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The shoulder joint is one of the most mobile joints in the body - it can rotate in different directions. A person can raise and lower his arm, make circular movements, forward and backward. The result of excessive loads on this joint is often its instability. This condition is characterized by the release of the head of the humerus from the scapular socket (dislocation). It occurs as a result of gradual overload or acute injury. As a result, the muscle tendons are stretched. In addition, the cartilage lining the cavity, as well as the so-called articular labrum located along its edge, is damaged. It is most susceptible to injuries, which sometimes go unnoticed.
However, as a result of its damage, instability of the joint occurs, which contributes to further trauma and a decrease in its function. Most often, the injury occurs in one shoulder, but sometimes it occurs on both sides. The latter is especially true for patients with weak connective tissue, as well as for professional athletes who perform parallel repetitive exercises with the upper limbs (for example, swimmers). If the cartilage tear involves the anterior portion of the labrum, the condition is called a Bankart injury. This is the most common shoulder injury, especially among professional athletes (tennis players, handball players).
Classification
It is customary to classify Bankart damage by type:
- Classical. It is characterized by a complete separation of the anterior part of the labrum from the scapula. At the time of injury, sharp pain and discomfort are felt, and a loud click is heard.
- Bone. In this case, the rupture is accompanied by a fracture in the area of the edge of the cavity, which requires immediate surgical intervention.
- Incomplete tearing is possible ; in this case, with early surgical treatment, fixation of the damaged area is most successful.
- Severance of the glenohumeral ligament from the head of the humerus , also causing anterior instability.
Causes
Most often, instability of the shoulder joint occurs due to injury, which also involves dislocation of the shoulder bone. For example, if there was a fall on your hand or there was a powerful blow. Footballers and rugby players are often injured in this way. In addition, the disease can develop gradually and be caused by repeated loads when performing constantly repeated identical movements - when throwing a shot, in swimming. Bankart disease also occurs in people with impaired biomechanics, when the technique is incorrect or safety measures are ignored. Doctors also consider congenital dysplasia of the connective tissue or shoulder joint to be one of the common causes.
There are also a number of factors that contribute to the development of the disease. Basically, we are talking about:
- constantly occurring subluxations;
- non-compliance with recommendations during rehabilitation after a dislocation;
- excessive load;
- imbalance in the exercises performed;
- incorrect technique;
- muscle strain;
- poor posture;
- sudden changes in the training scheme;
- refusal to warm up before exercise.
S40—S49 Injuries of the shoulder girdle and shoulder
S40 Superficial injury of the shoulder girdle and shoulder
- S40.0
Contusion of the shoulder girdle and shoulder - S40.7
Multiple superficial injuries of the shoulder girdle and shoulder - S40.8
Other superficial injuries of the shoulder girdle and shoulder - S40.9
Superficial injury of the shoulder girdle and shoulder, unspecified
S41 Open injury of the shoulder girdle and shoulder
- S41.0
Open wound of the shoulder girdle - S41.1
Open wound of shoulder - S41.7
Multiple open wounds of the shoulder girdle and shoulder - S41.8
Open wound of other and unspecified part of the shoulder girdle
S42 Fracture at the level of the shoulder girdle and shoulder
- S42.00
Closed clavicle fracture - S42.01
Open clavicle fracture - S42.10
Fracture of the scapula, closed - S42.11
Open fracture of the scapula - S42.20
Fracture of the upper end of the humerus, closed - S42.21
Open fracture of the upper end of the humerus - S42.30
Fracture of the body [diaphysis] of the humerus, closed - S42.31
Fracture of the body [diaphysis] of the humerus, open - S42.40
Fracture of the lower end of the humerus, closed - S42.41
Open fracture of the lower end of the humerus - S42.70
Multiple fractures of the clavicle, scapula and humerus, closed - S42.71
Multiple open fractures of the clavicle of the scapula and humerus - S42.80
Fracture of other parts of the shoulder girdle and shoulder, closed - S42.81
Open fracture of other parts of the shoulder girdle and shoulder - S42.90
Fracture of unspecified part of the shoulder girdle, closed - S42.91
Open fracture of unspecified part of the shoulder girdle
S43 Dislocation, sprain and overstrain of the capsular-ligamentous apparatus of the shoulder girdle
- S43.0
Shoulder dislocation - S43.1
Dislocation of the acromioclavicular joint - S43.2
Dislocation of the sternoclavicular joint - S43.3
Dislocation of other and unspecified part of the shoulder girdle - S43.4
Sprain and overstrain of the capsular-ligamentous apparatus of the shoulder joint - S43.5
Sprain and overstrain of the capsular-ligamentous apparatus of the acromioclavicular joint - S43.6
Sprain and overstrain of the capsular-ligamentous apparatus of the sternoclavicular joint - S43.7
Sprain and strain of the capsular-ligamentous apparatus of another and unspecified part of the shoulder girdle
S44 Nerve injury at the level of the shoulder girdle and shoulder
- S44.0
Ulnar nerve injury at shoulder level - S44.1
Injury to the median nerve at shoulder level - S44.2
Injury to the radial nerve at shoulder level - S44.3
Injury to the axillary nerve - S44.4
Musculocutaneous nerve injury - S44.5
Injury to the cutaneous sensory nerve at the level of the shoulder girdle and shoulder - S44.7
Injury of several nerves at the level of the shoulder girdle and shoulder - S44.8
Injury to other nerves at the level of the shoulder girdle and shoulder - S44.9
Injury to unspecified nerve at the level of the shoulder girdle and shoulder
S45 Injury to blood vessels at the level of the shoulder girdle and shoulder
- S45.0
Injury to the axillary artery - S45.1
Brachial artery injury - S45.2
Injury to the axillary and brachial vein - S45.3
Injury of superficial veins at the level of the shoulder girdle and shoulder - S45.7
Injury of several blood vessels at the level of the shoulder girdle and shoulder - S45.8
Injury to other blood vessels at the level of the shoulder girdle and shoulder - S45.9
Injury of unspecified blood vessel at the level of the shoulder girdle and shoulder
S46 Injury to muscle and tendon at the level of the shoulder girdle and shoulder
- S46.0
Rotator cuff tendon injury - S46.1
Injury to the muscle and tendon of the long head of the biceps muscle - S46.2
Injury to muscle and tendon of other parts of biceps muscle - S46.3
Injury to the triceps muscle and tendons - S46.7
Injury of several muscles and tendons at the level of the shoulder girdle and shoulder - S46.8
Injury to other muscles and tendons at the level of the shoulder girdle and shoulder - S46.9
Injury to unspecified muscles and tendons at the level of the shoulder girdle and shoulder
S47 Crushing of the shoulder girdle and shoulder
S48 Traumatic amputation of the shoulder girdle and shoulder
- S48.0
Traumatic amputation at the level of the shoulder joint - S48.1
Traumatic amputation between the shoulder and elbow joints - S48.9
Traumatic amputation of the shoulder girdle and shoulder at unspecified level
S49 Other and unspecified injuries of the shoulder girdle and shoulder
- S49.7
Multiple injuries of the shoulder girdle and shoulder - S49.8
Other specified injuries of the shoulder girdle and shoulder - S49.9
Injury of the shoulder girdle and shoulder, unspecified
Symptoms
Bankart injury is an injury with clear symptoms. First of all, the patient feels pain - at first it can be intense, sharp or aching - it depends on the degree of impairment and the degree of rupture of the labrum. In addition to the pain syndrome, a decrease in the functionality of the arm, the appearance of a characteristic crunch when bending, and loss of mobility are also noted. Since this joint is the most mobile, the slightest dysfunction will not go unnoticed. If you do not visit a specialist immediately, the pain will decrease over time, but the functionality of the limb will become worse. The lack of intervention can result in negative consequences - complications that will require much more complex and expensive treatment.
With all types of instability, patients note repeated clicks when performing the most common movements (raising and lowering, rotating the arm). A decrease in muscle strength and weakness during rotation (including in the supine position) are also possible. On palpation, pain will be clearly felt. It is also likely that you will experience a fear of throwing and a feeling of joint displacement. Particularly severe situations are accompanied by periodic numbness of the shoulder lasting from one to ten minutes. In addition, the patient can involuntarily cause dislocation of the humerus with a careless turn or minimal action - for example, turning over to the other side during sleep and even ordinary yawning.
Symptoms of a rotator cuff tear
The rupture is always accompanied by a sharp attack of pain localized in and around the shoulder joint. The pain often radiates to the hand, neck and forearms. A characteristic symptom is increased pain when trying to make a certain movement with the arm, for example, lift it or move it to the side. In some cases, patients are completely unable to move their arm. The individuality of symptoms and the degree of their severity depends on whether the rotator cuff tear was complete or partial. Patients also very often complain of the inability to sleep on the side where the joint is damaged.
The location where the center of pain is located directly depends on the location of the damaged tendon. The most common rupture in clinical practice is the rupture of the supraspinatus tendon. This case can be diagnosed by asking the patient to move his arm to the side. If we are dealing with just such damage, the patient will not be able to complete this task. If abduction of the arm is possible, but pronounced pain is felt, it is most likely that the tendon is not completely torn, but only severely damaged.
Diagnostics
First of all, the specialist performs an initial examination and collects anamnesis. It is necessary to establish exactly at what age the patient first encountered a dislocation, and in what position the limb was located. Symptoms of anterior instability most often appear when the shoulder is abducted or rotated; as for the posterior, it is expressed when the shoulder is brought to its natural position - the side of instability is determined through special tests. During the diagnostic process, the condition of the vessels and nerves of the affected location is assessed (for example, in elderly patients, there are frequent cases of disruption of the vascular system, ischemia).
The main diagnostic methods include radiography in various projections, which is repeated after reduction (if it is a normal dislocation). To identify the disorder, you will need to conduct a computer or magnetic resonance imaging scan, which will also help determine the presence or absence of a fracture. However, even after MRI and CT, the clinical picture may remain unclear. In this situation, diagnostic arthroscopy will be prescribed, which will give a 100% correct diagnosis, and will also make it possible to identify lesions that cannot be determined by general clinical methods. Today, this procedure is the most effective and allows you to find out in one session whether the patient has a Bankart lesion.
Diagnosis of rotator cuff injuries of the key joint
In order to make a correct diagnosis, the doctor carries out a set of measures to establish the clinical picture.
- The first method is patient interview
: the doctor needs to establish the circumstances under which the pain appeared, determine how long ago the patient experienced discomfort in this area and ask about the nature of his professional activity.
- Then you need thorough examination using specific tests
. In this way, the level and severity of the pain syndrome, the degree of weakness of motor function and the condition of the adjacent muscles are determined. Typically, a complete rupture has a number of pronounced symptoms, so it can be diagnosed without difficulty.
Below are several diagnostic tests to help your doctor understand the nature of your shoulder injuries.
Painful Dawborn arch
The arm is passively and actively retracted from the initial position along the body.
Grade
. Pain occurring during abduction between 70° and 120° is a symptom of damage to the supraspinatus tendon, which is compressed between the greater tuberosity of the humerus and the acromion process during this phase of movement (“subacromial impingement”).
Test of arm abduction from zero position
The patient stands with his arms down and relaxed. The physician grasps the distal third of each patient's forearm with his or her hands. The patient tries to spread his arms, while the doctor resists.
Grade.
Abduction of the arm is carried out by the supraspinatus and deltoid muscles. Pain and especially weakness during abduction and deviation of the arm strongly confirm a rotator cuff tear.
An eccentric position of the humeral head in the form of its superior displacement during a rotator cuff tear occurs due to an imbalance in the muscles surrounding the shoulder joint. Partial ruptures, which can be functionally compensated, impair function to a lesser extent with the same severity of pain. Complete ruptures are invariably characterized by weakness and loss of function.
Jobe Supraspinatus Test
This test can be performed with the patient standing or sitting. With the forearm extended, the patient's arm is placed in a position of 90° abduction, 30° horizontal flexion and internal rotation. The examiner resists this movement by applying pressure to the proximal humerus.
Grade.
If this test causes significant pain and the patient is unable to independently hold the arm abducted to 90° against gravity, this is called a positive drop arm sign. The upper portions of the rotator cuff (supraspinatus) are assessed primarily in the position of internal rotation (the first finger looks down), and the condition of the anterior portion of the cuff is assessed in the position of external rotation.
Falling hand test (symptom of falling flag, chess clock)
The patient sits, the doctor passively abducts the patient's extended arm approximately 120°. The patient is asked to independently hold his hand in this position, and then gradually lower it.
Grade.
Inability to hold the arm in this position with or without pain, or a sudden drop of the arm confirms a rotator cuff injury. The most common cause is a defect in the supraspinatus muscle. With pseudoparalysis, the patient cannot independently lift the injured arm. This is the main symptom confirming rotator cuff pathology.
External rotation abduction test for infraspinatus tendon rupture
The patient's arm is placed in a position of 90° abduction and 30° flexion. In this position, the action of the deltoid muscle as an external rotator is eliminated. The patient is then asked to begin external rotation, which the doctor prevents.
Grade.
A decrease in active external rotation in the abducted position of the arm is characteristic of clinically significant injury to the infraspinatus tendon.
Next, the patient is required to receive a referral for an x-ray. With the help of an X-ray examination, the doctor obtains a picture typical of a particular case. Unfortunately, the gap is not clearly defined; only a number of indirect signs can indicate it. The most informative diagnostic method today is magnetic resonance imaging. It can be used to visualize the tendons, muscles and ligaments of the shoulder joint. This method provides the clearest and most vivid picture of the condition of the patient’s soft tissues.
Treatment of shoulder instability.
The gold standard for treating damage is the Bankart procedure. It can be performed either through open surgery or arthroscopically. The second is preferable in most cases, as it is minimally invasive. During the manipulation, the separated part of the socket is fixed to the articular socket, which increases stability and prevents recurrent dislocations and other similar injuries. Careful preparation is carried out before arthroscopy. In consultation with a specialist, the patient’s tolerance to the components of anesthesia is clarified, blood and urine tests, and a coagulogram are taken. If blood clotting is poor, the patient is prescribed special medications. The procedure itself is carried out not under general anesthesia, but with the help of local (conduction) anesthesia, which is a significant advantage over classical surgery. During arthroscopy, the doctor makes two or three small incisions to access the joint, through which he inserts a camera and instruments. An image of the intra-articular cavity is displayed on the screen in real time, so all manipulations are clearly visible and can be carried out immediately after diagnosis.
If, as a diagnostic method, arthroscopy is sometimes inferior to MRI (due to the fact that MRI does not require even minimally invasive intervention), then as an operative technique it has no equal. The anatomical structure of the shoulder is quite difficult, and during a conventional operation it is inevitable to damage the tissue surrounding the problem area. Such a wound takes a very long time to heal and requires a very serious approach to the rehabilitation period, preventing one from leading a normal lifestyle for many months. There is no need to talk about a quick return to sports in such a situation. Previously, when arthroscopy was not yet so widespread, surgery was resorted to only as a last resort - after long and unsuccessful conservative treatment. Today, the situation has changed radically - its implementation does not cause additional injuries to a person, it even eliminates bleeding, which means that rehabilitation after arthroscopy is minimal.
To summarize, the main advantages of arthroscopy should be highlighted:
- low morbidity due to the minimally invasive method;
- minimizing the occurrence of complications;
- almost complete absence of cosmetic defects;
- quick recovery after surgery;
- highest diagnostic efficiency;
- simultaneous analysis of the problem and the operation itself.
Rehabilitation
After arthroscopy, recovery is really fast, however, you should not neglect the doctor’s recommendations - only by listening to them can you regain lost functions in a short time. A return to the full range of arm movements occurs approximately one and a half months after the procedure, provided that all doctor’s instructions are followed, physical therapy visits, massage and magnetic therapy (the latter as needed). Depending on the specifics of the activity, return to sports is acceptable after about three months. The percentage of relapses among those undergoing surgery is quite low (about 5-7%).