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Taping, Padding, and Bracing for the Shoulder Complex
CHAPTER 59 Taping, Padding, and Bracing
for the Shoulder Complex Jeff G. Konin, Thomas J. Kuster III, and Mark D. Miller
HISTORY OF PROTECTIVE EQUIPMENT
schools where coaches, managers, and student assistants are responsible for adequately fitting equipment, although they might not have the proper training, knowledge, and techniques for this task. A qualified professional must fit any type of preventive equipment and each athlete must be fitted individually.
Protective equipment, taping, padding, and bracing are commonly performed treatment adjuncts for the sports medicine professional. The lack of documentation makes it unclear when protective equipment was first used. As described by Plutarch, it is believed that protective equipment was first used in ancient times when Termerus destroyed his enemies by running into them head first. The first use of adhesive substances as external devices can be dated back to ancient times as well. The Greeks have been credited with formulating a healing paste composed of lead oxide, olive oil, and water, which was used for many different skin conditions.1
Protective equipment can be manufactured commercially or it can be fabricated on the spot by the fitter. Regardless of the nature of production, five basic concepts should be addressed with each piece of material or equipment:2 • Does the equipment protect the area of concern appropriately? • Can the athlete perform the skills required for his or her sport and position while wearing the device? • Will the device maintain a proper anatomic position? • Is the device potentially hazardous or injurious to other participants? • Is the device legal by the rules and regulations of the athlete’s particular sport?
Today, the difficulty lies not in finding protective equipment or padding but instead in choosing an appropriate, costeffective device that is appropriate to a specific function and protects an athlete from injury. Manufacturers have progressed in technology, and variously designed forms of athletic tapes, pads, and equipment are commercially available. Many organizations and committees have also been formed to provide rules for the use and conditions of these products.
Fitting Football Shoulder Pads Shoulder pads provide four main functions: absorb shock, protect the shoulders, protect the chest, and fit the midcervical spine to the trunk.3-7
PURPOSE OF PROTECTIVE EQUIPMENT
Proper fit to the chest is important in distributing the shock to the shoulders evenly. Better shoulder protection should allow one to de-emphasize the use of the head as a blocking and tackling instrument. Improperly fitted equipment can cause injury or increase the severity of an injury. Those who fit the shoulder pads must be extremely knowledgeable about fitting techniques.
The primary purpose of protective equipment and padding is to disperse and absorb forces of a blow by spreading them over a larger area than the initial point of contact, thus reducing the number and severity of injuries. For many sports, particularly those involving high levels of contact (e.g., football, lacrosse, ice hockey), protective equipment is part of the uniform. The idea behind this concept is to protect body parts prone to repeated blows or traumatic contact by the nature of the sport.
There are two basic types of shoulder pads: flat pads and cantilever pads (Fig. 59-1).5 Quarterbacks and receivers use flat pads because they allow greater glenohumeral motion. The cantilever pads are named for the bridge that extends over the superior portion of the shoulder and are worn by players who are in constant contact. There are two components of cantilever pads, the inside and the outside. The inside cantilever is more common, but the outside cantilever provides more protection with a larger blocking surface, and thus are used by linemen. Some pads are specifically designed with larger anterior surfaces that are
PREVENTIVE AND PROTECTIVE EQUIPMENT Injuries can be caused not only by inadequate protection from equipment but also by improper fitting of the equipment. An example of this takes place at many secondary 805
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Figure 59-1. Two types of shoulder pads: flat (A) and cantilever (B).
A
slanted slightly forward for players who receive blows in a standing position. In some cases, anthropometric calipers may be used to help properly fit shoulder pads. With this device, a measurement is taken from the edge of the shoulder across to the opposite shoulder. A similar measurement is then made on the undersurface of the pad and etched on the anterior surface of the pad. These measurements are then used to derive a correct size. Calipers are primarily used to speed the process of fitting. However, all principles of fitting should still be followed for a complete and proper fit. When applying shoulder pads for a fitting evaluation, the following points should be addressed:1,3,4 • The tip of the shoulder pad should fit just to the lateral edge of the shoulder • The neck opening should be large enough for a player to extend the arm overhead without impinging the neck and not allowing any excessive sliding about the shoulder. Neck openings that are too small can compress the cervical or deltoid regions. Pads with excessively large neck openings can cause cervical or acromioclavicular injuries. • Elastic straps holding the pads to the chest and back must be tight yet comfortable, allowing equal distribution of forces. • The flaps (epaulets) on the lateral aspects of the pads should completely cover the deltoid region. Additional epaulets may be attached to cover the deltoids adequately. • The anterior portion of the pads must adequately cover the sternum and clavicle and the posterior aspect of the pads must completely cover the scapulae. In addition to the two standard types of shoulder pads for football players, there are a few commercially manufactured devices that further protect specific areas of the shoulder complex and surrounding areas (discussed later). There are also differently designed forms of shoulder girdle protection for those playing men’s lacrosse and ice hockey. Because these sports have a high contact and collision
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B
component, men’s lacrosse and ice hockey shoulder pads are designed similar to football pads. Men’s football, ice hockey, and lacrosse pads are all designed to provide chest protection and glenohumeral protection while allowing a functional range of motion. Ice hockey pads protect against high collision forces, much like football pads. In men’s lacrosse, it has been demonstrated that a high percentage of acromioclavicular joint dislocations and clavicular fractures occur in attackmen who are struck in the clavicular region by defensemen.8 As a result, lacrosse shoulder pads allow greater protection of the clavicular region with highdensity polyethylene covering the clavicle and acromioclavicular joint.
Maintenance of Equipment All equipment should be inspected with documentation at the beginning and end of each season. Equipment should be constantly observed for damaged parts such as cracks, missing or loose rivets, and nonelastic or fraying straps. All defective equipment should be properly repaired by the manufacturer. Taking time to inspect and recondition faulty equipment adequately is significantly worthwhile because it allows the equipment to provide optimal protection.
Roles and Relationships with the Equipment Manager With organized sports, someone is often designated to oversee equipment. In the high school, college, university, and professional settings, this person is referred to as an equipment manager. The training and experience of an equipment manager vary widely throughout settings. In a high school setting, it is not uncommon to see coaches or parents serve as equipment managers. The same holds true in many recreational sports leagues. So long as the person responsible for ensuring that the equipment is properly maintained and meets current safety standards is competent, then equipment can be properly fitted and used. Otherwise, risk of injury and potential liability issues can arise.
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Many colleges, universities, and professional teams employ full-time equipment managers who receive formal training. The American Equipment Managers’ Association (AEMA) is the national governing body for equipment managers.9 The purpose of the AEMA is to promote, advance, and improve the equipment managers’ profession in all of its many aspects. This includes improving equipment for the greater safety of all participants in sports and recreation. In 1991, the AEMA initiated a certification program. The educational focus was targeted toward the five major domains equipment managers identified routinely in their jobs: purchasing (17.6%), fitting (22.2%), maintenance and repair (23.4%), management (17.6%), and accountability (19.2%). It is important to have a good relationship with the equipment manager. Communication between the clinician and the equipment manager can ensure the safest care to an athlete at all times. Appropriate modifications can be made to standard equipment to accommodate an athlete who might not otherwise be able to participate in a sporting event due to injury.
TAPING Taping of the shoulder can be a valuable adjunct to properly supervised therapeutic exercise for an injury. Taping is a skill that one can master only with extensive practice. Although at present there is minimal research on the effectiveness of taping the shoulder complex, some important functions of tape have been reported in the literature. These functions include increasing joint stability, limiting joint range of motion, improving kinesthetic awareness, stabilizing compressive-type bandages or padding, and preventing further insult to injury.1,4
Taping Materials Elastic Tape Elastic tape comes in many forms; some common brands are Conform (Bike), Elastikon (Johnson & Johnson), Lightplast (Beiersdorf), and Coban (3M). Elastic tape is made to stretch, so it is highly conforming to the affected area. Elastic tape should to be used when attempting to provide a gentle compressive force on tissues. For the shoulder complex, a rugged yet conforming tape should be used. Elastic tapes can be used to secure protective padding around the areas of the shoulder to which adhesive tape do not conform well. Adhesive Tape The primary use for adhesive (linen) tape is to prevent excessive motion of the joints and to aid in the stability of the functioning ligaments. This type of tape is much
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stronger than elastic tape and is better able to withstand vigorous athletic competition. Like most other types of tape, adhesive tape comes in many colors, sizes, and strengths. Tape width can vary from 0.5 to 3 inches. The most commonly used adhesive tape in athletic training is the cloth-backed variety, which comes in tubes or speed packs. Speed packs are wound more loosely than tubes and can be damaged more easily. Three factors should be considered when purchasing adhesive tape: tape grade, adhesive mass, and winding tension. The strength of linen or cloth-backed tape is graded by the number of longitudinal and vertical threads per inch. A stronger grade of tape backing contains in excess of 85 longitudinal fibers and 65 vertical fibers. In comparison, weaker cloth-backed tape contains 65 longitudinal and 45 vertical fibers or less per inch. Tape grade is always considered in the manufacturer’s expenses.3 Adhesive mass is simply the tape’s ability to adhere to skin surface despite circumstances such as perspiration and physical activity. It is important that the materials composing this mass contain as few irritants as possible and do not damage superficial layers of skin on removal. One of the most important concepts often overlooked when purchasing adhesive tape is the winding tension of each brand. Adhesive tape must contain an even and constant unwinding tension. All principles of taping applications to joints encompass anatomy, biomechanics, and tensile strength of the supporting structures. These techniques are designed with the simple fact that external supportive structures such as tape are of equal tension throughout, therefore not altering any mechanical characteristics of application. Leukotape is a form of hypoallergenic adhesive tape designed to assist with postural deviations by facilitating realignment of structures. This type of tape comes in a number of forms classified by its various label names and is reported to have an elasticity of 130% to 140% of its original length. It is often developed with a rayon backing and a zinc oxide adhesive component, yielding a high tensile strength. Common areas of the shoulder complex where Leukotape is used for treatment include the scapulothoracic, acromioclavicular, and glenohumeral joints. Leukotape is not applied directly to the skin, but rather is placed over another form of tape referred to as CoverRoll Stretch, designed to enhance localized adherence of the taping technique for longer-lasting postural changes.
Principles of Taping A complete taping application for any structure involving the shoulder complex should be effective and comfortable while affording consistent, compressive tension.
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The most important aspect of taping is to have a thorough understanding of why a certain technique is being used based on the anatomy and biomechanics of the involved structure. As with taping of any joint, the athlete should be in a comfortable position, and the shoulder should be easily accessible for taping. As long as the athlete has no open wounds, the area may be cleansed and prepared with a skin adherent. If the adherent or tape causes skin irritation, an underwrap may be used before applying the tape. This is usually made of a thin, porous, polyurethane foam. However, the effectiveness of the supporting tape is maximized when applied directly to the skin. All tape should be applied when the skin is at normal body temperature, and any excess body hair should be shaved. Just as important as applying tape correctly is the art of removing tape. Tape can be removed with the aid of bandage scissors (sharks) or by manual methods and should always be pulled off from the skin in a linear fashion. This is performed in a slow, controlled manner. After the tape is removed, the skin should be cleansed with soap and water to rid the surface of tape residue. A moisturizing cream or antibiotic ointment may then be applied to prevent skin abrasions. The area to be taped should be adequately prepared and positioned for easy access. Always observe the skin before application and after removal of tape for any irritations. Only apply tape and adhesive products when the area of concern is at normal skin temperature. The effectiveness of any taping application lies in the understanding of why it is being performed and the art of its completeness. Tape should be applied by following the natural contours of the athlete’s anatomy. The tension of application should be performed in a smooth, equal, and firm manner. Each athlete is taped individually according to his or her anatomy, and each strip of tape must be individualized to the anatomic location. Continuous strips of tape may be constricting and lead to circulatory problems. Each strip of tape applied in sequence should overlap the previous strip by one half. Follow each strip of tape by smoothing it down, being careful to avoid any wrinkles or gaps. Removal of tape should be slow and controlled, being careful not to damage superficial layers of the skin.
PROTECTIVE PADDING MATERIALS The athletic trainer must be skilled at recognizing the indications for using protective padding and must also be aware of the types of materials available. Pads absorb
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shock through closed-cell foam or water cells or through a semiliquid high-viscosity material. Materials can also be combined for functional purposes. For example, a pad can be fabricated with a rigid outer layer and a softer inner layer.
Rigid Materials Many rigid materials are used to fabricate custom padding. Often, a plastic material is used because of its chemical composition and reaction to heat. Three common types are thermoforming plastics, thermosetting plastics, and thermoplastic foams.3 The most popular plastics in athletic training are thermoforming. This plastic can be molded to the body part when heated to between 140° and 180° F. The most common brands are Orthoplast (synthetic rubber thermoplast) and Aquaplast (a polyester sheet). A more rigid and difficult to form plastic is the thermosetting type. This is usually formed from a mold rather than being formed directly on the body part. Thermosetting plastics require higher temperatures to alter the material for fabrication. Examples of this type of plastic are polyvinyl chloride (high-impact vinyl), polyvinyl chloride acrylic (Kydex), and thermoplaster acrylic (Myoplex). Plastics containing additional liquids and gases, or crystals that alter their density, are called thermoplastic foams. Polyethylene foams such as alloplast and Plastazote are two of the most common types. Other products often used as rigid outer layers of padding are Lighcast (Merck Sharpe Dohne, West Point, Penn), Hexalite (Hexcel, Dublin, Calif), and RTV-11 (Genulastic Silicone Products, Waterford, NY). Prefabricated rigid pads can be used to protect the shoulder. Cramer produces OSi protective padding. This is a precut, customized, lightweight, and breathable low-profile pad that can be custom molded to specific body parts such as the acromioclavicular joint and deltoid. To activate the curing process one wets the pad with water at any temperature and applies the pad to the body part. Within five minutes the pad becomes firm and is molded and conformed to the body part. These pads are NCAA compliant to standards for rigid protective devices. The Impact AC (acromioclavicular) pad (Fig. 59-2) uses a dome design that when applied rests over (not on) the injured area, allowing greater dispersion of force. This padding is easily moldable by immersion in a hydrocollator and is secured to the athlete with hook-and-loop tape straps.
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aids in the dispersion of forces. It is heat sensitive, so it responds to the body heat of the athlete as it molds to the contours of the body.
PROTECTING AND PADDING JOINTS IN THE SHOUDLER Protection of the Acromioclavicular Joint In many contact sports such as football, lacrosse, and ice hockey, the acromioclavicular joint is susceptible to frequent injury.8 Athletes with acromioclavicular joint sprains can return to competition with satisfactory functional testing and with the approval of the team physician. However, adequate protection should be provided to the acromioclavicular joint to prevent further injury.
Figure 59-2. Impact AC (acromioclavicular) prefabricated pad.
Soft Materials Soft materials are equally important for preventive measures. These can vary in shape and size and are easy to mold to the contours of the body. Foam rubber is particularly effective because of its variety of thicknesses. It protects the body area from force and is resilient and nonabsorbent. Ther-o-foam (Cramer Products, Gardner, Kan) and Ensolite (Whiroyal, Mishawka, Ind) are two of the most common types of foam used today. Felt is another popular soft material. Felt produces a firmer pressure than most foam rubbers because of its comfortable, semi-resilient surface. This type of material is composed of matted wool fibers pressed into varying degrees of thickness. Felt can absorb perspiration and therefore must be replaced daily to allow it to be fully effective. However, its ability to absorb moisture allows it to keep better skin contact, thus decreasing the tendency of the pad to migrate. Other soft materials such as adhesive felt (moleskin), gauze, cotton, and lamb’s wool can also be used as adjuncts to protective devices. Viscoelastic polyurethane foam (memory foam) is a relatively new type of foam available to the clinician and comes with either an adhesive or nonadhesive backing. It has great shock-absorbing properties and is moldable and conformable. It is available in soft, medium, or firm density. This open-cell foam recovers its shape slowly, which
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One form of protection is by using a foam pad insert called a shoulder injury pad or a spider pad (Adams Plastics, Cookeville, Tenn) (Fig. 59-3). This type of pad is lightweight yet directs the attention of a blow to the acromioclavicular joint toward the elevated foam pad.10 This is commercially available and should be properly fitted to the individual athlete. A specialized pad for the acromioclavicular joint can also be made.10-12 This is done to provide a more custom fit for the athlete. Many types of material have been recommended for construction of the pad. The pad basically takes on an elevated donut or dome shape with a rigid outer shell and a softer inner padding. The rigid material is molded to the athlete’s acromioclavicular joint region. When doing this, a dome of 1.5 inches should be constructed, so the acromioclavicular joint itself is not directly in contact with the pad (Fig. 59-4). A softer material made of foam is then used as a dispersive medium between the athlete’s shoulder and the rigid dome. This pad can be held in place by taping it to the skin with adhesive tape, by creating a strap or belt system, or by using an elastic bandage and applying a spica-type wrap to the shoulder. The key to making a successful acromioclavicular pad is to make sure that the pad is raised off the injured area to distribute the force of a blow around that area, allowing the force to be absorbed by the pad itself.
Taping the Acromioclavicular Joint Taping of the acromioclavicular joint has been used for first- or second-degree sprains, because it can provide some external support while not limiting the athlete’s range of motion. The area of involvement should be cleansed and shaved to allow good contact surfaces. The nipple can be protected with an adhesive bandage or a small piece of felt or gauze. Initially, two anchors are applied. The first is
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A
B
Figure 59-3. Spider pad. A, Side view. B, Anterior view.
More support strips are applied in a diagonally from the arm to the shoulder anchors. These strips are applied in a fanning pattern, both anterior to posterior and posterior to anterior (see Fig. 59-5C). Anchor strips can then be applied from the chest to the back, attaching to the initial anchor. These should be overlapped halfway, allowing a more stable support (see Fig. 59-5D). Strips are then applied completely around the chest and arm to close off the taping procedure (see Fig. 59-5E and F).12
Protecting the Sternoclavicular Joint Although the sternoclavicular joint can be injured in numerous sporting activities, mostly from the result of a direct force, it can actually be protected quite well following an injury through the use of assistive protective devices. Injuries to the sternoclavicular joint involve either an anterior or posterior subluxation or dislocation to the medial end of the clavicle as it displaces from the stable sternum.
Figure 59-4. Custom acromioclavicular pad.
placed from the chest at its midline, over the shoulder to the back, and ending just below the tip of the scapula. A second anchor is applied from the anterior to the posterior aspect of the thorax (Fig. 59-5A). A series of nonelastic support strips are then placed upward from the arm to the anchor strips on the shoulder (see Fig. 59-5B).
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Historically, athletes with sternoclavicular joint sprains have been withheld from physical participation when contact is involved until the area is stable enough to reduce the risk of recurrence. With return to participation, it is a good idea to provide a protective covering in the form of a shell made of thermoplastic materials (Fig. 59-6). The shell appears much more effective in preventing against posterior sternoclavicular instability because the mechanism for that type of injury would be a direct blow to the medial end of the sternum or
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A
C
E
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D
F
Figure 59-5. Taping the acromioclavicular joint. A, Anchor strips. B, Fan is applied. C, Fan is reinforced. D, Anterior/posterior anchors applied. E, Transverse anchors applied. F, Completed procedure.
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Protecting the Glenohumeral Joint By nature of its anatomic design and the forces applied to it during athletic activity, the glenohumeral joint is susceptible to numerous conditions. Most notable of these are contusions and glenohumeral instability issues.
Figure 59-6. Sternoclavicular pad.
forceful horizontal adduction of the humerus, of which the latter is not as often seen. When using a shell to protect against further sternoclavicular joint injuries, it is important to maintain adequate functional mobility and not compromise movements necessary for participation. Such compromise can lead to additional injuries and create a vulnerable situation in general with respect to the ability to protect oneself from further damage to the preexisting injury. Athletes who return to participation with a shell to protect the sternoclavicular joint should do so after a careful screening of abilities and potential vulnerability considerations, always under the final clearance of a physician.
Figure 59-7. A, Donut-shaped pad to protect the lateral aspect of the humerus from direct forces. B, Close-up view.
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Contusions Direct blows to the glenohumeral joint are common in contact sports. Complications such as tackler’s exostosis and myositis ossificans can be prevented with proper protection to the glenohumeral region.1,13 Often, the area of concern is just distal to the glenohumeral joint, near the insertion of the deltoid muscle and the origin of the brachialis muscle. This is an area that might not be adequately protected with football shoulder pads. Protective donut-shaped pads can be designed to cover the lateral humerus in a manner similar to those for contusion of the acromioclavicular joint (Fig. 59-7). Anterior Instability One of the most difficult challenges that a medical team faces is how to adequately prevent an athlete from recurrent anterior instability of the glenohumeral joint. Because of the complexity of the capsuloligamentous structures, there is no true device or taping procedure guaranteed to protect the unstable shoulder. Because the mechanism of injury for anterior subluxation or dislocation is external rotation and abduction of the shoulder, braces have been designed to limit these motions while allowing an athlete to return to competition.14 However, an athlete who must compete by bringing his or her shoulder into external rotation and abduction is a viable candidate for a reinjury regardless of the type of brace being worn. Many sports,
B
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such as skiing, are somewhat style conscious, and the likelihood of gaining acceptance for any type of brace may be impractical.15 Many different types of shoulder braces have been designed to prevent recurrent episodes of anterior subluxation and dislocation. The Shoulder Subluxation Inhibitor (SSI, Physical Support Systems, Inc, Windham, NH) (Fig. 59-8) is custom-fitted and made of low- and high-density polyethylene.16 It is designed with a hyperextension strap used to restrict excessive external rotation about the shoulder (Fig. 59-9). The C.D. Denison–Duke Wyre Shoulder Vest (C.D. Denison Orthopaedic Appliance Co, Baltimore, Md) (see Fig. 59-9) is constructed of sturdy canvas and is chrome leather stitched with nylon.17 This harness contains a biceps cuff, with a lacer attachment to the chest vest used to limit abduction and extension of the shoulder. Also, laces can be threaded to limit horizontal adduction and shoulder elevation. The Sawa Shoulder Orthosis (BRACE International, Scottsdale, Ariz) is an off-the-shelf brace made of a hypoallergenic blend of cotton and rubber material.18 It is reinforced for strength, shape, and form with hookand-loop tape front closures and fasteners. A glenohumeral hook-and-loop strap attached to the humeral cuff limits adduction, abduction, flexion, and extension. (Fig. 59-10).
Figure 59-9. C.D. Denison–Duke Wyre shoulder brace.
Newer braces include the Sully Shoulder Stabilizer, the Cadlow Shoulder Stabilizer, the Simply Stable Shoulder Stabilizer, the MAX Brace, and the Donjoy Shoulder Brace (Fig. 59-11). The Sully Shoulder Stabilizer provides support while allowing some restricted range of motion. Elastic straps attach with hook-and-loop tape to a neoprene vest at any point, in any direction, and with varied
Figure 59-10. Sawa shoulder orthosis.
Figure 59-8. Shoulder subluxation inhibitor.
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amounts of force to allow the clinician to selectively and functionally stabilize or restrict movement according to each patient’s needs. The Cadlow is a unique brace that uses a pull system of elastic tubes to provide glenohumeral stability while allowing a full range of motion. In addition, the tubes have graduated resistance that allows the athlete to strengthen the shoulder. The Simply Stable Shoulder Stabilizer is designed for simplicity and ease of use. It consists of an elastic strap that attaches directly to the shoulder pads and encircles the humeral head, restricting the motions of abduction and external rotation. For athletes
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Figure 59-12. Simply Stable Shoulder Stabilizer. Figure 59-11. The Donjoy shoulder brace.
not involved with football, there is a harness that can be attached to the humeral strap (Fig. 59-12). The MAX Brace facilitates and controls glenohumeral range of motion and can also be used to support acromioclavicular separations. Studies have shown minimal effects on shoulder positioning sense and glenohumeral joint active and passive range of motion using a variety of shoulder braces.19-21 The ultimate preventive brace for recurrent anterior instability is one that would allow enough motion for the athlete to be as functional as possible in his or her particular sport, yet provide restricted support to stabilize the glenohumeral joint. Because no surgery or rehabilitative protocol can ever replace the original anatomic and biomechanical functions of the shoulder, more research is needed to help create an individualized shoulder restrictor that is lightweight, comfortable, functional, and effective.
Postoperative Shoulder-Bracing Options There are basically four different options for postoperative bracing. The simplest and most useful brace for most procedures is a sling (Fig. 59-13). This affords the patient some protection but also can be easily removed for early postoperative range of motion. Most surgeons allow early passive motion after most procedures, and this can easily be done with a sling. If additional protection is desired, a shoulder immobilizer can be used. This holds the shoulder in a position similar to a sling, but it is more stable. For open posterior capsulorraphy procedures, a gunslinger type brace may be necessary. This brace puts less strain on the posterior capsule in the early postoperative period.
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Figure 59-13. Shoulder sling.
The shoulder is positioned in slight abduction, external rotation, and flexion. Typically, these braces are used for 4 to 6 weeks, and shoulder motion is discouraged. Elbow motion can be allowed by removing the forearm from the brace. With the advent of arthroscopic procedures, many surgeons are electing not to routinely use these braces.
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A variation of the traditional gunslinger brace is an external rotation brace that uses a soft wedge to hold the arm in external rotation. These braces may be useful in the acute management of anterior shoulder instability.
Calleghan reported taping techniques to inhibit trapezius tone when there is a hitching associated with rotator cuff pathology resulting in a decreased humeral inferior glide.25
The final commonly used postoperative brace is an abduction brace. This is a popular soft wedge-type brace. These braces have traditionally been used following rotator cuff repair. Recently, however, their use has been discouraged, because surgeons have recognized that if the cuff can not be repaired without tension in adduction, then the repair is unlikely to be successful.
Not all studies measuring the effects of scapular taping have shown beneficial results. Cools and colleagues looked at taping techniques for the trapezius and serratus anterior muscles during dynamic full range of motion abduction and forward flexion and found no significant influence of tape application on electromyographic activity in healthy subjects.26 As with all other treatment interventions, scapular taping may play an assistive role with certain populations of athletes while not necessarily being as beneficial for others. It is up to the clinician to identify the athletes who can benefit from scapular taping procedures.
There are many factors to consider when prescribing a postoperative brace. These include tissue quality, surgical technique, patient compliance, and goals. Close cooperation and communication among the surgeon, clinician, and patient allow team approach and successful postoperative management.
Taping for Rehabilitative Purposes Studies have shown using Kinesiotape can be effective in assisting with rehabilitation programs. In 2005, Keirns and colleagues demonstrated effective treatment interventions for recruiting suprascapular and infrascapular muscle firing using scapular taping techniques.22 Effects were optimal during forward reaching motion below the horizontal plane (Fig. 59-14). Others have identified scapular taping as an effective measure to treat anterior shoulder impingement when returning athletes to overhead sports activities.23 Methods of scapular taping have even been shown to be effective with performing artists. Ackermann and colleagues identified a 49% increase in electromyographic activity of the left trapezius muscle in professional violinists with the intervention of scapular taping.24
LEGAL AND ETHICAL CONSIDERATIONS A substantial amount of controversy exists regarding the effectiveness of external devices used to protect the athlete’s shoulder. When considering the use of any protective equipment, one should always be aware of the concerns in the specific sport and any ethical ramifications that may arise in regard to the design and application of the equipment itself. Liability is defined as the legal responsibility of a person in a certain situation to do a particular task in a reasonable and prudent manner.3 Failure to perform such action in a reasonable and prudent manner can make the person legally liable for the results of that action. The courts can hold the person negligent when it is shown that the person has done something that a reasonable and prudent person would not do.3 More specifically, knowingly using dangerous or faulty equipment is a type of negligence that an athletic trainer, therapist, coach, or team physician can be held accountable for should an accident result. All athletes and medical personnel should be aware that no single piece of equipment can be 100% reliable in terms of injury or reinjury. The statement that a piece of equipment can treat or prevent a certain injury should be completely avoided in all discussion. The implication of such a statement can lead to implied liability should an injury occur in this situation.
Figure 59-14. Using tape to assist in the rehabilitation of scapular muscles.
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Special care is required with any device made by the medical staff. No piece of equipment should predispose an athlete to further injury. Of primary concern are devices constructed to limit an athlete’s range of motion. The following is a list of suggestions to help maintain safety parameters with the use of protective equipment.3
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• Maintain accurate records of each athlete’s injuries, both present and past. • Establish qualified and adequate supervision of all equipment. • Properly instruct the medical staff, the coaches, the equipment managers, and the athletes themselves on correct procedures for equipment fitting. • Thoroughly inspect equipment on a regular basis, looking for faulty or hazardous parts. • Inform all athletes that no piece of equipment is 100% able to prevent injury. • Use sound, logical judgment when applying any type of external device. • Have a thorough understanding of the rules of the sport your athlete is participating in. It is the ultimate responsibility of the medical staff to ensure that every athlete is treated in a reasonable and prudent manner. Any person deviating from this principle is subject to ethical and legal complications.
SUMMARY The complexity of the shoulder joint has caused many of us to use different methods of prevention and protection through the use of external protective devices. Taping, padding, and bracing of the shoulder complex have become skills in which all of us involved in sports medicine are attempting to become more proficient. An external protective device will never replace a thorough rehabilitation program, nor will it restore normal biomechanics of the injured shoulder. However, performed within the guidelines of one’s qualifications and legal considerations, external protective devices for the shoulder can be a valuable adjunct for returning an athlete to competition.
References 1. Kuland D: The Injured Athlete. Philadelphia, JB Lippincott, 1988. 2. Miller R: Protective Padding. Presented at the NATA National Convention and Symposium, Columbus, Ohio, June 1987. 3. Arnheim DD: Modern Principles of Athletic Training. St Louis, Mosby, 1985. 4. Fahey TD: Athletic Training: Principles and Practice. Palo Alto, Calif, Mayfield Publishing, 1986. 5. Gieck J, McCue FC III: Fitting of protective football equipment. Am J Sports Med 8(3):192-196, 1980. 6. Malacrea R: Protective equipment fit. Proceedings of the NATA Professional Preparation Conference. Nashville, NATA Professional Education Committee, 1978. 7. Watkins RG: Neck injuries in football players. Clin Sports Med 5(2):215-246, 1986.
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8. Silloway KA, McLaughlin RE, Edlich RC, Edlich RF: Clavicular fractures and acromioclavicular joint dislocations in lacrosse: Preventable injuries. J Emerg Med 3(2):117-121, 1985. 9. Athletic Equipment Managers’ Association: Home page. Available at http://www.aema1.com/ (accessed March 26, 2008). 10. Biron SA: Acromioclavicular protection of ice hockey players. Athletic Training 18:103, 1983. 11. Deutch B, Fashour T: MA, Fashover T: Football hip pad protection for hip pointers and AC sprains on ice hockey players. Athletic Training 16:2-00, 1981. 12. Wershing CE: A specialized pad for the acromioclavicular joint. Athletic Training 15:102-103, 1980. 13. Booher JM, Thibodeau GA: Athletic Injury Assessment. St Louis, Mosby, 1985. 14. Rovere GD, Curl WW, Brownig DG: Bracing and taping in an office sports medicine practice. Clin Sports Med 8(3):497-515, 1989. 15. Weaver JK: Skiing-related injuries to the shoulder. Clin Orthop Relat Res (216):24-28, 1987. 16. Physical Supports Systems: Shoulder subluxation inhibitor (information packet). Windham, NH, Physical Supports Systems, Inc, 1989. 17. Denison Orthopedic Appliance Corp: CD Denison-Duke Wyre Shoulder Vest (information packet). Baltimore, CD Denison Orthopedic Appliance Corp, 2005. 18. Brace International: Sawa shoulder orthosis (information packet). Scottsdale, Ariz, Brace International, 2005. 19. Chu JC, Kane EJ, Arnold BL, Gansneder BM: The effect of a neoprene shoulder stabilizer on active joint-reposition sense in subjects with stable and unstable shoulders. J Ath Train 37(2):141-145, 2002. 20. Ulkar B, Kunduracioglu B, Cetin C, Guner RS: Effect of positioning and bracing on passive position sense of shoulder joint. Br J Sports Med 38(5):549-552, 2004. 21. Weise K, Sitler MR, Tierney R, Swanik KA: Effectiveness of glenohumeral-joint stability braces in limiting active and passive shoulder range of motion in collegiate football players. J Ath Train 39(2):151-155, 2004. 22. Keirns MA, Taylor M, Bailey-Carter D: The effects of scapular taping on the suprascapular and infrascapular muscle recruitment in individuals with forward head/rounded shoulder posture [abstract]. Phys Ther, 2005. Available at http://www.apta.org/AM/abstracts/pt2005/abstractsPt. cfm?pubNo⫽PO-RR-107-TH (accessed March 26, 2008). 23. Host HH: Scapular taping in the treatment of anterior shoulder impingement. Phys Ther 75(9):803-812, 1995. 24. Ackermann B, Adams R, Marshall E: The effects of scapula taping on electromyographic activity and musical performance in professional violinists. Aust J Physiother 48(3):197-203, 2002. 25. Callaghan MJ: Role of taping and bracing in the athlete. Br J Sports Med 31(2):102-108, 1997. 26. Cools AM, Witvrouw EE, Danneels LA, Cambier DC: Does taping influence electromyographic muscle activity in the scapular rotators in healthy subjects? Man Ther 7(3):154-162, 2002.
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for the Shoulder Complex Jeff G. Konin, Thomas J. Kuster III, and Mark D. Miller
HISTORY OF PROTECTIVE EQUIPMENT
schools where coaches, managers, and student assistants are responsible for adequately fitting equipment, although they might not have the proper training, knowledge, and techniques for this task. A qualified professional must fit any type of preventive equipment and each athlete must be fitted individually.
Protective equipment, taping, padding, and bracing are commonly performed treatment adjuncts for the sports medicine professional. The lack of documentation makes it unclear when protective equipment was first used. As described by Plutarch, it is believed that protective equipment was first used in ancient times when Termerus destroyed his enemies by running into them head first. The first use of adhesive substances as external devices can be dated back to ancient times as well. The Greeks have been credited with formulating a healing paste composed of lead oxide, olive oil, and water, which was used for many different skin conditions.1
Protective equipment can be manufactured commercially or it can be fabricated on the spot by the fitter. Regardless of the nature of production, five basic concepts should be addressed with each piece of material or equipment:2 • Does the equipment protect the area of concern appropriately? • Can the athlete perform the skills required for his or her sport and position while wearing the device? • Will the device maintain a proper anatomic position? • Is the device potentially hazardous or injurious to other participants? • Is the device legal by the rules and regulations of the athlete’s particular sport?
Today, the difficulty lies not in finding protective equipment or padding but instead in choosing an appropriate, costeffective device that is appropriate to a specific function and protects an athlete from injury. Manufacturers have progressed in technology, and variously designed forms of athletic tapes, pads, and equipment are commercially available. Many organizations and committees have also been formed to provide rules for the use and conditions of these products.
Fitting Football Shoulder Pads Shoulder pads provide four main functions: absorb shock, protect the shoulders, protect the chest, and fit the midcervical spine to the trunk.3-7
PURPOSE OF PROTECTIVE EQUIPMENT
Proper fit to the chest is important in distributing the shock to the shoulders evenly. Better shoulder protection should allow one to de-emphasize the use of the head as a blocking and tackling instrument. Improperly fitted equipment can cause injury or increase the severity of an injury. Those who fit the shoulder pads must be extremely knowledgeable about fitting techniques.
The primary purpose of protective equipment and padding is to disperse and absorb forces of a blow by spreading them over a larger area than the initial point of contact, thus reducing the number and severity of injuries. For many sports, particularly those involving high levels of contact (e.g., football, lacrosse, ice hockey), protective equipment is part of the uniform. The idea behind this concept is to protect body parts prone to repeated blows or traumatic contact by the nature of the sport.
There are two basic types of shoulder pads: flat pads and cantilever pads (Fig. 59-1).5 Quarterbacks and receivers use flat pads because they allow greater glenohumeral motion. The cantilever pads are named for the bridge that extends over the superior portion of the shoulder and are worn by players who are in constant contact. There are two components of cantilever pads, the inside and the outside. The inside cantilever is more common, but the outside cantilever provides more protection with a larger blocking surface, and thus are used by linemen. Some pads are specifically designed with larger anterior surfaces that are
PREVENTIVE AND PROTECTIVE EQUIPMENT Injuries can be caused not only by inadequate protection from equipment but also by improper fitting of the equipment. An example of this takes place at many secondary 805
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Figure 59-1. Two types of shoulder pads: flat (A) and cantilever (B).
A
slanted slightly forward for players who receive blows in a standing position. In some cases, anthropometric calipers may be used to help properly fit shoulder pads. With this device, a measurement is taken from the edge of the shoulder across to the opposite shoulder. A similar measurement is then made on the undersurface of the pad and etched on the anterior surface of the pad. These measurements are then used to derive a correct size. Calipers are primarily used to speed the process of fitting. However, all principles of fitting should still be followed for a complete and proper fit. When applying shoulder pads for a fitting evaluation, the following points should be addressed:1,3,4 • The tip of the shoulder pad should fit just to the lateral edge of the shoulder • The neck opening should be large enough for a player to extend the arm overhead without impinging the neck and not allowing any excessive sliding about the shoulder. Neck openings that are too small can compress the cervical or deltoid regions. Pads with excessively large neck openings can cause cervical or acromioclavicular injuries. • Elastic straps holding the pads to the chest and back must be tight yet comfortable, allowing equal distribution of forces. • The flaps (epaulets) on the lateral aspects of the pads should completely cover the deltoid region. Additional epaulets may be attached to cover the deltoids adequately. • The anterior portion of the pads must adequately cover the sternum and clavicle and the posterior aspect of the pads must completely cover the scapulae. In addition to the two standard types of shoulder pads for football players, there are a few commercially manufactured devices that further protect specific areas of the shoulder complex and surrounding areas (discussed later). There are also differently designed forms of shoulder girdle protection for those playing men’s lacrosse and ice hockey. Because these sports have a high contact and collision
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B
component, men’s lacrosse and ice hockey shoulder pads are designed similar to football pads. Men’s football, ice hockey, and lacrosse pads are all designed to provide chest protection and glenohumeral protection while allowing a functional range of motion. Ice hockey pads protect against high collision forces, much like football pads. In men’s lacrosse, it has been demonstrated that a high percentage of acromioclavicular joint dislocations and clavicular fractures occur in attackmen who are struck in the clavicular region by defensemen.8 As a result, lacrosse shoulder pads allow greater protection of the clavicular region with highdensity polyethylene covering the clavicle and acromioclavicular joint.
Maintenance of Equipment All equipment should be inspected with documentation at the beginning and end of each season. Equipment should be constantly observed for damaged parts such as cracks, missing or loose rivets, and nonelastic or fraying straps. All defective equipment should be properly repaired by the manufacturer. Taking time to inspect and recondition faulty equipment adequately is significantly worthwhile because it allows the equipment to provide optimal protection.
Roles and Relationships with the Equipment Manager With organized sports, someone is often designated to oversee equipment. In the high school, college, university, and professional settings, this person is referred to as an equipment manager. The training and experience of an equipment manager vary widely throughout settings. In a high school setting, it is not uncommon to see coaches or parents serve as equipment managers. The same holds true in many recreational sports leagues. So long as the person responsible for ensuring that the equipment is properly maintained and meets current safety standards is competent, then equipment can be properly fitted and used. Otherwise, risk of injury and potential liability issues can arise.
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Many colleges, universities, and professional teams employ full-time equipment managers who receive formal training. The American Equipment Managers’ Association (AEMA) is the national governing body for equipment managers.9 The purpose of the AEMA is to promote, advance, and improve the equipment managers’ profession in all of its many aspects. This includes improving equipment for the greater safety of all participants in sports and recreation. In 1991, the AEMA initiated a certification program. The educational focus was targeted toward the five major domains equipment managers identified routinely in their jobs: purchasing (17.6%), fitting (22.2%), maintenance and repair (23.4%), management (17.6%), and accountability (19.2%). It is important to have a good relationship with the equipment manager. Communication between the clinician and the equipment manager can ensure the safest care to an athlete at all times. Appropriate modifications can be made to standard equipment to accommodate an athlete who might not otherwise be able to participate in a sporting event due to injury.
TAPING Taping of the shoulder can be a valuable adjunct to properly supervised therapeutic exercise for an injury. Taping is a skill that one can master only with extensive practice. Although at present there is minimal research on the effectiveness of taping the shoulder complex, some important functions of tape have been reported in the literature. These functions include increasing joint stability, limiting joint range of motion, improving kinesthetic awareness, stabilizing compressive-type bandages or padding, and preventing further insult to injury.1,4
Taping Materials Elastic Tape Elastic tape comes in many forms; some common brands are Conform (Bike), Elastikon (Johnson & Johnson), Lightplast (Beiersdorf), and Coban (3M). Elastic tape is made to stretch, so it is highly conforming to the affected area. Elastic tape should to be used when attempting to provide a gentle compressive force on tissues. For the shoulder complex, a rugged yet conforming tape should be used. Elastic tapes can be used to secure protective padding around the areas of the shoulder to which adhesive tape do not conform well. Adhesive Tape The primary use for adhesive (linen) tape is to prevent excessive motion of the joints and to aid in the stability of the functioning ligaments. This type of tape is much
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stronger than elastic tape and is better able to withstand vigorous athletic competition. Like most other types of tape, adhesive tape comes in many colors, sizes, and strengths. Tape width can vary from 0.5 to 3 inches. The most commonly used adhesive tape in athletic training is the cloth-backed variety, which comes in tubes or speed packs. Speed packs are wound more loosely than tubes and can be damaged more easily. Three factors should be considered when purchasing adhesive tape: tape grade, adhesive mass, and winding tension. The strength of linen or cloth-backed tape is graded by the number of longitudinal and vertical threads per inch. A stronger grade of tape backing contains in excess of 85 longitudinal fibers and 65 vertical fibers. In comparison, weaker cloth-backed tape contains 65 longitudinal and 45 vertical fibers or less per inch. Tape grade is always considered in the manufacturer’s expenses.3 Adhesive mass is simply the tape’s ability to adhere to skin surface despite circumstances such as perspiration and physical activity. It is important that the materials composing this mass contain as few irritants as possible and do not damage superficial layers of skin on removal. One of the most important concepts often overlooked when purchasing adhesive tape is the winding tension of each brand. Adhesive tape must contain an even and constant unwinding tension. All principles of taping applications to joints encompass anatomy, biomechanics, and tensile strength of the supporting structures. These techniques are designed with the simple fact that external supportive structures such as tape are of equal tension throughout, therefore not altering any mechanical characteristics of application. Leukotape is a form of hypoallergenic adhesive tape designed to assist with postural deviations by facilitating realignment of structures. This type of tape comes in a number of forms classified by its various label names and is reported to have an elasticity of 130% to 140% of its original length. It is often developed with a rayon backing and a zinc oxide adhesive component, yielding a high tensile strength. Common areas of the shoulder complex where Leukotape is used for treatment include the scapulothoracic, acromioclavicular, and glenohumeral joints. Leukotape is not applied directly to the skin, but rather is placed over another form of tape referred to as CoverRoll Stretch, designed to enhance localized adherence of the taping technique for longer-lasting postural changes.
Principles of Taping A complete taping application for any structure involving the shoulder complex should be effective and comfortable while affording consistent, compressive tension.
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The most important aspect of taping is to have a thorough understanding of why a certain technique is being used based on the anatomy and biomechanics of the involved structure. As with taping of any joint, the athlete should be in a comfortable position, and the shoulder should be easily accessible for taping. As long as the athlete has no open wounds, the area may be cleansed and prepared with a skin adherent. If the adherent or tape causes skin irritation, an underwrap may be used before applying the tape. This is usually made of a thin, porous, polyurethane foam. However, the effectiveness of the supporting tape is maximized when applied directly to the skin. All tape should be applied when the skin is at normal body temperature, and any excess body hair should be shaved. Just as important as applying tape correctly is the art of removing tape. Tape can be removed with the aid of bandage scissors (sharks) or by manual methods and should always be pulled off from the skin in a linear fashion. This is performed in a slow, controlled manner. After the tape is removed, the skin should be cleansed with soap and water to rid the surface of tape residue. A moisturizing cream or antibiotic ointment may then be applied to prevent skin abrasions. The area to be taped should be adequately prepared and positioned for easy access. Always observe the skin before application and after removal of tape for any irritations. Only apply tape and adhesive products when the area of concern is at normal skin temperature. The effectiveness of any taping application lies in the understanding of why it is being performed and the art of its completeness. Tape should be applied by following the natural contours of the athlete’s anatomy. The tension of application should be performed in a smooth, equal, and firm manner. Each athlete is taped individually according to his or her anatomy, and each strip of tape must be individualized to the anatomic location. Continuous strips of tape may be constricting and lead to circulatory problems. Each strip of tape applied in sequence should overlap the previous strip by one half. Follow each strip of tape by smoothing it down, being careful to avoid any wrinkles or gaps. Removal of tape should be slow and controlled, being careful not to damage superficial layers of the skin.
PROTECTIVE PADDING MATERIALS The athletic trainer must be skilled at recognizing the indications for using protective padding and must also be aware of the types of materials available. Pads absorb
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shock through closed-cell foam or water cells or through a semiliquid high-viscosity material. Materials can also be combined for functional purposes. For example, a pad can be fabricated with a rigid outer layer and a softer inner layer.
Rigid Materials Many rigid materials are used to fabricate custom padding. Often, a plastic material is used because of its chemical composition and reaction to heat. Three common types are thermoforming plastics, thermosetting plastics, and thermoplastic foams.3 The most popular plastics in athletic training are thermoforming. This plastic can be molded to the body part when heated to between 140° and 180° F. The most common brands are Orthoplast (synthetic rubber thermoplast) and Aquaplast (a polyester sheet). A more rigid and difficult to form plastic is the thermosetting type. This is usually formed from a mold rather than being formed directly on the body part. Thermosetting plastics require higher temperatures to alter the material for fabrication. Examples of this type of plastic are polyvinyl chloride (high-impact vinyl), polyvinyl chloride acrylic (Kydex), and thermoplaster acrylic (Myoplex). Plastics containing additional liquids and gases, or crystals that alter their density, are called thermoplastic foams. Polyethylene foams such as alloplast and Plastazote are two of the most common types. Other products often used as rigid outer layers of padding are Lighcast (Merck Sharpe Dohne, West Point, Penn), Hexalite (Hexcel, Dublin, Calif), and RTV-11 (Genulastic Silicone Products, Waterford, NY). Prefabricated rigid pads can be used to protect the shoulder. Cramer produces OSi protective padding. This is a precut, customized, lightweight, and breathable low-profile pad that can be custom molded to specific body parts such as the acromioclavicular joint and deltoid. To activate the curing process one wets the pad with water at any temperature and applies the pad to the body part. Within five minutes the pad becomes firm and is molded and conformed to the body part. These pads are NCAA compliant to standards for rigid protective devices. The Impact AC (acromioclavicular) pad (Fig. 59-2) uses a dome design that when applied rests over (not on) the injured area, allowing greater dispersion of force. This padding is easily moldable by immersion in a hydrocollator and is secured to the athlete with hook-and-loop tape straps.
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aids in the dispersion of forces. It is heat sensitive, so it responds to the body heat of the athlete as it molds to the contours of the body.
PROTECTING AND PADDING JOINTS IN THE SHOUDLER Protection of the Acromioclavicular Joint In many contact sports such as football, lacrosse, and ice hockey, the acromioclavicular joint is susceptible to frequent injury.8 Athletes with acromioclavicular joint sprains can return to competition with satisfactory functional testing and with the approval of the team physician. However, adequate protection should be provided to the acromioclavicular joint to prevent further injury.
Figure 59-2. Impact AC (acromioclavicular) prefabricated pad.
Soft Materials Soft materials are equally important for preventive measures. These can vary in shape and size and are easy to mold to the contours of the body. Foam rubber is particularly effective because of its variety of thicknesses. It protects the body area from force and is resilient and nonabsorbent. Ther-o-foam (Cramer Products, Gardner, Kan) and Ensolite (Whiroyal, Mishawka, Ind) are two of the most common types of foam used today. Felt is another popular soft material. Felt produces a firmer pressure than most foam rubbers because of its comfortable, semi-resilient surface. This type of material is composed of matted wool fibers pressed into varying degrees of thickness. Felt can absorb perspiration and therefore must be replaced daily to allow it to be fully effective. However, its ability to absorb moisture allows it to keep better skin contact, thus decreasing the tendency of the pad to migrate. Other soft materials such as adhesive felt (moleskin), gauze, cotton, and lamb’s wool can also be used as adjuncts to protective devices. Viscoelastic polyurethane foam (memory foam) is a relatively new type of foam available to the clinician and comes with either an adhesive or nonadhesive backing. It has great shock-absorbing properties and is moldable and conformable. It is available in soft, medium, or firm density. This open-cell foam recovers its shape slowly, which
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One form of protection is by using a foam pad insert called a shoulder injury pad or a spider pad (Adams Plastics, Cookeville, Tenn) (Fig. 59-3). This type of pad is lightweight yet directs the attention of a blow to the acromioclavicular joint toward the elevated foam pad.10 This is commercially available and should be properly fitted to the individual athlete. A specialized pad for the acromioclavicular joint can also be made.10-12 This is done to provide a more custom fit for the athlete. Many types of material have been recommended for construction of the pad. The pad basically takes on an elevated donut or dome shape with a rigid outer shell and a softer inner padding. The rigid material is molded to the athlete’s acromioclavicular joint region. When doing this, a dome of 1.5 inches should be constructed, so the acromioclavicular joint itself is not directly in contact with the pad (Fig. 59-4). A softer material made of foam is then used as a dispersive medium between the athlete’s shoulder and the rigid dome. This pad can be held in place by taping it to the skin with adhesive tape, by creating a strap or belt system, or by using an elastic bandage and applying a spica-type wrap to the shoulder. The key to making a successful acromioclavicular pad is to make sure that the pad is raised off the injured area to distribute the force of a blow around that area, allowing the force to be absorbed by the pad itself.
Taping the Acromioclavicular Joint Taping of the acromioclavicular joint has been used for first- or second-degree sprains, because it can provide some external support while not limiting the athlete’s range of motion. The area of involvement should be cleansed and shaved to allow good contact surfaces. The nipple can be protected with an adhesive bandage or a small piece of felt or gauze. Initially, two anchors are applied. The first is
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A
B
Figure 59-3. Spider pad. A, Side view. B, Anterior view.
More support strips are applied in a diagonally from the arm to the shoulder anchors. These strips are applied in a fanning pattern, both anterior to posterior and posterior to anterior (see Fig. 59-5C). Anchor strips can then be applied from the chest to the back, attaching to the initial anchor. These should be overlapped halfway, allowing a more stable support (see Fig. 59-5D). Strips are then applied completely around the chest and arm to close off the taping procedure (see Fig. 59-5E and F).12
Protecting the Sternoclavicular Joint Although the sternoclavicular joint can be injured in numerous sporting activities, mostly from the result of a direct force, it can actually be protected quite well following an injury through the use of assistive protective devices. Injuries to the sternoclavicular joint involve either an anterior or posterior subluxation or dislocation to the medial end of the clavicle as it displaces from the stable sternum.
Figure 59-4. Custom acromioclavicular pad.
placed from the chest at its midline, over the shoulder to the back, and ending just below the tip of the scapula. A second anchor is applied from the anterior to the posterior aspect of the thorax (Fig. 59-5A). A series of nonelastic support strips are then placed upward from the arm to the anchor strips on the shoulder (see Fig. 59-5B).
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Historically, athletes with sternoclavicular joint sprains have been withheld from physical participation when contact is involved until the area is stable enough to reduce the risk of recurrence. With return to participation, it is a good idea to provide a protective covering in the form of a shell made of thermoplastic materials (Fig. 59-6). The shell appears much more effective in preventing against posterior sternoclavicular instability because the mechanism for that type of injury would be a direct blow to the medial end of the sternum or
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A
C
E
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D
F
Figure 59-5. Taping the acromioclavicular joint. A, Anchor strips. B, Fan is applied. C, Fan is reinforced. D, Anterior/posterior anchors applied. E, Transverse anchors applied. F, Completed procedure.
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Protecting the Glenohumeral Joint By nature of its anatomic design and the forces applied to it during athletic activity, the glenohumeral joint is susceptible to numerous conditions. Most notable of these are contusions and glenohumeral instability issues.
Figure 59-6. Sternoclavicular pad.
forceful horizontal adduction of the humerus, of which the latter is not as often seen. When using a shell to protect against further sternoclavicular joint injuries, it is important to maintain adequate functional mobility and not compromise movements necessary for participation. Such compromise can lead to additional injuries and create a vulnerable situation in general with respect to the ability to protect oneself from further damage to the preexisting injury. Athletes who return to participation with a shell to protect the sternoclavicular joint should do so after a careful screening of abilities and potential vulnerability considerations, always under the final clearance of a physician.
Figure 59-7. A, Donut-shaped pad to protect the lateral aspect of the humerus from direct forces. B, Close-up view.
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A
Contusions Direct blows to the glenohumeral joint are common in contact sports. Complications such as tackler’s exostosis and myositis ossificans can be prevented with proper protection to the glenohumeral region.1,13 Often, the area of concern is just distal to the glenohumeral joint, near the insertion of the deltoid muscle and the origin of the brachialis muscle. This is an area that might not be adequately protected with football shoulder pads. Protective donut-shaped pads can be designed to cover the lateral humerus in a manner similar to those for contusion of the acromioclavicular joint (Fig. 59-7). Anterior Instability One of the most difficult challenges that a medical team faces is how to adequately prevent an athlete from recurrent anterior instability of the glenohumeral joint. Because of the complexity of the capsuloligamentous structures, there is no true device or taping procedure guaranteed to protect the unstable shoulder. Because the mechanism of injury for anterior subluxation or dislocation is external rotation and abduction of the shoulder, braces have been designed to limit these motions while allowing an athlete to return to competition.14 However, an athlete who must compete by bringing his or her shoulder into external rotation and abduction is a viable candidate for a reinjury regardless of the type of brace being worn. Many sports,
B
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such as skiing, are somewhat style conscious, and the likelihood of gaining acceptance for any type of brace may be impractical.15 Many different types of shoulder braces have been designed to prevent recurrent episodes of anterior subluxation and dislocation. The Shoulder Subluxation Inhibitor (SSI, Physical Support Systems, Inc, Windham, NH) (Fig. 59-8) is custom-fitted and made of low- and high-density polyethylene.16 It is designed with a hyperextension strap used to restrict excessive external rotation about the shoulder (Fig. 59-9). The C.D. Denison–Duke Wyre Shoulder Vest (C.D. Denison Orthopaedic Appliance Co, Baltimore, Md) (see Fig. 59-9) is constructed of sturdy canvas and is chrome leather stitched with nylon.17 This harness contains a biceps cuff, with a lacer attachment to the chest vest used to limit abduction and extension of the shoulder. Also, laces can be threaded to limit horizontal adduction and shoulder elevation. The Sawa Shoulder Orthosis (BRACE International, Scottsdale, Ariz) is an off-the-shelf brace made of a hypoallergenic blend of cotton and rubber material.18 It is reinforced for strength, shape, and form with hookand-loop tape front closures and fasteners. A glenohumeral hook-and-loop strap attached to the humeral cuff limits adduction, abduction, flexion, and extension. (Fig. 59-10).
Figure 59-9. C.D. Denison–Duke Wyre shoulder brace.
Newer braces include the Sully Shoulder Stabilizer, the Cadlow Shoulder Stabilizer, the Simply Stable Shoulder Stabilizer, the MAX Brace, and the Donjoy Shoulder Brace (Fig. 59-11). The Sully Shoulder Stabilizer provides support while allowing some restricted range of motion. Elastic straps attach with hook-and-loop tape to a neoprene vest at any point, in any direction, and with varied
Figure 59-10. Sawa shoulder orthosis.
Figure 59-8. Shoulder subluxation inhibitor.
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amounts of force to allow the clinician to selectively and functionally stabilize or restrict movement according to each patient’s needs. The Cadlow is a unique brace that uses a pull system of elastic tubes to provide glenohumeral stability while allowing a full range of motion. In addition, the tubes have graduated resistance that allows the athlete to strengthen the shoulder. The Simply Stable Shoulder Stabilizer is designed for simplicity and ease of use. It consists of an elastic strap that attaches directly to the shoulder pads and encircles the humeral head, restricting the motions of abduction and external rotation. For athletes
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Figure 59-12. Simply Stable Shoulder Stabilizer. Figure 59-11. The Donjoy shoulder brace.
not involved with football, there is a harness that can be attached to the humeral strap (Fig. 59-12). The MAX Brace facilitates and controls glenohumeral range of motion and can also be used to support acromioclavicular separations. Studies have shown minimal effects on shoulder positioning sense and glenohumeral joint active and passive range of motion using a variety of shoulder braces.19-21 The ultimate preventive brace for recurrent anterior instability is one that would allow enough motion for the athlete to be as functional as possible in his or her particular sport, yet provide restricted support to stabilize the glenohumeral joint. Because no surgery or rehabilitative protocol can ever replace the original anatomic and biomechanical functions of the shoulder, more research is needed to help create an individualized shoulder restrictor that is lightweight, comfortable, functional, and effective.
Postoperative Shoulder-Bracing Options There are basically four different options for postoperative bracing. The simplest and most useful brace for most procedures is a sling (Fig. 59-13). This affords the patient some protection but also can be easily removed for early postoperative range of motion. Most surgeons allow early passive motion after most procedures, and this can easily be done with a sling. If additional protection is desired, a shoulder immobilizer can be used. This holds the shoulder in a position similar to a sling, but it is more stable. For open posterior capsulorraphy procedures, a gunslinger type brace may be necessary. This brace puts less strain on the posterior capsule in the early postoperative period.
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Figure 59-13. Shoulder sling.
The shoulder is positioned in slight abduction, external rotation, and flexion. Typically, these braces are used for 4 to 6 weeks, and shoulder motion is discouraged. Elbow motion can be allowed by removing the forearm from the brace. With the advent of arthroscopic procedures, many surgeons are electing not to routinely use these braces.
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A variation of the traditional gunslinger brace is an external rotation brace that uses a soft wedge to hold the arm in external rotation. These braces may be useful in the acute management of anterior shoulder instability.
Calleghan reported taping techniques to inhibit trapezius tone when there is a hitching associated with rotator cuff pathology resulting in a decreased humeral inferior glide.25
The final commonly used postoperative brace is an abduction brace. This is a popular soft wedge-type brace. These braces have traditionally been used following rotator cuff repair. Recently, however, their use has been discouraged, because surgeons have recognized that if the cuff can not be repaired without tension in adduction, then the repair is unlikely to be successful.
Not all studies measuring the effects of scapular taping have shown beneficial results. Cools and colleagues looked at taping techniques for the trapezius and serratus anterior muscles during dynamic full range of motion abduction and forward flexion and found no significant influence of tape application on electromyographic activity in healthy subjects.26 As with all other treatment interventions, scapular taping may play an assistive role with certain populations of athletes while not necessarily being as beneficial for others. It is up to the clinician to identify the athletes who can benefit from scapular taping procedures.
There are many factors to consider when prescribing a postoperative brace. These include tissue quality, surgical technique, patient compliance, and goals. Close cooperation and communication among the surgeon, clinician, and patient allow team approach and successful postoperative management.
Taping for Rehabilitative Purposes Studies have shown using Kinesiotape can be effective in assisting with rehabilitation programs. In 2005, Keirns and colleagues demonstrated effective treatment interventions for recruiting suprascapular and infrascapular muscle firing using scapular taping techniques.22 Effects were optimal during forward reaching motion below the horizontal plane (Fig. 59-14). Others have identified scapular taping as an effective measure to treat anterior shoulder impingement when returning athletes to overhead sports activities.23 Methods of scapular taping have even been shown to be effective with performing artists. Ackermann and colleagues identified a 49% increase in electromyographic activity of the left trapezius muscle in professional violinists with the intervention of scapular taping.24
LEGAL AND ETHICAL CONSIDERATIONS A substantial amount of controversy exists regarding the effectiveness of external devices used to protect the athlete’s shoulder. When considering the use of any protective equipment, one should always be aware of the concerns in the specific sport and any ethical ramifications that may arise in regard to the design and application of the equipment itself. Liability is defined as the legal responsibility of a person in a certain situation to do a particular task in a reasonable and prudent manner.3 Failure to perform such action in a reasonable and prudent manner can make the person legally liable for the results of that action. The courts can hold the person negligent when it is shown that the person has done something that a reasonable and prudent person would not do.3 More specifically, knowingly using dangerous or faulty equipment is a type of negligence that an athletic trainer, therapist, coach, or team physician can be held accountable for should an accident result. All athletes and medical personnel should be aware that no single piece of equipment can be 100% reliable in terms of injury or reinjury. The statement that a piece of equipment can treat or prevent a certain injury should be completely avoided in all discussion. The implication of such a statement can lead to implied liability should an injury occur in this situation.
Figure 59-14. Using tape to assist in the rehabilitation of scapular muscles.
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Special care is required with any device made by the medical staff. No piece of equipment should predispose an athlete to further injury. Of primary concern are devices constructed to limit an athlete’s range of motion. The following is a list of suggestions to help maintain safety parameters with the use of protective equipment.3
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• Maintain accurate records of each athlete’s injuries, both present and past. • Establish qualified and adequate supervision of all equipment. • Properly instruct the medical staff, the coaches, the equipment managers, and the athletes themselves on correct procedures for equipment fitting. • Thoroughly inspect equipment on a regular basis, looking for faulty or hazardous parts. • Inform all athletes that no piece of equipment is 100% able to prevent injury. • Use sound, logical judgment when applying any type of external device. • Have a thorough understanding of the rules of the sport your athlete is participating in. It is the ultimate responsibility of the medical staff to ensure that every athlete is treated in a reasonable and prudent manner. Any person deviating from this principle is subject to ethical and legal complications.
SUMMARY The complexity of the shoulder joint has caused many of us to use different methods of prevention and protection through the use of external protective devices. Taping, padding, and bracing of the shoulder complex have become skills in which all of us involved in sports medicine are attempting to become more proficient. An external protective device will never replace a thorough rehabilitation program, nor will it restore normal biomechanics of the injured shoulder. However, performed within the guidelines of one’s qualifications and legal considerations, external protective devices for the shoulder can be a valuable adjunct for returning an athlete to competition.
References 1. Kuland D: The Injured Athlete. Philadelphia, JB Lippincott, 1988. 2. Miller R: Protective Padding. Presented at the NATA National Convention and Symposium, Columbus, Ohio, June 1987. 3. Arnheim DD: Modern Principles of Athletic Training. St Louis, Mosby, 1985. 4. Fahey TD: Athletic Training: Principles and Practice. Palo Alto, Calif, Mayfield Publishing, 1986. 5. Gieck J, McCue FC III: Fitting of protective football equipment. Am J Sports Med 8(3):192-196, 1980. 6. Malacrea R: Protective equipment fit. Proceedings of the NATA Professional Preparation Conference. Nashville, NATA Professional Education Committee, 1978. 7. Watkins RG: Neck injuries in football players. Clin Sports Med 5(2):215-246, 1986.
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8. Silloway KA, McLaughlin RE, Edlich RC, Edlich RF: Clavicular fractures and acromioclavicular joint dislocations in lacrosse: Preventable injuries. J Emerg Med 3(2):117-121, 1985. 9. Athletic Equipment Managers’ Association: Home page. Available at http://www.aema1.com/ (accessed March 26, 2008). 10. Biron SA: Acromioclavicular protection of ice hockey players. Athletic Training 18:103, 1983. 11. Deutch B, Fashour T: MA, Fashover T: Football hip pad protection for hip pointers and AC sprains on ice hockey players. Athletic Training 16:2-00, 1981. 12. Wershing CE: A specialized pad for the acromioclavicular joint. Athletic Training 15:102-103, 1980. 13. Booher JM, Thibodeau GA: Athletic Injury Assessment. St Louis, Mosby, 1985. 14. Rovere GD, Curl WW, Brownig DG: Bracing and taping in an office sports medicine practice. Clin Sports Med 8(3):497-515, 1989. 15. Weaver JK: Skiing-related injuries to the shoulder. Clin Orthop Relat Res (216):24-28, 1987. 16. Physical Supports Systems: Shoulder subluxation inhibitor (information packet). Windham, NH, Physical Supports Systems, Inc, 1989. 17. Denison Orthopedic Appliance Corp: CD Denison-Duke Wyre Shoulder Vest (information packet). Baltimore, CD Denison Orthopedic Appliance Corp, 2005. 18. Brace International: Sawa shoulder orthosis (information packet). Scottsdale, Ariz, Brace International, 2005. 19. Chu JC, Kane EJ, Arnold BL, Gansneder BM: The effect of a neoprene shoulder stabilizer on active joint-reposition sense in subjects with stable and unstable shoulders. J Ath Train 37(2):141-145, 2002. 20. Ulkar B, Kunduracioglu B, Cetin C, Guner RS: Effect of positioning and bracing on passive position sense of shoulder joint. Br J Sports Med 38(5):549-552, 2004. 21. Weise K, Sitler MR, Tierney R, Swanik KA: Effectiveness of glenohumeral-joint stability braces in limiting active and passive shoulder range of motion in collegiate football players. J Ath Train 39(2):151-155, 2004. 22. Keirns MA, Taylor M, Bailey-Carter D: The effects of scapular taping on the suprascapular and infrascapular muscle recruitment in individuals with forward head/rounded shoulder posture [abstract]. Phys Ther, 2005. Available at http://www.apta.org/AM/abstracts/pt2005/abstractsPt. cfm?pubNo⫽PO-RR-107-TH (accessed March 26, 2008). 23. Host HH: Scapular taping in the treatment of anterior shoulder impingement. Phys Ther 75(9):803-812, 1995. 24. Ackermann B, Adams R, Marshall E: The effects of scapula taping on electromyographic activity and musical performance in professional violinists. Aust J Physiother 48(3):197-203, 2002. 25. Callaghan MJ: Role of taping and bracing in the athlete. Br J Sports Med 31(2):102-108, 1997. 26. Cools AM, Witvrouw EE, Danneels LA, Cambier DC: Does taping influence electromyographic muscle activity in the scapular rotators in healthy subjects? Man Ther 7(3):154-162, 2002.
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