Shoulder

Instability

Glenohumeral dislocation is not difficult to diagnose but athletes are prone to subtle instability due to stretching of the anterior capsular structures. Abducting the shoulder and using the arm above shoulder height are painful. A diagnosis of subacromial impingement is often made because of a failure to elicit a positive apprehension test. Standing behind the athlete, abduct their shoulder to 90degree and then try to pull their elbow posteriorly: if the test is positive they will ask you to stop, not because of pain, but apprehension. In subtle cases of instability you may need to stress the joint by pushing the humeral head forwards with your thumb to reproduce the symptoms.

Treatment should start with a rehabilitation programme to improve proprioception and rotator cuff muscle strength. If there is no improvement after 3 months then a stabilisation is performed by double-breasting the anterior capsule (infe­rior capsular shift procedure). Athletes with multidirectional instability due to ligamentous laxity should be identified and treated nonoperatively as surgery in these cases is complex and less proven.

Throwing injuries

Throwing involves a number of distinct phases, each with characteristic injuries (Table 29.2). Skeletally immature athletes, despite the same mechanisms of injury, sustain avulsion fractures of the ligament insertions rather than rupture the ligament.