Sport Specific Overuse Injuries

Sport Specific/Overuse Injuries in

Tennis Players
Relative Speeds

Overhand Serve Forehand Backhand

Rotational
Velocity: 1500°/sec 387°/sec 895°/sec

Hand Speed @
Ball Impact: 47 mph 37 mph 33 mph 1
 Throwing Motion

• At release:
– Angular velocity is 6000 º/s @ shoulder.
– Angular velocity is 4500 º/s @ elbow. 1
 Overuse Injuries - Baseball

• Rotator Cuff
• Glenoid Labrum
• GH Ligaments
• Biceps Anchor
Overuse Injuries - Baseball

Rotator Cuff Injuries

 Rotator Cuff Injuries
1. Full Thickness Tears (traumatic)
A. AC joint separation
B. GH dislocation
2. Impingement/Instability
A. 1°
B. 2°
C. Chronic RC Injury
1. RC Tendinitis
2. Partial tears
3. Bicipital Tendinitis
D. Subacromial Bursitis
 RC Tendons
• Superior surface: bursal
surface.
• Inferior surface: articular
surface.
– 1st affected: INTERNAL
IMPINGEMENT.
– Ant. aspect of
supraspinatus tendon
adjacent to long head of
biceps tendon.
 Rotator Cuff Injuries

• Different approach with older populations.

• Traditionally three Mx:
– Primary impingement.
– Secondary impingement d/t underlying instability.
– Tensile overload.
 RC Tears
• Full thickness tears: acute, severe trauma.
– Dislocation, fall from height, MVC.

• More Chronic Conditions: continuum.

– 1. RC cuff tendinitis.
– 2. Partial tears.
– 3. Bicipital Tendinitis
– 4. Subacromial Bursitis.
 RC Tendinitis

• Athletes in 20’s & 30’s.

• Usually supraspinatus tendon.
• Flxn/Abd  mechanical impingement.
– Max @ abd in scapular plane with int. rot.
– Part of throwing motion.
 2º Impingement

• Increased GH translation due to instability

results in increased propensity for
subacromial impingement.
 Subacromial Bursitis

• 2º to Impingement.
• Distinguishing from tendinopathy may not be
relevant as treatment is aimed at 
mechanical impingement.
Rotator Cuff Tears

Tests
 Drop-arm Test

• Examiner abducts arm to 90º.

• Ask patient to slowly lower arm to side.
• Pain or inability to control motion are positive
signs.
• “+” rotator cuff tear.
 Supraspinatus Test
• Patients arm abducted to 90º with no
rotation.
• Manual resistance.
• Internally rotate arm, horizontally adduct to
30º.
• Again apply manual resistance.
• “+” is pain and weakness.
Impingement Syndrome
 Primary Impingement

• RC impinging on the coraco-acromial arch.

– Types II & III assoc with greater incidence.

• Rarely the cause of of disease in young

athletes.
 Primary Impingement
Acromion types
I – flat, straight
undersurface
II – downward curve
III – hooked

Acquired or Congenital?
YES!
 Primary Impingement

• XR:
– ALVIS View
– DJD – AC joint
– Os Acromial
 Impingement – Clinical Findings
• Relatively gradual onset.
• Activity related Sy. – overhead activity.
• Difficulty localizing pain – around delt.
– DDx: AC jt. Sy. – more localized
• 2º Impingement – overlap Sy. of RC patholgy
– Painful RC with older pts.  Adhesive Capsulitis
 RC Impingement: S & Sy
1. “Crunching” with movement (calcific).
2. Poorly localized deep ache in shoulder
following overhead activity.
3. Pain @ night, esp. with lying on shoulder.
4. CLASSIC: pain radiating down lateral arm.
 RC Impingement
• Stage I: younger pt. tendinitis type Sy.
• Stage II:
– 30 – 40 YO
– Tendon has irreversible fibrotic changes.
• Stage III:
– 40 – 50 YO
– Partial to full thickness tear of underside of
supraspinatus tendon at insertion of gr. tub.
 RC Impingement
• Stages:
I: Edema & hemorrage.
II: Fibrosis & tendinitis (-osis?)
III: Tears of RC, rupture of biceps tendon, bony
changes.

What are our treatment goals at each stage?

 Impingement Syndrome

• Mechanism:
– Supraspinatus weakness/inhibition allows deltoid
to overpower its ability to stabilize/compress the
humeral head, allowing superior migration.
 Impingement: Imaging
• XR: when pain persists after several weeks &
doesn’t respond to activity modification.
– Calcific tendonitis, degeneration of AC/GH jts.
– Superior migration of H. head  large RC tear
– Not much inter-observer reliability. 3
– Outlet view: lateral view of scapula with tube
angled 10º caudally.
1º Impingement: Outlet View
 Impingement: Imaging
• Arthrogram & US: full thickness RC tears only.
• MR:
– Correlate clinically.
– High in false “+’s”, tendinopathic changes in
normal individuals.
Impingement: MRI
 Impingement Test
• PP: supine

• DP: head of table

• CH: contralateral hand at humeral head,

ipsilateral hand on wrist.
 Impingement Test cont…
• MX: move arm into 180° abduction and full
lateral rotation.
• No history of subluxation/dislocation.
+ = reproduce symptoms, anterior or posterior
shoulder pain; anterior translation→2°
impingement →grade II or III according to
Jobe’s Classifications.
Impingement Test cont…
 Alternate Impingement Sign

• Abduct to 90º, internally rotate to maximum.

• Over pressure is applied in horizontal
adduction.
• Pain is positive sign.
 Reverse Impingement Sign

• Performed if pt has painful arc or pain on

lateral rotation.
• PP, DP, CH: same as for impingement test.
• MX: push humeral head inferior as arm is
abducted and laterally rotated.
“+” = reduction of symptoms.
Hawkins-Kennedy Impingement Test

• PP: seated.
• DP: in front of patient.
• CH: contralat. hand on elbow, ipsilat. hand on
wrist.
• MX: forward flex arm to 90º, forcefully
medially rotate humerus.
Hawkins-Kennedy Impingement Test
 Internal Impingement
• Abd. & Ext. rot. of humerus causes direct
contact of the RC’s undersurface with the
posterior glenoid labrum.
– Part of cocking phase.
– Partial undersurface RC tears with corresponding
posterior shoulder pain in throwing athletes. 2
– More posterior location than supraspinatus path.
 most cases of impingement syndrome.
 Internal Impingement
• Breakdown of the
undersurface of the
tendon due to
frictional force of
tendon over glenoid
rim.
 Impingement
• Triggers immediate protective guarding of
shoulder ER’s & ↓ overall IR.
• Limited IR: tight posterior capsule or
contraction of infraspin/teres to minimize
compression within the suprahumeral space.
 Impingement
• Posterior tightness
causes anterior-
superior shift of
humeral head with
flexion.
• 2° Impingement
 Impingement: Treatment
• Activity modifications.
• Controlled strength/flexibility program.
• Scapular stabilizers/core strengthening.
• Anti-inflammatory measures?
– Inflammation not dominant feature!
• Injections?
 Impingement: Treatment
• Rehab. 2-3 mos.
• Sx: if 4-6 mos. rehab. doesn’t work
– Stage II: improved success rates with Sx still
questionable
– Anterior acromioplasty, os acromial (fusion)
– Subacromial decompression: not as good in older
populations – 1º degeneration of tendon, not
effected by decompression
 Overuse Injuries

Biceps Tendinitis/Subluxation
Primarily a Tendinosis
 Biceps Tendon
• Originates from ant/post labrum &
supraglenoid tubercle.
– 4 types
• Intra-articular but extrasynovial.
– Avg. length is 9 cm. 6
– Max stretch in ext. & add.
– 2 blood supplies.
 Biceps Tendon
• Secured in rotator interval: coracohumeral &
superior GH ligs. are main structures
responsible for securing the tendon. The
transverse humeral lig. is not believed to have
a substantial role. 6,7
• In pts. with intact RC’s, Pawolainen et. al.8,
were unable to dislocate the biceps after
sectioning the THL.
Biceps Tendon
 Biceps Tendon
• 1º role is elbow deceleration in throwing.
• Tendon does not slide in groove
(abbynormial).
• Humerus moves under a fixed biceps T. during
shoulder motion. 5,9
– Lucas10: biceps has a resultant force to act as a
humeral head depressor.
– Habermeyer & Walch6: stabilizer during 1st 90º
abd., >90º helps as elevator.
 Biceps Tendon

• Itoi et. al.11:

– Long & short heads function as anterior stabilizers
in humeral abd. & ext. rotation.
– Stabilizing role increased after Bankhart lsn.
• Ting et. al.12:
– During arm adb. & flxn., EMG activity was greater
in shoulders with RC tears.
 Biceps Tendon
• As tendon passes from
its origin to the
bicipital groove, it
makes an angled turn
of 30-40º.
• Dislocation is always
assoc. with pathology
of the subscapularis.
 Biceps Tendinitis
• Overuse tendon injuries are distinctly
different from acute tendon injuries in two
ways:
– Absent/few inflammatory cells
– Predominant degenerative changes are thought to
result from cell matrix adaptation to failed self
repair. 3
 Biceps Tendinitis
• Tendon degeneration without inflammation is
Tendinosis
• B. Tendinitis: clinical syndrome of pain
origination from the biceps tendon, its sheath,
or both, not histopathological condition.
 Biceps Tendinitis

• 1º B.T. ~ 5% of cases (younger individuals)

• 2º to impingement & RC disorders 4,5
– RC Tear/Impingement  check for
Bicipital Tendinitis
Bicipital Tendinitis: Clinical Presentation

• Pain in bicipital groove, may radiate to deltoid

insertion
– Pain at night may exist
• Usu. no Hx. of acute trauma
– Repetitive overhead activities
• Instability with “snap” during throwing motion
 Tenderness in Motion Test
• Point tenderness over bicipital groove.
• “Tenderness in Motion” Test
– 10º int. rot. – intertubercular groove faces
forward.
– Palpate for tenderness
– Turn arm laterally
– “+” if tenderness moves laterally
• Burkhead et all 13: most specific finding
Tenderness in Motion Test
Bicipital Tendinitis: Speed’s Test

Forearm supinated, elbow extended.

Examiner resists forward flexion of
shoulder.
Positive result is pain in the bicipital
groove.
Speed’s test
 Bicipital Tendinitis: Tx
• Conservative treatment following
inflammatory stage - highly successful
• ROM
• Avoid horizontal abduction
• Posterior capsular stretches
• RC strengthening/re-coordinating
• Injections – into subacromial space, not
tendon
 TOS: Etiology
• Compression of the neurovascular bundle
– Brachial plexus, subclavian artery/vein
• Between:
– 1st rib (cervical rib) & clavicle (callous from clavicle
Fx.): Costoclavicular syndrome.
– Anterior & middle scalenes: Scalenus Anticus
syndrome.
– Pec minor muscle & coracoid process:
Hyperabduction syndrome.
 TOS: Symptoms

• Pain, paresthesia, cold sensation, impaired

circulation in fingers, muscle weakness &
atrophy, and radial nerve palsy
• Clinical diagnosis: reproduce symptoms
 Allen Maneuver: Hyperabduction
• Abduction to 90º, elbow flexed to 90º, lateral
rotation and horizontal extension
• Palpate radial pulse
• Have patient rotate head away from test side
• Test is positive if pulse is absent when head is
turned
Allen
 Anterior Scalene Test: Adson’s
• Patient’s head rotated to face affected side
and extended.
• Laterally rotate and extend arm.
• Patient instructed to breathe deep and hold it
while examiner monitors brachial pulse.
• Disappearance of pulse is positive sign.
Adson
 Halstead Maneuver
• Patient head is extended and rotated away
from affected side
• Traction is placed on arm as brachial pulse is
monitored
• Absence of pulse indicates positive test
Halstead
 Costoclavicular Syndrome Test
• Examiner palpates radial pulse
• Patients shoulder is drawn down and back
• Absence of pulse is positive sign