SPORTS INJURIES REFRESHER SHOULDER JOINT

mine and place my hands against theirs (my palm to dorsum of their hand) and ask them to push their hands firmly against mine. This assesses the power of infraspinatus (external rotation) (see Video 5). n Then I move my hands over to the palmar side of their hands and do the reverse movement (internal rotation) which assesses subscapularis (see Video 5). n To test supraspinatus power, ask them to imagine carrying a glass in each hand and to pour them over their feet. I place my hands on their elbows and ask them to resist me as I push down towards their chest. Whilst the elbows are at 90 degrees, ask them to resist you straightening and flexing the elbow, checking biceps and triceps power respectively (see Video 5).

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KEY POINT: Muscles experiencing pain cannot contract fully. Injured muscles that are not working for one day, take three days to rehabilitate.

The final basic move is called the ‘scarf sign’. Ask the

patient to place the affected arm around their neck like a scarf. Illicited pain often originates from the AC joint or occasionally the manubrio-clavicular joint. Check or elicit pain with a short sharp nudge of the elbow. However you examine these muscles, develop a routine you can use reliably and quickly. Modify the instructions so the patient understands. A multi-directional limitation of movement (without

loss of power) indicates bursitis (usually subacromial) or a frozen shoulder. History revision is the key here. A frozen shoulder has a slow onset, is often familial and may be related to Dupytrens contracture. Subacromial bursitis can be acute (small calcium pyrophosphate crystal deposits in the supraspinatus tendon burst into the bursa, causing a gout-like reaction which tends to be very painful, but settles quickly) or chronic (slow onset, multi-directional and usually responds very well to intra-bursal steroid injection).

Feel By now you should be 90% sure of the lesion location. Palpation of the AC joint with the tip of the index finger (nail cut short) confirms a positive scarf sign. Tenderness over the GH joint is less specific.

SHOULDER INJURIES Acute or chronic

Shoulder injuries can be divided into acute and overuse. Acute injuries involve a dysbalance between strength and mobility of the shoulder girdle components and the forces put through them. Overuse injuries on the other hand are caused by

repetitive movements, often with underlying weakness, laxity or misuse of the shoulder components. Learning the aetiology and pathology, then recognising them in the patient, is the key to diagnosis and treatment. Enquire about occupation/posture and work station and body building/resistance exercises as this may well point to overuse/instability problems.

Mechanism of injury Acute injuries commonly involve the RC, usually a tear. A fall on an outstretched arm or against a solid object (with the

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arm fully adducted) will often damage the RC (particularly at the musculo-tendinous junction or rotator cuff tendon itself). This is validated by decreased internal rotation and decreased abduction, i.e. a painful arc. Injuries amongst sports people, especially in contact sports, are often not as clear cut as in older, non-sporting populations. Partial thickness tears often demonstrate more pain and less weakness. Full thickness tears of the RC usually demonstrate the opposite. Weakness of the accessory muscles of the scapula is

more likely to present as an overuse problem (i.e. an ache at rest, and pain in all directions). An anteriorly translated head of humerus on the glenoid fossa indicates an over- protracted scapula, usually associated with a weak lengthened trapezius, a cause of secondary impingement. Satellite trigger points (3) can often be found in SS, IS, trapezius and levator scapulae. Again in my experience these are often secondary to minor joint dysfunction in the cervical

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Video 5: Range of muscle strength tests

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Video 3: Normal external rotation

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Video 4: Normal internal rotation