Shoulder sports injuries (shoulder dislocation)

The shoulder joint is anatomically a complex joint. This joint is formed by the articular surfaces of the scapula and head of the humerus (the clavicle is also involved in the formation of this joint), but it should be noted that the articular surfaces do not completely overlap each other. However, the amount of movement in this joint is greater than in the others. This is provided by the muscles and tendons of the joint, which also ensure its stability. The rotator cuff assists in raising the arm and rotating the shoulder joint in different directions. This joint includes four tendons: supraspinalis, infraspinalis, subscapularis, and teres minor.

There are two causes of rotator cuff tears: traumatic injuries and degeneration.

• Traumatic tears occur from momentary movement and falling on the arm. These injuries are mostly found in athletes and young patients.
• Degenerative tears result from thinning of the tendons that form the rotator cuff over time. The reasons for this are: frequent use of the limb, decreased blood supply to the tendons of the joint, and perforation of the cuff by bone attachments or tendon compression.

What kind of complaints do patients come to the doctor with?

• Pain at night and that does not go away when resting
• Inability to raise the arm upward and pain that occurs when trying to do so
• A “crunching” sound that occurs during certain movements

Over time, pain syndrome in patients intensifies and becomes unbearable, does not go away when taking painkillers, develops pain that makes you wake up at night. Performing routine activities such as brushing hair and putting on clothes becomes painful.

How is the diagnosis made?

First of all, it is imperative to gather the patient’s anamnesis. After collecting the medical history and performing tests (Neer, Kennedy, Hawkins, Yergasson, etc.), proceed to instrumental methods of diagnosis. Especially after an MRI (magnetic resonance imaging) is performed to establish the diagnosis. X-rays can show fractures in the bones that occurred as a result of trauma and bony processes that are located in the direction of tendon movement. During an MRI examination, problems in the soft tissues (muscles, ligaments, tendons, etc.) can be seen. There are total and parsial tendon ruptures.

Partial and complete rotator cuff tear shown

How is shoulder injuries treated?

Rotator cuff tears are treated conservatively and surgically.

• Conservative treatment is mainly carried out for partial tendon rupture. Diversion bandages, non-steroidal anti-inflammatory drugs, strengthening of the muscles around the shoulder joint with exercises (physiotherapy) are recommended. In some cases intra-articular injections may show satisfactory results in patients. If conservative treatment does not have a positive result, surgical treatment methods must be used.
• Surgical treatment is performed by open and arthroscopic methods. Open surgical treatment is used when the cuff tendon is widely ruptured.
• With arthroscopic surgical access, two or more incisions of 1 cm in length are made and a camera and instruments are inserted into the joint cavity. With this method, tendon rupture repair, removal of bone processes and seals can be performed.
• During open surgical treatment, a 5-6 cm incision is made (Neer incision), the joint is opened and the tendon is repaired, and the bony processes and seals are removed. Since more soft tissue damage occurs during this surgery, the recovery period is longer.
• In both methods of treatment, different types of implants (Anchor – oblique sutures, etc.) are used in the treatment of tendons. Anchor is placed on the proximal part of the humerus and the severed tendon is sutured to the bone.

The figure shows the suturing of the severed tendon to the humerus with the Anchor suture

After the surgery, the upper extremity is kept in a diverting orthosis for 4-6 weeks. Then physical therapy and muscle strengthening programs are performed.

Shoulder dislocation

Since the range of motion in the shoulder joint is the largest and the size of the articular surfaces of the head of the humerus and scapula are relatively small, this joint is more frequently injured than others. One of the most frequently observed injuries is “shoulder dislocation.

Dislocation of the shoulder joint can also occur in sports injuries. In most cases, unilateral, and in some cases bilateral damage occurs (during electrical injuries, etc.). In the shoulder joint in which a dislocation was previously observed, dislocations may reappear, which are called “recurrent dislocations”. Dislocations can occur in the posterior, anterior, inferior, and superior directions (during a fracture).

Signs of a shoulder dislocation

During a dislocation, a certain number of signs are observed. The main sign is an acute pain. In this case, the patient takes a forced position and can’t provide movement in the shoulder joint. In addition, in the area of the dislocation joint there are signs such as: swelling, bruising, deformity, numbness of the limb.

Dislocations mainly occur when a patient falls with the palm open on the floor and stresses the outer surface of the shoulder joint. Shoulder dislocation can occur in every age group. In older patients, avulsion fractures, which occur when the bone fragment along with the tendon and ligaments break off, are observed in addition to shoulder dislocations.

In older patients, recurrent dislocations are rare after a dislocation has been repaired (under local or general anesthesia) and proper treatment methods have been used. If dislocations suddenly occur many times, they are called repeated dislocations of the humerus. When the first dislocation occurs after a serious injury, recurrent dislocations can occur even with normal movements. As we noted earlier, because the shoulder joint is a complex joint, its stability is maintained by ligaments, tendons, articular jaws, and periarticular cartilage. When injuries are found in the tissues that stabilize the joint, we confirm the risk of repeated dislocations. These injuries are mostly seen in a group of young patients who are actively involved in sports.

Diagnosis

To make a diagnosis of a dislocated shoulder joint, an x-ray examination is sufficient. At this time the dislocation of the shoulder joint can be clearly seen on the X-ray. After the dislocation has been repositioned, a follow-up X-ray is taken to check for proper reduction and possible additional fractures. If cartilage damage, ligament damage or tendon rupture is suspected, an MRI scan should always be performed.

Shoulder dislocation treatment methods

The dislocation can be corrected by open and closed methods.

The closed method uses local or general anesthesia. Most dislocations that are in the acute period are repositioned using this method. If there is suspicion of any nerve or vascular damage, or if it is not possible to achieve a complete reduction of the dislocation, the dislocation is repositioned using the open method.

Open method – the orthopedist-traumatologist uses this method of treatment when there is suspicion of nerve, vessel, or soft tissue damage, and when the dislocated joint is unstable.

After the dislocation is corrected, the joint is fixed with a Welpau bandage, and nonsteroid anti-inflammatory drugs and rest are prescribed. Conservative treatment begins with a four-week immobilization of the joint after its reduction. Next, physical therapy is given to strengthen the muscles and tendons that keep the joint stable.

Repeated dislocations of the shoulder joint

If the shoulder joint is dislocated two or more times, these dislocations are called repeated dislocations. One of the causes of repeated dislocations of the shoulder joint is insufficient wearing of a bandage for recovery, when the joint lip and capsule rupture.

They are mostly seen in athletes, young people, and those with active lifestyles.

Classification of dislocations

Traumatic recurrent dislocations are dislocations that occur after a fall, car accident, etc., and end with damage to the articular lip surrounding the joint.

Atraumatic recurrent dislocations are dislocations that occur during daily movements. With these dislocations, patients are already able to set the dislocated limb back on their own.

Arbitrary repetitive dislocations are dislocations in which the patient can self-dislocate and right the joint.

Treatment methods for repeated shoulder dislocations

Most cases of repeated dislocations are treated surgically.

Most of the ligaments that make up the capsule of the shoulder joint are attached to the labrum. For this reason, when the head of the humerus leaves the joint capsule, it pulls on the labrum and causes it to tear. The labrum ruptures mostly in the anterior-lower part. This tear is called “Bankart’s tear”. Sometimes there are tears in the upper part (where the tendon of the long head of the biceps brachii is attached) that are called SLAP tears (Superior Labrum Anterior Posterior).

Bankart type tears are confirmed by MRI after clinical examination.

The treatment of a torn labrum is done surgically. The torn labrum is reattached to the joint socket using oblique sutures. Surgery is performed using open and arthroscopic (closed) methods.

With both types of surgery, the labrum is sutured and stabilized with a set (suture anchor) during the repair of the Bankart type tear.

SLAP tears as well as Bankart tears are confirmed by MRI after clinical examination.

In patients who go to the doctor immediately after the injury, the initial therapy is done conservatively. This involves rest, medications against swelling, and it is very important to keep the upper extremity in a stationary position. After 4-6 weeks other movements are allowed in addition to physiotherapy.

If conservative methods of treatment are ineffective and patients come to the hospital late after the injury, surgical treatment is recommended. Surgical treatment is done by open and arthroscopic (closed) methods. With both methods, the torn part of the articular lip is cleaned and sewn back into place with suture material. The patient’s hand remains in a dressing for 2-4 weeks after surgery. Later, physical therapy and passive movements are started. Full active movements are allowed by the twelfth week.