Common sports related shoulder injuries

Common sports-related shoulder injuries

S houlder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presen-

tation, assessment and management of these conditions in general practice.

The GP curriculum and common sports-related shoulder injuries

Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In

particular, GPs are expected to be able to: . Communicate health information effectively to promote better outcomes . Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as

barriers to recovery . Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness . Agree treatment goals and facilitate supported self-management, particularly around pain, function and physical

activity . Assess the importance and meaning of the following presenting features:

. pain: nature, location, severity, history of trauma

. variation of symptoms over time

. loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or occupation

. Understand that reducing pain and disability rather than achieving a complete cure could be the goal of treatment

. Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans

. Diagnose common, regional soft-tissue problems that can be managed in primary care

. Understand the challenge that many musculoskeletal conditions might be better and more confidently managed by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills

during their training . Refer those conditions which may benefit from early referral to an orthopaedic surgeon

The four most common categories of shoulder pain

seen in primary care are (Mitchell, Adebajo, Hay, &

Carr, 2005): . Rotator cuff disorders (85% tendinopathy) . Glenohumeral disorders . Acromioclavicular joint disease, and . Referred neck pain.

There are many different types of sports that can cause acute or chronic shoulder injuries. In professional English

Rugby Union, for example, the most common match

injury is of the acromioclavicular joint (32% overall) and

the most severe injury requiring the longest time off

(mean of 81 days) is shoulder dislocation (Headey,

Brooks, & Kemp, 2007).

Shoulder injuries can also occur in non-contact sports,

such as golf, tennis, swimming and weightlifting.

Although shoulder injuries may be more common in con- tact sports, the injury may have a larger impact on the

performance of individuals playing non-contact sports.

For example, golfers require very precise manoeuvres

of their dominant shoulder to swing a golf club with accuracy…

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InnovAiT, 10(1), 30–38 DOI: 10.1177/1755738016678436

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Anatomy ………………………………………………….. The shoulder complex (Fig. 1) consists of the glenohumeral joint, the acromioclavicular joint and the sternoclavicular joint. These work collectively with the scapulothoracic joint to achieve normal shoulder girdle movements.

The glenohumeral joint is a ball-and-socket joint that con- sists of the glenoid cavity, glenoid labrum, glenohumeral ligaments and the joint capsule. These components all articulate with the head of the humerus and the scapula. Four muscles form the rotator cuff that controls move- ments of the glenohumeral joint. The deltoid muscle and the muscles that control the scapula also provide move- ment and stability of the shoulder. These muscles and their primary actions are summarised in Table 1.

History ………………………………………………….. In general practice, a history of the shoulder problem is probably your most helpful tool when trying to formulate a diagnosis. Establish the nature, location, duration, and the exact mechanisms of injury. When asking about the shoulder pain, enquire about locking, clicking, catching, popping, stiffness, swelling, redness, warmth, giving way, night pain, weakness, and paraesthesia. A training history to include frequency, intensity and any changes to training routine may also be relevant.

Ask about any referred pain, and do not forget possible

gastrointestinal or cardiac causes of shoulder pain. Look out for other more sinister features, such as night sweats,

fevers, weight loss and history of cancer.

Common shoulder sports injuries ………………………………………………….. Rotator cuff disorders Rotator cuff tendinopathy is an overuse condition whereby the rotator cuff tendons at a microscopic level

demonstrate hypercellularity, neovascularisation and col- lagen matrix disruption. The tendons are typically swol-

len, but have minimal or absent inflammation (Rees, Maffulli, & Cook, 2009). They mainly occur in sports

that involve overhead movements of the shoulder and patients may report a history of overuse, such as an

increase in training intensity for a competition.

Figure 1. The acromioclavicular joint and associated structures. Reproduced from Brukner P., Khan, K. (2012). Brukner & Khan’s Clinical Sports Medicine (4th ed.), with permission from McGraw-Hill Education. ..

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Table 1. The primary action of the muscles around the scapula and shoulder.

Shoulder muscles Primary actions

Rotator cuff muscles

Supraspinatus Abduction of humerus

Infraspinatus External rotation of humerus

Teres minor External rotation of humerus

Subscapularis Internal rotation of humerus

Other muscles

Deltoid Abduction, flexion and extension of humerus

Trapezius Retracts, elevates, rotates and stabilises scapula

Serratus anterior Protracts and laterally rotates scapula

Rhomboids Retracts and medially rotates scapula

Levator scapulae Elevates scapula

Pectoralis minor Protracts, medially rotates scapula

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Patients typically present with a gradual onset dull shoul- der pain exacerbated by overhead activities or reaching above the shoulder level. They may get symptoms from reaching behind the back and with lifting movements. Night pain can also be a feature, and weakness can develop in late stages (Factor & Dale, 2014).

The rotator cuff muscles or tendons can also tear, espe- cially in older patients. Tears can be partial or full thick- ness, and may present acutely or develop gradually. Other symptoms include night pain, stiffness, weakness and clicking sensations.

Glenoid labral injuries The glenoid labrum is a ring of fibrocartilaginous tissue attached to the rim of the glenoid cavity, it allows the cavity size to be expanded and therefore provide more stability to the joint (Brukner & Khan, 2012). The long head of the biceps brachii tendon attaches to the labrum.

Patients with labral injuries present with pain usually in the posterior aspect of the shoulder exacerbated by overhead activities with associated features of shoulder weakness, popping, catching, and grinding sensations.

Mechanisms of labral injuries include a single traumatic event, such as a direct blow or fall onto the shoulder, a forceful or excessive traction on the labrum, such as drop- ping then catching a heavy object, or repeated micro- trauma to the labrum, such as from cocking the shoulder in throwing sports (Wilk et al., 2005). It is always important to consider a diagnosis of labral injury, as early referral to a shoulder specialist is indicated for best results.

Shoulder instability and dislocation Shoulder instability refers to symptomatic laxity within the glenohumeral joint that can be caused by over- stretched or torn shoulder ligaments, muscles, tendons or labrum. Dislocation occurs when the humeral head no longer sits within the glenoid cavity (i.e. a complete dis- ruption to the joint). A partial disruption to the joint is termed subluxation.

The causes of subluxation or dislocation can be traumatic or atraumatic. Traumatic dislocation is common in ath- letes, and approximately 95% of first time shoulder dis- locations result from a forceful collision, a fall onto an outstretched arm or a sudden twisting movement: 98% of traumatic dislocations occur in an anterior direction. Approximately 5% of dislocations overall are atraumatic in nature, and these individuals may have altered muscle control of the shoulder, capsular laxity, or both (Hayes, Callanan, Walton, Paxinos, & Murrell, 2002).

Patients present with anterior or posterior shoulder pain, visible deformity, popping or catching sensations, weak- ness, unstable feeling and night pains. They may have a history of recurrent dislocations and be involved in

specific high-risk activities, for example, throwing a jav- elin, being a pitcher in baseball or swimming.

Clavicle fracture Clavicle fractures, particularly the mid-third of the clav- icle, are the most common acute shoulder injuries and account for one in twenty adult fractures. Fractures located more laterally can disrupt the acromioclavicular joint. Over 80% of clavicle fractures can be managed conservatively (Quillen, Wuchner, & Hatch, 2004). These injuries usually occur from a fall onto the clavicle or, less frequently, a direct blow to the clavicle.

Patients may be involved with contact sports or other at- risk sports such as horse-riding and cycling. They present with acute localised pain with swelling and sometimes visible deformity. Acute injuries are more likely to present to the hospital Accident & Emergency Department than primary care.

Acromioclavicular joint injury Acute acromioclavicular joint (ACJ) injuries can occur due to a direct force to the acromion typically with the shoul- der adducted, or from an indirect force elsewhere in the body, for example, a fall onto an outstretched arm (Simovitch, Sanders, Ozbaydar, Lavery, & Warner, 2009). Patients present with acute localised pain, swelling and sometimes redness. Injuries can range from a simple acromioclavicular ligament sprain that can be managed conservatively, to ligament tears with ACJ displacement that often require surgery.

Chronic ACJ pain can occur following acute ACJ injuries or from repeated irritation to the joint that can develop into osteolysis or osteoarthritis. These chronic changes can be caused by sports that involve throwing or lifting weights. The symptoms will be similar to acute ACJ, but the pain develops insidiously.

Biceps tendinopathy The biceps brachii muscle has both a short head and a long head. The short head originates from the coracoid process of the scapula, whereas the long head originates from the supraglenoid tubercle of the scapula where it attaches to the superior aspect of the glenoid labrum. The long head of the biceps (LHB) tendon exits the glenohumeral joint and travels through the bicipital groove between the greater and lesser tuberosities.

Biceps tendinopathy usually refers to an overuse injury of the LHB tendon. It has a close relationship with the glenoid labrum and the insertion sites of the rotator cuff tendons. An accurate diagnosis of LHB tendinopathy can therefore be difficult; and other shoulder injuries, such as rotator cuff disease, labral lesions, and shoulder instability, may co-exist (Krupp, Kevern, Gaines, Kotara, & Singleton, 2009). The typical features are gradual onset dull anterior..

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shoulder pain in someone with risk factors for biceps over- use such as weightlifters and bench pressers.

Examination ………………………………………………….. Have a system for examining joints. Several exist; how- ever, the ‘Look, Feel, Move’ system is perhaps the sim- plest. Start by inspecting the shoulder from the front, side and back, looking for any swelling, asymmetry, deformity, skin changes and scarring.

Palpate from the sternoclavicular joint, move laterally to the ACJ, then across the spine of the scapula and along the border of the scapula. It is also important to feel the corac- oid process, humeral head, bicipital groove and surround- ing shoulder musculature for any swelling or tenderness.

It is important to test the range of both passive and active movements of the shoulder in all directions. Table 2 sum- marises ‘normal’ range of shoulder movement (ROM), how- ever, in reality, normal range varies between individuals and it is therefore better to compare ROM with the unaffected side for patients with unilateral shoulder injuries.

Special tests ………………………………………………….. BLISS is a helpful mnemonic to remember which condi- tions to examine for using special tests. It stands for: . B – Biceps tendon . L – Labral . I – ‘Impingement’ . S – ‘Scarf’ (referring to the ACJ), and . S – Stability tests

A systematic review of 45 studies evaluating specific shoulder tests, demonstrated that the diagnostic accuracy for many of these tests is limited (Hegedus et al., 2008). Therefore, special tests should only be used to provide supporting evidence for or against a shoulder injury sus- pected on the basis of history and general examination.

Biceps tendon tests The Yergason’s test and Speed’s test are the two com- monly used tests for biceps tendon pathology. They may also be positive in labral lesions, as the LHB tendon is attached to the labrum. They have low sensitivities (43% and 32%, respectively), but are moderately specific (79% and 75%, respectively). The positive predictive value (PPV) of Yergason’s test and that of Speed’s test is 60% and 50%, respectively, compared with shoulder arthros- copy (Holtby & Razmjou, 2004).

Yergason’s test is performed with the patient’s elbow flexed to the side at 90� with forearm pronated. The patient is then asked to actively supinate the forearm

against the examiner’s resistance. A positive test will elicit pain in the bicipital groove.

Speed’s test is performed with the patient’s elbow extended and forearm supinated. The patient is then asked to elevate (forward flex) their humerus against the examiner’s resistance. A positive test will elicit pain in the bicipital groove.

Labral pathology tests There are a variety of special tests for labral lesions, but a test called ‘Biceps Load 2’ (Fig. 2) has the highest sensi- tivity (89.7%) and specificity (96.9%) with a PPV of 92.1% (Kim, Ha, Ahn, & Choi, 2001). The test is performed with the patient supine, arm abducted to 120� and max- imally externally rotated with elbow flexed at 90� and forearm supinated. The patient is then asked to actively flex his or her elbow against the examiner’s resistance. In a positive test, this manoeuvre should increase or repro- duce the shoulder pain.

Impingement tests Impingement itself is actually a syndrome or clinical sign rather than a specific diagnosis. It is usually due to narrow- ing of the subacromial space, and causes include rotator cuff tendinopathy, rotator cuff calcification, bony spurs under the acromion, and subacromial bursal pathology.

With impingement syndrome, a ‘painful arc’ can be detected when assessing ROM for abduction whereby pain occurs between 60� and 120� degrees of abduction and eases above 120�. The Hawkins–Kennedy test and Neer’s sign are two other tests for impingement that have moderate sensitivities of 79%, and lower specifici- ties of 59% and 53%, respectively (Hegedus et al., 2008).

Table 2. Types of shoulder movement and their ’normal’ range of movement

Types of shoulder movement

‘Normal’ range of movement (degrees)

Forward flexion 180

Extension 50

Abduction 180

Adduction 30

Internal rotation with elbows at the side flexed at 90�

70

External rotation with elbows at the side flexed at 90�

90

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The Hawkins–Kennedy test is performed by the exam- iner taking the patient’s arm into 90� of forward flexion then flexing the patient’s elbow to 90� followed by pas- sive internal rotation of the humerus. A positive test occurs when symptoms are reproduced on passive inter- nal rotation.

Neer’s sign is performed with the examiner stabilising the patient’s scapula, internally rotating the patient’s arm, and passively forward flexing the patient’s arm. A posi- tive test occurs when symptoms are reproduced on pas- sive forward flexion of the arm.

ACJ tests The ‘Scarf’ test, also known as the cross-body adduction test, has a sensitivity of 77%, but only a 20% PPV, for chronic ACJ pathology (Chronopoulos, Kim, Park, Ashenbrenner, & McFarland, 2004). The test is per- formed with the patient’s arm and elbow flexed and then forcibly adducted by the examiner across the chest. A positive test will reproduce pain in the ACJ. There is, however, a far simpler ACJ test. ACJ tenderness on palpation has a sensitivity of 96% and a 52% PPV for chronic ACJ pathology (Walton et al., 2004).

Stability tests The ‘apprehension test’ for anterior shoulder instability has shown sensitivities between 53 and 72% and specifi- cities between 96 and 99% (Biederwolf, 2013). The test is

best performed with the patient supine with arm pos- itioned in 90� abduction with external rotation. The examiner gradually applies more external rotation while observing the patient for apprehension (not just pain alone). Care must be taken when performing this test, as there is a risk of acutely dislocating an unstable shoulder.

A test of postero-inferior instability can be performed with the ‘Jerk’s test’ that has a sensitivity of 73% and specificity of 98% (Biederwolf, 2013). The test is performed with the patient’s arm abducted to 90� with internal rotation while the examiner stabilises the patient’s scapula with one hand and grasps the elbow with the other. The examiner then proceeds to apply an axial load to the humerus while horizontally adducting the patient’s arm across the body (Fig. 3). A positive test is indicated by reproduction of pain, or reproduction of a click or clunk.

Clinical examination findings ………………………………………………….. The clinical signs for each of the common causes of sports-related shoulder pain are summarised in Table 3. It is important to understand that clinical signs may over- lap in different conditions, as the structures within the shoulder are so closely associated with each other. There may also be more than one pathological process occur- ring in the shoulder simultaneously…

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.. Figure 2. Biceps load 2 test with patient lying supine.

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Investigations ………………………………………………….. There are potentially three radiological investigations that can be requested from general practice, although direct access does vary from area to area in the UK. These are X-rays, ultrasound scans, and magnetic resonance ima- ging (MRI).

X-rays In the context of sporting injuries, X-rays are primarily indicated for detecting any bony fractures or disloca- tions. If there is any suspicion of these injuries then the patient needs to be referred for immediate X-ray or, if this is not available, to the local emergency or minor injuries unit.

For rotator cuff disorders, an X-ray is not indicated, but it may reveal calcified tendons. X-ray can be helpful for chronic ACJ injuries as it may show osteoarthritic changes and osteolytic lesions suggestive of a stress fracture.

Ultrasound A meta-analysis of five studies (311 shoulders) that used an ultrasound scan (USS) to diagnose rotator cuff dis- orders found a sensitivity level of 79% and a specificity of 94% (Roy et al., 2015). Ultrasound scanning is, there- fore, a very valuable investigation for rotator cuff disorders.

An USS can also identify pathologies in and around the subacromial space, which is useful if patients have impingement signs. However, before requesting a shoul- der USS, the age of the patient needs to be taken into consideration, as the incidence of asymptomatic rotator cuff tears increases after the age of 40 (Oschman, Janse van Rensburg, Maritz, Boraine, & Owen, 2007).

MRI MRI can be used to evaluate both soft tissue and bony injuries in detail. It is unclear whether MRI is more accur- ate at detecting rotator cuff tendinopathy compared with USS, but both are equally effective in detecting partial or full thickness tears (Gazzola & Bleakney, 2011). Labral injuries can be detected with MRI, but a meta-analysis revealed that magnetic resonance arthrography is super- ior to MRI (Smith, Hilton, Toms, Donell, & Hing, 2011). The cost implications of referring patients for a shoulder MRI need to be carefully considered in general practice, and onward referral to a specialist rather than requesting a MRI maybe a better management option in some cases.

Management ………………………………………………….. Rotator cuff disorder In rotator cuff tendinopathy, it is important to counsel patients about relative rest from the sport or the specific activities that trigger the pain. Non-steroidal anti-inflam- matory drugs (NSAIDs) and application of ice can pro- vide symptomatic relief. Subacromial corticosteroid injections do result in a reduction in pain symptoms, but multiple injections over a short period of time and injection into the tendon itself increases the risk of tendon rupture (Gomoll, Katz, Warner, & Millett, 2004).

Referral to physiotherapy for rotator cuff muscle strengthening and scapulohumeral work is recom- mended for all patients. The treatment of a tear in a rotator cuff is similar to rotator cuff tendinopathy, with the exception that young sports-people with a full thick- ness rotator cuff tear normally require referral for surgical repair (Brukner & Khan, 2012).

Figure 3. Jerk’s test viewed from the side.

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Glenoid labral injuries Conservative management of glenoid labral injuries is usu- ally unsuccessful (Brukner & Khan, 2012). These injuries need to be referred to an orthopaedic shoulder specialist for an arthroscopic repair (reattachment) of the labrum, or, if the labral injury is stable, arthroscopic debridement. Post- operative physiotherapy input is needed to gradually rehabilitate and restore normal shoulder function.

Shoulder instability and dislocation In non-acute atraumatic shoulder instability, physiother- apy referral is required to provide progressive scapular stabilisation exercises, strengthen the rotator cuff mus- cles, and control the glenohumeral translation (Hayes et al., 2002). If physiotherapy is unsuccessful, then cap- sular surgery can be considered.

In acute or traumatic shoulder dislocation, the patient should be referred to the local Accident & Emergency Department for diagnostic X-rays, reduction of the shoul- der with appropriate analgesia, and post-reduction X-rays.

Clavicle fractures Patients with a clavicle fracture need analgesia and prompt referral to the Accident & Emergency Department for X-rays. If there is low risk of clavicle foreshortening then a broad arm sling (or figure-of- eight bandage) is usually applied, and the fracture grad- ually heals over a month or so. Surgical intervention is indicated if there is a risk of clavicle foreshortening, delayed union, or non-union.

ACJ injuries In acute ACJ injuries, patients should be given analgesia and a sling for immobilisation if available. If an ACJ sprain is suspected, then it may be reasonable to treat with ice, analgesia, and immobilisation followed by a review 48 hours after the acute episode. If the ACJ appears deformed, the pain is difficult to control, or there is uncer- tainty about the degree of ACJ injury, then referral to the Accident & Emergency Department or to the on-call

Table 3. Sports-related shoulder conditions and their possible clinical signs.

Condition Possible clinical signs

Rotator cuff tendinopathy

. Asymmetry and muscle wasting

. Palpation tenderness at the greater tubercle (insertion sites of three rotator cuff muscles)

. Reduced active ROM

. Passive ROM intact

. Reduced power on resisted movements

. Impingement signs

Rotator cuff tears

. Shoulder shrug appearance

. Partial or no active ROM

. Passive ROM often intact

. Reduced power on resisted movements

. Drop-arm sign in complete tears if arm cannot be actively maintained at 90� abduction

. Impingement signs

Glenoid labral injury

. Palpation tenderness in the anterior shoulder structures

. Swelling if acute

. Reduced external rotation and or abduction ROM

. Reduced power on resisted movements

. Biceps load 2 test positive if superior labrum anterior posterior (SLAP) tear

. Speed’s test positive if SLAP

. Yergason’s test positive if SLAP

. Jerk’s test positive if postero- inferior labral injury

Shoulder instability and dislocation

. Prominent humeral head if anter- ior dislocation

. Swelling if acute

. Reduced active and passive ROM if dislocated

. Increased active or passive ROM if instability with laxity

. Apprehension test positive if anterior dislocation

. Jerk’s test positive if postero- inferior dislocation

. Upper arm axillary nerve sensa- tion can be reduced in anterior dislocations

Clavicle fracture

. Localised swelling with deformity

. Clavicle shortened or angulated

. Localised bony tenderness

(continued)

Table 3. Continued.

Condition Possible clinical signs

ACJ injury . Step deformity and swelling if acute

. Localised ACJ tenderness

. Scarf test positive

. Impingement signs if chronic

Biceps tendinopathy

. Bicipital groove tenderness

. Speed’s test positive

. Yergason’s test positive

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orthopaedic team is appropriate. Surgery is indicated for tears in both the acromioclavicular and coracoclavicular ligaments with displacement of the clavicle (Tauber, 2013).

The management of chronic ACJ injuries requires relative rest and activity modification, such as reducing the weight load when bench pressing. NSAIDs and cortico- steroid injections into the ACJ can have therapeutic benefits, particularly in younger patients (Hossain, Ayekoloye, Odumala, & Jacobs, 2003). Referral to physiotherapy for range of motion and strength training can aid recovery. In chronic persistent ACJ pain, ortho- paedic referral for consideration of surgical excision of the distal clavicle may be necessary.

Biceps tendinopathy Initial treatment of biceps tendinopathy involves a period of relative rest, withdrawal from exacerbating activities, ice and NSAIDs. The next step is referral for physiother- apy rehabilitation that involves restoration of passive biceps ROM, followed by active biceps ROM exercises, and then finally rotator cuff strengthening. If symptoms fail to respond after 6–8 weeks of conservative measures then corticosteroid injections into the subacromial space can be beneficial, and in resistant cases, injections into the biceps tendon sheath can be tried (Krupp et al., 2009). There are a variety of surgical options for biceps tendinopathy, such as decompression, debridement, ten- otomy and tendon transfer, but choice of procedure is a specialist decision.

Specialist referral ………………………………………………….. Patients presenting acutely with sports-related injuries who have severe pain, and/or symptoms in keeping with acute bony injury or joint dislocation should be referred for immediate Accident & Emergency Department review.

Most other sports-related shoulder injuries can be man- aged in primary care with rest, ice, analgesia, physiother- apy and possible local steroid injection. Specialist sports physiotherapy input can be helpful if available and may be particularly useful in helping patients to avoid repeat injury when they return to their sport.

Consider specialist orthopaedic referral if: . No clear cause of the patient’s pain can be found –

this referral should be urgent if the patient has a past history of cancer, the pain is worsening, or the pain is associated with any constitutional symptoms such as night sweats or raised erythrocyte sedimentation rate

. Pain is not resolving despite conservative measures in primary care

. The patient is young (under 40 years) and is found to have a full thickness rotator cuff tear on imaging

. The patient has a glenoid labral tear

Key points . Sports-related shoulder injuries are common and

can cause both acute and chronic symptoms . A concise history and a targeted examination is

essential for initial diagnosis of sports-related shoulder injuries in primary care

. Special tests in the examination of sports-related shoulder injuries are useful only to provide sup- porting evidence for a specific suspected injury

. X-ray, USS and MRI may all be useful in further evaluation of patients with sports-related shoulder pain depending on local availability

. The majority of patients with sports-related shoul- der injuries can be managed in primary care; some acute injuries will require prompt referral to the Accident and Emergency Department for further imaging and immediate management

. Refer to an orthopaedic shoulder specialist if the diagnosis is unclear, the symptoms fail to settle with primary care management, if the patient is young and has a full-thickness rotator cuff tear, or if the patient has a glenoid labral tear

References and further information

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. Brukner, P., & Khan, K. (2012). Brukner & Khan’s clinical sports medicine, fourth edition. New York: McGraw-Hill Medical

. Chronopoulos, E., Kim, T. K., Park, H. B., Ashenbrenner, D., & McFarland, E. G. (2004). Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. American Journal of Sports Medicine, 32(3), 655–661. doi: 10.1177/0363546503261723

. Factor, D., & Dale, B. (2014). Current concepts of rotator cuff tendinopathy. International Journal of Sports Physical Therapy, 9(2), 274–288. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/ PMC4004132/

. Gazzola, S., & Bleakney, R. R. (2011). Current ima- ging of the rotator cuff. Sports Medicine and Arthroscopy Review, 19(3), 300–309. doi: 10.1097/JSA.0b013e3182189468

. Gladstone, J. N., & Rosen, A. L. (1999). Disorders of the acromioclavicular joint. Current Opinion in Orthopaedics, 10(4), 316–321. doi: 10.1097/ 00001433-199908000-00011

. Gomoll, A. H., Katz, J. N., Warner, J. J., & Millett, P. J. (2004). Rotator cuff disorders: Recognition and management among patients with shoulder pain. Arthritis and Rheumatism, 50(12), 3751–3761. doi: 10.1002/art.20668..

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. Krupp, R. J., Kevern, M. A., Gaines, M. D., Kotara, S., & Singleton, S. B. (2009). Long head of the biceps tendon pain: Differential diagnosis and treatment. Journal of Orthopaedic Sports Physical Therapy, 39(2), 55–70. doi: 10.2519/ jospt.2009.2802

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. Tauber, M. (2013). Management of acute acromio- clavicular joint dislocations: Current concepts. Archives of Orthopaedic and Trauma Surgery, 7(133), 985–995. doi: 10.1007/s00402-013-1748-z

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Dr Raymond Leung Freelance Locum GP, Sutton United Football Club Doctor, MSc student in Sports and Exercise Medicine, London Email: [email protected]

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