online

Video 6: Abnormal

external rotation

dislocation normally results from a direct blow either forcing the head of the humerus anteriorly or inferiorly.

TREATMENT Most injuries will respond to exercises for the RC primarily and the PM. These can be explained to the patient by an interested GP or a physio. Pain from an RC tear will inhibit the RC action. Analgesia, NSAIDs, acupuncture or intra- bursal steroid injection will often relieve pain enough to allow exercises to strengthen the RC. Debridement and repair of complete RC tears are needed surgically if these approaches don’t work.

Similarly weak accessory scapula muscles are often online

Video 7: Abormal internal rotation

inhibited by pain from trigger points. These in turn are irritated by stretching of the muscles, due to poor posture or excessive anterior wall muscle strengthening without concomitant posterior chest wall exercises (a common presentation of body builders). Deactivation of these trigger points is required before strengthening of scapula muscles will be effective.

+ References

and thoracic spinal facet joints and the vertebra-costal joints (especially the first rib). Treatment of these non-shoulder problems is required to allow normal muscle function - but this is beyond the scope of this article. (See the further reading box for more information).

The PC muscles are rarely injured (except by direct

blows locally). Biceps is the exception to the rule. Summarising injuries

Intra-articular GH disease is usually witnessed by pain over the upper arm, aggravated in a capsular pattern, i.e. decreased external rotation, abduction then flexion in that order. n AC joint pain is usually felt over the AC joint (pin-pointed by a pointing finger) above 135 degrees from the horizontal. n Pain in the nape of the neck or over the scapula is usually from the scapula accessory muscles. n Impingement - the narrowing of the space between the inferior aspect of the acromium (with the subacromial bursa below the acromium) and the superior aspect of the head of the humerus (the rotator cuff tendon covering the head of the humerus). Impingement can be primary (i.e. congenital/ osteophyte formation on the inferior surface of the acromium) or secondary (i.e. weakness of the RC, the RC normally depresses the head of the humerus, increasing the subacromial space). Strengthening the RC muscles may improve impingement, if it doesn’t an x-ray may reveal another cause. n Instability - usually results from weakness of the gleno- humeral ligaments due to stretching. This may result initially in subluxation or even temporary dislocation. Assessment involves stressing the joint either anteriorly or inferiorly with the patient’s shoulder supported whilst resting prone. (For detailed instructions see Bunker and Schrantz). Major

12 FURTHER READING

Sports Injuries 1. Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1. Lippincott Williams and Wilkins 1998. Buy on Amazon ISBN 0683083635 http://bit.ly/aL6tLV (£55.19). Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 2. Lippincott Williams and Wilkins 1992. Buy on Amazon ISBN 0683083678 http://bit.ly/am9D1q (£55.50). 3. Manual Therapy by B.Mulligan

THE AUTHOR

Dr Simon Kay, MBBS MRCGP DRCOG DIPL and MSc Sports medicine, member of FSEM BASEM BMAS SOC and Honoury Education Fellow Exeter University. Simon is a full-time GP/

Sports Physician, Yorkshire Missionary in Devon. He has been a GP for 25 years and is a keen ex-rugby player. He became interested in sports injuries since injuring his knee in 1988 and completed his Diploma in Sports Medicine in 1997, followed by his MSc in 2006. Since 1999 he has added acupuncture, SOM teaching, manipulation, podiatry and sports therapy teaching to his repertoire. He teaches students, GPs and sports therapists and has been medical officer to various rugby clubs, notably Halifax RUFC and Exmouth RFC, England SW U18 Rugby, and now Exmouth ABA. For more information visit www.sports-doctor.co.uk

sportEX medicine 2010;44(Apr):9-12

1. Travell and Simons. Pain distribution from the Shoulder in Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1, chapter 6 p287-289; chapter 19 p494; chapter 21 p539; and chapter 22 p556

2. Capsular Pattern of Shoulder Pain. Society of Orthopaedic Medicine 3. Travell and Simons. Satellite Trigger Points. Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1, chapter 1, p6.

KEY POINT: Muscles can refer pain to other sites, a fact that is uncontested when discussing the heart muscle. It thus follows that other muscles can also work this way..