Diagnosis and Nonoperative Treatment of Acromioclavicular Joint Injuries in Athletes and Guide for Return to Play

Injury to the acromioclavicular (AC) joint accounts for approximately 40% to 50% of all shoulder injuries. In contact sports, the prevalence of AC joint injury increases. This injury is frequently encountered and treated by fellowship-trained as well as general orthopedic surgeons. As such, it is important to understand the diagnostic and treatment pathways for AC joint disruption. The treatment pathways in athletes may be different from those in the general population. This article will focus on the diagnosis and nonoperative treatment of AC joint injuries in athletes. We will also comment on return-to-play guidelines after this nonoperative treatment.

Return to Sports Following Shoulder Injury: Clinical Evaluation, Isokinetic, and Functional Testing

ABSTRACT

The shoulder is commonly injured in overhead sports. This is associated with a high degree of mobility at the expense of stability, sports specific demands, high volume or intensity of practice and competition, biomechanical deficits, and poor technique. Following injury, the return to competition process includes nonsurgical or surgical treatment, comprehensive rehabilitation, and a structured return to sports program. The return to sports continuum is divided into phases which include return to practice of the sport, return to competition at a lower level or with reduced performance, and return to expected performance. Components of the return to sports decision include clinical evaluation of physical and psychological readiness, measurement of muscle strength using isokinetic tests, evaluation of overhead functional tasks, and progression in a supervised interval throwing program. The evidence for the effectiveness of return to sports programs following shoulder injury is limited but evolving and is an area that will merit continued investigation.

A Sports Medicine Clinician's Guide to the Diagnosis and Management of Distal Clavicular Osteolysis

ABSTRACT

Weightlifting associated shoulder injuries have seen a dramatic rise in the last 20 years. Distal clavicular osteolysis, coined weightlifter's shoulder, is one such condition caused by repetitive microtrauma to the distal clavicle with subsequent, painful development of bony erosions and resorption of the distal clavicle. Diagnosis, treatment, and prevention of this condition can be challenging. In this article, we highlight evidence-based clinical recommendations for the diagnosis and management of distal clavicular osteolysis, including specific considerations for atraumatic and posttraumatic etiologies, to help clinicians better care for their patients. Activity modification and rehabilitation are the mainstays of the initial treatment. Adjuvant treatments, such as injections or surgery, may be required in refractory cases or in certain patient populations. Early recognition and treatment of weightlifter's shoulder is essential to prevent progression to acromioclavicular joint pathology or instability and to allow for continued participation in sport-specific activities.

Assessment of return to play after an acute shoulder injury: protocol for an explorative prospective observational German multicentre study

INTRODUCTION

To date, there is no valid single test or battery of tests for informing return-to-play (RTP) decisions following an acute shoulder injury. The purpose of this exploratory study is to evaluate a diagnostic test battery based on a Delphi consensus at the time of unrestricted return to team training after acute shoulder injury.

METHODS AND ANALYSIS

Data for this prospective multicentre cohort study are collected at two measurement time points: when the respective physician clears the patient for RTP (t1) and 12 months after RTP (t2). The study participants are 18-35 years old athletes participating at a professional level in the following team sports: handball, basketball, ice hockey, soccer, volleyball and American football. Maximum comparability will be ensured via uninjured matched pair teammates. To assess the subjective assessment of shoulder functioning and the athlete's readiness to RTP, patient-reported outcome measures (Western Ontario Shoulder Instability Index, Quick-Disabilities of the Arm, Shoulder and Hand, Psychological Readiness of Injured Athlete to Return to Sport and Shoulder Instability-Return to Sport after Injury) will be completed. After a medical check-up with a range of motion and anthropometric measurements as well as clinical tests, the participants will perform a structured warm-up protocol. The functional tests comprise handgrip strength, upper quarter Y-balance test, isometric strength, closed kinetic chain upper extremity stability test, wall hop test, functional throwing performance index and the unilateral seated shot put test and isokinetic tests.

ETHICS AND DISSEMINATION

The results of this study will be disseminated through peer-reviewed publications and scientific presentations at national and international conferences. Ethical approval was obtained through the Institutional Review Board of Martin-Luther-University Halle-Wittenberg (reference number: 2022-016).

TRIAL REGISTRATION NUMBER

DRKS00028265.

What Do We Know About Shoulder Injury Related to Vaccine Administration? An Updated Systematic Review

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) is postulated to be an immune-mediated inflammatory response to a vaccine antigen injected into or near the subacromial bursae or synovium, leading to shoulder pain and dysfunction. The number of studies on this topic is rapidly increasing. Recent comparative studies have reported conflicting conclusions, which suggests that a systematic review of the best-available evidence may be helpful.

QUESTIONS/PURPOSES

In this systematic review, we asked: What are the (1) clinical characteristics, (2) diagnoses, and (3) management approaches and outcomes reported in association with SIRVA?

METHODS

A search was performed on October 4, 2021, of the PubMed and Medline databases for studies related to SIRVA. Inclusion criteria were English-language comparative studies, case series, and case reports that involved shoulder pain occurring after vaccination. Studies of exclusively neurologic conditions after vaccination were excluded. Forty-two studies met the eligibility criteria, including three retrospective comparative studies (72 patients and 105 controls), five database case series (2273 patients), and 34 case reports (49 patients). Study quality was assessed for the database case series and retrospective comparative studies using the Methodological Index for Non-randomized Studies tool.

RESULTS

Among patients in the case reports, the median age was 51 years (range 15-90 years), and 73% (36 of 49) were women. BMI was reported for 24% of patients (12 of 49) in case reports, with a median of 23.5 kg/m2 (range 21-37.2 kg/m2). The most common symptoms were shoulder pain and reduced ROM. The most common diagnoses were shoulder bursitis, adhesive capsulitis, and rotator cuff tears. The most frequent management modalities included physical or occupational therapy, NSAIDs, and steroid injections, followed by surgery, which was generally used for patients whose symptoms persisted despite nonsurgical management. Full resolution of symptoms was reported in 2.9% to 56% of patients.

CONCLUSION

The association between inflammatory conditions of the shoulder (such as bursitis) and vaccination appears to be exceedingly rare, occurring after approximately 1:130,000 vaccination events according to the best-available comparative study. Currently, there is no confirmatory experimental evidence supporting the theory of an immune-mediated inflammatory response to vaccine antigens. Although the clinical evidence is limited, similar to any bursitis, typical treatments appear effective, and surgery should rarely be performed. Additional research is needed to determine the best injection technique or evaluate alternate injection sites such as the anterolateral thigh that do not involve positioning a needle close to the shoulder.

Sensory and Psychological Factors Predict Exercise-Induced Shoulder Injury Responses in a High-Risk Phenotype Cohort

Our prior studies identified a high-risk phenotype (ie, high pain sensitivity variant of the catechol-O-methyltransferase gene (Single Nucleotide Polymorphism [SNP] rs6269) and pain catastrophizing scores) for shoulder pain. The current study identified sensory and psychological predictors of heightened pain responses following exercise-induced shoulder injury. Healthy participants (N = 131) with the SNP rs6269 catechol-O-methyltransferase gene and Pain Catastrophizing Scale scores ≥5 underwent baseline sensory and psychological testing followed by an established shoulder fatigue protocol, to induce muscle injury. Movement-evoked pain, pain intensity, disability, and strength were assessed 24 hours postinjury. Demographic, sensory, and psychological variables were included as predictors in full and parsimonious models for each outcome. The highest variance explained was for the shoulder disability outcome (full model R2 = .20, parsimonious R2 = .13). In parsimonious models, the individual predictors identified were: 1) 1st pulse heat pain sensitivity for isometric shoulder movement-evoked pain and pain intensity; 2) pressure pain threshold for shoulder disability; 3) fear of pain for active shoulder movement-evoked pain and shoulder disability; and 4) depressive symptoms for shoulder strength. Findings indicate specific pain sensitivity and psychological measures may have additional prognostic value for self-reported disability within a high-risk phenotype. These findings should be tested in a clinical cohort for validation. PERSPECTIVE: The current study extends previous work by providing insight regarding how poor shoulder outcomes may develop within a high-risk phenotype. Specifically, 1st pulse heat pain sensitivity and pressure pain threshold were sensory measures, and fear of pain and depressive symptoms were psychological measures, that improved prediction of different shoulder outcomes.

Surgical management of Rockwood type 3 acromioclavicular joint injuries: a retrospective comparison of outcomes of suture anchor fixation and double-button fixation techniques

The treatment of type 3 acromioclavicular joint injuries has still controversial issues. In this retrospective study, we aimed to compare the radiological and functional outcomes of the suture anchor and double-button fixation methods for the treatment of type 3 acromioclavicular joint injuries.This study included 20 patients who underwent suture anchor (9 patients) and double-button fixations (11 patients) for isolated type 3 acromioclavicular dislocation. Injuries were classified according to the Rockwood Classification System. Coracoclavicular(CC) distances and anterior translation have been measured pre-operatively and at the 12th month follow-up. Functional evaluation was performed using the DASH, and Constant-Murley scores of the patients were recorded at the12th-month follow-up.The mean age of the patients was 37 (22-50) years in Group 1(double-button group) and 39 (24-56) years in Group 2(suture anchor group). All of the patients were male. There was no statistically significant difference between the DASH and Constant-Murley scores of the 2 groups (P > .05). The mean DASH score of the patients evaluated at the postoperative 12th month was 6.65 (0-38.3) in Group 1 and 2.48 (0-4.2) in Group 2. The mean Constant-Murley score of the patients evaluated at the postoperative 12th month was 89,6 (50-98) in Group 1 and 93,6 (90-98) in Group 2. Comparison of the pre- and post-operative CC distances and pre- and post-operative anterior translation distances of both groups revealed that there was no statistically significant difference between groups regarding postoperative CC distances and anterior translation distances (P > .05).Suture anchor and double-button techniques are reliable treatment methods that are not superior to one another and can yield excellent functional outcomes.

Clinical Outcomes of Open Subpectoral Biceps Tenodesis with Cortical Button Fixation

BACKGROUND

Open subpectoral biceps tenodesis (OSBT) with cortical button fixation can deliver acceptable results for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a potential reduced risk of postoperative humeral shaft fracture. However, functional outcomes and complications of a button-only technique with a small diameter tunnel in the subpectoral region have not been studied sufficiently.

PURPOSE

We sought to determine whether OSBT with cortical button fixation results in significant functional improvements from preoperative to final follow-up. The secondary purpose was to determine whether there is a lower risk of major postoperative complications.

METHODS

A retrospective review of patients who underwent OSBT with cortical button fixation at one institution was conducted with objective measurements and clinical outcomes collected with a minimum of 2 years of follow-up. Surgical data was collected for analysis. Objective measures obtained at follow-up included physical exam, strength testing using a handheld dynamometer, and Long-Head of the Biceps score. Clinical outcomes were measured using the following validated questionnaires preoperatively and postoperatively: American Shoulder and Elbow Surgeons score (ASES), Disabilities of the Arm, Shoulder and Hand score (DASH), and Oxford Shoulder Score (OSS).

RESULTS

Sixty-one patients with mean age of 53.1 ± 10.1 years at the time of surgery were enrolled in the study. Mean follow-up time was 42.4 ± 16.9 months (range: 24 to 64 months). The postoperative LHB score was 95.5 ± 6.1 (range: 77 to 100). All functional outcome measures (ASES, DASH, and OSS) demonstrated statistically significant improvements at final follow-up (p < 0.05 for each). At total of 92.5% of patients stated they would have the procedure again if necessary. Mean elbow flexion strength on the operative side measured 98.7% ± 15.9% (range: 74.1% to 142.3%) of the contralateral arm. The mean LHB tendon diameter was 5.7 ± 0.8 mm and mean tunnel diameter was 5.9 ± 0.7 mm. There were no cases of intraoperative or postoperative fracture, infection, or Popeye deformity noted during the follow-up period.

CONCLUSION

Subpectoral biceps tenodesis with cortical button fixation is a safe and effective surgical treatment option to relieve pain and restore function.

Effect of Shoulder Stabilization on Career Length and Performance in National Basketball Association Athletes

PURPOSE

Untreated episodes of shoulder instability can have major consequences on athletic careers. Operative shoulder stabilization reduces the rate of recurrent instability and allows for high rates of return to sport (RTS). Basketball players who experience an episode of instability have high rates of recurrence, though little is known about postoperative player performance. The purpose of this study was to identify the impact of shoulder instability and surgical stabilization on player performance and career lengths in the National Basketball Association (NBA).

METHODS

NBA players who had episodes of shoulder instability between 1994-2014 were identified using the NBA Injury Surveillance and Analytics Database. Players were stratified according to operative versus nonoperative treatment of shoulder instability. Two demographic- and performance-matched controls were chosen for each test subject. Univariate analyses were used to compare pre- and postoperative player performance metrics. Survival analysis was used to assess the effect of shoulder surgery on postoperative career lengths.

RESULTS

Fifty athletes were identified, 46 (92.0%) returned to play in the NBA. Compared to controls, there was no significant difference in postoperative performance according to either 1- or 3-year averages. Survival analysis demonstrated no significant difference in postoperative career lengths between athletes with a history of shoulder surgery for instability and matched controls.

CONCLUSION

NBA players return to professional basketball in high numbers following orthopedic surgery for shoulder instability. Shoulder instability may not be a career-altering event, as there are highly effective methods of shoulder stabilization available to athletes.

Validity and reliability of serratus anterior hand held dynamometry

BACKGROUND

Strength testing of the serratus anterior muscle with hand held dynamometry (HDD) in supine subjects has low reproducibility, and is influenced by compensatory activity of other muscles like the pectoralis major and upper trapezius. Previously, two manual maximum voluntary isometric contraction tests of the serratus anterior muscle were reported that recruited optimal surface electromyography (sEMG) activity in a sitting position. We adapted three manual muscle tests to make them suitable for HHD and investigated their validity and reliability.

METHODS

Twenty-one healthy adults were examined by two assessors in one supine and two seated positions. Each test was repeated twice. Construct validity was determined by evaluating force production (assessed with HHD) in relation to sEMG of the serratus anterior, upper trapezius and pectoralis major muscles, comparing the three test positions. Intra- and interrater reliability were determined by calculating intra-class correlation coefficients (ICC) smallest detectable change (SDC) and standard error of measurement (SEM).

RESULTS

Serratus anterior muscle sEMG activity was most isolated in a seated position with the humerus in 90° anteflexion in the scapular plane. This resulted in the lowest measured force levels in this position with a mean force of 296 N (SEM 15.8 N). Intrarater reliability yielded an ICC of 0.658 (95% CI 0.325; 0.846) and an interrater reliability of 0.277 (95% CI -0.089;0.605). SDC was 127 Newton, SEM 45.8 Newton.

CONCLUSION

The results indicate that validity for strength testing of the serratus anterior muscle is optimal with subjects in a seated position and the shoulder flexed at 90° in the scapular plane. Intrarater reliability is moderate and interrater reliability of this procedure is poor. However the high SDC values make it difficult to use the measurement in repeated measurements.

[Shoulder pain rehabilitation in young athletes]

Early specialisation in sports continues to increase and is a risk factor for the incidence of injuries in young athletes. In overhead athletes, the shoulder is the most affected joint, related to a combination of impingement and glenohumeral instability, as well as musculoskeletal immaturity. Identification of risk factors and rehabilitation is usually an effective recovery option for these athletes.

Managing Shoulder Injuries in the Emergency Department: Fracture, Dislocation, and Overuse

The complex structures of the shoulder can be injured by fracture, dislocation, and overuse, and correctly identifying and classifying injury is essential to avoiding pain, disability, and life- and limb-threatening complications. This issue presents a systematic approach to classifying shoulder injuries based on the mechanism of injury and clinical presentation, choosing appropriate imaging, and determining the best strategies for treatment, including reduction, surgical consultation, or outpatient referral. Newer recommendations on intra-articular versus intravenous analgesia are presented to increase patient comfort and improve reduction outcomes.

[A man with shoulder pain after a survival run]

A 31-year-old man presented with pain of the left shoulder after acute protraction of the shoulder with a forced abduction and exorotation during a survival run. Flexion and abduction were painful, as well as palpation at the medial side of the coracoid process. Isolated rupture of the minor pectoralis muscle was confirmed.

Cross-cultural adaptation of Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score: Reliability and validity in Turkish-speaking overhead athletes

OBJECTIVE

Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC-SES) is a subjective assessment tool to measure functional status of the upper extremities in overhead athletes. The aim was to translate and culturally adapt the KJOC-SES and to evaluate the psychometric properties of the Turkish version (KJOC-SES-Tr) in overhead athletes.

METHODS

The forward and back-translation method was followed. One hundred and twenty-three overhead athletes completed the KJOC-SES-Tr, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the American Shoulder and Elbow Surgeons Evaluation Form (ASES). Participants were assigned to one of the following subgroups: asymptomatic (playing without pain) or symptomatic (playing with pain, or not playing due to pain). Internal consistency, reliability, construct validity, discriminant validity, and content validity of the KJOC-SES-Tr were tested.

RESULTS

The test-retest reliability of the KJOC-SES-Tr was excellent with an interclass coefficient of 0.93. There was a strong correlation between the KJOC-SES-Tr and the DASH and the ASES, indicating that the construct validity was good for all participants. Results of the KJOC-SES-Tr significantly differed between different subgroups and categories of athletes. The floor and ceiling effects were acceptable for symptomatic athletes.

CONCLUSION

The KJOC-SES-Tr was shown to be valid, reliable tool to monitor the return to sports following injuries in athletes.

Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury Than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball

PURPOSE

The primary aims of this work were to (1) describe normal range of motion (ROM) profiles for elite pitchers, (2) describe the characteristics of shoulder and elbow injuries in professional pitchers over a 6-year period in one Major League Baseball organization, and (3) identify ROM measures that were independently associated with a future shoulder or elbow injury.

METHODS

Over 6 seasons (2010-2015), a preseason assessment was performed on all pitchers invited to Major League Baseball Spring Training for a single organization. ROM measures included shoulder flexion, horizontal adduction, external rotation (ER), internal rotation, as well as elbow flexion and extension, were measured for both the dominant and nondominant arm, and total range of motion and deficits were calculated. All noncontact shoulder and elbow injuries were identified. Using multivariate binomial logistic regression analysis to control for age, height, weight, and all other ROM measures, the factors associated with an increased risk of subsequent shoulder or elbow injury were identified.

RESULTS

A total of 53 shoulder (n = 25) and elbow (n = 28) injuries occurred during 132 pitcher seasons (n = 81 pitchers). The most significant categorical risk factor associated with increased elbow injury rates was the presence of a shoulder flexion deficit >5° (odds ratio [OR] 2.83; P = .042). For continuous variables, the risk of elbow injury increased by 7% for each degree of increased shoulder ER deficit (OR 1.07; P = .030) and 9% for each degree of decreased shoulder flexion (OR 1.09; P = .017). None of the measures significantly correlated with shoulder injuries.

CONCLUSIONS

Preseason shoulder ER and flexion deficits are independent risk factors for the development of elbow injuries during the upcoming season. Although prior work has supported the importance of reducing glenohumeral internal rotation deficits in pitchers, this study demonstrates that deficits in shoulder ER and flexion are more significant predictors of subsequent elbow injury.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Heightened clinical utility of smartphone versus body-worn inertial system for shoulder function B-B score

Background

The B-B Score is a straightforward kinematic shoulder function score including only two movements (hand to the Back + lift hand as to change a Bulb) that demonstrated sound measurement properties for patients for various shoulder pathologies. However, the B-B Score results using a smartphone or a reference system have not yet been compared. Provided that the measurement properties are comparable, the use of a smartphone would offer substantial practical advantages. This study investigated the concurrent validity of a smartphone and a reference inertial system for the measurement of the kinematic shoulder function B-B Score.

Methods

Sixty-five patients with shoulder conditions (with rotator cuff conditions, adhesive capsulitis and proximal humerus fracture) and 20 healthy participants were evaluated using a smartphone and a reference inertial system. Measurements were performed twice, alternating between two evaluators. The B-B Score differences between groups, differences between devices, relationship between devices, intra- and inter-evaluator reproducibility were analysed.

Results

The smartphone mean scores (SD) were 94.1 (11.1) for controls and 54.1 (18.3) for patients (P < 0.01). The difference between devices was non-significant for the control (P = 0.16) and the patient group (P = 0.81). The analysis of the relationship between devices showed 0.97 ICC, −0.6 bias and −13.2 to 12.0 limits of agreement (LOA). The smartphone intra-evaluator ICC was 0.92, the bias 1.5 and the LOA −17.4 to 20.3. The smartphone inter-evaluator ICC was 0.92, the bias 1.5 and the LOA −16.9 to 20.0.

Conclusions

The B-B Score results measured with a smartphone were comparable to those of an inertial system. While single measurements diverged in some cases, the intra- and inter-evaluator reproducibility was excellent and was equivalent between devices. The B-B score measured with a smartphone is straightforward and as efficient as a reference inertial system measurement.

Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts

Ice hockey is a fast-paced contact sport that is becoming increasingly popular in North America. More than 1 million men, women, and juniors are playing hockey in the United States and Canada. With players colliding forcefully with one another and with the boards surrounding the ice, injury rates are among the highest in all of competitive sports. Physicians caring for a hockey team should be aware of the more common injuries, involving the head, the neck, and the shoulder. In this review, we discuss evaluation and treatment of these hockey injuries, return to play, and, where applicable, prevention strategies.

Use of Physical Therapists to Identify and Treat Musculoskeletal Injuries at "The Tip of the Trident"

Musculoskeletal injuries continue to be the most common cause of decreased readiness and loss of productivity in all military environments. In commands with smaller footprints, such as Naval Special Warfare (NSW), every asset is critical for mission success. Studies have shown that early intervention by a medical provider can enhance healing and maintain unit readiness by preventing medical evacuations. Reports are limited with regard to Special Forces commands, especially during deployment. This article describes the injury characteristics and treatment of injuries seen by a physical therapist while deployed at forward operation commands embedded with NSW Group 2 Team 4. Over 4 months, 282 patients were evaluated and treated in southeast Afghanistan. In descending order, the three most common injured body regions were the lumbar/sacral spine (n = 82), shoulder (n = 59), and knee (n = 28). Therapy exercises (n = 461) were the most frequently performed treatment modality, followed by mobilization/manipulation (n = 394) and dry needling (n = 176). No patient evaluated was medically evacuated from the area or sent to an advanced medical site. Our data are similar to other published data reported on deployed units in terms of mechanisms and locations of injuries; thus, Special Forces commands do not appear to have unique injury patterns. These results support continued use of physical therapists in forward operations because of their ability to evaluate injuries and provide treatment modalities that help maintain the integrity of small commands at the site of injury.

Wearable IMU for Shoulder Injury Prevention in Overhead Sports

Body-worn inertial sensors have enabled motion capture outside of the laboratory setting. In this work, an inertial measurement unit was attached to the upper arm to track and discriminate between shoulder motion gestures in order to help prevent shoulder over-use injuries in athletics through real-time preventative feedback. We present a detection and classification approach that can be used to count the number of times certain motion gestures occur. The application presented involves tracking baseball throws and volleyball serves, which are common overhead movements that can lead to shoulder and elbow overuse injuries. Eleven subjects are recruited to collect training, testing, and randomized validation data, which include throws, serves, and seven other exercises that serve as a large null class of similar movements, which is analogous to a realistic usage scenario and requires a robust estimator.

Evaluation of three-dimensional scapular kinematics and shoulder function in patients with short malunion of clavicle fractures

BACKGROUND

The presence of short malunion of clavicle fractures could result in alterations in static scapular position and dynamic scapular motion. Nevertheless, no report has ever addressed the kinematic changes of the scapula in patients with short malunion of clavicular fractures. The goal of this study was to compare the changes of shoulder function, and the consequent scapular kinematic changes between the fractured side and the sound side of the shoulder in non-surgically treated patients.

METHODS

Fourteen patients with a short malunion (>10 mm) of midshaft clavicular fracture following conservative treatment were recruited. Outcome analysis included standard clinical follow-up, plain radiography, Shoulder Pain and Disability Index (SPADI) score, shoulder range of motion (ROM), shoulder muscle strength and scapular resting position. The 3-dimensional scapular motion during arm movement in the scapular plane was recorded using an electromagnetic tracking device. The kinematic changes between the fractured side and sound side were analyzed.

RESULTS

The mean shortening length of the clavicle was 12.9 ± 2.8 mm. The fractured sides showed a significantly higher SPADI score and limited ROM in both shoulder flexion and abduction. Significantly weaker shoulder external rotators (1.1 kg, p = 0.017) and lower trapezius (0.7 kg, p = 0.041) were found in the fractured sides when compared with the sound side. The fractured side exhibited significantly more forward shoulder (3.9 mm, p = 0.034) and slightly more anteriorly tilted scapula (5.8°, p = 0.094) in static scapular position. Scapular kinematics showed that the fractured side trended toward greater scapular internal rotation and smaller posterior tilt during arm elevation and lowering phases, especially after the arm rising above horizontal level.

CONCLUSIONS

This study showed that significant changes in scapular kinematics and shoulder function were found after short malunion of clavicle fractures. Recognition and evaluation of the changes could lead to a comprehensive framework regarding the treatment of shortened clavicle fractures.

Acute Shoulder Injuries in Adults

Acute shoulder injuries in adults are often initially managed by family physicians. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acromioclavicular joint injuries and clavicle fractures mostly occur in young adults as the result of a sports injury or direct trauma. Most nondisplaced or minimally displaced injuries can be treated conservatively. Treatment includes pain management, short-term use of a sling for comfort, and physical therapy as needed. Glenohumeral dislocations can result from contact sports, falls, bicycle accidents, and similar high-impact trauma. Patients will usually hold the affected arm in their contralateral hand and have pain with motion and decreased motion at the shoulder. Physical findings may include a palpable humeral head in the axilla or a dimple inferior to the acromion laterally. Reduction maneuvers usually require intra-articular lidocaine or intravenous analgesia. Proximal humerus fractures often occur in older patients after a low-energy fall. Radiography of the shoulder should include a true anteroposterior view of the glenoid, scapular Y view, and axillary view. Most of these fractures can be managed nonoperatively, using a sling, early range-of-motion exercises, and strength training. Rotator cuff tears can cause difficulty with overhead activities or pain that awakens the patient from sleep. On physical examination, patients may be unable to hold the affected arm in an elevated position. It is important to recognize the sometimes subtle signs and symptoms of acute shoulder injuries to ensure proper management and timely referral if necessary.

Acute shoulder injuries: A clinical review of diagnosis and management in the deployed Naval environment

Musculoskeletal injuries of the shoulder are a common presentation in primary care. Injuries to this highly mobile region can have a profound impact on the range of movement, resulting in severe functional limitation. The shoulder can also be one of the more complicated regions to examine due to its high mobility, poor localisation of pain and numerous supporting structures. This article aims to review the anatomy of the shoulder, examination technique and the pathology underlying common acute injuries in order to provide guidance to medical personnel deployed with the Royal Navy and Royal Marines.