Understanding Shoulder Injuries: When is Surgery Necessary?
Lets Discuss the most common injuries in the upper body and when surgery is needed
Glenohumeral Joint Dislocations
Anterior dislocations are the most common direction of dislocation, comprising up to 97% of shoulder dislocations, and require emergent reduction
The most common lesions are of the anterior-inferior labrum (Bankart lesion) and of the posterior superior humeral head (Hill-Sachs lesion).
Anterior shoulder dislocations occur when the arm is in an abducted and externally rotated position and an anterior force is applied to the shoulder.
We see patients come into the office with the arm adducted and internally rotated.
Posterior shoulder dislocations occur more commonly due to a fall from height or motor vehicle accident with a posterior force directed to the shoulder with the arm in extension.
Summary of Shoulder Injuries in Sports and When to have surgery, and what happens if you delay surgery
Treatment
Recurrence rates have been noted to be greater than 75% within at-risk populations without operative treatment.
There are a multitude of described reduction techniques, though no optimal maneuver has been established.
Traction-counter traction is commonly used, as is the Stimson maneuver which involves hanging weight from the affected arm while the patient is in the prone position
THEN came back to the chiropractic office to work on rehab of the shoulder and the rotator cuff muscles.
Acute Traumatic Rotator Cuff Tears
Epidemiology
Acute traumatic rotator cuff tears (ATRCT) are generally accepted to be injuries to the rotator cuff due to a specific event within the prior 6 months.
Patients with Acute Traumatic Rotator Cuff Tears are typically younger relative to patients with degenerative tears with an average age of 55, and are more commonly male.
Typical injury mechanisms include forced abduction and external rotation, glenohumeral dislocation, or fall on an outstretched hand.
Treatment
Surgical treatment for patients with full-thickness ATRCTs >10mm has better long-term functional outcomes when compared to conservative management
If proceeding with conservative management, the recommendation is for repeat advanced imaging at 12-18 months to evaluate tear progression and muscle atrophy.
Sternoclavicular Joint Dislocation
Sternoclavicular (SC) joint dislocations are rare injuries occurring in less than 3% of shoulder girdle injuries. Dislocations occur more than 80% of the time during sports participation through both direct and indirect mechanisms, predominantly in contact athletes, and occur in less than 1% of severely injured trauma patients
Symptoms to monitor for include dyspnea, dysphonia, dysphagia, odynophagia, neurological dysfunction, or vascular congestion
Treatment
Immediate stabilising procedures depend on presenting symptoms and severity of injury. In low-grade sprains (Allman grade 1-2 injuries), sling immobilisation from 1-6 weeks is advised. Failure to reduce SC dislocations, however, has been associated with poor outcomes
Pectoralis Major Rupture
Epidemiology
Rupture of the pectoralis major tendon has become increasingly prevalent in the last few decades.
The mechanism of pectoralis major rupture often occurs with forced abduction and external rotation.
Tears can occur at the humeral insertion, musculotendinous junction, or the muscle belly. The tears reported at the humeral insertion site are often complete
Treatment
The location of the tear, the extent of the tear (partial or full), and clinical picture of the patient are the guide operative versus nonoperative treatment with young active individuals being more likely to benefit from operative intervention
Partial tears can be repaired surgically with success for those who wish to maintain full strength and continue high activity levels.
Distal Biceps Rupture
Epidemiology
This injury predominantly occurs in middle-aged males and has an increased associated risk among smokers and anabolic steroid users.
Typically an avulsion of the distal biceps tendon occurs when an eccentric load is placed against a flexed elbow.
Patients may report hearing an audible pop with pain over the anterior elbow and experience decreased strength in supination and flexion.
On our patients, most will come with Popeye deformity due to the tendon rapture
Treatment
For the majority of distal biceps tendon ruptures, surgical treatment is recommended. Non-operative treatment of distal biceps rupture results in a loss of 40% of supination strength and 30% of flexion strength and is reserved for patients who are poor surgical candidates or in low-demand.
Outcomes after surgical repair of distal biceps rupture demonstrate a return to pre-injury levels of flexion and supination strength, a 97.5% return to sport amongst athletes, and a low rate of re-rupture (1.5%).
Triceps Rupture
Epidemiology
Rupture of the distal triceps tendon is rare, estimated at about 1% of all tendon ruptures.
Most reports have been associated with anabolic steroid use, weightlifting, and laceration, however, chronic systemic illnesses associated with tendon weakening have also been described as commonly occurring with forceful eccentric contractions such as bench pressing or fall on an outstretched hand.
Treatment
Treatment of these injuries should be individualized to the patient’s functional and medical status and injury severity.
Partial ruptures with intact extensor mechanisms may be treated non-operatively with splint immobilization for four weeks.
Urgent primary repair is indicated for most active patients or patients with complete tears and extension weakness.
Injury | Complications of Delayed Intervention | Special Considerations and Recommendations |
Irreducible/Locked Glenohumeral Joint Dislocation |
| Surgery should proceed within 24-48 hoursfor patients presenting with an irreducible/locked dislocation. |
Acute Traumatic Rotator Cuff Tear |
| Surgery should proceed within 3 weeks. Surgery may not be necessary in patients with smaller partial-thickness tears. |
Sternoclavicular Joint Dislocation |
| Surgery should proceed within 48 hours if closed reduction fails. More urgent surgery warranted with locked posterior dislocation compromising airway or vascular structures. |
Type 4-6 Acromioclavicular Injury |
| Surgery should proceed within 3-4 weeks. |
Pectoralis Major Rupture |
| Surgery should proceed within 6-8 weeks. |
Distal Biceps Rupture |
| Surgery should proceed within 4-6 weeks. |
Triceps Rupture |
| Surgery should proceed within 2-3 weeks. |
For more information about how we can help. Please call Health Wise Chiropractic 03 9467 7889 or book online to see one of our Chiropractors in Sunbury or Melton/Strathtulloh Today!
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Reference
Rosenthal RM, Featherall J, Putko RM, McGlone PJ, Feeley SM, Panarello NM, Lilley BM, Rabin S, Lewis DC, Parkes CW, Sanderson RL, Waltz RA, Ernat JJ. Time-sensitive injuries for the sports medicine surgeon - "Sports Medicine Trauma", Part 1: Upper Extremity. Orthop Rev (Pavia). 2024 Dec 7;16:126704. doi: 10.52965/001c.126704. PMID: 39654631; PMCID: PMC11627319.
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