Clinical Conditions

        If you have explored the previous sections discussing the pectoral girdle, its bony structures, articulations, and musculature, you might have realized that this could be a vulnerable area. As the shoulder is the body’s most mobile joint, it comes at the cost of structural integrity. Many of the conditions we will go over in this section are a direct result of this mobility that is abnormal to other joints. Take for example the elbow, which is considered a “hinge” joint (you will learn more about this joint’s clinical conditions later in this section), it is a uniaxial joint. This means that the elbow just moves in one plane; this only allows for flexion and extension in the sagittal plane. Compare that to the shoulder joint which is a triaxial joint, allowing for many more actions. This illustrates the complexity of the joint and the possible complications that arise from such complexity.

Shoulder Separation

Definition:

A common clinical condition for both athletes and normal individuals alike is a shoulder separation. When discussing shoulder separations we generally mean a dislocation of the acromioclavicular joint, causing its “separation”. A separation does not always imply a tear in the ligaments reinforcing the acromioclavicular joint, but rather it could be a strain or even just a partial tear. This injury results in the clavicle separating from the acromion process, shifting upwards, while the acromion and the scapula is depressed.

Symptoms:

• Pain at the moment the injury occurs
• Limited movement in the shoulder are (typically due to pain)
• Swelling and/or Bruising
• Tenderness over acromioclavicular joint
• Possible deformity

Cause:

This could occur as a result of trauma to the area, a fall, or a blow to the shoulder; imagine a block or a tackle went wrong during a football game.

Treatment & Surgical Intervention:

Generally this injury is not treated with surgery, but in some severe conditions surgery may be necessary. As such the injury is graded to assess the severity of the condition. Grades 1 through 3 are the most common forms of the injury, where grade 1 is a slight displacement, grade 2 is a partial dislocation and grade 3 is a complete dislocation; during partial separation only the acromioclavicular ligaments are torn, while a complete separation means both the acromioclavicular and coracoclavicular ligaments are torn. While grades 4 to 6 require surgery, due to the amount of damage to the whole area. Depending on the severity of the injury physical therapy is often a rehabilitative therapy doctors will prescribe.

Sternoclavicular Dislocation

Definition:

A similar injury to an acromioclavicular joint separation, is the sternoclavicular joint dislocation. Although this injury is much less common, it could entail more severe consequences. This injury is also brought about as a result of severe trauma to the region. It could mean either an anterior dislocation of the clavicle, or a posterior dislocation of the clavicle.

Symptoms:

• Pain in area where the sternum and clavicle meet
• Swelling, bruising or tenderness over the joint
• Limited range of motion in the arm

Cause:

The more common form of sternoclavicular joint dislocation is the anterior dislocation of the clavicle, where a blow to the lateral anterior area of the pectoral girdle rotating it backwards, shifting the clavicle anteriorly. Whereas, a posterior dislocation of the clavicle could come about as a direct blow to the articulation between the clavicle and the sternal region; this is a more severe form of the injury because of the damage it could entail to the deeper structures in the region, such as the trachea, and great blood vessels passing through this area. This injury is also graded in 3 degrees of severity. The first degree could be a simple sprain which involves a partial tear of the sternoclavicular and costoclavicular ligaments; this is the most common degree of damage. The second degree is a sublux of the clavicle from its sternal attachment either in the anterior or posterior direction, this means that the joint partially dislocates; this causes a complete tear of the sternoclavicular ligaments, but only a partial tear of the stronger costoclavicular ligament. The third and final degree of severity of this injury is a complete rupture of the sternoclavicular and costoclavicular ligaments, which results in a complete dislocation of the clavicle from the manubrium.

Treatment & Surgical Interventions:

Most clinicians can solve this problem through the fixation of the joint back in its location and overtime the injury will settle, but in the more severe cases surgery becomes necessary.

Glenohumeral Joint Dislocation

Definition:

glenohumeral joint dislocation, commonly referred to as a shoulder dislocation. A glenohumeral dislocation is when the head of the humerus comes out of the glenoid cavity and the surrounding structures. There are 4 types of glenohumeral dislocations, an anterior, a posterior, a superior and an inferior dislocation. Another case where a dislocation may occur, is the tearing of the glenohumeral ligament from the humeral head; clinicians refer to this as the HAGL lesion (meaning abnormal change in structure); HAGL stands for humeral avulsion (meaning tearing) of the glenohumeral ligament. There is also a form of dislocation of the glenohumeral joint that is called a Hill-Sachs lesion, where the humeral head again loses part of its articulation with the glenoid cavity because of a tear in the medial portion of the glenohumeral ligament.

Symptoms:

• Pain in the joint, leaving the arm feeling heavy
• Swelling and/or buising
• Inability to move the joint comfortably
• A visible deformity or out-of-place shoulder

Causes:

The most common cause of this injury is a fall with an outstretched arm or a fall on the shoulder itself. The most common form of this dislocation, is the anterior inferior dislocation of the humeral head, causing a tear in the glenoid labrum surrounding the glenoid cavity.

Treatment & Surgical Interventions:

These dislocations generally are repaired with surgery, although unfortunately the joint becomes highly prone to being re injured after the first dislocation, even if treated properly. This is because the surrounding structures become much more relaxed after the first dislocation to mitigate some of the pain that comes along with the dislocation the first time around. These complications lead to other clinical conditions.

Rotator Cuff Tear

Definition:

The glenohumeral joint is greatly supported by the rotator cuff group of muscles. As a reference, this group consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. A tear of the rotator cuff is generally classified from small to massive. A small tear is up to 1 cm, medium is 1 cm to 3 cm, large is 3 cm to 5 cm, and finally massive is anything above 5 cm, and it could extend across multiple tendons.

Symptoms:

• Dull aches, and pains deep in the shoulder
• Disturb sleep, especially if lying on the affected shoulder
• Arm weakness, little to know circumduction can occur at this joint

Cause:

A rotator cuff tear is the most common in the older population, as their muscles begin to atrophy (meaning lose size and therefore strength), they can no longer enforce the glenohumeral joint like they’re supposed to. This injury can still occur in a young individual in cases of trauma; a strong enough blow to the region, and repeated use or overuse are the most common causes in this demographic.

Treatment & Surgical Interventions:

Treatment consists of a combination of physical therapy and anti-inflammatories ranging from a simple ibuprofen regularly, to a corticosteroid injection in some cases. In the more severe forms of the injury, surgery becomes necessary as other conservative treatments will show no progress and prolong the patient’s recovery.

Medial Epicondylitis

Definition:
Commonly known as golfers elbow and pitchers elbow.  It occurs with repetitive lateral to medial movements of the wrist or repetitive flexion at the wrist.  As a result, there is an overload on the common tendon. In medial epicondylitis, micro tearing is occurring, and the tendon degenerates instead of repairs.  Due to it being an overuse injury the majority of the people suffering from it are professionals who do repetitive motion daily (carpenters, plumbers, etc.).

Symptoms:

• Pain on the inside of your elbow, that radiates down the wrist
• Elbow stiffness
• Hand and wrist weakness
• Tingling sensation or numbness in the fingers
• Difficulty moving the elbow

Causes:
It develops when the muscles of the forearm with the common insertion on the medial epicondyle of the humerus. Resulting in pain on the ulnar side of the forearm, the wrist and occasionally the fingers.

Treatment & Surgical Interventions:
 The first step is to reduce or stop the movement that is causing discomfort to reduce swelling, next is to start building strength back into the muscles by going through the full range of motion of the wrist.  Following this stage, it is important to look at the athlete or professional and look at their equipment or technique to identify how the problem arose in the first place and mend this issue to prevent it from happening in the future.

Lateral Epicondylitis

Definition:
Lateral epicondylitis is also commonly known as tennis elbow. Tennis elbow is the inflammation of the tendons that join the forearm muscles on the lateral bony feature of the elbow. The forearm muscles and tendons become damaged from overuse, this is a result of repeating the same motion over and over again. Which leads to pain and tenderness on the outside of the elbow.

Symptoms:

• The initial pain is mild, and slowly worsens and spreads
• Burning sensation
• Weak grip strength
• Elbow stiffness
• Pain when supinating and pronation forearm

Cause:
This injury is caused by overuse of the extensors of the forearm, and may additionally be from supination and pronation.  This injury can occur a lot in people that use their computers a lot as it keeps your wrist in a state of flexion. Injuries occur on the lateral side at least five times as often as the medial side.  If present in a given sport or activity these factors significantly raise the risk of becoming injured; handling tools more than 1 kilo (2.2 pounds), handling loads over 20kg (44.4 pounds) more than 10 times a day or completing the same task for more than two hours a day.  The cause of this can be inflammation, micro-tearing or a degenerative process.

Treatment & Surgical Intervention:
Rest is the first step in recovery, and frequently the most overlooked. It is important that the individual stops participation in sports or heavy work activities. The use of physical therapy and specific exercises are helpful for strengthening the muscles of the forearm. When symptoms don’t respond after 6 to 12 months of treatment, doctors may recommend surgery.

Carpal Tunnel Syndrome

Definition:
Anteriorly supported by the flexor retinaculum and posteriorly by the carpal bones, the carpal tunnel is a narrow passageway by which the long flexor tendons of the digits and median nerve traverse. This narrow inlet is an area of vulnerability, and the compression of the structures results in a condition called carpal tunnel syndrome. Compression of the median nerve results weakness, pain, and sensory changes of the thenar eminence. Causes of this condition generally include repetitive activities, infection/trauma, fluid retention, and inflammation of the tendon sheaths. Treatment options include: taking anti-inflammatory medications, corticosteroid injections, wearing a wrist splint, and surgical intervention.

Ulnar Neuropathy

Definition:
Commonly referred to as cyclist’s palsy, ulnar neuropathy is a fairly typical affliction prevalent with the long distance cycling aficionados. Due to the pressure exerted on the handlebars, the ulnar nerve becomes irritated and compressed.

Symptoms:

• Numbness and tingling
• Clumsiness
• Cramping
• Pain that radiates up the arm

Causes:
The position of the cyclist’s body attributes to the condition whereby most cyclists tend to ride with hyperextended wrists, stretching and compressing the nerve as it travels through the wrist into the hand.

Treatment & Surgical Interventions:
Options include seeking a physiotherapist, active rehabilitation, modifying bike set-up, corticosteroid injection, and the list goes on.

Dupuytren’s Contracture

Definition:
Dupuytren’s contracture is a hereditary condition that results in an abnormal thickening of the tissue between the tendons in the palm and the skin. A contracture is an abnormal shortening of tissue that affects the range of motion. This gradually can limit the function of the fingers in the affected area, and cause the fingers to be pulled in flexion towards the palm. Eventually making it impossible to extend the digits fully.

Symptoms:

• Small nodule on the palm, most commonly located closest to the base of the little and ring fingers.
• Sensitive to touch the area affected
• Develop over years
• Inability to fully extend fingers
• Dimples or lumps appear in the palm, with the skin puckering over these areas

Causes:
Studies show that the condition commonly affects people from Northern Europe. Other possible causes include alcohol consumption, older age, and specific genes. Lastly, those with diabetes and epilepsy are at a higher risk for developing Dupuytren’s contracture.

Treatment & Surgical Interventions:
Nonsurgical options are such as collegians injections which most effective in the early stages, or formation of the nodule. It should be noted that surgical intervention is only a temporary solution to restore function back to the fingers. With the surgery only removing or loosening the cords in the hand.

De Quervain’s Tenosynovitis

Definition:
De Quervain is a condition related to the irritation and swelling of the sheath or tunnel that surrounds the tendons of the thumb – as they pass from wrist to the thumb.

Symptoms:

Symptoms can get worse with activity, and pain can radiate up the forearm. Common Symptoms include:

• Pain near the base of the thumb
• Swelling at the base of the thumb
• Difficulty moving your thumb and wrist while performing repetitive tasks that require fine motor movements; such as pinching or grasping
• The sensation like something is catching in the thumb

Cause:
The source of this disease is generally unknown, but can be attributed to overuse and repetitive motions;  commonly associated with pregnancy and inflammatory conditions such as rheumatoid arthritis. Other causes of De Quervain tenosynovitis include: Direct injury to the wrist or tendon; scar tissue can restrict movement of tendons.

Treatment & Surgical Interventions:
Treatment is aimed at reducing the localized swelling and inflammation, as well as, preserving movement in the thumb and preventing recurrence. Therapy options include splinting to immobilize your thumb and reducing movements that irritate your thumb. Some doctors will recommend injections of corticosteroid to reduce symptoms. Surgical options may include: opening the sheath to allow tendons to glide more freely.

Below are some key injuries of the brachium region.

Biceps Tendonitis

Definition:
Bicep tendonitis is an inflammation of the biceps tendon. More commonly known as the long head biceps tendon. In the early stages, the tendon becomes red and swollen, and as it develops the tendon sheath thickens. Occasionally, in severe cases, if untreated it can lead to damage and tearing to the tendon. In severe cases, the long head tendon can rupture. A rupture of the bicep tendon occurs when the muscle is detached from the bone at the point of attachment. This can be either at the elbow or the shoulder. A rupture of the biceps tendon usually results from a powerful contraction or flexion of the bicep against a great resistance. This injury can also be the result of an already weak tendon from prolonged wear and tear. Once the tendon has separated from its attachment the tendon will coil, or form a ball in the mid or lower portion of the anterior arm sometimes recognized at the Popeye deformity.

Symptoms:

• Pain in the front of the shoulder and weakness that worsens with overhead activity
• Tenderness or pain that moves down the humerus, sometimes feeling “heavy”
• Tingling sensation through the fingers

Causes:

The injury is usually the result of wear and tear from lifetime activities. With age your tendons slowly weaken, this degeneration can worsen from overuse. Sports activities that require repetitive overhead motion often contribute to shoulder injuries, such as, swimming, tennis, and baseball.

Treatment & Surgical Intervention:
Typically, this condition is treated with rest, ice, and avoiding the activities that induce the pain. Physical therapy can then be used to strengthen and restore the range of motion. In some cases where the symptoms don’t improve surgery may be required. Arthroscopically a surgeon will remove the painful part of the biceps, then re-attaching the remaining tendon to the humerus.

Humerus Fractures

The humerus is the long bone of your upper arm that articulates with the with the ulna and radius. Together they form the elbow joint. There are three common types of humerus fracture, they depend on the location of the fracture:

• Proximal: a proximal humerus fracture is a break in the upper part of the humerus near the shoulder. As mentioned in the bones section, the humerus contains a bone feature named the “surgical neck”. Fractures in and around the surgical neck are common. Fracture type injuries are more often prevalent in the elderly population, and those with osteoporosis. This injury can be a result of a fall with all the impact contacting the hand, traveling up the length of the arm.

• Mid-shaft: is a fracture in the humeral body. A fracture to the humeral body can result from a direct blow to the bone causing a transverse fracture. Depending on where the fracture occurs on the humerus it can be referred to as a mid-humeral fracture or a supracondylar fracture.
• Distal: distal humeral fractures occur near the elbow. An avulsion fracture of the greater tubercle is common in the distal region. This injury can be particularly common in middle-aged and also elderly people. This injury is a result of a fall that contacts the shoulder, the acromion more specifically. In the younger population, this injury is a result of a fall on the hand. Muscles pull the arm into medial rotation. A result from this can be an inferior dislocation of the shoulder joint.

Causes:
Majority of fractures that occur in the humerus are a result of hard blows or falls. The type of injury is going to impact the type of fracture and individual gets. Whether it be: falling with an outstretched arm resulting in a mid-shaft fracture, A high impact collision resulting in a distal humeral fracture, or a pathologic fracture.

Treatment & Surgical Interventions
Doctors will use a series of X-Rays to determine the kind of fracture. In many cases, proximal fractures don’t require surgery. However, casting, splints, and slings are frequently used to immobilize your arm for healing purposes. Occasionally, surgery is required with either plates, screws, or rods to hold the ends of broken bones together for healing. Healing time is greatly dependent on the type and severity of the fracture.