1. Mr. Nnamdi Obi Specialist registrar United Kingdom
Anatomy, diagnosis and classification of sports injuries in the shoulder
Mr. Nnamdi Obi
Specialist registrar
United Kingdom

2. Objectives Review anatomy of the shoulder
Review history and examination
Acute traumatic shoulder instability

3. Introduction Instability Glenohumeral dislocation ACJ dislocation
SLAP tears
ACJ dislocation

4. 30 YO male,Professional Rugby payer, first episode

5. Anatomy Synovial ball and socket joint
Articular surface covered with hyaline cartilage
Glenoid cavity deepened by labrum
Articulations

6. Rotator cuff
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis

7. Ligaments Glenohumeral Shoulder girdle Superior Glenohumeral ligament
Middle Glenohumeral Ligament
Inferior Glenohumeral Ligament
Shoulder girdle
Coraco clavicular
ACJ proper
Acromioclavicular

8. Biomechanics Static restraints Dynamic restraints Glenoid labrum
Articular version + conformity
Glenohumeral ligaments
Negative intra-articular pressure
Rotator cuff muscles
Biceps tendon
Scapular stabilizers
Neuromuscular factors

9. History (Acute traumatic instability)
Age
Mechanism
Traumatic
Atraumatic
Chronicity
Ease of dislocation
Expectations
Return to play

10. Examination Acutely Delayed Pain limits most
Pre and post axillary nerve function
Sensory
Motor
Delayed
Hyperlaxity – predisposing
Provocative tests
Labral pathology (SLAP tear)

11. Sulcus sign

12. Apprehension

13. Relocation test

14. Labrum (SLAP)
O’Brien’s

15. Labrum
Load & Shift

16. Special investigations
Bones
Glenoid
Head humerus
Soft tissues
Rotator cuff
Labrum
X Ray
CT scan
Ultrasound – no labrum
MRI
CT arthrogram
MRI arthrogram

17. Lateral radiographs
Posterior oblique scapular projection (“Neer lateral”, Neer 1970)
Produces considerable image overlap
Transthoracic (Vastamaki and Solonen 1980)
Image overlap
Axial (Warrick 1965)
Requires shoulder abduction
Modified axial (Rockwood 1984)
Some shoulder abduction
Velpeau lateral (Wallace and Hellier 1983)
Patient needs to sit up
Apical oblique (Garth, Slappey and Ochs 1984)

18. This is posterior dislocation But outlines glenoid and humeral head
J Bone Joint Surg [Br] l988;70-B:

19. Axial view
Small Hills sachs
Anterior glenoid Fine
Almost normal AP
Same patient Apical oblique
Large Hills sachs
Blunting anterior glenoid

20. Bone loss
- Plain x-ray
- CT
- CT recon

21. 30 YO male, football, first episode

22. Treatment
How long ?

23. MRI study Randomized 40 pts IR Labrum off glenoid
ER tension rests on glenoid
Randomized 40 pts
Sling IR Vs ER
Recurrence
IR 6/20, 30%
ER 0/20
J Shoulder Elbow Surg 2003;12:

24. JBJS – B VOL. 91-B, No. 7, JULY 2009

25. Premise
Younger = recurrent instability = immobilize longer
Older = stiffness = mobilize sooner
No benefit to immobilization in internal rotation > 1 week in pts under 30 yrs of age
Age of less than thirty years at time of injury predicts increased recurrence.
Best available evidence does show a clinical benefit to treatment in external rotation over conventional sling immobilization, but this advantage did not reach significance
BUT most ITOI
J Bone Joint Surg Am. 2010;92:

26. Take Home Reduce Sling comfort Under 30 years, continue contact sport
Discard in 1 week
Physiotherapy, strengthen dynamic stabilizers
Under 30 years, continue contact sport
Counsel recurrence rate
Consider surgery following first dislocation

27. SLAP Lesions
May be associated with dislocation but commonly due to pull on the arm, weightlifting, throwing, tackling
Symptoms – clicking, pain with overhead activities
Clinically – pain with eccentric biceps loading (e.g. going down on bench press)

28. SLAP lesion classification

29. Acromioclavicular joint (ACJ) injuries
Usually injured by a direct fall onto the point of the shoulder
Scapular forced downwards
Clinically, lateral end of clavicle prominent

30. 30 YO rugby player again

31. Classification of ACJ Injuries (Rockwood)
Anatomy
diathrodial joint
· has fibrocartilage intraarticular disc
· Usually degenerative by 4th decade
· Clavicle may lie superior normally- See more at:
Stability of ACJ
Coracoacromial ligaments
Primary restraint to superior translation
Primary suspensory ligament of upper limb
Trapezoid Ligament
Arises anterolateral on coracoid
Inserts trapezoid ridge anterolateral to conoid
Almost horizontal in sagittal plane
PRIMARY restraint to AXIAL compression
Conoid Ligament
Arises posteromedial to trapezoid
Inverted cone
Inserts conoid tubercle
Lies vertically
PRIMARY restraint to SUPERIOR & Anterior translation
ACJ Capsule
Strongest superiorly
As reinforced by acromioclavicular ligament (strongest superiorly)
Has incomplete fibrocartilage intra-articular disc arising from it
Usually degenerates by 4th decade
Deltotrapezial Fascia
Dynamic stabiliser -

32. Treatment
Non Operative
Grade 1-3
Operative
Grade 4-6

33. Conclusions Acute instability common in athletes
Glenohumeral
ACJ
High level of function
Early return to play
Axillary or modified axillary view
Apical oblique

34. References Websites: https://www.shoulderdoc.co.uk

35. The End