Multidirectional Instability of the Shoulder Causing Impingement

Case 17: A 14-year-old year round right handed swimmer has three months of intermittent right shoulder pain. The pain usually occurs with butterfly stroke. She feels as though the shoulder clicks and slips with certain movements. She denies paresthies or an injury. She has limited internal rotation of her shoulder and weakness with resisted external rotation and supraspinatous testing. She has a positive sulcus sign along with a positive apprehension and relocation test. She has scapulothoracic dysfunction and weak scapular muscles. She goes into a valgus maneuver with single leg squats.

Throwers, swimmers, wrestlers, tennis players, and athletes participating in overhead activities commonly present with shoulder pain.

Chronic Shoulder Instability
Figure 14 Shoulder diagram.

Table 3 Sports Shoulder Injuries

Injury

Mechanism/history

Physical exam

Treatment

AC sprain (shoulder separation) Biceps tendonitis

Burner/stinger

Clavicle fracture

Rotator cuff tendonitis

Chronic Salter Harris I fracture of proximal humerus

Shoulder dislocation

Fall on an outstretched hand or lateral blow to shoulder

Overuse injury from repetitive throwing/overhead activity

Compression or traction injury to the neck resulting in stretch of brachial plexus

Fall or hit to area (usually mid-clavicle)

Overuse injury from repetitive throwing or overhead activity

Overuse injury from repetitive throwing/overhead activity

Hit to shoulder in an abducted/ externally rotated position as with throwing a football; traumatic hit or fall

Pain at AC joint; limited shoulder ROM; positive crossover test

Pain at insertion of long head of biceps; weakness of rotator cuff muscles; positive Speed's test Limited shoulder ROM/weakness; occasional weakness of upper extremity/numbness or tingling; negative axial load/Spulring's maneuver Pain/deformity at clavicle, limited shoulder ROM

Limited/painful ROM, weakness of rotator cuff especially external rotators and supraspinatous Pain at proximal humeral physis, limited ROM especially internal rotation, weakness of rotator cuff, scapular stabilizers and core body, poor throwing technique (throwing with arm not the body) Swelling, pain with shoulder palpation, limited ROM especially internal rotation, weakness of rotator cuff, decreased sensation along deltoid if axillary nerve injury

Rest, ice, rehabilitation for grades I—III; surgery for grades IV-VI

Rest, ice, rehabilitation of scapular/ shoulder muscles; review of technique; iontophoresis prn Rehabilitation, including ROM and strengthening, ice

Ice, pain medications, sling for support; use of arm as tolerated; 6-8 weeks for healing

Rest, ice, rehabilitation of scapular muscles and rotator cuff; review of technique Rest from throwing activity, rehabilitation of core body and scapular stabilizers, throwing program once pain free, review of proper pitching mechanics, avoid overuse in future Rest, ice, sling for support for 2-5 days, early rehabilitation, debate over need for surgery with first time dislocators

Abbreviations: AC, acromioclavicular; ROM, range of motion.

Shoulder instability from repetitive overload causing impingement combined with muscular imbalance and scapulothoracic dysfunction has been implicated in overuse shoulder injuries in overhead athletes. The shoulder joint is a ball and socket joint likened to a golf ball (humeral head) on a golf tee (glenoid rim). As the bony stability of the shoulder is not structurally sound (i.e., the golf ball is not stable on the small golf tee on which it sits), the shoulder relies on the strength of the surrounding labral capsule, musculature of the shoulder, scapula and neck along with ligamentous integrity to provide support and maintain dynamic stability. When participating in repetitive overhead activities, adolescents may experience pain and impingement if there is increased laxity in the shoulder joint. As many adolescent athletes have natural ligamentous laxity, this instability can cause subsequent impingement of the soft tissues of the subacromial space and act like rotator cuff impingement or tendonitis, seen more often in adults. During swimming, the initial pull through and recovery portions of both freestyle and butterfly stroke cause excessive shoulder impingement as does the overhand tennis serve.

History often reveals an overuse picture with repetitive overhead movements causing shoulder pain. Pain along the anterior shoulder or along the lateral deltoid region may occur with activity, rest, and at night. Pain can be elicited along the long head of the biceps tendon in many athletes. Adolescents with multidirectional instability have increased laxity with anterior, posterior, and inferior shoulder movements. Many symptomatic athletes have scapulothoracic and scaplohumeral dysfunction. This scapulothoracic dysfunction can be visualized by standing behind the patient and watching scapular movement with slow active shoulder abduction. Athletes will have weakness of the rotator cuff, specifically with resisted external rotation and supraspinatous testing (empty can test) (Fig. 15). Anterior and posterior apprehension and relocation testing may be positive and patients may have a sulcus sign, suggesting inferior instability. Impingement testing is commonly positive. AP, axillary, and scapular Y radiographic views of the shoulder are usually normal.

Rehabilitation consists of rest from overuse in the overhead position. Yearlong swimmers or throwers may need a complete break (minimum of 3 months) from the sport to allow for rest and rehabilitation. Rehabilitation focuses on daily scapular stabilization, internal rotation flexibility, rotator cuff strengthening and core strengthening. Icing the shoulder for 15 to 20 minutes after activity and occasional NSAID use after activity is used for pain control. Technique should be reviewed and intensity decreased until symptom free. Decreasing activity by at least 50% in terms of time/yardage and intensity is essential as this is an overuse injury. Avoiding specific activities, such as the butterfly or freestyle stroke, throwing or tennis serves, may help decrease symptoms.

Figure 15 Supraspinatous/empty can test. The examiner places his or her hands on the patient's wrists. With the patient's arm abducted to 90°/forward flexed to 30°/ thumbs pointed downward, have them resist downward displacement of their wrists. Weakness or inability to resist downward displacement suggests injury to the supraspinatous rotator cuff muscle.

Figure 15 Supraspinatous/empty can test. The examiner places his or her hands on the patient's wrists. With the patient's arm abducted to 90°/forward flexed to 30°/ thumbs pointed downward, have them resist downward displacement of their wrists. Weakness or inability to resist downward displacement suggests injury to the supraspinatous rotator cuff muscle.

Very rarely are subacromial bursal cortisone injections recommended for overuse injury in adolescents. Shoulder stabilization surgery is occasionally necessary for those that fail conservative therapy or have frank dislocations of the shoulder.

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