Upper Limb Injuries

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SHOULDER INJURIES

SUBACROMIAL PROBLEMS – ROTATOR CUFF TENDINOPATHY AND BURSITIS

Movement around the shoulder is a fairly complex combination of rotations of the glenohumeral joint, (the joint at the end of the upper arm and shoulder blade) the scapula (shoulder blade) the joints around the clavicle and even the thoracic spine.

In order for it to achieve this movement the shoulder has to sacrifice stability for mobility. Some of the stability is provided by a cuff of muscles around the shoulder joint itself (the glenohumeral joint). These muscles also help in the movements of the shoulder but due to the tight configuration of the tendons looping under the acromial arch – a tunnel formed by the clavicle and the scapula – this can become sore and inflamed and is one of the commonest causes of shoulder pain, so-called rotator cuff tendinopathy/supraspinatus tendinopathy or inflammation of the subacromial bursa (a fluid filled ‘shock absorber’ to protect the tendons).

Treatment has traditionally involved corticosteroid and local anaesthetic injection into the space around the tendons or into the bursa. This can be valuable in reducing pain in the short term but identifying and treating the cause perhaps through physiotherapy or altering sport technique or work practices can both cure and prevent future recurrence.

SCAPULAR STABILITY AND SHOULDER IMPINGEMENT

The alignment of the joint surface of the scapula – the glenoid – can be critical in avoiding shoulder impingement, where the rotator cuff muscles get pinched as they go under the acromial arch. An important element to correct this is teaching the body how to better align the scapula through strengthening and balancing of the muscles that control its movement. This allows the shoulder blade to be correctly aligned, particularly in overhead movements and sporting action such as swimming, throwing and racquet sports such as tennis and badminton.

BICEPS INJURIES, SLAP LESIONS AND LABRAL TEARS

Occasionally the biceps tendon, attached to the cartilaginous rim of the glenoid (the socket joint on the shoulder blade), can pull off this rim of cartilage which stabilises the shoulder, a so-called SLAP lesion or labral tear. Clicking and discomfort in the shoulder characterises this condition and it is sometime difficult to diagnose without a special MRI where dye is injected into the joint.

Chronic overload or friction of the biceps tendon can eventually lead to snapping of one of the two tendons of this muscle – biceps tendon rupture. This relatively benign but uncomfortable event leads to a ‘Popeye’ deformity of the biceps muscle with a prominent lump when flexing the muscle. A reasonable level of power will eventually return over the coming months as the muscle compensates for this injury. Surgical repair rarely improves the situation – physiotherapy and training being the mainstay of treatment.

ACROMIOCLAVICULAR JOINT PROBLEMS

A fall on the shoulder or excessive loading such as weight training can lead to a localised injury to the joint at the end of the clavicle where it joins the shoulder blade – the acromioclavicular joint (ACJ). This joint relies heavily on ligaments which may rupture when falling onto the point of the shoulder. Minor disruption can be successfully be treated without surgery but when completely disrupted, this may need a repair of the ligament complex.

Arthritis is not uncommon in this joint and can occur surprisingly early in dedicated weight lifters.

THE GLENOHUMERAL JOINT

The glenohumeral joint is the joint articulating the upper arm with the shoulder blade. By virtue of its wide range of movement, it is susceptible to ligament injury and even dislocation. Once dislocated it can become permanently unstable and require surgery. Sometimes through over stretching, as in repetitive throwing or tennis and other racquet sports, the capsule of the joint and its surrounding ligaments become loose and allow excessive movement and pain in the joint. In this situation, surgery is not often the best course of action – physiotherapy, adjusting sporting technique and strengthening of the muscles is the better course of action.

The glenohumeral joint can occasional become very stiff and remain so for a year to 18 months – a frozen shoulder. This responds poorly to most interventions. Sometimes early injection of corticosteroid helps. Surgery has been tried with variable results. Physiotherapy and patience is often the best course of action.

When this stiffness is more generally associated with pain it is important to differentiate frozen shoulder from an acutely inflamed rotator cuff tendon or arthritis. If arthritis is the main problem then sometimes a corticosteroid or other injection can be of benefit.

ELBOW INJURIES

The elbow joint is a complexly engineered joint where the stability of the joint relies heavily on the bony architecture and ligaments rather than the strength of the muscles around it. Movements at the elbow allows the forearm to bend and rotate and is key to the complex movement we have in many of our day to day and sporting activities. Key muscle groups attach around the elbow – the flexors – allow grip strength around the wrist and hand and attach to the inner or medial epicondyl (common flexor origin CFO). The common extensor origin (CEO) is situated on the outer latela epicondyle, its muscles allowing stability when gripping and straightening the wrist and fingers.

LATERAL EPICONDYLITIS – TENNIS ELBOW

This is a fairly common condition seen in sport but also commonly in people using a computer or in those using tools such as a screwdriver. Sports requiring a tight grip are common culprits. Localised pain in the area was traditionally treated by corticosteroid injection and although still fairly commonly done and effective in the short term may not be an effective long-term therapy. Understanding the underlying cause and treating it – be it at work or in sporting action is key to success.

LITTLE LEAGUERS ELBOW

In younger players a separation of the growth plate at the CEO muscle attachment around the inner part of the elbow – known as Little Leaguers Elbow (first described in players of the American junior baseball game). This can be associated with a disruption of the radial head joint as it is compressed on the other side.

MEDIAL EPICONDILITIS – GOLFERS ELBOW

The condition attributed to golf injuries is probably more commonly seen in tennis! In golf it may be due to grounding the stroke and more often seen after playing on hard ground or off mats. Again, correcting the cause is the key to successful treatment

RADIAL HEAD ARTHRITIS OR OSTEOCHONDRITIS

Damage to the head of the radius can occur after acute or old injury – a missed fracture following a fall onto an outstretched arm can lead to a deflected position of the joint and result in early wear. Overuse such as in a thrower or tennis player can put excessive strain on this area and lead to damage to the joint. Careful diagnosis is key to managing this condition and a careful plan of action to treat and prevent is important.

OLECRNAON BURSITIS

The joint at the back of the elbow can abut and squeeze the soft tissue between the bones of the forearm and upper arm. This is most commonly seen where sporting or other action involves snapping the elbow straight. Inexperienced karate or boxing competitors can commonly experience this.

ULNAR NERVE ENTRAPMENT

Close to the CEO is the ulnar nerve – the culprit of the discomfort felt when hitting your ‘funny bone’. Pain is often experienced down the arm into the little fingers – the distribution of this nerve and weakness of grip can result. Looking for a cause is important when managing this condition and sometimes moving the nerve surgically can improve symptoms.

WRIST HAND AND FINGER INJURIES

Direct trauma is probably the most common cause of wrist and hand injuries although some important conditions involving overuse or ‘repetitive strain’ can occur in this area in response to overuse of the tendons.

The carpal bones make up a complex joint of many bones – the bones and the ligaments holding the joints together can be damaged in falls or when punching in boxing or karate and other martial arts. The scaphoid is a common bone to injure. The injuries can sometimes be difficult to visualise and require more specialist imaging such as a CT or MRI to look for damage.

TRIGGER FINGER

Sometimes a tendon can become inflamed as it goes through a pulley in the hand and results in the finger sticking when you attempt to straighten it. This is often successfully treated by a small steroid injection

MALLET FINGER DEFORMITY

An important condition not to miss is when the tendon on the end joint of the finger is abruptly pulled off when a finger is stubbed such as when trying to catch a ball in sport. The end of the finger drops – it is important to splint this at an early stage to avoid later problems.

RACQUET SPORT INJURIES

Tennis and other racquet sports utilise a movement pattern closely associate with a throwing action. These activities are often repeated for hours on end and result in a number of overuse injuries

• supraspinatus and other rotator cuff tendinopthy
• subacromial bursitis
• ACJ disruption
• shoulder instability
• medial and lateral epicondylitis
• Little Leaguers elbow

Scapular stability training plays an important role in preventing injuries and is a key element used in good tennis academies to prevent shoulder and elbow injuries. The shoulder is not the only area to suffer in tennis players, particularly those on the circuit or who play many hours of the sport.

Injury to the lateral epicondyle (tennis elbow) is traditionally cited as an important injury. This can be the result of poor grip technique, playing with an old or heavy racquet, particularly if the grip size is incorrect), playing with wet tennis balls and poor technique. Players using more forehand topspin may experience medial epicondylits or, in younger players, Little Leaguers Elbow.

The sports doctor, working with coaches, strength and conditioning practitioners, physiotherapists and others can direct a course of preventative interventions that will hopefully settle the problem down and save months of discomfort.

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