platelets, white blood cells, red blood cells, and activated and inactivated platelets), and stem cells (circulating stem cells, adipose-derived, bone marrow aspirate, bone marrow aspirate concentrate, amniotic mem- brane-derived). The choice to utilize one of these treatment options varies from patienttopatientand conditiontocondi- tion, and current research is beginning to thoroughly evaluate these interventions and to standardize treatment protocols [21, 23, 45, 46, 49]. Indications for these injections include pain impairing athletic performance, connective tissue laxity impairing athletic performance, and pain impairing rest and quality of life [49]. Future research is needed to de- termine which LHBT disorders respond best to, and what patient populations are the most suitable candidates for, such procedures. Acromioclavicular joint injuries Indications for nonoperative treatment of acromioclavicular joint injury Injuryclassificationisthesinglemostim- portant factor in determining the most appropriate treatment of acromioclavic- ular (AC) joint injuries. In 1989, Rock- wood and colleagues developed the clas-
  • 87. Obere Extremität 2 · 2018 93 Review article Fig. 3 8 Radiographs of a 26-year-oldmale patientafteradirectfallonto his rightshoulder.a Panoramic view after in- jury showing a probable Rockwoodtype II injury.b However,the Alexanderview demonstratestheclavicleoverriding the acromion, thus indicating horizontal instabilityanddefining thisasa RockwoodtypeIVinjury.Accordingly,the patient un- derwentoperativetherapywithtwodog- bonesinsteadofoneinordertobetteraddressthehorizontalinstability ,aspictured in c, the postoperative panoramicradiograph.d Postoperatively, the horizontal instability wasresolvedasdemonstratedon the Alexanderview 6 weeks aftersurgery sification system that is most widely used for AC joint injuries today [79]. No- tably, this system, which is based on the work of Tossy et al. [74], recognizes the importance of the coracoclavicular (CC) ligaments in joint stability [79]. Rockwood type I injuries are charac- terized by a sprain without rupture of the AC ligaments with no anatomic dis- location and intact trapezius and deltoid fascia. Type II injuries involve rupture of the AC joint ligaments but are otherwise similar to type I. Type III injuries are characterized by rupture of both the AC andCCligamentswithsuperiordisplace-
  • 88. ment of the clavicle of 25–100% com- pared with the contralateral shoulder; notably, the trapezius and deltoid fascia are disrupted with this injury. Type IV injuries generally present with additional horizontal instability (. Fig. 3). Type V injuries are similar to type-III injuries, but the clavicle is superiorly displaced more than 100% compared with the con- tralateral side. Type-VI injuries, which are rarely seen, involve rupture of both AC and CC ligaments with inferior dis- placement of the distal clavicle under- neath the acromion; the trapezius and deltoid fascia are disrupted [74, 79]. Although high-level studies are rare inthe orthopedic literature todefinitively guide optimal treatment, there is a com- mon consensus regarding the most ap- propriatetreatmentsbasedonRockwood type [6]. It is generally agreed that type I and II injuries should undergo initial nonop- erative treatment while types IV–VI re- quire surgery [6]. Optimal management of type III injuries has been controver- sial. In the highest-level study to date, the Canadian Orthopedic Trauma Soci- ety [16] recently completed a prospective randomized trial of 83 patients compar- ing nonoperative treatment of grade III, IV, or V AC joint injuries with operative intervention using a hook plate. Out- come scores at short-term follow-up as
  • 89. far as 2 years demonstrated no signifi- cant difference between the groups with the exception of superior radiographic results in the operative group [16]. Moreover, Petri and colleagues re- viewed 41 patients with Rockwood grade III AC joint injuries who were initially treated nonoperatively [60]. Nonoperative management consisted of formalphysicaltherapytwotothreetimes per week for at least 6 weeks using a pha- sic approach with progression dictated by patient tolerance and evidence of improved scapulohumeral kinematics. Nonoperative treatment failed in 12 pa- tients, who ultimately required surgery. Reasons cited for nonoperative failure included unremitting pain, weakness, instability, and dysfunction in spite of physical therapy. At a mean follow-up of 3.3 years, patient-reported outcome scores—including the American Shoul- der and Elbow Surgeons score (ASES), Quick Disabilities of the Arm, Shoul- der, and Hand score (QuickDASH), Single Assessment Numeric Evalua- tion score (SANE), and Short Form 12 Physical Component Summary (SF- 12 PCS)—did not significantly differ be- tween those who successfully completed nonoperative therapy and those who required eventual surgery [60]. In general, there is consensus that
  • 90. the horizontal stability of the clavicle is considered a potential key factor for a successful postoperative outcome. It is hypothesized that an unstable clavi- cle causes pain and functional deficits. Therefore, the ISAKOS shoulder com- mittee [7] recently proposed a modifica- tion to the classic Rockwood classifica- tion in which type III injuries may be fur- ther subdivided into types IIIA and IIIB; 94 Obere Extremität 2 · 2018 type IIIA injuries are horizontally stable and may respond well to conservative management, but type IIIB injuries are unstable and should therefore be treated surgically [7]. Treatment Typical nonoperative treatment consists of primary immobilization and subse- quent active rehabilitation [15]. How- ever, evidence to support the efficacy of specificrehabilitationprotocolsislimited [15]. Gladstoneetal. [25]publishedaphys- icaltherapyregimenforthenonoperative treatment of AC joint injuries types I, II, andIIIinathletes. Phase1lasts3–10days and focuses on elimination of pain and sling immobilization to protect the AC
  • 91. joint. Range-of-motion exercises begin in phase 2 with gradual progression of isotonic exercise for strengthening. Phase 3 involves advanced strengthen- ing, and phase 4 involves sports-specific training before full returntoactivity[25]. The total length of rehabilitation can last 3–6 months. Moreover, it is important to check on the scapula movement since a significant number of patients suffering from AC joint injuries also present with scapula dyskinesis. Overall, the general consensus re- garding management of AC joint in- juries is fairly straightforward: initial nonoperative treatment for Rockwood grades I–II, and operative intervention for grades IV–VI. For patients with grade III lesions, a closer look con- cerning the stability of the clavicle is necessary. Proximal humeral fracture Indications for nonoperative treatment of proximal humeral fractures The number of bone parts and concomi- tant displacement mainly influences the treatment strategy of proximal humeral fractures. Nonoperative treatment of two-part fractures with early rehabil- itation has been found to be at least as efficacious as surgical treatment in
  • 92. injuries with minimal displacement [29]. Betteroutcomesmaybeachievedwith surgical fixation in cases with signifi- cant displacement, a bony avulsion of the supraspinatus tendon, a block to range of motion, andinvolvementoftheanatomic neck. However, well-designed compar- ative studies of operative vs. nonoper- ative management of two-part fractures are lacking [26]. Some authors have found that greater tuberosity fractures with >5mm of dis- placement may benefit from surgical fix- ation to reduce the risk of subacromial impingement [58, 63]. Lesser tuberosity fractures with internal rotation impinge- ment may also benefit from surgery if nonoperative management fails [52]. In contrast to other parts of the proximal humerus, the anatomic neck is devoid of soft-tissue attachments and has a tenu- ous blood supply, which may result in an increased risk of osteonecrosis. Court-Brown et al. recommend 2 weeks of sling immobilization followed byphysical therapyforpatients with two- part surgical neck fractures and valgus- impacted fractures [17, 18]. Two-part proximal humeral fractures with >66% translation were treated with either sling immobilization or with internal fixation with flexible intramedullary nailing and tension-band wires [17, 18]. No statis-
  • 93. tical difference was reported between the groups with regard to Neer score, return to activities of daily living, and union rates [17, 18]. The data demon- strate that the Constant score diminishes with advancing age and degree of dis- placement. However, when calculated based on age-adjusted Constant score, the older patients actually had better scores than the younger patients [14, 17, 18, 34]. Therefore, sling immobilization is an appropriate treatment option for patients older than age 60 years with valgus-impacted, two-part surgical neck or two-part tuberosity fractures. Although three-part and four-part fractures often require surgical fixation, nonoperative management can be con- sidered for patients with poor baseline function and/or an inability to toler- ate surgery. In select three-part and four-part fractures, particularly valgus- impacted fractures with <1cm of dis- placement of the tuberosities in relation to the head fragment, nonsurgical treat- ment may yield good-to-excellent results [17]. Although surgical treatment of com- plex fracture patterns is generally advo- cated, theefficacyofoperativevs. nonop- erativemanagementremainstobeclearly delineated. In a study of 60 elderly pa- tients with a displaced three-part frac-
  • 94. ture of the proximal humerus, Olerud et al. found that surgical management with a locking plate resulted in better functional outcomes and health-related quality of life than did nonsurgical treat- ment, butatacostofadditionalsurgeryin 30% of patients [56]. By contrast, a meta- analysis of randomized controlled trials did not find improved functional out- comes with open reduction and internal fixation (ORIF) compared with nonsur- gical treatment in elderly patients with displaced three-part or four-part prox- imal humeral fractures [40]. The study concluded that these results must be con- sidered in the context of variable patient demographics. A systematic review supported the use of nonsurgical treatment of proximal humeral fractures and noted a 2% rate of osteonecrosis mainly associated with three-part and four-part fractures, high rates of radiographic union, and modest complication rates [32]. Ultimately, the patient’s baseline physiology and func- tion may help to quantify the potential advantages of nonsurgical management, even in the setting of complex fracture patterns. Treatment A number of proximal humeral fractures may be treated nonoperatively. However, patients must understand the expecta-
  • 95. tions with this treatment approach and comply with the accompanying restric- tions. In general, excellent results have been achieved with short-term immobi- lization (<2 weeks) in a sling and early physical therapy [28, 63, 72]. While the literature supports early mobilization, it is important to ensure that further frac- ture displacement does not occur. Sling immobilization with or without closed reduction also has a role in the man- Obere Extremität 2 · 2018 95 Review article agement of displaced proximal humeral fractures [69]. Practical conclusion 4 For rotator cuff tears, the best pos- sible outcomes with nonoperative therapyaregenerallyachievedforpa- tients presenting pain as the primary symptom of an atraumatic rotator cuff tear, largely intact coronal and axial force couples, and a willingness to trade functional deficits to avoid surgical risks. 4 In patients suffering from anterior shoulder instability, careful consid- eration of the injury mechanism,
  • 96. patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonoperative vs. opera- tive intervention. Patients <35 years should rarely be treated nonopera- tively. 4 For tendinitis of the LHBT, treatment generally begins with a nonoperative treatment protocol including activity modification and NSAIDs. In patients with structural instability of the biceps tendon complex, or in any individual who continues to have symptoms of pain after nonoperative treatment, surgery is favored. 4 The general consensus regarding management of AC joint injuries sug- gests initial nonoperative treatment for Rockwood types I–II, and oper- ative intervention for types IV–VI. For patients with type III lesions, a pathologic instability of the clav- icle potentially requiring surgical stabilization should be considered. 4 Tuberosity fractures with >5mm of displacement may benefit from surgical fixation to reduce the risk of subacromial impingement as well as displaced multifragment fractures in young and active patients. Corresponding address
  • 97. P. J. Millett, M.D., M.Sc. The Steadman Clinic 181 West Meadow Drive suite 400, 81657 Vail, CO, USA [email protected] thesteadmanclinic.com Compliance with ethical guidelines Conflict of interest. A.B. Imhoffservesasaboardor committeememberforAGA,servesontheeditorial boardofArchives of Orthopaedic and Trauma Surgery, isapaidconsultantandreceivesroyaltiesandresearch supportfromArthrex, Inc.,servesontheeditorial boardofArthroskopie, isapaidconsultantandreceives royaltiesfromArthrosurface,servesasaboardor committeememberforDGOOC,servesasaboardor committeememberforDGOU,servesasaboardor committeememberforISAKOS,servesontheeditorial boardofKSSTA, isapaidconsultantformedi-bayreuth, servesontheeditorialboardofOOTR,andreceives royaltiesandfinancialsupportfromSpringerand Thieme. P.J.Millett isapaidconsultantforArthrex, Inc., receivesroyaltiesfromArthrex, Inc.,Medbridge, andSpringerPublishing,ownsstockorstockoptions inGameReadyandVuMedi,andreceivesresearch supportfromArthrex, Inc.,Ossur,Siemens,andSmith andNephew. J.Pogorzelski,E.M.Fritz,andJ.A.Godin declarethattheyhavenocompetinginterests. Thisarticledoesnotcontainanystudieswithhuman participantsoranimalsperformedbyanyoftheau- thors.
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