DIFFERENTIAL DIAGNOSIS OF SHOULDER INJURIES IN SPORTS

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REPAIR OF ATHLETIC SHOULDER INJURIES

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DIFFERENTIAL DIAGNOSIS OF SHOULDER INJURIES IN SPORTS Stephen Owens, MD, and John M. Itamura, MD

Athletic injuries to the shoulder are both common and unique, and even for the most experienced examiner they can be difficult to diagnose and manage. Most occur from either direct or indirect trauma or result from repetitive use. Fractures, dislocations, sprains, and tendon ruptures are everyday occurrences in contact sports that produce frequent falls and collisions, whereas chronic injury is the product of strain and fatigue from overuse. Patterns develop across sports that place similar demands on the shoulder and that require similar motion. These injury patterns are most prevalent in overhand throwers. There is an ongoing attempt to better understand these challenging clinical problems, and the treatment of shoulder injuries is an evolving science. The objective of this article is to review the cause of shoulder pain and injury resulting from both trauma in the contact athlete and from overuse in the overhead athlete. The diagnosis of a shoulder injury requires a detailed, yet focused, history and physical examination, accompanied by a fundamental knowledge of the anatomy. These are the most useful tools in eliciting the clinical features of tissue injury, which can be quite subtle. The ability to correlate the history with the physical examination depends on understanding the mechanism of injury and being able to reproduce the symptoms clinically. Knowledge of the patient’s participation, the movement and positions that cause pain, the symptoms described, and their temporal

relationships and duration is important, in particular when a chronic injury presents. The age of the patient can help identify certain risk factors. For instance, the older athlete is more prone to degenerative tendinopathy of the rotator cuff with subacromial impingement, whereas the younger athlete, with greater tissue laxity, is more prone to instability. Shoulder pain can be a misleading symptom. Referred pain from cervical radiculopathy is common, and an examination of the cervical spine, including provocative maneuvers such as the Spurling test and cervical traction, as well as a sensory and motor neurologic examination, evaluates these lesions. Cardiac ischemia, pericarditis, intra-abdominal pathologic conditions, or thoracic outlet syndrome can present as shoulder pain, as can carpal tunnel syndrome and other peripheral nerve entrapment syndromes. Bone and soft tissue tumors are often associated with continuous, irregular, deep pain, along with constitutional symptoms such as fever, weight loss, malaise, or fatigue. A brief review of systems will help determine the relevance of these entities in the evaluation. ACUTE SHOULDER INJURIES

Acute injury prevention has greatly improved with the development of sophisticated equipment and protective gear, but the tremendous forces generated in collision sports

This article was originally published in the October 2000 issue of Operative Techniques in Sports Medicine. From USC Orthopaedic Surgery Associates, Los Angeles, Califomia

ORTHOPEDIC CLINICS OF NORTH AMERICA VOLUME 32 NUMBER 3 JULY 2001

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continue to cause injury. The traumatic shoulder can present a challenging clinical encounter, especially when there is inhibition and guarding. Knowledge about the position of the arm and forearm at the time of injury, the degree of muscle contraction or relaxation, and the direction and momentum of the athlete helps determine the type and severity of the injury. Additionally, information about the mechanism and force of the injury, giving-way sensations, pops or snaps, or numbness and paresthesias helps describe the pathoanatomy. Often a delayed examination is useful to allow the acute swelling and pain to resolve. Traumatic injuries to the shoulder can be categorized into osseous, soft tissue, and nerve lesions. The clavicle is the most frequently fractured bone and occurs by either a direct or indirect mechanism. A history of a fall directly onto the tip of the shoulder is typical, as is a history of a fall onto the outstretched hand. There is little difficulty in making the diagnosis of a clavicle fracture. Associated soft tissue disruption, particularly that to the coracoclavicular Ligaments, can be a troublesome feature of the distal clavicle fracture, and appropriate management mandates an accurate classification. Proximal humerus fractures occur infrequently. Fracture geometry can be complex, and a computed tomography (CT) scan may be required to realize the extent of the bony injury. A fracture-dislocation involving the greater tuberosity indicates a disruption of the anterior capsulolabral complex and a likely rotator cuff tear. Fractures of the scapula involving the body, glenoid neck or rim, coracoid, and acromion are uncommon in sports, and usually have associated injuries. An anteroposterior (AP), axillary, and Y-view are necessary to avoid missing these lesions. Anterior or anteroinferior glenoid rim fractures typically represent a bony Bankart lesion, with associated anterior instability. A history of a dislocation confirms this. The acromion fracture occurs after a fall onto the shoulder or a direct blow. Either the West Point or axillary view is most helpful in characterizing these fractures. Isolated coracoid process fractures are very uncommon and in the literature are described only in case reports.16This injury produces pain anteriorly that worsens with deep inspiration. Radiographically they are best detected with either the axillary view or a 30" cephalic tilt view. Resisted arm flexion and forearm supination recreates pain, and the mechanism of injury

appears to be indirect with the arm abducted, extended, and oriented backward. Stress fractures about the shoulder, though exceedingly rare, are considered when symptoms are vague and atypi~a1.l~ Bony tenderness of insidious onset that is slow to resolve may represent such an injury. There have been 2 reported cases of stress fracture to the clavicle, confirmed with bone scan. These were in a javelin thrower and a diver. Scapular stress fractures have been reported, one along the superomedial edge in a jogger who was using hand-held weights, another at the base of the acromion in an offensive lineman, and another at the coracoid base in a trap shooter. Bone scans and magnetic resonance imaging (MRI) scans remain the best radiographic modalities. Soft tissue injuries caused by blunt or indirect trauma are routine occurrences in contact and collision sports. Soft tissue contusions over the deltoid, and the trapezius at the base of the neck, regularly occur in tacklers, and not uncommonly lead to myositis ossificans. A history of direct trauma to the region associated with local tenderness and ecchymosis helps differentiate these injuries from the more chronic cuff tendinitis, and provocative tests for rotator cuff pathology are generally negative. Myositis, when present, can be exquisitely tender and painful, and radiographically appears as lacy peripheral ossification with soft tissue swelling. An athlete with an acromioclavicular (AC) joint sprain will describe a fall directly onto the shoulder, a direct blow to the shoulder, or a fall on an outstretched arm. Local tenderness and excessive joint mobility are good clinical indicators, but radiographs are needed to rule out a distal clavicle fracture. Weighted radiographs are rarely needed because a good history and physical examination are usually sufficient to make the diagnosis. Localized pain with elevation of the arm occurs because of the pull of the deltoid and trapezius on the injured joint, and cross-body adduction compresses the joint, causing pain. Nondisplaced type I sprains should be differentiated from rotator cuff pathology, glenohumeral subluxation, and burner syndrome. Glenohumeral dislocations are most common anteriorly and inferiorly. The classic traumatic dislocation causes an avulsion of the anterior-inferior labrum and ligamentous restraints and varying degrees of plastic deformation to the anterior capsule. In certain instances, subscapularis tearing occurs. A

DIFFERENTIALDIAGNOSIS OF SHOULDER INJURIES IN SPORTS

violent extension of the abducted, externally rotated arm is the most frequent mechanism. Clinically, the arm is held away from the body and externally rotated, and the posterior deltoid contour is flattened or absent. A first-time dislocator occasionally will reduce spontaneously before treatment, although this is the exception.Axillary nerve injury can be a cause of late deltoid dysfunction, and brachial plexus injuries may occur, so a thorough neurologic examination before and after intervention is warranted. The diagnosis is usually clinical, but orthogonal radiographs in AP and lateral planes are necessary to rule out associated fractures and to determine the direction of dislocation. Either a scapular Y view or a Velpeau lateral is useful when an axillary lateral view is not accomplished. Close attention to the glenoid will avoid missing a bony Bankart lesion. A West Point view will help visualize this, although a CT scan will provide more information about the size and geometry of the fracture, as it will for a large Hill-Sachs lesion. Posterior dislocations caused by trauma are much less common and usually occur from a fall onto the flexed, adducted, and internally rotated arm. Less deformity is evident, and the same radiographs are necessary to confirm the diagnosis. The arm is internally rotated and held at the side. This posturing is not unique and contributes to the reported 50% misdiagnosis rate. A good lateral radiograph, part of every trauma series, cannot be overstated. A reverse Hill-Sachs lesion can be appreciated with an external rotation radiograph, but, again, is best characterized by a CT scan. Traumatic rotator cuff tears occur rarely in athletes younger than 35 years and are best understood as a consequence of degeneration and impingement in the older athlete. Acute ruptures result from a violent mechanism in which the torn muscle-tendon unit maximally contracts against an eccentric load. Cuff weakness is best shown by the supraspinatus test and resisted external rotation at the side with injury to either the supraspinatus or infraspinatus, respectively. Isolated subscapularis tears show weakness on the lift-off test, which is performed by the patient’s hand pushing off from the back. Pain and tenderness are usually found over the greater tuberosity or underneath the anterolateral acromion with a tear of the supraspinatus.Subscapularis tears produce anterior shoulder pain and tenderness. Anterior instability may be contributory to these latter injuries, and the apprehen-

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sion sign is commonly positive. A subluxed biceps frequently accompanies a tear of the subscapularis tendon, particularly when the tear extends into the rotator interval. An irritated biceps tendon is shown by a positive Yergason and Speed’s test combined with direct tenderness along the bicipital groove. OBrien’s test also may be positive. Acute rotator cuff tears, like degenerative tears, commonly produce a dull ache and cause night pain. The differential includes an AC joint sprain, deltoid strain, subluxation, isolated biceps lesions, or suprascapular neuropathy. It is, therefore, important to sort out true weakness from painful inhibition. Acute nerve injuries about the shoulder have been reported in a variety of different sports. Perhaps the most susceptible and troublesome is the axillary nerve, which is injured in 9% to 18% of anterior shoulder dislocations. Blunt trauma and hematoma formation also have been implicated in cases of axillary neuropathy?’ Deltoid atrophy occurs as a consequence of chronic denervation, though in the acute setting weakness is the most pronounced finding. Sensation is often preserved and is not a reliable indicator of nerve injury. An isolated axillary nerve injury is differentiated from a more proximal lesion along the brachial plexus, and a rotator cuff tear, especially after a traumatic shoulder dislocation. Electromyograph/nerve conduction study (EMG/NCS) are the most useful diagnostic tools.26 The suprascapular nerve may be injured by a blow to the superior shoulder or, more commonly, from acute stretching. The location of the injury defines the motor involvement to the supraspinatus and infraspinatus. Clinical similarities with rotator cuff tears make differentiating these two lesions challenging. Suprascapular neuropathy generally produces vague aching pain posterosuperiorly but can coexist with impingement signs and symptoms. Atrophy, weakness, normal sensation, and a preserved deltoid are not unique to either diagnosis. EMG/NCS are needed to confirm the diagnosis. Scapular winging indicates weakness of the serratus anterior, which is innervated by the long thoracic nerve. Injury to this nerve was first reported in 1937 and has been found to occur in sports ranging from archery to footba11.I8It is most commonly a traction phenomenon, though contusion from a direct blow is possible. Winging of the scapula is the classic physical examination finding and is best dem-

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onstrated by having the patient perform a standing pushup against the wall. Scapular winging may not occur for several weeks after injury until the trapezius stretches out. Thus, the early findings are often limited to aching/ burning pain in the posterior shoulder with associated weakness on arm elevation and abduction. EMG/NCS are, again, the necessary tests. CHRONIC INJURIES

The mechanism of chronic shoulder injury in overhand athletes is a complicated, and perhaps controversial, topic. The glenohumeral joint is the most mobile joint in the body, and its anatomy is variable and complex. The intricate coordination of motion and stability allows for remarkable athletic versatility. Repetitive motion at or beyond its physiologic range, which is typical of most overhead sports, threatens the integrity of the soft tissue stabilizers in their efforts to maintain joint congruity. Most overuse injuries are now understood as the result of a breakdown in joint stabilization. A large volume of literature has been devoted to understanding the mechanism of shoulder instability in athletes, and our knowledge continues to evolve. This forceful, repetitive strain combines with muscle fatigue and poor scapulohumeral rhythm to create a spectrum of capsulolabral pathology. Excessive translation of the humeral head on the glenoid results. There are varying theories as to the cause of this instability phenomenon, from stretching of the anterior capsule and microinstability, to the circle concept, with a loss of capsular integrit caused by posterosuperior labral peelback.B Labrum, capsule, biceps anchor, rotator cuff, and coracoacromial arch pathologic conditions are common in these athletes. Age has significant bearing on the type of lesion seen. Tissue injury in the athlete over age 35 years usually relates to degenerative processes, in contrast to the younger athlete, in whom instability is the primary contributor. Nerve compression also can cause pain and can mimic symptoms associated with cuff and deltoid pathology. Important aspects of the history, aside from age, include type of sport, handedness, location, duration and character of pain, mechanical symptoms such as clicking or catching, and the nature of onset. Valuable information is gained from knowing the relationship of pain

to the specific activity, as is knowing at what phase during the throwing motion pain occurs and the location of the pain. Also valuable is knowledge about training techniques, which, if unsupervised and performed incorrectly, can propagate the injury. Numerous lesions cause pain anteriorly in the shoulder. A common consequence of anterior instability is anterior shoulder pain, and pain that occurs in the late cocking or early acceleration phase of the throwing motion is convincing. Varying degrees of laxity may be appreciated on physical examination, but a positive apprehension sign and relocation test is usually diagnostic. Pathologic conditions that can be associated with anterior instability or subluxation, aside from a disruption of the anterior labrum and capsule, include a rotator interval tear or even a partial subscapularis tear. Again, biceps instability and tendonitis frequently result from this. These 3 lesions also cause pain anteriorly and are suspected in the face of continued weakness and pain on internal rotation, pain with provocative biceps tests as previously described, and tenderness anteriorly and along the bicipital groove. Lesions of the superior labrum and biceps anchor may produce pain anteriorly. Commonly the thrower will give a history of painful catching or clicking in the abducted, externally rotated position. Several different maneuvers have been described for identifying these SLAP lesions, most of which create tension along the long head of the biceps with the humerus internally rotated and adducted. Deltoid muscle strains in the anterior head will be point tender over the site of injury and possibly ecchymotic, painful with forward elevation, and the history is usually straightforward. Poorly localized anterior shoulder pain associated with nondermatomal upper extremity paresthesias may represent compression of the axillary nerve as it passes through the quadrilateral space. Symptoms are most pronounced when the shoulder is placed in the abducted, externally rotated position. Rare but seen in the young overhead athlete, the quadrilateral space syndrome is best diagnosed with an arteriogram. Occlusion of the posterior humeral circumflex artery, which courses with the axillary nerve, is seen as the arm achieves the position of abduction and external rotation. Pain over the lateral deltoid and subacromial region raises suspicion for either rotator cuff injury or impingement and bursitis. Overuse in the younger athlete from throwing,

DIFFERENTIAL DIAGNOSIS OF SHOULDER INJURIES IN SPORTS

swimming, or other overhead activities can fatigue and injure the cuff, causing rotator cuff tendinitis. Increased training, improper mechanics, poor conditioning, or a combination thereof are suspected. Achy pain made worse with abduction or forward flexion of the arm, tenderness along the cuff insertion and subacromial region, and impingement signs are usually found. Symptoms that persist despite a course of physical therapy and antiinflammatories are suggestive of a rotator cuff tear, particularly if the history elicits disruptive night pain. Other causes of lateral shoulder pain include calcific tendinopathy and suprascapular nerve compression. Calcific tendinopathy can be marked by severe, unrelenting burning pain that is either abrupt in onset or more gradual in onset and progressive. Radiographs aid in making this diagnosis. Suprascapular neuropathy from compression at the transverse scapular ligament or the spinoglenoid notch may initially be difficult to distinguish from mff pathology. Pain is vague but often lateral and posterior, and weakness on elevation and external rotation mimics a rotator cuff tear. The younger athlete with persistent weakness and evolving atrophy of either the infraspinatus or both the infraspinatus and supraspinatus is rarely found to have a large rotator cuff tear, and a suprasca ular nerve lesion should be suspected.2,18*2The older athlete with this history has a cuff tear until proved otherwise. The appropriate imaging and electrodiagnostic studies facilitate the diagnosis. Posterior shoulder pain can be a symptom of instability, glenohumeral arthritis, posterior deltoid or proximal triceps strain, or lower cervical nerve root compression. Posterior glenohumeral instability, like its anterior counterpart, is a positional phenomenon that is as difficult to manage as it is to diagnose. Offensive linemen who are repeatedly pushing off with their arms against defensive players are prone to developing posterior instability, frequently in players who display ligamentous laxity. Pain with the arm flexed to 90" and internally rotated is usually present, and pain with a posterior drawer to the glenohumeral joint is provocative. Interestingly, subtle anterior instability commonly produces posterior shoulder pain. The abducted, externally rotated arm can pinch the undersurface of the rotator cuff insertion, and even slight anterior

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translation can drive this insertion into the posterior glenoid, damaging the posterior labrum with repeated episodes. On examination, pain posteriorly in this position indicates this pathologic condition. Posterior pain in the older athlete could represent degenerative joint disease, which may be seen radiographically. Crepitation, stiffness, and atrophy may exist, though cuff strength and integrity is usually preserved. Pain caused by scapular grinding presents posteriorly, and palpable crepitation makes this an easy diagnosis. Superior shoulder pain that radiates along the trapezius and down the arm to the hand suggests a cervical origin. Spurling's test may contribute to an accurate diagnosis, although hand weakness, dermatomal sensory loss, and diminished reflexes may be the most specific objective findings. An athlete with cervical radiculitis typically displays some degree of neck stiffness. A tender AC joint combined with pain on flexion and adduction of the humerus is consistent with AC joint arthritis, although distal clavicle osteolysis presents with the same type of symptoms. Radiographs are needed to differentiate these lesions. SUMMARY

Shoulder injuries are common problems in all types of sports. There can be a good deal of variability in how symptoms are expressed from individual to individual, and part of the challenge in understanding the injury is being able to interpret the athlete's complaints as they relate to examination findings and the conditions that produce the symptoms. The history is particularly important because the sensitivity and specificity of many aspects of the examination are variable. A relaxed patient and a systematic evaluation is the best way to be thorough. Radiographs and even MRIs are frequently negative in soft tissue problems in the young athlete. This underscores the importance of a good examination. There may be some utility in using contrast-enhanced MIUS to look at labral pathologic conditions, cysts, or ganglions, but this information is certainly less useful than the patient's description of symptoms and the examiner's findings. With this awareness, we can manage these injuries with more confidence.

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