Shoulder Joint Injury

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

AC Joint Separation: Acromioclavicular (AC) joint separation refers to the dislocation or separation of the clavicle from the scapula at the acromioclavicular joint, commonly resulting from trauma.

Biceps Tendonitis: Biceps tendonitis involves inflammation of the tendon of the long head of the biceps muscle, often due to overuse or repetitive strain. "Popeye Deformity" refers to the characteristic bulge in the upper arm that occurs when the long head of the biceps tendon ruptures.

Aetiology

The causes of AC joint separation and biceps tendonitis include:

• AC Joint Separation:
  • Trauma: A direct blow to the shoulder, such as from a fall onto the shoulder or a collision during sports, is the most common cause of AC joint separation.
  • Overuse: Repetitive overhead activities can weaken the ligaments supporting the AC joint, increasing the risk of separation.
• Biceps Tendonitis:
  • Overuse: Repetitive overhead activities, such as lifting or throwing, can lead to microtrauma and inflammation of the biceps tendon.
  • Trauma: A sudden forceful contraction of the biceps muscle can cause tendon rupture, leading to the "Popeye Deformity."
  • Degeneration: Age-related degeneration of the tendon can weaken it, making it more susceptible to inflammation or rupture.

Pathophysiology

The pathophysiology of AC joint separation and biceps tendonitis involves:

• AC Joint Separation: The injury disrupts the ligaments that stabilise the acromioclavicular joint, leading to displacement of the clavicle. The severity of the separation is classified into different grades based on the extent of ligament damage and clavicular displacement.
• Biceps Tendonitis: Inflammation of the biceps tendon due to repetitive strain leads to pain and limited function. In cases of tendon rupture, the tendon detaches from its insertion point on the shoulder, causing the characteristic bulge ("Popeye Deformity") as the muscle retracts.

Risk Factors

• AC Joint Separation:
  • Participation in contact sports or activities with a high risk of falls (e.g., rugby, football, cycling)
  • Previous shoulder injuries or dislocations
  • Occupation or activities involving repetitive overhead motions
• Biceps Tendonitis:
  • Age, with older adults being more susceptible to tendon degeneration
  • Participation in sports or activities that involve repetitive overhead or lifting motions (e.g., weightlifting, tennis)
  • Previous shoulder injuries or rotator cuff pathology
  • Occupation or activities involving repetitive lifting or pulling

Signs and Symptoms

The signs and symptoms of AC joint separation and biceps tendonitis include:

• AC Joint Separation:
  • Pain and tenderness over the AC joint, particularly after trauma
  • Visible deformity or bump over the shoulder, especially in higher-grade separations
  • Limited range of motion in the shoulder, particularly with overhead movements
  • Swelling and bruising around the shoulder
  • Weakness in the affected arm
• Biceps Tendonitis:
  • Pain in the front of the shoulder, which may radiate down the biceps muscle
  • Tenderness over the bicipital groove
  • Weakness or discomfort during overhead activities or lifting
  • "Popeye Deformity" – a visible bulge in the upper arm due to tendon rupture
  • Clicking or snapping sensation in the shoulder with movement

Investigations

Specific investigations to assess AC joint separation and biceps tendonitis include:

• AC Joint Separation:
  • Physical examination: Assessment of shoulder deformity, range of motion, and stability. The cross-arm adduction test may be used to provoke pain at the AC joint.
  • X-rays: Anteroposterior (AP) and axillary views are typically used to assess the degree of AC joint separation and rule out associated fractures.
  • MRI: May be used to assess soft tissue damage, including ligament injuries and any associated rotator cuff pathology.
• Biceps Tendonitis:
  • Physical examination: Assessment of tenderness over the bicipital groove, pain with resisted supination or forward flexion (Speed's test), and the presence of the "Popeye Deformity."
  • Ultrasound: Useful for visualising tendon inflammation, tears, or rupture.
  • MRI: May be used to assess the extent of tendonitis or to evaluate associated shoulder pathology, such as rotator cuff tears.

Management

Primary Care Management

• AC Joint Separation:
  • Rest and activity modification: Avoid activities that exacerbate symptoms, particularly overhead movements.
  • Ice application: To reduce pain and swelling in the acute phase.
  • NSAIDs: Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) for pain relief and inflammation control.
  • Sling immobilisation: For 1-2 weeks to support the shoulder and allow for healing.
  • Physiotherapy: Referral to physiotherapy for range of motion exercises, strengthening, and gradual return to activity.
• Biceps Tendonitis:
  • Rest and activity modification: Avoid activities that exacerbate symptoms, particularly repetitive lifting or overhead movements.
  • Ice application: To reduce pain and inflammation in the acute phase.
  • NSAIDs: For pain relief and inflammation control.
  • Physiotherapy: Referral to physiotherapy for exercises to improve flexibility, strengthen the shoulder, and prevent further injury.
  Corticosteroid injections: Considered for persistent symptoms that do not respond to conservative management. Injections can help reduce inflammation in the tendon sheath.

Specialist Management

• AC Joint Separation:
  • Referral to orthopaedics: Necessary for higher-grade separations (Grades III-VI) or if there is persistent pain and dysfunction despite conservative management.
  • Surgical intervention: Surgical options may include reconstruction of the damaged ligaments or excision of the distal clavicle (Mumford procedure) in cases of chronic pain or instability.
• Biceps Tendonitis:
  • Referral to orthopaedics: Indicated for cases of tendon rupture ("Popeye Deformity"), severe tendonitis that does not respond to conservative treatment, or associated rotator cuff tears.
  • Surgical intervention: Surgery may be required to reattach the ruptured tendon or to perform a tenodesis or tenotomy in cases of chronic tendonitis with significant dysfunction.

References

1. NHS (2024) AC Joint Separation. Available at: https://www.nhs.uk/conditions/ac-joint-separation/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Shoulder Problems: Rotator Cuff Disorders and Shoulder Instability. Available at: https://cks.nice.org.uk/topics/shoulder-pain-rotator-cuff-disorders/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Biceps Tendonitis and "Popeye Deformity": Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h3900 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Biceps Tendonitis and Tendon Rupture. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/biceps-tendonitis/ (Accessed: 24 June 2024).

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