Introduction
During a football game, a 25-year old football player was hit by several running fellow players in pursuit of the ball. The player fell to the ground and lost consciousness. He was admitted to the emergency department following the accident. Apart from the superficial injuries sustained, he was found to have a glenoid labrum tear. The football player complained that his shoulder joint injury is extremely painful. The doctors and healthcare professionals that attended to him found out that the young football player has sustained a SLAP lesion.
Problem Description
The shoulder is the most mobile joint in the human body. It consists of a complex arrangement of structures (ligaments, tendons and muscles) working together to provide the movement necessary for daily life. Unfortunately, the exceptional flexibility and great mobility of the shoulder joint also has a drawback, it comes at the expense of stability. It is very easily dislocated (Marieb, 2004).
Certain work or sports activities like a football game can put great demands upon the shoulder, and injury can occur when the limits of movement are exceeded and/or the individual structures are overloaded.
The articulation of the shoulder joint occurs between the rounded head of the humerus and the shallow, pear-shaped glenoid cavity of the scapula. The articular surfaces are covered by hyaline articular cartilage, and the glenoid cavity is deepened by the presence of a fibrocartilaginous rim called the glenoid labrum (Snell, 2000). The glenoid cavity is indeed shallow and the shoulder joint is poorly reinforced by ligaments.
The labrum - a disk of cartilage on the glenoid, or "socket" side of the shoulder joint - is considered to be a very important part of the shoulder. Essential to shoulder movement and functionality, the labrum helps stabilize the joint and acts as a "bumper" to limit excessive motion of the humerus, or "ball" side of the shoulder joint (Sykes, 2005). More importantly, it holds the humerus securely to the glenoid. The secure but flexible fit of the humerus within the glenoid permits the great range of motion of the healthy shoulder.
When the labrum of the shoulder joint is torn, the stability of the shoulder joint is compromised. Another very common labral injury is a tear that occurs on the top of the labrum, extending from the front to the back of the cartilage. This is known as a SLAP tear ("SLAP" is an acronym for superior labral anterior to posterior tear). This injury affects the attachment of the biceps tendon to the glenoid. An injury in this area can be extremely painful, and can cause the biceps tendon to rupture (Sykes, 2005). This is what the injured football player experienced.
The main symptom caused by a labral tear is a sharp pop or catching sensation in the shoulder during certain shoulder movements. This may be followed by an aching sensation for several hours. Pain caused by a torn labrum varies from patient to patient--but ultimately results in an unstable shoulder--and can lead to many future injuries if not treated.
Possible Solutions
Reduction should be accomplished as soon as possible in patients with acute dislocation of the shoulder. A sedating intravenous dose of a narcotic such as meperidine (Demerol) and a benzodiazepine such as midazolam (Versed) is usually required to facilitate the reduction (Smith, 1999).
Two commonly used techniques for reduction of anterior dislocations are the modified Kocher method and the Stimson method. The modified Kocher method is performed by placing the patient in the supine position with the body stabilized and applying traction on the humerus while the arm is in an adducted, externally rotated and flexed position. If spontaneous reduction is not accomplished with this technique, the arm is then internally rotated and further adducted (Smith, 1999).
In the Stimson technique, the patient lies in a prone position, and a weight is placed on the dislocated arm. The humerus spontaneously returns to its normal position with the aid of gravity. This may take five to 15 minutes. Posterior dislocations are reduced by applying traction on the arm while it is in an adducted and internally rotated position. If muscle spasm is present or locking is noted with attempted reduction, anesthesia may be required before reduction can be accomplished (Smith, 1999).
Following reduction, the arm of the football player should be immobilized for two to six weeks (average: three weeks). This would mean that he cannot play in any football game for the next six weeks.
Along with all these, there is also a need for the football player for conservative management which involves a program of exercises for shoulder rehabilitation, along with close follow-up.
Athletic trainers and physical therapists concentrate on four phases of rehabilitation. Phase I includes rest and pain control. Phase II begins with strengthening exercises for the dynamic rotator cuff and the scapular stabilizers, initially with isometric exercises and progressing to isotonic exercises. Phase III adds an endurance program to the strengthening exercises, with the goal of reaching 90 percent strength in the injured shoulder compared with the uninjured shoulder. The last phase consists of progressively increasing the patient's activity to sport- or job-specific activities. The rate at which the patient progresses through each phase of rehabilitation depends on the level of pain and the degree of improvement in strength (Smith, 1999).
Conclusion
The young football player had easily dislocated his shoulder joint during a game through a glenoid labrum tear or SLAP lesion. This condition is very painful and the football player requires techniques such as the Kocher method or the Stimson method to reduce the dislocation. He will not be able to play football or engage in other physical activities for at least six weeks after that. A close follow up is still needed after reduction of dislocation as there is a possibility that the shoulder joint may be dislocated again.
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