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Injuries to the athletic shoulder Injuries to the athletic
shoulder Dr.H.Saremi Orthopaedic surgeon, Hand & Shoulder
fellowship Hamedan university of medical sciences Besat
Hospital
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Sport injuries Sport specific injuriesSport specific injuries
Regional InjuriesRegional Injuries
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Shoulder 4joints4joints The least stable jointThe least stable
joint
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Injuries to the athletic shoulder InstabilityInstability
Impingement and rotator cuff problemsImpingement and rotator cuff
problems Biceps labral complex injuriesBiceps labral complex
injuries Ac joint injuriesAc joint injuries S.c joint injuriesS.c
joint injuries FracturesFractures Neurovascular
injuriesNeurovascular injuries
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Instability Unique anatomy for Mobility and StabilityUnique
anatomy for Mobility and Stability Sports that stress the static
and dynamic stabilizers beyond their physiological
limit(repeatative overhead maneuvers)Sports that stress the static
and dynamic stabilizers beyond their physiological
limit(repeatative overhead maneuvers)
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Instability PainPain Feeling that the shoulder is looseFeeling
that the shoulder is loose Painfull giving way associated with dead
arm syndromPainfull giving way associated with dead arm syndrom
DislocationDislocation
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Instability Post traumatic anterior SX or DXPost traumatic
anterior SX or DX Post traumatic posterior SX or DXPost traumatic
posterior SX or DX Atraumatic Anterior SX or DXAtraumatic Anterior
SX or DX Atraumatic posterior SX or DXAtraumatic posterior SX or DX
Multidirectional SX or DXMultidirectional SX or DX
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Instability Description of arm position when symptoms
occurDescription of arm position when symptoms occur Is it
completely involuntaryIs it completely involuntary
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Traumatic anterior DX 98% of shoulder dislocations98% of
shoulder dislocations Excessive abduction and Ex rotationExcessive
abduction and Ex rotation Direct blow from the behindDirect blow
from the behind Pain,decreased ROM,guardingPain,decreased
ROM,guarding An immediate reduction may be attempted on the playing
field,if unsuccessful another attemp can be made in the locker
roomAn immediate reduction may be attempted on the playing field,if
unsuccessful another attemp can be made in the locker room
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Simple reduction manuvere
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Traumatic anterior DX Immobilization?Immobilization? 6w(>40
y 7-10 days)6w(>40 y 7-10 days) Internal or ex rotation?Internal
or ex rotation? Recurrency?Recurrency?
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Traumatic anterior DX The criteria for returning to sport are
based on a FULL ROM and FULL strengthThe criteria for returning to
sport are based on a FULL ROM and FULL strength
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Traumatic anterior DX If repeated or sustained instability
symptoms and signs ARTHROSCOPIC REPAIRIf repeated or sustained
instability symptoms and signs ARTHROSCOPIC REPAIR
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LABRAL DETACHMENT
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GLENOID DEFECT
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Posterior traumatic sx or dx Less commonLess common Direct blow
to the anterior shoulderDirect blow to the anterior shoulder Direct
forces with the arm I flx, Add, int rotDirect forces with the arm I
flx, Add, int rot Axillary view is criticalAxillary view is
critical 40y---2-3w 40y---2-3w
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Atramatic anterior shoulder instability Sign and symptoms of
instability without significant initial traumaSign and symptoms of
instability without significant initial trauma Repetitive over head
activityRepetitive over head activity Thrawers in acceleration
phaseThrawers in acceleration phase Swimmers during the backsroke
or turnsSwimmers during the backsroke or turns Pain may be
posteriorPain may be posterior
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Atramatic anterior shoulder instability Sling and
antiinflamatory medicationSling and antiinflamatory medication
Vigorous physical therapyVigorous physical therapy Arthroscopic
repairArthroscopic repair
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Atraumatic posterior shoulder instability Unlike posterior
dislocation,is relatively commonUnlike posterior dislocation,is
relatively common Athlete usually complain of pain rather than
instabilityAthlete usually complain of pain rather than instability
Follow through in pitching, pull through phase in swimming,serving
motions or backhand in tennisFollow through in pitching, pull
through phase in swimming,serving motions or backhand in
tennis
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PH.EX
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Atraumatic posterior shoulder instability Sling and
antiinflamatorySling and antiinflamatory PhysiotherapyPhysiotherapy
Arthroscopic repairArthroscopic repair
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Multidirectional instability Instability occurring in more than
one plan(antero inferior,posteroinferior,or three
directionsInstability occurring in more than one plan(antero
inferior,posteroinferior,or three directions May have generalized
ligamentous laxity(beighton hypermobility score)May have
generalized ligamentous laxity(beighton hypermobility score)
Physical therapyPhysical therapy
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Multidirectional instability The athlete may return to activity
at a low level during therapy as long as the specific activities
that couse that symptoms are avoidedThe athlete may return to
activity at a low level during therapy as long as the specific
activities that couse that symptoms are avoided Therapy should
progress until the patient can return to activities without
symptomsTherapy should progress until the patient can return to
activities without symptoms Arthroscopic repair and capsular
shiftArthroscopic repair and capsular shift
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A
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Impingement and rotator cuff problems Subacromial impingement
is one of the most common couse s of shoulder pain in
athletesSubacromial impingement is one of the most common couse s
of shoulder pain in athletes
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Rotator cuff
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DEPRESSION effect
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Impingement Outlet impingementOutlet impingement Non outlet
impingementNon outlet impingement An unstable head that subluxes
anteriorly due ro capsular laxity may displace upward against the
acromionAn unstable head that subluxes anteriorly due ro capsular
laxity may displace upward against the acromion Stabilize the
shoulderStabilize the shoulder Secondary impingement is the most
common type of impingement in young athletes Stabilize the
shoulder
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Impingement syndrom
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ACROMIO Humeral distance
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CUFF ARTHROPATHY
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Impingement syndrom Painful arc signPainful arc sign Positive
howkins sign and jobe testPositive howkins sign and jobe test Non
operative treatmentNon operative treatment Operative
treatment(arthroscopic)Operative treatment(arthroscopic)
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Internal Glenoid impingement
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Rotator cuff tear Repetitive microtrama,occasionally single
traumatic eventRepetitive microtrama,occasionally single traumatic
event Progressive pain and weaknessProgressive pain and weakness
Restriction of ROMRestriction of ROM May be an aging process(30-50%
cadavr)May be an aging process(30-50% cadavr) Partial or
fullthicknessPartial or fullthickness Non operative treatmentNon
operative treatment operative treatment(arthroscopic)operative
treatment(arthroscopic) Rotator cuff arthropathyRotator cuff
arthropathy
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Non operative treatment Physio therapyPhysio therapy
NASAIDNASAID Corticoid injectionCorticoid injection
Non operative treatment STEP 2: Restore normal flexibilitySTEP
2: Restore normal flexibility Stretch out all the direction of
tightnessspecially posteriorStretch out all the direction of
tightnessspecially posterior Most effective by the patientMost
effective by the patient Gentle stretched five times a day by
patientGentle stretched five times a day by patient To the point of
pull of tightness not to the point of pain Each stretche for 1
min----30 min a day Obvious improvement---1 m may be 3 m full
recovery
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Non operative treatment STEP 3: Restore normal strenthSTEP 3:
Restore normal strenth When near normal passive flexibility of the
shoulder is restoredWhen near normal passive flexibility of the
shoulder is restored Internal and external strenthening
excersiseswith the arm at the sideInternal and external
strenthening excersiseswith the arm at the side By the patientBy
the patient
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Non operative treatment Deltoid strengthing is added when it
can be performed comfortablyDeltoid strengthing is added when it
can be performed comfortably
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Scapular motorsScapular motors
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Non operative treatment STEP 4:Perform aerobic exerciseSTEP
4:Perform aerobic exercise To get back in shape and improve the
sense of well beingTo get back in shape and improve the sense of
well being 5 days a week,sweaty ex 30 min5 days a week,sweaty ex 30
min
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Non operative treatment STEP5: Modify work or sportSTEP5:
Modify work or sport Reviewe the technique of sportReviewe the
technique of sport Modifiy the jobModifiy the job
A hundred times every day,I remained myself that my inner and
outer life are based on the labors of other men living and dead,and
that I must exert myself in order to give in the same measure as I
have received. ALBERT EINSTEIN
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Frozen shoulder(adhessive capsulitis) Restricted active and
passive motionRestricted active and passive motion
Idiopathic(DM,IHD,cervical
discopathyimmmobilizationhyperthyroidism,stro
ke,MiIdiopathic(DM,IHD,cervical
discopathyimmmobilizationhyperthyroidism,stro ke,Mi
Secondary(trauma,shoulder surgery)Secondary(trauma,shoulder
surgery) Pain and restrictedROM(Int.R,Flex,ext.Rot)Pain and
restrictedROM(Int.R,Flex,ext.Rot)
Pain,Stiffness,ThawingPain,Stiffness,Thawing Non operative
treatmentNon operative treatment Operative treatment(arthroscopic
release)Operative treatment(arthroscopic release)
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Calcific tendinitis Site of diminished blood suply(1.5-2 cm to
insertion of supraspinatus)Site of diminished blood suply(1.5-2 cm
to insertion of supraspinatus) >30y/o>30y/o W>MW>M
Precalcification stagePrecalcification stage Calcification
stageCalcification stage Phase of formation Resting phase
Resorptive phase Post calcification phase Post calcification
phase
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Calcific tendinitis Non operative treatmentNon operative
treatment Operative treatment(arthroscopic)Operative
treatment(arthroscopic)
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Biceps tendinitis
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>30-40 years>30-40 years Pain during flx and supination
of elbowPain during flx and supination of elbow Non operative
treatmentNon operative treatment Operative treatmentOperative
treatment RUPTURERUPTURE
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Trauma to shoulder Fx of the clavicle Most common fx in
children mechanism N.V damage Open Skin irritation 1/3 distal
>2cm over riding Fliale shoulder
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FX of clavicle Complications N.V damage Non union malunion
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AC dislocation MechanismMechanism ClassificationClassification
treatmenttreatment
Glenohumeral dislocation More than 90% anteriorMore than 90%
anterior Abd,ext.RotAbd,ext.Rot PH.exPH.ex ComplicationComplication
TreatmentTreatment Post oppPost opp
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Posterior dislocation Not obvious in Ap viewNot obvious in Ap
view Abd,Int.rotAbd,Int.rot Following seizureFollowing seizure
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Posterior dislocation
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Fx arround the shoulder Greater tuberosityGreater tuberosity
Surgical neckSurgical neck shaftshaft