Guest Editorial Special Edition: Shoulder Injuries in Sport The shoulder was regarded as the “forgotten joint” in orthopaedic circles until recently. There has been, however, an “explosion” o f interest in the shoulder over the past few years The biomechanics and pathology o f shoulder con­ ditions have been well researched recently and has re­ sulted in a thorough understanding of effective treat­ ment modalities. This is reflected in an excellent arti­ cle on shoulder rehabilitation by Ms Gisela Lauterbach. The advent o f shoulder arthroscopy has made an in­ valuable contribution to our understanding o f the nor­ mal and pathological anatomy. Arthroscopic surgical techniques have advanced to a level where they do not only compete with the open surgical procedures, but have becom e the methods o f choice, especially when caring for the shoulder o f the young athlete. It is generally accepted in 1994 that a knee surgeon would perform a larger proportion o f procedures arth- roscopically — the same is fast applying to the shoulder. It is therefore appropriate that we wrote a short arti­ cle on “The role o f arthroscopy in shoulder problems o f the athlete". An article on “Acute shoulder injuries in the athlete” is a summary o f the more comm only encountered in­ juries and the treatment thereof. The most common shoulder problem (in athletes and the non-athletic population alike) is that o f chronic ro­ tator cuff pathology and a separate article deals with this. We trust that this Shoulder Edition will contribute to effective care o f the shoulders o f our athletes JF de Beer MBChB, M Med (O rth o p ) SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) THE SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE VOLUME 1 NUMBER 2 NOVEMBER 1994 Guest Editor Dr J F de Beer Editorial Board Dr M P Schwellnus University o f Cape Town Dr M E Moolla Private Practitioner Durban Dr A Venter Private Practitioner Bloemfontein Dr P de Jager Private Practitioner Pretoria Dr J Skowno Private Practitioner Johannesburg Dr I Surve Private Practitioner Cape Town Dr P Schwartz Private Practitioner Port Elizabeth Prof G Strydom Potchefstroom University Prof R Stretch University of Fort Hare Mrs J Morton Private Physiotherapist Durban Mr D Rehbock Podiatrist Johannesburg International Advisory Board Lyle J Michell Associate Clinical Professor of Orthopaedic Surgery Boston, USA Chester R Kyle Research Director, Sports Equipment Research Associates California, USA Prof HC Wildor Hollman President des Deutschen Sportarziebundes Koln, West Germany Howard J Green Professor, Department of Kinesiology Ontario, Canada George A Brooks Professor, Department of Physical Education California, USA Neil F Gordon Director, Exercise Physiology Texas, USA Edmund R Burke Associate Professor, Biology Department, University of Colorado Colorado, USA CONTENTS Editorial J F de Beer 1 Forthcoming Conferences 3 Acute Shoulder Injuries in the Athlete J F de Beer M A de Beer M P Schwellnus 5 Rotator Cuff Impingement Syndrome in Athletes M P Schwellnus J F de Beer M A de Beer 12 The Role of Arthroscopy in Shoulder Problems of the Athlete M A de Beer J F de Beer 18 Rehabilitation of the Athlete’s Shoulder G Lauterbach 19 A survey — Anabolic Androgenic Steroids used by competitive bodybuilders in South Africa S D Titlestad M / Lambert M P Schwellnus 24 A profile of Biokinetic Services in South Africa from 1988-1991 M F Coetsee 29 THE EDITOR THE SOOTH AFRICAN SPORTS MEDICINE ASSOCIATION PO Box 38567, P PRODUCTION Andrew Thomas PUBLISHING Glenbarr Publishers cc Dunkeld 2196 Tel: (O il) 442-9759 Fax; (O il) 880-7898 Cover sponsored The views expressed in individual articles are the personal views o f the Authors and are not necessarily shared by the Editors, the Advertisers or the Publishers. No articles may be reproduced without the written consent o f the Publishers. 'inelands 7430 by Ciba-Geigy ADVERTISING Marika de Waal/Andrew Thomas REPRODUCTION: Output Repro PRINTING: Hortors 2 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Forthcoming Conferences NATIONAL March 22-24, 1995. SASM A CONGRESS, ELANGENI HOTEL, DURBAN. Professional Sports Care Through Unity. A ll correspondence and requests to the Confer­ ence Organizers: McKenzie Dickerson International, PO Box 4272, Rivonia, 2128. Tel: (O il) 402-3240/53/ 57. Fax: (O il) 402-0164. June 19-22. INTERNATIONAL RUGBY MEDICAL AND SPORTS TRAUMATOLOGICAL CONGRESS, SUN CITY. For further information contact the Venue Coordinator, Rugby World Cup 1995. International Rugby Medical and Sports Traumatological Congress, PO Box 99, Newlands 7725. Tel: (021) 685-3038. Fax: (021) 685-6771. July 20-23, 1995. ICPFAR SYMPOSIUM 1995, THE IN­ TE RNATIO NAL COUNCIL FOR PHYSICAL FITNESS A N D ACTIVITY RESEARCH, ltala Game Reserve, Northern Natal. Abstracts should be submitted before January 15, 1995. For further details contact Prof M F Coetsee, Department Human Movement Science, Uni­ versity o f Zululand, Private Bag X1001, Kwa Dlangez- wa 3886. Tel: (0351) 93911 ext 235. Fax: (0351) 93911. INTERNATIONAL April 5-7, 1995. CONFERENCE ON NUTRITION A N D PHYSICAL ACTIVITY, TO OPTIMIZE PERFORMANCE A N D WELL-BEING. The Ritz-Carlton, Buckhead, Atlan­ ta, Georgia, USA. Contact Ms Lili C Merritt, Internation­ al Life Science Institute, 1126 Sixteenth Street, NW, Washington, DC 20036, USA. Tel: 202 659 0074. Fax: 202 659 3859. May 21-25, 1995. FIRST WORLD FORUM O N PHYSI­ CAL ACTIVITY A N D SPORT, QUEBEC, CANADA. Con­ tact: World Forum on Physical Activity and Sport, 2 Olace Quebec, Suite 510, Quebec City, Quebec, Cana­ da G1R 2B5. Tel: (418) 648-6000. Fax: (418) 648-0404. May 23-27, 1995. 10TH INTERNATIONAL SYMPOSI­ UM ON AD APTED PHYSICAL ACTIVITY. Contact 10th ISAPA Secretariat, The Norwegian University o f Sport and Physical Education, Department o f Information, Postboks 40, Kringsja, N-0807, Oslo, Norway. May 27-30, 1995. THE ELEVENTH INTERNATIONAL JERUSALEM SYMPOSIUM ON SPORTS INJURIES, DAN PANORAM A, TE L AVIV, IS R A E L Contact: Con­ gress Secretariat, Dan Knassim Ltd., PO Box 57005, Tel Aviv 61570, Israel. Tel: (972) 3 562 6470. Fax: (972) 3 561 2303. June 1997. INTERNATIONAL ASSOCIATION O F SPORTS INFORMATION CONGRESS, 10TH SCIENTIF­ IC CONGRESS, PARIS. Contact: Mr A Poncet, Comite d’Organisation, 11 Avenue du Tremblay, 75012 Paris, France. Tel: 33 1 43 74 11 21 Email FRA 7501 @ CR1- UC. UNICAEN. FR. August 25-26 1995. F1SU/CESU CONFERENCE, FUKUOKA, JAPAN. Sport and man: Creating a New Vi­ sion. Contact: The Organizing Committee for the Universiade 1995, Fukuoka. Cesu Conference Planning Section, 6-1 Tenjin 2-chome, Chuo-ku, Fukuoka City 810, Japan. Tel: 81 92 733 5212. Fax: 81 92 733 5290. September 14-17, 1995. THE XITH FINA WORLD SPORTS MEDICINE CONGRESS, ATHENS HILTON, GREECE. Contact Public Relations Centre, Helen Haly- vides, 102 Michalakopoulou Street, 115 28 Athens, Greece. Tel: (301) 775 6336 or 777 1056. Fax: (301) 771 1289. LETTERS to the EDITOR R e a d e rs ' le tte r s c o n c e r n in g a r tic le s in th e J o u r n a l a re in v ite d , a n d w ill b e f o r w a r d e d to o u r E d ito r s f o r c o n s id e r a tio n f o r p u b lic a tio n . P le a s e p o s t to: G len b a rr Publishers C .C . 25 - Bom pas R o ad Dunkeld 2196 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SIXTH SOUTH AFRICAN SPORTS MEDICINE ASSOCIATION CONGRESS MARCH 22-24 1995 — ELANGENI HOTEL, DURBAN Professional Sports Care Through Unity An international congress to unite all professionals active in sports medical care in South Africa. Themes of Symposia and Workshops: Exercise Science, Sports Medicine, Sports Physiology, Physiotherapy, Sports Podiatry and Biokinetics. International experts in Sports Medicine presenting papers. ENQUIRY FORM Fax back to: McKenzie Dickerson Fax: (O i l) 402-0164 Tel: (O i l) 402-3240 □ I am interested in presenting a free paper. Please send me an abstract form. □ I am interested in exhibiting at the congress. □ I am interested in attending the 3 day congress. Please send me a registration form. Name ...................................................................... Surname ................................................................. M r ....... M r s ....... Miss ....... D r ....... P r o f ...... Position ................................................................... Company/ University etc ......................................... Postal address ........................................................ Sports Medicine Exhibition for products and techniques to be shown to a highly selective target audience. T e l:.................................Fax: PRESS RELEASE The Sixth South African Sports Medicine Association Congress will be held at the Elangeni Hotel, Durban be­ tween 22-24 March 1995. The theme thoughout the congress o f “ Professional Sports Care Through Unity” , will encompass discus­ sions o f Sports Medicine areas over the three days. These will include nutrition, sports medicine and inju­ ries, exercise science, physiotherapy, psychology, bioki­ netics and sports podiatry. Areas that compliment and have association will be dealt with in joint workshops. S om e combinations are Sports Medicine/Physiotherapy, Exercise Science/ Bi­ okinetics and Physiotherapy/Biokinetics. Various symposia on the above subjects will be avail­ able each day in three different venues, with two ses­ sions each morning and afternoon. Free Communica­ tion consisting o f presented papers on relevant topics will be held immediately after morning and afternoon tea every day. Interested parties can contact the num­ bers below for an abstract form. The visiting speakers will include: Dr Louis Burke — Nutrition, the competitive edge. Prof Claude Bouchard — Muscles, performance and genes. Mr Craig Purdam — Rehabilitation o f ankle injuries in sport. Dr Ken Crighton — Tibial stress fractures: Update on diagnosis and management. Titles cover a broad spectrum o f topics such as mus­ cle injury and disease in sport, difficult hamstring in­ juries in sport, exercise, infection and immunity, isoki­ netic dynanometry, drugs in sport. Conference registration will commence on Tuesday March 21 at the Elangeni Hotel, with a W elcom e Cock­ tail function that evening. On each o f the congress mornings, a sporting activity will be organised during the three day period. It is hoped that the delegate congress package cost will be kept to the 1993 price charged in Cape Town. Special rates for group airfares, accommodation and car hire will be available to congress delegates. In conjunction with the congress, will be the largest and most exciting sports medicine exhibition to date. New products and techniques, plus a variety o f excit­ ing material will be on display. Stand space is still avail­ able to any companies who wish to exhibit to a highly selective target audience. For further information contact Sue or Val — McKenzie Dickerson Int. Tel: (O il) 402-3240. Fax: (O il) 402-0164. 4 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Acute Shoulder Injuries in the Athlete JF de Beer MBChB M Med (Orthop)f MA de Beer MBChB M Med (Orthop)* MP Schwellnus MBBCh MSc (Med) MD FACSM** Introduction The aim o f this article is to discuss som e o f the more common acute injuries o f the shoulder complex. The injuries in each area will be discussed with respect to the mechanism o f injury, clinical diagnosis, special in­ vestigations and management. The rehabilitation o f acute injuries as well as the management o f overuse injuries will be discussed in another paper in this journal. Sternoclavicular (SC) Joint Dislocation Injuries to this joint are rare. The main acute injury to consider in the SC joint is dislocation. Acute disloca­ tion o f the SC joint can be either anterior or posterior, with the anterior type being the most common, and for­ tunately the most benign. Anterior dislocation The mechanism o f anterior SC dislocation is either from forces transmitted from the hand or a direct blow to the shoulder. The pathological feature that is o f importance is tear­ ing o f the joint capsule and costo-davicular ligam ent This may be a problem as it can result in a mechanical block and obstruct attempts at reduction. The clinical features are acute pain, swelling and de­ formity o f the medial end o f the clavicle. Overhead or rotational movement o f the arm can cause grating, clicking and popping. This condition must be distin­ guished from a proximal clavicular fracture by X-Rays. Due to overlying shadows this is a difficult area to dis­ tinguish detail on X-rays and specialized views, tom o­ grams and computerized tomography (CT) scans are often needed. The condition is managed by achieving reduction as follows; The arm is pulled in abduction and the prox­ imal clavicle is manipulated to achieve reduction. The reduction is often difficult to hold but surgery for acute anterior dislocation is seldom indicated as it carries a high risk due to the proximity o f such vital structures as the large vessels. Moreover, the chronically dislocat­ ed SC joint is usually compatible with good painless t Leeuwendal Medi-Clinic, 3 Derwent Road, Tamboers- kloof, 8001. Tel: (021) 23-4040. * Jacamnda Hospital, Suite 3, 213 Middelberg St, Muck- leneuk, 0181, Pretoria. Tel: (012) 343-0296. * * Sports Medicine, M R C /U C T Bioenergetics o f Exer­ cise Research. Unit, Department o f Physiology, University o f Cape Town Medical School, Observatory, 7925. Tel: (021) 406-6504. function. The long term complications are that the athlete may notice aching, swelling, clicking or popping in that area. Resection o f the proximal portion o f the clavicle may be required, with or without stabilization for the rare case. It must be stressed again that surgical interven­ tion for acute or chronic cases should be the exception. Posterior (retrosternal) dislocation The mechanism o f injury is similar to that described for anterior dislocation, except that the direction o f the forces are different. The clinical presentation o f posterior dislocation is classical and requires immediate intervention. Impor­ tant retrosternal structures such as the trachea and the great vessels are compressed and this may be life- threatening. Classical symptoms are dysphagia, snort­ ing type o f breathing and neurovascular symptoms in the upper extremity. The management is immediate reduction (anaesthe­ sia might be required) by the following method: The patient lies supine with a sandbag or equivalent be­ tween the two scapulae. The arm is abducted and ex­ tended while traction is applied. The clavicle may have to be grasped with a towel clip and then manoeuvered up and forward to achieve reduction. Fractured Clavicle The most common acute injury to the clavicle is a frac­ ture. The mechanism o f the injury is a fall on the out­ stretched arm. The most comm on site is the middle third o f the shaft The distal fragment is pulled down by the weight o f the shoulder girdle while the proximal fragment is held in place by the trapezium and sternomastoid mus­ cle. There may be a central fragment. The diagnosis is made clinically and confirmed on X-ray examination. The management is mostly conser­ vative. It is not possible or essential to achieve good reduction but the position may be improved by pull­ ing both shoulders backwards. A figure o f eight band­ age could be used to hold the position but it is only effective in children, not in adults. It is m ore important to support the limb with a sling for 3 weeks for pain. Mobilization o f the fingers, wrist and elbow should be­ gin early. Most fractures o f the clavicle will unite, usually resulting in mal-union which is compatible with normal function. The patient is left with a lump in the area which may get smaller with time, and a slightly “short­ ened" shoulder. Fractures o f the clavicle in children have excellent remodelling potential, but this does not apply to adults to nearly the same extent. SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) In rare instances reduction and internal fixation of clavicle fractures are indicated. These are: i) severely displaced fracture fragments (with the skin being endangered due to pressure from the under­ lying fragments) ii) for severe pain Hi) when multiple injuries have been sustained iv) if early function is critical v) cosmetic considerations A c r o m io c la v ic u la r (AC) Joint Sprain Mechanism o f injury The most common mechanism is a fall o ra direct blow to the top o f the shoulder.1 The force is directed down­ wards and medially. This results in damage to the sup­ porting structures. Th e magnitude o f the forcewiH de termine which structures are damaged and thus the severity o f the injury. The w e a k e s t structures and he first to be damaged are the AC joint capsule and the AC ligament. With progressive increase in the magni­ tude of the force the coracoclavicular ligaments are damaged and rarely the coracoid process is fractured. There are other rarer mechanisms of injury. These are: — a direct lateral blow to the shoulder causing mtra- articular damage but no ligament disruption — a force that is directed posteriorly which damages capsular ligaments, muscles and the trapezoid liga­ ment alone ____ — a fall on the outstretched arm which drives the hu­ merus into the acromion damaging the capsular structures but not affecting the coracoclavicular liga­ ments Classification . . . A classification of acute acromioclavicular injuries (Rockwood) is listed in Table 1. Types 1, 11 and III are by far the most common injuries. Clinical features Clinically, athletes present with a history o f acute trau­ ma to the top of the shoulder followed by varying degrees of pain, deformity and loss of function (typi­ cally unable to abduct the arm). In type 1 injuries there is pain and tenderness over the AC joint. This may be the only finding or mild swell­ ing and loss of abduction may also be present. In type 11 and 111 injuries there is more severe pain swelling and loss of function. However, associated defor­ mity differentiates these from type 1 injuries. In type IV injuries (posterior displacement of the distal clavicle) there is more pain. Clinically, the displacement can be best appreciated by looking from above the shoulder. Type V injury is an exacerbation of the Type 111 injury in which the upper extremity is grossly drooping lower than the normal side. Pain is also more severe than in type 111. Type VI injury is due to an abduction force to the up­ per extremity and the distal clavicle is displaced inferior to the acromion process. The superior aspect of the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) shoulder therefore has a flat appearance. This is ex tremely rare. Special investigations The following X-Rays may be useful in the diagnosis of AC joint dislocation. The routine A P view often demon­ strates the AC joint adequately. A better view is the Zanca AC joint view. This is an A P view which is tilted 15° upwards and centred on the AC joint To distinguish between type II and III injuries, stress views can be done; weights are strapped to both wrists in the standing posi­ tion and the AC joint views are taken o f both shoulders If the coracoclavicular distance is increased by more than 50% compared to the normal side it represents torn coracoclavicular ligam ents If a posterior disloca­ tion is suspected the axillary view is useful as a diag­ nostic investigation. Treatment Type I injuries The treatment o f these injuries is symptomatic. A sling may be necessary for 7-10 days Rehabilitation should commence as soon as possible and should emphasize strengthening o f the trapezium and deltoid muscle groups Return to sport can occur as soon as pain allows Type II injuries The treatment o f type II injuries is also symptomatic although a slightly more aggressive approach is advo­ cated. The sling could be worn for 10-14 days for pain relief. A well designed rehabilitation programme is again important. Type III injuries There is controversy in the literature on the manage­ ment o f type 111 injuries. The two approaches are either conservative (closed) or surgical (open). Conservative management (“expert neglect”) will lead to a chroni­ cally dislocated joint which can be compatible with nor­ mal painless function. In the young overhead athlete it is probably best to do early open surgery: reduce the acromioclavicular joint and repair the ligaments, in­ cluding the tom periosteal tube and delto-trapezius fas­ cia. If the injury was left untreated and resulted in a chronically painful instability a late reconstruction with excision o f the distal end o f the clavicle can be done successfully (Weaver-Dunn procedure). Types IV, V and VI injuries The treatment is usually surgical: open reduction and repair o f soft tissue, including the delto-trapezius fas­ cia, acromioclavicular ligament and coracoclavicular ligaments The authors prefer immobilization of the re­ pair using an absorbable sling o f PDS tape from the clavicle around the coracoid. Glenohumeral Joint Instability Classification Glenohumeral instability can be classified accordina to:2’3 M LEADER OF THE P A C K When you need pain-killing power to get there first. o ru * G E T S T H E R E FIRS R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) — the degree o f instability (subluxation, dislocation) __the circumstances o f the instability (acute, chronic, recurrent or voluntary) — the aetiology (traumatic, non-traumatic) — the direction o f the instability (anterior, posterior, multidirectional) In this article acute glenohumeral instability will be discussed. Acute anterior glenohumeral dislocation Anatom y The shoulder provides more mobility than stability ana is therefore prone to instability. The main anatomical structures that prevent anterior displacement o f the hu_ meral head are the glenoid labrum, the long head of the biceps tendon, subscapularis and the glenohumeral ligaments (the inferior ligament is the most important). The rotator cuff muscles also provide an important mechanism for stabilizing the humerus because they contract and pull the humeral head against the glenoid. Mechanism o f injury Acute anterior dislocation can occur when one or more o f the anterior stabilizers o f the shoulder are stretched or disrupted. The forces that may cause this disruption may be direct (applied to the posterior aspect o f the humeral head) or indirect (a movement associated with vigorous hyperextension, abduction and/or external ro­ tation). The latter mechanism is common in sports par­ ticipation. . . . . The magnitude o f the force that is applied will de­ termine the extent o f damage. The damage may be only an anterior capsular sprain or there may be sub­ luxation or dislocation. The stability o f the shoulder is challenged in any sport where the shoulder is active in extension, abduction or external rotation. Pathology , , , . . Displacement o f the humeral head from the glenoid cavity results in injury to the joint capsule, glenoid labrum, humerus, nerves, blood vessels and the rota­ tor cuff. , . . . . . The joint capsule may be stretched, tom (more likely in older people) or avulsed from its attachment to the glenoid (younger people) — the so-called Bankart le­ sion. Tears o f the glenoid labrum, especially the anterior labrum can occur as part o f the Bankart lesioa Superior labral tears, involving the biceps anchor can occur (SLAP lesions). Fractures of the greater tuberosity can occur. I he size o f the fragment, displacement o f the fragment and site o f the fracture are important to consider. If healing takes place with a fragment in a displaced position impinge­ ment can result. Fragments displaced > 5mm should be manaaed by open reduction and internal fixation. Large fragments (> 2 5 % o f the head) should be managed by open reduction and internal fixation. Im­ paction o f the humeral head against the anterior gle­ noid lip can cause fractures of the posterolateral hume­ ral articular surface (Hill-Sacks lesion). This results in loss o f joint congruity and can result in recurrent in­ stability. . , . . . The brachial plexus is located antero-infero-medial to the glenohumeral joint Damage may therefore occur to this structure. The most common nerve that is dam­ aged is the axillary nerve (5-33% o f cases). Both sen­ sory (sergeant stripe area) and motor (deltoid) function must be assessed before and after reduction o f the dis­ located shoulder. Persistent neurological deficits must be assessed by EMG. The nerve injury is usually a neuropraxia that spontaneously improves in a six- month period. . The axillary artery lies in close proximity to the brachial plexus and may also be damaged in anterior dislocation. The pathology may be an intimal tear, lacer­ ation, occlusion, branch avulsion or a complete rupture. The rotator cuff may also be torn in anterior disloca­ tion. It may be difficult to assess the rotator cuff initial­ ly but two useful tests are isometric strength in abduc­ tion and external rotation. Subscapularis may be torn or avulsed; the important “ lift-off test’ will indicate this. Rotator cuff tears are more common in older people. Classification o f anterior dislocation The following types o f anterior glenohumeral disloca­ tion have been described according to the site o f the humeral head. . — Subcoracoid: This is the commonest type in athletes and is characterized by anterior displacement o f the humeral head so that it lies inferior to the coracoid process. — Subglenoid: This is the second most common type and here the humeral head lies anterior but inferior to the glenoid fossa. — Subclavicular. This is rare and here the humerus lies medial to the coracoid process and inferior to the lower border o f the clavicle. — Luxatio erecta: In this condition the humeral head is dislocated anteriorly but the arm is fixed in a po­ sition o f complete elevation. — lntrathoracic In this type the humeral head is driven between the ribs into the thoracic cavity. Diagnosis . The athlete will present with pain and loss of function after an acute precipitating event The classical history o f the mechanism o f injury can be obtained. On exami­ nation the shoulder is held in slight abduction and the i/ottanen s&lQQ Diclophenac sodium 1 0 0 mg mw_______ __ PASl '/« WIISENACH 93065 D'dophenWcsodium WOmg 8 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) athlete is unable to adduct, abduct or rotate the shoul­ der. The lateral contour o f the shoulder may be flat­ tened and the humeral head may be palpated below the coracoid process The physical examination should also include an as­ sessment o f the possible neurological and vascular complications o f anterior shoulder dislocation. The diagnosis should be confirmed by X-Rays Two views at right angles to each other should be taken. These can be an anteroposterior view, lateral view or an axillary view. Radiographs can indicate the type o f dislocation as well as any associated fractures Management The immediate management is to reduce the dislocated shoulder. Gentle reduction may be attempted on the field if the diagnosis is obvious Early reduction has the following advantages less muscle spasm to overcome, less risk o f damaging neurovascular structures and minimizes damage to the humeral articular surface. Reduction can be achieved by a number o f methods The principle that is to be followed is that o f applying traction to the arm in the abducted and flexed positions. The methods o f reduction are briefly as follows: Lying supine on the bed with traction applied in 30° abduction while countertraction is applied (H iDDO- cratic method) — Lying supine with the elbow flexed. Traction is ap­ plied, the arm is slightly externally rotated and then internally rotated while adducted (Kochers method) — Lying prone on the bed with the injured arm hang­ ing down over the side. Traction may be applied in a downward fashion. Immediately after reduction the athlete should be re­ assessed clinically and with X-Rays. It is important to re-assess the neurovascular status as well as the integrity of the rotator cuff. With the development of arthroscopic shoulder surgery the treatment is more aggressive. The younger the athlete, the more important early stabili­ zation becomes. The reason for this is the high rate of recurrent instability in young athletes after the first dis­ location: in the 20-year old recurrence can be as high as 100% and for any athlete playing contact sport ± In traumatic anterior dislocations the most important features of the post reduction management are im m o­ bilization and rehabilitation. Immobilization is done in the position o f relaxed anterior structures (adduction, internal rotation) and is best achieved by a sling. The duration o f immobilization is usually 3 weeks. The rehabilitation will be discussed in another article in this journal but the principles are to strengthen the anterior supporting structures (subscapularis inferior glenohumeral ligament) and the external rotators (infra­ spinatus). Complications The complications o f acute anterior glenohumeral dis­ location are: — recurrent anterior instability is a very common complication — neurovascular damage associated injuries to other structures (rotator cuff and biceps tendon) joint stiffness after dislocation (caused by prolonqed immobilization or unreduced dislocation) Acute posterior glenohumeral dislocation Posterior glenohumeral dislocation is much less com ­ mon in the athlete. The incidence ranges from 1 to 4% o f all acute dislocations The sports in which this injury has been described are: skiing, throwing, football, vol­ leyball, gymnastics racquet ball, wrestling and tennis Mechanism o f the injury The mechanisms o f an acute traumatic injury can be- — a severe blow to the front o f the shoulder in inter­ nal rotation and adduction — a fall on the outstretched hand with the elbow ex­ tended and the humerus in internal rotation Other more comm on non-athletic mechanisms o f in- jury are falls during seizures electric shocks motor ve­ hicle accidents industrial injuries and congenital ab­ normalities that predispose to posterior dislocation (qle- noid dysplasia). Clinical diagnosis This is an injury that is often missed and would there­ fore only be diagnosed by carefully paying attention to detail. The mechanism o f injury is important to estab­ lish and careful questioning is required The athlete may also complain o f severe pain (m ore than in an anterior dislocation). The features on clinical examination are: — locking o f the shoulder in internal rotation and ad­ duction (no external rotation is possible) — abnormally prominent coracoid process flattening o f the anterior deltoid prominent head o f the humerus posteriorly posterior angulation o f the long axis o f the arm — lack o f either active or passive external rotation or abduction o f the affected arm A high index o f suspicion is required to make the di­ agnosis clinically Special investigations It is most important to obtain the correct X-Ray views if the diagnosis is to be made. The view that will con­ firm the diagnosis is an axillary view or trans-scapular view. Management The challenge in this condition is to make the diagnosis as early as possible. Once the diagnosis is made the treatment is early reduction. This is best done by an experienced orthopaedic surgeon. The method is to ap­ ply gentle traction to the arm in adduction, applying gentle anterior pressure to the humeral head and as pressure is maintained to slowly externally rotate the arm. General anaesthesia is usually required. Maintenance o f reduction is achieved by holding the arm in external rotation and slight abduction with a plaster jacket for 3 weeks Active rehabilitative exercises are carried out after this until function is regained. Acute Traumatic Subacromial Bursitis This injury is caused by a sudden impact force which drives the humerus against the acromion. The usual po­ sition producing this injury is a fell on the outstretched SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) hand with the arm in slight abduction. The clinical pre­ sentation is severe pain and loss o f function. Haemor­ rhage occurs in the bursa and blood can be aspirated from the bursa. Pain can be relieved by instilling local anaesthetic into the bursa. The treatment is conservative consisting o f rest fol­ lowed by mobilization and rehabilitation. Recovery re­ quires 6-8 weeks o f treatment.11 This condition is diffi­ cult to distinguish from acute rotator cuff rupture and will often require ultra sonography or arthrogram to ex­ clude the latter. Fractures of the Scapula Fractures of the scapula are uncommon in athletes but have been described in football, ice hockey and riding. The mechanism of injury is usually a direct crushing force which fractures the body, neck, acromion or cora­ coid process Rarely the injury may be associated with fractured ribs or clavicle, or dislocation of the sterno­ clavicular joint or AC joint. On examination the athlete will complain of painful shoulder movements but generally the movements will still be possible. If there are associated respiratory symptoms a thoracic injury must be excluded. X-Rays are usually necessary to confirm the diagnosis. In cer­ tain scapular fractures there might be pseudo-paralysis of the rotator cuff muscles mimicking a rotator cuff tear. The management is conservative. A sling can be worn for comfort and active exercises o f the shoulder, elbow and hand should be encouraged from as early as possible. Fractures o f the scapula may lead to com­ partment syndrome o f the supra- or the infra spinatus muscles: this complication should be recognized early and dealt with surgically. More serious scapular fractures that require operative intervention are usually due to high impact injuries (road accidents) and are not in the scope o f this paper. Acute Soft Tissue Injuries of the Shoulder Acute rotator cuff tear Tears of the rotator cuff muscles are rare in younger individuals, but should always be considered in the older patient with a shoulder injury (40 years and older). A tear of the supraspinatus is the most common and can result from a direct fall on to the shoulder or in­ direct forces on the arm. Larger tears can extend pos­ teriorly to involve the infraspinatus and teres minor. Tears o f the subscapularis tendon are rare and should specifically be considered in the older sportsman where the arm was forced into abduction and external rotation. Rotator cuff tears present clinically as follows: — Severe pain not responding to conservative treat­ ment modalities — Weakness of elevation. Weak supraspinatus test (‘Uobe’s thumb down” test) — Weak “ lift-off’ test (subscapularis tears). — Weak external rotation (infraspinatus/teres minor tears) Confirmation o f the tears is by ultra-sound, arthrogram or MR1. Traumatic tears of the rotator cuff should be repaired surgically as soon as possible. Partial thickness tears occur commonly and can be diagnosed most accurately with the arthroscope. Rupture o f the deltoid muscle Rupture o f the deltoid is infrequent but has been de­ scribed in handball and volleyball players. It may occur as a result o f an acute blow to the arm or as a result o f overuse. It usually affects only a part o f the muscle. The diagnosis is made on clinical signs and the treat­ ment is conservative followed by active rehabilitation. Rupture o f the pectoralis major muscle The pectoralis major can be injured (partial or complete rupture) if excessive loads are applied to the shoulder in internal rotation. Sports in which this has been de­ scribed are weight lifting (bench press), wrestling, shot- put, discus and javelin. The clinical signs are pain at the insertion o f pec­ toralis on the humerus, swelling, bruising and loss of function. The management is conservative except in cases o f total rupture where surgical repair is indicated. Active rehabilitation post injury is encouraged. Rupture o f the long head of biceps Rupture of the long head o f the biceps is seen in older athletes (40-50 years). This is usually secondary to some degenerative change in the tendon, and is associated with rotator cuff tears. The sports where this has been described are: gymnastics, tennis, badminton, wrestling, weight lifting, javelin and oarsmen. The clinical features are pain over the anterior aspect o f the shoulder, swelling (which is prominent on the an­ terior aspect o f the humerus on contraction of the mus­ cle) and loss o f function (weakness). Management is conservative in older athletes but sur­ gical repair is indicated in the competitive or younger athlete (tenodesis o f the tendon in its groove). Active rehabilitation post injury or surgery is indicated. Rupture of the triceps muscle tendon The tendon of triceps may rupture during sport by falls on the flexed arm or in throwing. The clinical features are pain on the posterior aspect of the elbow and some­ times a gap can be felt. Loss of function is characterized by pain on elbow extension. Treatment is conservative unless there is a total rupture in a young competitive athlete. Voltaren (JT50 Diclophenac sodium SO mg w.™ 10 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) TABLE I The modified classification is as follows: TY P E 1 Sprain o f acromioclavicular ligament Acromioclavicular joint intact Coracoclavicular ligaments intact Deltoid and trapezius muscles intact T Y P E II Acromioclavicular joint is disrupted Acromioclavicular joint wider; may be a slight ver tical separation when compared with the normal shoulder Sprain o f the coracoclavicular ligaments Coracoclavicular interspace might be slightly increased Deltoid and trapezius muscles intact TY P E III Acromioclavicular ligaments disrupted Acromioclavicular joint dislocated and the shoul­ der complex displaced inferiorly Coracoclavicular ligaments disrupted Coracoclavicular interspace greater than the nor­ mal shoulder (i.e. 25 to 100 per cent greater than in the normal shoulder) Deltoid and trapezius muscles usually detached from the distal end o f the clavicle In children, a pseudodislocation o f the acromi­ oclavicular joint occurs The coracoclavicular ligaments remain intact to the intact periosteal tube, and the clavicle is displaced out of the peri­ osteal tube. T Y P E IV Acromioclavicular ligaments disrupted Acromioclavicular joint dislocated and clavicle anatomically displaced posteriorly into or through the trapezius muscle Coracoclavicular ligaments completely disrupted Coracoclavicular space may be displaced, but may appear to be same as the normal shoulder Deltoid and trapezius muscles detached from the distal clavicle T Y P E V Acromioclavicular ligaments disrupted Coracoclavicular ligaments disrupted Acromioclavicular joint dislocated and gross dis­ parity between the clavicle and the scapula (i.e., 100 to 300 per cent greater than the normal shoulder) Deltoid and trapezius muscles detached from the distal half o f the clavicle TYP E VI Acromioclavicular ligaments disrupted Coracoclavicular ligaments disrupted Acromioclavicular joint dislocated and clavicle dis­ placed inferior to the acromion or the coracoid process Coracoclavicular interspace reversed with the clavi­ c le being inferior to the acromion or the coracoid Deltoid and trapezius muscles are detached from the distal clavicle Fractures of the Proximal Humerus Fractures o f the proximal humerus can occur during sports participation. It is more common in the older ath­ lete and is usually the result of a fell on the outstretched arm or direct trauma to the shoulder. It has been described in contact sports such as football, rugby, ski­ ing and riding. The most common site o f fracture is the neck o f the humerus Avulsion fractures o f the greater tuberosity (supraspinatus insertion) often occurs with shoulder dislocation. The lesser tuberosity (sub- scapularis tendon insertion) can be avulsed in posteri­ or dislocation. The clinical presentation is pain, swelling and loss o f function. Adequate and comprehensive X-Rays are most important to establish the extent and type o f in­ jury. The “Trauma Series" o f X-Rays should include a true AP, scapular lateral and "trauma axillary” view. In general the management is conservative (sling) with early mobilization being very important Surgical treatment is indicated in severe angulation ( > 40°), in epiphyseal plate fractures and displaced fractures of the greater tuberosity (associated with tears in the rotator cuff). More complex fractures o f the proximal humer­ us involving multiple parts o f the humeral head usual­ ly require surgical reconstruction by a shoulder surgeon. REFERENCES 1. Wickiewicz TL: Acromioclavicular and sternoclavicular joint iniu- lies. Clin Sports Med 1983; 2 (2): 429-438. 2. Matsen FA and Zuckerman JD: Anterior glenohumeral instabiUtu Clin Sports Med 1983; 2 (2): 319-338. 3 l̂ eerS ^ and Welstl RP: The shoulder in sports. Orthop Clin North Am 1977; 8: 583-591. 4 ^ 9 8 ^ 2 ^ 2 ^ 3 9 ^ 5 4 ^ ̂ ShOLdder 61 atMetes- CUn Sports Med FURTHER SUGGESTED READING: Andrews JR and Wilk KB The athletes shoulder. Churchill Livingstone, new York 1994. Apley AG and Solomon L: Apley's system o f orthopaedics and frac- tunes Butterworth and Co, (Publisher) Ltd, 1982, London. Davies GJ, Gould JA and Larson RL■ Functional examination of the shoulder girdle. Phys and Sportsmed 1981; 9 (6): 82-104. Jobe FW and Bradley JP: The diagnosis and nonoperative treatment of shoulder injuries in athletes. CUn Sports Med 1989- 8 (3Y 419-438. ' ^ E d 11982^ inJUred atMete' IJPPincoU' Philadelphia, Toronto, 2nd Ma?9 9 2 J: SkOUlder lnJurieS ^ Sports' M pen Publishers, Rockville, Peterson L and Renstrom P: Sports injuries: Their prevention and treat­ ment. M Duncan and G Beaton (editors). Juta and Co Ltd, 1986 Johannesburg. Rockwood and Matson: The shoulder. W Saunders, 1990. Rosenom M and Pederson EB: The significance o f the coracoclavicu­ lar ligament in experimental dislocation of the acromioclavicular joint Acta Orthop Scand 1974; 45: 346-. Samilson RL and Prieto V: Posterior dislocation o f the shoulder in ath­ letes. CUn Sports Med 1983; 2 (2): 369-378. Snyder SJ: Shoulder arthroscopy and related surgery. Orthop CUn north Am 1993; January. Q SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Rotator Cuff Impingement Syndrome in Athletes MP Schwellnus MBBCh MSc (Med) MD FACSM* JF de Beer MBChB M Med (Orthop)t MA de Beer MBChB M Med (Orthop)** Introduction The most cx>mmon chronic shoulder injury in the athlete is the rotator cuff impingement syndrome. Pain presenting in the shoulder joint as a result o f pathology in the rotator cuff represents a spectrum o f clinical con­ ditions which have been labelled as painful arc syn­ drome, rotator cuff tears, supraspinatus tendonitis and subacromial bursitis o f the shoulder.2 However, all these syndromes represent a spectrum o f diseases and can all probably best be described clinically by the term rotator cuff impingement syndrome. Mechanism of injury There are two proposed mechanisms o f injury to the rotator cuff in the rotator cuff impingement syndrome. These have been termed the mechanical model and the vascular model. MECHANICAL MODEL This model, which was proposed in the early 1970’s, states that mechanical compression o f the soft tissues in the subacromial area is the principle mechanism o f injury.3 The basis for this compression is the approx­ imation o f the greater tuberosity o f the humerus to the coracoacromial arch specifically during elevation o f the arm. The exact site o f the impingement has been iden­ tified. Initially it was thought that the impingement was on the lateral acromion but subsequent studies have shown that the predominant area o f impingement was the anterior part o f the acromion.4 The normal function o f the rotator cuff involves the movement o f soft tissues (rotator cuff tendons, capsule and biceps tendon) in the subacromial space (space bet­ ween the humeral head and the coracoacromial liga­ m ent) The predisposing factors to mechanical impinge­ ment can therefore be related to either narrowing o f the subacromial space, or abnormal movement o f tissue * Sports Medicine, M R C /U C T Bioenergetics o f Exercise Research Unit, Department o f Physiology University o f Cape Town Medical School, Observatory, 7925 Teh (021) 406-6504 f Leeuwendal Medi-Clinic, 3 Derwent Road, Tamboers- kloof, 8001, Cape Town. Tel: (021) 23-4040. * * Jacaranda Hospital, Suite 3, 213 Middelberg St, Muckleneuk, 0181, Pretoria. Tel: (012) 343-0296. through the subacromial space. Th e factors that play a role in each o f these mechanisms will now be discussed. Narrowing of the subacromial space This is probably the most important cause for impinge­ ment. Th e size o f the subacromial space can be decreased by any o f the following mechanisms. Type o f shoulder movement: The size o f the subacromial space does not remain con­ stant during shoulder m ovem ent Elevation o f the arm, particularly in abduction and forward flexion, causes narrowing o f the subacromial space. This is aggravated if the arm is held in internal rotation during the move­ ment because the greater tuberosity o f the humerus then enters the canal. It has been shown that during forward flexion and internal rotation the distance bet­ ween the coracoid and the humerus is reduced to 6.7mm. This space must accommodate the articular c a rtila ge o f the hum eral head (2-3m m ), the subscapularis muscle (2-4mm), the joint capsule (l-2mm) and still leave room for m ovem ent Small varia­ tion s in t h e ' an atom y m ay p red isp o se to impingement.5 Weakness and/or fatigue o f the shoulder girdle muscles: During shoulder function the subacromial space may also decrease if there is excessive movement o f the humeral head (upwards movement). The rotator cuff muscles are responsible for approximation, stabilization and centralization o f the humeral head during shoulder movement. Any weakness or fatigue o f these muscles can result in excessive movement o f the humeral head and therefore obliteration o f the subacromial space.6 Pathology in the subacromial bursa: Hypertrophy and fibrosis o f the subacromial bursa can result in obliteration o f the subacromial space.7 Pathology o f the acromioclavicular (A C ) joint: Degenerative lesions, thickening or separation o f the acromioclavicular joint have been described as associated factors in impingement syndrome.38 The mechanism by which AC joint pathology causes imp­ ingement is that it causes narrowing o f the subacromial space. Acromion process: It has been postulated that variations in the shape, size, slope or thickness o f the acromion process can 12 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) predispose an individual to narrowing o f the subacromial space and therefore the impingement syndrome.49 In this regard the slope and thickness o f the acromion appears to play an important role. In par­ ticular, if the shape o f an acrom ion is one that angles down too far and forms a “ beak” on the end it causes narrowing o f the subacromial space.10 Bigliani" has classified the acromion in three types: Type I (flat), Type 11 (curved) and Type 111 (hooked). Abnormal movement a. Excessively frequent movement: It has been postulated that excessive repetitive m ove­ ment o f the shoulder in the elevated position can cause irritation and inflammation o f the rotator cuff. The resultant oedem a will cause swelling and therefore in­ crease the volume o f soft tissue in the subacromial space.12 In more chronic cases the inflammation pro­ gresses to fibrosis and calcification. A compromised blood flow to the area can also aggravate this process (see vascular m odel).13 b. Abnormal type o f movement: There are specific movements that are related to rotator cuff impingement syndrome. These are all movements in which there is arm movement above the shoulder level. The sports in which this is a common movement are throwing (baseball, cricket), racquet sports and swimming. If overhead movements are associated with internal rotation o f the shoulder the risk o f impinge­ ment is greater. c. Muscle weakness: Impingement can occur due to relative weakness of the humeral head depressors. In swimmers and other over­ head athletes there is often an imbalance between the internal and external rotators o f the shoulder (the lat­ ter being weaker). Attention to these muscles (infra­ spinatus and teres minor) as a cause o f secondary im­ pingement is mandatory. Poor function o f the “scapular setting” muscles can be associated with secondary impingement. The peri- scapular muscles (trapezium, rhomboids, levator scap­ ulae and serratus anterior) “position” the scapula to en­ able the rotator cuff to function properly. Should this function be inadequate, the rotator cuff is fatigued and this leads to impingement. d. Shoulder instability: Instability (even minor or “ subtle” instability) is also an important cause o f secondary impingement. During elevation o f the arm the humeral head can sublux antero-superiorly, and cause impingement. The in­ stability obviously needs to be assessed and treated (often arthroscopically) for the impingement to be cured. VASCULAR MODEL The vascular model for rotator cuff pathology is based on findings o f the microvascular pattern o f the rotator cuff tendons during movement. Th e classical descrip­ tion o f the avascular zone o f the supraspinatus and biceps tendon was reported in 1970.14 The rotator cuff tendons have a poor blood supply which predispose them to poor healing following repeated microtrauma. The blood supply to the supraspinatus tendon and the intracapsular portion o f the biceps tendon is decreased when the arm is in the adducted position (arm hanging at the side) due to the pressure o f the humeral head on the blood vessels. If the shoulder is abducted the vessels are filled.9 The mechanical model and the vascular model may compliment each other to explain the mechanism of impingement (mechanical irritation and poor healing). However, it has been stated that the area o f avascularity may have developed as a protective mechanism to prevent recur­ rent haemorrhage in an area which is susceptible to repeated microtrauma.7 Pathology of rotator cuff impingement syndrome The pathology o f chronic lesions o f the rotator cuff can be regarded as a continuous process which ranges from irritation o f the soft tissues and ends in rupture o f the rotator cuff. Most authors therefore adopt a process of staging lesions of the rotator cuff along this continuum. The most widely accepted staging is that o f Neer.91517 Clinical diagnosis and treatment o f the impingement syndrome is based on Neer’s stages. The pathology of these stages will now be discussed. Neer’s stage I (Oedema and haemorrhage) This is the first stage o f rotator cuff impingement and is characterized by oedem a and haemorrhage in the rotator cuff.3 The site o f the injury can vary from be­ ing predominantly in the supraspinatus tendon (most common) or the biceps tendon (less common). It oc­ curs typically in the young athlete ( < 2 5 years) and is reversible if managed correctly. This is the predominant lesion seen in the young active sportsperson. Neer’s stage II (Fibrosis) This stage is characterized by fibrosis in the rotator cuff and therefore reflects persistent inflammation usually as a result o f repeated irritation.3 The site o f fibrosis and thickening can be in the rotator cuff tendons (main­ ly supraspinatus), subacromial bursa or the long head o f biceps can also becom e involved. It is more common in the older age group (25-40 years) and is not necessarily reversible. Neer’ stage III (Rotator cuff tears, biceps rupture) This stage o f the rotator cuff impingement syndrome is characterized by permanent changes in the tissues. These changes are ruptures o f the rotator cuff (partial or full) and ruptures o f the long head o f the biceps. Neer’s stage IV (bony changes) Specific examples o f bony changes that can occur are traction spurs in the coracoacromial ligament and on the ventral surface o f the acromion followed by erosion o f the anterior acromion.3 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Neer’s stage V (cuff tear arthropathy) Due to the chronic rotator cuff tear there is cartilaginous degeneration o f the glenohumeral joint. Typically the patients that present with rotator cuff impingement syndrome (types 111, IV and V) are older ( > 4 0 years). The changes are also permanent unless treated surgically. Although the same principles o f staging are used generally, other authors have used a four stage classification o f impingement syndrome. JOBE’S CLASSIFICATION O F ROTATOR CUFF IMPINGEMENT1-16 Stage I This stage is characterized by oedem a and inflamma­ tion. There is temporary thickening o f the bursa and rotator cuff but no permanent defect. Stage II This stage is characterized by disruption o f fibres o f the rotator cuff but no actual tear. If allowed to heal without correct treatment there is a risk o f developing contrac­ tures In addition there is permanent thickening o f the bursa and rotator cuff with scar formation. Stage III This stage is characterized by permanent thickening and scar formation (as in stage 11) but there is a possi­ ble partial tear o f less than 1 cm. This tear refers to a tear greater than 1cm in the circumferential plane. Stage IV In this stage there is permanent thickening o f the bur­ sa and the capsule, associated scarring and a tear in the rotator cuff which is greater than 1cm in the cir­ cumferential plane. In this classification the management is again bas­ ed on the stage o f the syndrome.16 In this paper the staging o f Neer will be used unless indicated otherwise as this is the most widely accepted staging o f rotator cuff impingement syndrome. Diagnosis of rotator cuff syndrome SYM PTOM S: Although it is important to elicit the symptoms in order to establish the correct diagnosis it must be emphasiz­ ed that the history should also include thorough ques­ tioning on the mechanisms and possible causes o f the athletes’ shoulder com plaint This should include history o f the mechanism o f injury, training program, and equipment used. Stage I The main presenting symptom in all stages is pain in the shoulder. However, the nature o f the pain may dif­ fer. In stage I the pain is often a dull ache only after the activity. The pain may be described as “tooth ache” like pain.15 This can then progress to pain experienc­ ed during activity which eventually interferes with the activity.15 A hallmark o f this pain is that it subsides on cessation or modification o f the activity. The pain may also manifest as night pain. There is no associated weakness o f muscles in stage 1 except that related to pain. In the overhead athlete the arm movement must be analyzed and note should be taken where in the movement the pain occurs, as this can help with the diagnosis, eg. in the baseball-pitcher, if the pain occurs in the “cocked” position it is more likely due to instability. If the pain occurs when the arm is overhead it is more than likely due to impingement, and so on. This pattern can be applied for all the dif­ ferent overhead sports Stage II The symptoms o f stage 11 are an extension o f those in stage 1. The pain is often more frequently encountered during the day and may be experienced during non­ sports activities such as reaching overhead. Night pain is also m ore prominent. There may be complaints o f a slight limitation of movement or associated muscle weakness in stage 11. The hallmark o f stage 11 is that the disease process is no longer reversible with activity modification or cessation.3 Stage III The young competitive athlete rarely presents in this stage. There is usually a long history o f chronic pain and loss o f function. Athletic activity is often not possi­ ble because o f the limitations o f pain and weakness The symptoms o f stiffness (due to loss o f range o f movement) and muscle weakness (abduction and ex­ ternal rotation) are prominent. The periods o f pain are prolonged and are particularly prominent at night The hallmarks o f this stage are the chronicity o f the disease and the permanent pathological changes SIGNS It is important to elicit the clinical signs that will con­ form the correct diagnosis as well as identify the stage o f the disease. However, a thorough biomechanical ex­ amination o f the shoulder must include evaluation o f the range o f m ovem ent, m uscle strength and mechanism o f injury. Stage I The most important clinical sign in the diagnosis o f this condition is a positive Neer’s impingement sign.3 The diagnosis can be confirmed by a positive Neer’s imp­ ingement test (injecting the subacromial space with 6-10ml local anaesthetic and repeating the impinge­ ment test). Other clinical signs are:13 — palpable tenderness over the greater tuberosity of the humerus at the supraspinatus insertion — palpable tenderness along the anterior edge o f the acromion — painful abduction specifically between 60 and 120° (painful arc sign) — muscle weakness associated with abduction which disappears after injection o f local anaesthetic into the subacromial space — tenderness over the biceps tendon (biceps involve­ ment in stage 1 however, is rare and this finding is not common).17 14 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Stage II The clinical signs o f stage 1 can all be demonstrated in stage 11. In addition there is: — limitation o f movement — the weakness is more pronounced (can however be normal following the injection o f local anaesthetic) — soft tissue crepitus — a catching sensation during abduction at approx­ imately 100° which is due to fibrosis and scarring. Stage III The findings on physical examination o f staqe III a r e : 13.l5,l8 — limitation o f shoulder movement (active more than passive) — muscle atrophy (infraspinatus and supraspinatus) — biceps tendon lesions ranging from tenderness to rupture — acromioclavicular joint involvement (positive com­ pression test) — weakness o f shoulder musculature which persists after injection o f local anaesthetic into the subacromial space — positive clinical signs for rupture o f the rotator cuff muscles — sings o f shoulder instability may also be present SPECIAL INVESTIGATIONS X-Rays Good quality X-Rays should be done including the following views: — True A P — Supraspinatus outlet view — Axillary view — A P 3 0 ° (caudal tilt) is optional — AC joint view is essential The X-Ray findings in stage 1 are normal. The X-Ray changes o f impingement syndrome typically lag behind the clinical course.15 However, causes o f underlying predisposing factors may be identified on X-Rays (acromial shape and angle, AC joint pathology). There may be features noted on X-Rays later in stage 11. These are cystic changes in the greater tuberosity of the humerus as seen best on the 10° AC view, osteophytes on the undersurface o f the acromion and, changes in the acromioclavicular joint. X-Ray changes are most likely seen in stage 111. The abnormalities that must be identified are:915 — narrowing o f the subacromial space ( < 5mm space indicates a rotator cuff tear) — superior migration o f the humeral head — erosion o f the acromion sclerosis and osteophyte formation on the acromion and greater tuberosity o f the humerus X-Rays must also be evaluated for the presence of underlying predisposing factors to impingement and causes o f narrowed subacromial space should be identified. Ultrasonography Ultrasound is cost-effective and accurate to detect tears o f the rotator cuff but is operator-dependant. It is also very helpful to show calcific deposits in the cuff, biceps tendon pathology, subscapularis tears and coracoid impingement. Arthrography Double contrast arthrography o f the shoulder joint is a useful technique for the diagnosis o f rotator cuff tears with an accuracy o f 99%.19 Communication o f contrast medium between the glenohumeral joint and the subacromial bursa indicates a complete tear o f the rotator cuff. It can be combined with CAT scan (“CT ar­ thrography”). Arthrography only indicates the presence, not the size o f a rotator cuff tear. Magnetic resonance imaging (MRI) MR1 is a very useful investigation to delineate exact pathology in the soft tissues (a shoulder dedicated coil must be used). It is therefore accurate in the diagnosis o f rotator cuff pathology. The major limitation is the tim e it takes and the expense involved, and should on­ ly be used in the exceptional case. Arthroscopy of the shoulder joint This technique is rapidly becom ing the investigative procedure o f choice in rotator cuff impingement syn­ drome. It is very accurate for the identification o f rotator cuff pathology and has the added advantage that surgery m ay be perform ed at the sam e tim e.15 Surgical procedures that can be done arthroscopically include bursectomy, acromioplasty, excision o f the lateral end o f the clavicle, rotator cuff debridement and stabilization procedures like anterior and posterior Bankart repair and S L A P lesion repair. (The diagnosis and treatment o f the latter can in fact only be done arthroscopically). Differential diagnosis The following conditions must be distinguished from impingement syndrome.13 — acute traumatic bursitis — shoulder instability syndromes (which may be associated with secondary impingement) — primary acromioclavicular pathology — cervical spine disease — glenohumeral arthritides — calcific tendonitis — frozen shoulder Management of Rotator Cuff Impingement Syndrome Stage I This stage o f the disease process is reversible and should therefore be managed correctly to avoid progres­ sion. The management is conservative and the princi­ ples o f conservative management are to diminish the in­ flammation, maximize shoulder function and to correct or modify the activity.18 The conservative management and rehabilitation will be addressed in a separate article. General principles It is important to note that rotator cuff impingement in the young athlete is often secondary to instability SA JOGRNAL OF SPORTS MEDICINE NOVEMBER 1994 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) — the latter should then be addressed first. Weakness o f the humeral head depressors (rotators) is also a com mon causative problem and specifically strengthening o f the external rotators (infra spinatus and teres minor) should be addressed. Posterior capsular tightness is often an associated causative factor and stretching of the posterior capsule is mandatory. N on steroidal anti-inflammatory drugs A short course o f these drugs can be prescribed to d e cre a s e in fla m m atio n in this sta ge o f the disease.1315’20 Subacromial cortisone injection Although this is a comm on form o f therapy, frequent injections without caution increases the risk o f tendon rupture.21 In general no more than two or three cor­ tisone injections are recommended. The cortisone can be mixed into the solution when doing the im pinge­ ment (injection) test with local anaesthetic. Surgical treatment (Stage I) Rarely athletes with stage I lesions are not successfully rehabilitated on conservative treatment Although these athletes are a small minority, surgery may have to be considered if conservative treatment has failed (at least 6 months o f adequate conservative treatment must be allowed).13 The athlete must also be aware that athletic competition after surgery may be compromised (impor­ tant in the throwing athlete). Surgical management should include a thorough arthroscopic evaluation o f the gleno humeral joint to exclude instability with secondary impingement and other pathology, follow­ ed by evaluation o f the sub-acromial space to confirm im pingem ent If bursectomy, excision o f the coraco- acromial ligament and acromioplasty is decided upon it should preferably be done arthroscopically in the young athlete. Stage II Conservative treatment The initial treatment for stage II o f rotator cuff impinge­ ment syndrome is conservative. The type o f treatment is essentially the same as stage 1. Differences in the con­ servative approach to stage 1 and II are: — activity in stage 11 must be restricted more than in stage I (ie. only kicking in swimming, complete rest from throwing and limiting tennis shots to the forehand hitting against a wall) — medication use in stage 11 may be more prolonged — greater emphasis is placed on a range o f motion ex­ ercises in stage II to prevent adhesive capsulitis — resistance exercises tend to be less intense in stage 11 to prevent overloading o f the rotator cuff Surgical management o f stage II Surgical management is more common in stage II than in stage 1. The main indication for surgery is failed con­ servative treatment (duration o f at least 6-12 months). Other indications for surgery are i) permanent narrow­ ing o f the subacromial space for example if there is an abnormal angle o f the acromion and ii) associated in­ stability o f the shoulder which results in im pingement Under these circumstances conservative treatment is likely to fail unless the underlying defect is corrected. Surgical management should again include arthrosco­ pic evaluation and arthroscopic treatment as far as possible. Stage III The treatment of stage III o f the rotator cuff im pinge­ ment syndrome is surgical.101315’22 Surgery involves decompression, repair o f the rotator cuff and anterior acromioplasty. The outer part o f the clavicle and the acromioclavicular joint may also have to be resected as part o f the decompression. The tendency is to per­ form arthroscopy of the shoulder earlier and this is both as a diagnostic procedure as well as performing the surgery arthroscopically. Prognosis There are no published controlled clinical trials on the conservative treatment of rotator cuff impingement syndrome.15 In one report on the outcome following surgical treatment for rotator cuff tears in athletic population, the results indicate pain relief post operatively in 76% of subjects, but only 32% o f the professional pitchers were able to return to the same level o f competition after surgery.22 REFERENCES 1. Jobe FW and Jobe CM: Painful athletic injuries of the shoulder. CUn Orthop and Rel Res 1983; 173: 117-124. 2. Brunet ME, Haddad RJ and Porche EB: Rotator cuff impingement syndrome in sports. Phys Sportsmed 1982; 10 (12): 86-94. 3. Neer CS and Welsh RP: The shoulder in sports. Orthop Clin North Am 1977; 8: 583-591. 4. Neer CS. Impingement lesions. CUn Orthop 1983; 173: 70-77. 5. Gerber C, Terrier F and Gam R: The role of the coracoid process in the chronic impingement syndrome. J Bone Joint Surg (Br) 1985; 67: 703-708. 6. Pappas A, Zwacke R and McCarthy C: Rehabilitation of the pit­ ching shoulder. Am J Sports Med 1985; 13: 223-235. 7. Ciullo JV and Steuens GG: The prevention and treatment of in­ juries to the shoulder in swimming. Sports Med 1989; 7: 182-204. 8. Kessel L and Watson M: The painful arc syndrome. J Bone Joint Surg (Br) 1977; 59: 166-172. 9. Hawkins RJ and Hobeika PE: Impingement syndrome in the athletic shoulder. CUn Sports Med 1983; 2 (2); 391-404. 10. Nash HL: Rotator cuff damage: Reexamining the causes and treatments. Phys and Sportsmed 1988; 16 (8): 12135. 11. Bigliani LCI: Arthroscopic Resection of the Distal Clavicle. Or­ thopaedic CUnics of North America 1993; 24: 133-141. 12. Penny JN and Welsh RP: Shoulder impingement syndromes in athletes and their surgical management Am J Sports Med 1981; 9 (1): 11-15. 13. Hawkins RJ and Kenndy JC: Impingement syndrome in athletes. Am J Sports Med 1980; 8 (3): 151-158. 14. Rathbun J and Macnab 1: The microvascular pattern of the rotator cuff. J Bone Joint Surg (Br) 1970; 52: 540-553. 15. Thein LA: Impingement syndrome and its conservative manage­ ment JOSFT 1989; 11 (5); 183-191. 16. Jobe FW and Moynes DR: Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med 1982; 10 (6): 336-339. 17. Ciullo JV: Swimmer's shoulder. CUn Sports Med 1986; 5 (1): 115-136. 18. Simon ER and Hill JA: Rotator cuff injuries: An update. JOSPT April 1989; 394-398. 19. Newberg AH: The radiographic evaluation of shoulder and elbow pain in the athlete. Clin Sports Med 1987; 6: 785-809. 20. Richardson A: Overuse syndromes in baseball, tennis, gymnastics and swimming. CUn Sports Med 1983; 2: 379-389. 21. Kennedy JC, Hawkins R and Krissoff WB: Orthopaedic manifesta­ tions o f swimming. Am J Sports Med 1978; 6 (6): 309-322. 22. Tibone JE, Elrod B, Jobe FW, Kertan RK et al: Surgical treatment o f tears of the rotator cuff in athletes. J Bone and Joint Surg 1986; 68A (6): 887-891. □ 16 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Pevaryl • Broad spectrum antimicrobial action • Derm atophytes • Yeasts • Moulds • Gram positive bacteria" • Fungicidal effects' • Sporocidal effects^ • H ig h m y c o lo g ic a l c u r e r a te o f 9 2 % ' • M in im a l r e la p s e r a te e v e n a f t e r 1 y e a r ' • N o r e s i s t a n c e r e p o r t e d ' OFTEN CHALLENGED . . . . STILL UNSURPASSED Pevaryl The No.l topical antifungal Econazole nitrate d’ TTnma**'* t J) H u n ■ i n — i i r U . . . . T 3V X«WkTiu«Muil% n>u h o t on Ate < ».*)«: N"rtucu On) un V *'■ r.*! licniiJH)k>Rt»3 IMJ.fti- 5> Scfmrafanfi R Kcacanrh ftpon Ichl fat |fc Ji Rndtc ProiiiKt* (Prr) uo 6) OS! ’ ( Scto.tidtlmwhra|j*CjlW20(i«w> R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) The Role of Arthroscopy in Shoulder Problems of the Athlete MA de Beer MBChB M Med (Orthop)* JF de Beer MBChB M Med (Orthop)t Introduction Arthroscopy has revolutionized our knowledge o f the anatomy and pathology o f shoulder problems. A r­ throscopy has also vastly improved the accuracy o f diagnoses, and instituted more specific treatment with much better outcome. A surgeon can not adequately deal with shoulder problems without a thorough work­ ing knowledge o f shoulder arthroscopy. Impingement The majority o f impingement syndromes in young athletes are secondary to instability and other lesions like labral tears (including S LA P lesions). These pro­ blem s can best be diagnosed and treated ar­ throscopically. In primary (structural) impingement in the athlete, resistant to conservative treatment, an ar­ throscopic acromioplasty is the treatment o f choice. The advantages o f arthroscopic acromioplasty (rather than open acromioplasty) are: — The gleno-humoral joint can be inspected to rule out other causes o f impingement (this is mandatory in the "overhead athlete” like throwers, swimmers, etc). — The sub-acromial space can be inspected to confirm impingement. — There is no damage to the deltoid muscle as in open acromioplasty. — There is early return to full function. — There is usually minimal post operative pain. — Short hospital stay (can be done on an “out-patient” basis). — Cosmetic advantage: no incisions with an unaccep­ table appearance. The results o f arthroscopic acromioplasty have become so good that it will probably be regarded as “ unaccep­ table” to do open acromioplasty in young athletes. Posterior Impingement Posterior impingement is caused by abduction and ex­ ternal rotation o f the shoulder, mostly in throwers. In this position the posteriosuperior glenoid rim acts as a “chisel” stripping the insertion o f the rotator cuff from the greater tuberosity. This diagnosis can only be made with dynamic arthroscopy. S L A P lesions (Superior Labrum Anterior to Posterior) These are tears o f the superior glenoid labrum and in­ * Jacaranda Hospital, Suite 3, 213 Middelberg St, Muckleneuk, 0181, Pretoria. Tel: (012) 343-0296. f Leeuwendal Medi-Clinic, 3 Derwent Road, Tamboers- kloof, 8001, Cape Town. Tel: (021) 23-4040. sertion o f the tendon o f the long head o f the biceps. Lesions can only be diagnosed, differentiated and treated arthroscopically. Shoulder Instabilities Arthroscopy has increased our understanding o f shoulder instability and labral tears. The direction, degree and pathology o f instability can be assessed ar­ throscopically. Although open surgical repair o f Bankart lesions had been regarded as the “gold standard” ar­ throscopic stabilization has becom e a successful pro­ cedure in the hands o f experienced shoulder ar- throscopists. The following procedures can be adequate­ ly performed: — Anterior Bankart repair — Posterior Bankart repair — Capsular plication (multi directional instability) — Labral repair (like S L A P lesion repair). Rotator cuff tears Full-thickness tears: can be accurately detected if there was doubt about the diagnosis. Smaller tears can be repaired arthroscopically. Partial-thickness tears: occur mostly on the joint side o f the cuff and can only be diagnosed arthroscopically. At the same time they can be debrided using the arthroscope. Full-thickness tears o f the rotator crescent, with an intact rotator cable (= “ functional” tears as described by Burkhart) can be treated arthroscopically with debridement and arthroscopic acromioplasty. This would usually apply to the older sportsperson in less demanding sports like golf, bowls, etc. Acromioclavicular joint pain Painful acromioclavicular joint is common in sports people. In those where conservative treatment has fail­ ed, excision o f the lateral end o f the clavicle becomes indicated (“Mumford” procedure). This procedure can be adequately performed arthroscopically, in fact the open procedure is less acceptable in the “overhead athlete” as it can lead to dam age to the delto-trapezius fascia and weakening o f the shoulder. The arthroscopic procedure also avoids damage to the acromioclavicular ligament with less likelihood o f joint instability. Chondral and Osteochondral lesions These lesions o f the joint surfaces can only be diagnos­ ed arthroscopically and can often be treated at the same time. “GLAD” lesions (gleno-labral articular disruption) is a good example o f this (Continued on page 2 3 ) 18 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Rehabilitation of the Athlete’s Shoulder Gisela Lauterbach Abstract A holistic approach to the rehabilitation o f athlete’s shoulder is presented. Factors that should be included 3re poSture' sPinal and neuromenin- geal m obility, physiological and accessory m ovem ents o f all join ts o f the shoulder com plex, stability tests, resisted m ovem ents, and synchrony o f m ovem en t dur­ ing active m ovem ents. D ecrease o f pain and control o f in flam m ation are im portant initial goa/s o f rehabilita- r , ° rma ranLg e o f m °vem ent o f all joints o f the shoulder girdle should be achieved before starting with a strengthening programm e and mobilizations should be based on the normal arthrokinematics. Dynamic proximal control must be established before adding dis- S r w 1 y' ? V stren9thening exercises for the rota­ tor cult therefore are o f paramount importance. The hu- meroscapular rhythm must be restored during eleva­ tion before strengthening specific muscles. Closed ki­ netic chain exercises enhance static control. Both con­ centric and eccentric contractions should be included and techniques should be adapted to replicate the bio- mechamcs o f the specific sporting activity. Progression o f exercises is determined by the control o f movement presence o f pain or related symptoms, and never by I T KanfJ u Wf r f xtremity strength and endur­ ance work should be included into the programme. The programme should employ correct movement patterns fo rm a n S f retUm ° f Symptoms and for improved per- INTRODCiCTION sp^ nJ ; on o f the T h ie le ’s shoulder is a commonly seen condition in a sports injuries dinic. Symptoms may range from pain during or after activity, weakness, S S l ? f n.sat'ons’ or loss o f performance. Varied ap- S S S ^ T T been described- The Cyriax (1980) approach advocates treating localized lesions bv ;.eeP ftraJnsverser Actions; Travell and Simons (1983) identified specific pain distributions o f trigger points o f each muscle which are locally treated. Results of “ T6 ° f f n disaPPointin9 and frustrating for the athlete. Too often, treatment is directed to a s p ^ ific component o f the pain only, neglecting the multi-struc­ tural approach to the shoulder complex. • fa,ctors should be considered as possible ori- £ £ f r * shoulder f u n c t i o n . In the overhead ath­ lete utilizing repetitive movement o f the arm at hiqh foroesandjccelera tio n , secondary impingement is a Department o f Physiotherapy University o f Cape Town Anzio Road 7925 Observatory TOmmon syndrome. Contributing factors are minor in­ a b ilities, loss o f functional stabilization by the scapular muscles, fatigue and/or loss o f depressor action o f the ™ scle (“ amkar 1993). The aim o f rehabili- tation is to return the athlete to the previous level o f performance in the shortest, yet safest possible time Further; predisposing factors to injury must be identi­ fied and corrected as m ore emphasis is placed on inju­ ry prevention. Detailed reviews o f rehabilitation pro- P in lT T S f^ T f fr° m reC6nt literature (Jobe and TQ& w S Ll‘ ch/ield et al 1993> Magarey and Jones to S i , a" d IA rn go 1993> The aim o f this paper is S w S T r f , n w I f apProach to the rehabilitation o f athletes shoulder. A s a detailed assessment o f the ath­ lete forms the basis o f the rehabilitation programm e components that should be examined are presented Assessment Maitland (1991) presents a systematic approach to the examination o f the shoulder joint. A detailed history and training programm e o f the athlete is taken The & re ° f tf?e athletj must be analyzed as increased sil?nn h kyP hosis and an anteriorly displaced head po- to l h l iH 5 “ ? Identified as Possible factors leading f f yu Unctlon 1992> Further, range o f movement o f the cervical and thoracic spine is assessed P h l ^ r S . lS PredisPosing factors to dysfunction, the accessory movements o f all joints o f the shoulder complex should be tested for range and Hnhfn*n hPaiK and m usde sPasm- Posterior capsular tightness has been identified as a factor leading to secondary impingement (Kamkar 1993) This is as sessed by the amount o f anterior displacement o f the +UiS o rah i el ^ 9 passive medial rotation o f the aDaucted arm. are Perfomied' including apprehension (Malone 1994??; r 3nd Posterior drawer signs (Malone 1994). It is important to determine the ranqe o f movement o f these, the end-feel and the response P . n ..ur!'?g th®se tests. Testing positions should be adapted to the athlete's specific biomechanics. For ex­ ample, with the throwing athlete, the anterior drawer sign, usually performed in 9 0 ° flexion in the scapular plane may be repeated in the position o f full flexion £ 5 ? r° ^ t'0nu(F ig- P - With the swimmer it may be s t r o k e ^ ' i l l * P 03!!100 ° f mid-recovery o f the crawl stroke i.e. in the quadrant position. Resisted movements are used to determine a soft tis­ sue component, for example lesions of the rotator cuff. However, if these are used as isolated findings, the full functional biomechanics o f the shoulder complex is not appreciated. Control o f movement in f u X I a X c SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Fig. 1. Anterior drawer sign tested in a functional posi­ tion. The relative movem ent between the fixed coracoid and the humeral head is noted. tions is considered more important in the evaluation of shoulder dysfunction than pure reproduction o f pain during a specific resisted test For example, scapula con­ trol and the function of the rotator cuff in various posi­ tions must be tested and compared to the uninvolved shoulder adapting the tests to the athlete’s specific sports activity. Isokinetic equipment may be used to as­ sess muscle power. However, these tests are often in non-functional isolated directions In the shoulder joint control and co-ordination o f complex movement are more important than muscle power per se in the shoul­ der join t Neuromeningeal structures have been identified as possible components o f shoulder dysfunction (Butler 1991) in both overuse and traumatic injuries. The upper limb tension tests are used to assess firstly, the mobili­ ty and integrity o f the neural structures o f the brachial plexus and sympathetic nervous system and, secondly, response of presenting symptoms to these movements. Planning o f the rehabilitation programme needs to incorporate every component found to be comparable to the athlete’s symptoms during examination. It should be designed according to the athlete’s specific needs and recipe-type programmes should not be used. Rather, signs and symptoms must be re-assessed cons­ tantly and the programme be progressed accordingly. Principles of Rehabilitation 1. Decrease o f pain Decrease o f pain and control o f inflammation are im ­ portant initial goals of rehabilitatioa Anti-inflammatory modalities, ice and electrotherapy, may be applied. To treat pain, Grade 1 and II passive accessory mobiliza­ tions o f the involved joints are used (Maitland 1991). Anterior-posterior mobilizations of the cervical spine are effective if neural tension techniques were comparable to the patient’s pain during the examination (Fig. 2). 2. Increase of range o f movement Before starting strengthening programmes it is abso­ Fig. 2. Anterior-posterior mobilizations o f the cervical spine. lutely necessary to achieve normal glenohumeral and scapulothoracic motion. Without normal flexibility ab­ normal movement patterns may be enhanced (Pappas et al 1985). Mobilization o f the shoulder joint should be based on the normal arthrokinematics The acces­ sory movements o f inferior and posterior glide occur during the first 90° o f flexion, followed by an inferior and anterior glide. Specific techniques can be used at the limitation o f the physiological range o f movement as Grade IV mobilizations to stretch the capsule and restore normal motion (Fig. 3). Fig. 3. Mobilization o f the posterior capsule. Compression through the long axis o f the humerus is added oscillatory on horizontal adduction. Athletes often need an increased range of movement for efficient performance and mobilization techniques should be adapted towards these. Lateral rotation of 170° in full elevation has been documented in base­ ball pitchers (Dillman et al 1993). Hypermobility of the anterior shoulder is common in swimmers and is neces- 20 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Fig. 4. Mobilizations o f the thoracic spine. sary during the recovery phase o f the crawl phase. The quadrant position (Maitland 1991) best replicates these movements and should be “cleared” before discharging the athlete from rehabilitation. Further, mobilization of the cervical and thoracic spine may be necessary if these joints were found to be stiff or painful on exami­ nation (Maitland 1987) (Fig 4). 3. Improvement o f the rotator cuff function The rotator cuff and biceps muscles function as depres­ sors during elevation and have a strong eccentric con­ traction during follow-through o f the throw (Diilman et al 1993). If this function is reduced by early fatigue or weakness, impingement o f the cuff occurs against the anterior coracoacromial arch (Kamkar 1993). Early strengthening exercises, maintaining control o f the scapular position, are therefore o f paramount impor­ tance. Isometric contractions using rhythmical stabili­ zation techniques (Knott 1968) in neutral position are progressed to various positions o f flexion and abduc­ tion into the direction needed in the particular sport­ ing activity (Fig. 5). Once painfree control is achieved in various positions, dynamic through-range exercises are added. Various methods o f resistance can be em ­ ployed, for example manual resistance by the therapist, self resistance, elastic bands and light weights Scapu­ lar control must be emphasized throughout to prevent re-injury. As endurance is an important factor to be con­ sidered, it is advisable to use low weights with high repetition. 4. Re-education o f movement The correct muscle firing pattern is an important pre­ requisite for optimum performance and injury preven­ tion. In the shoulder dynamic proximal control must be established before adding distal mobility. The hume- roscapular rhythm must therefore be restored during elevation before strengthening specific muscles. As painfree range o f movement is regained, control of the scapula can be achieved in various starting positions, for example using proprioceptive neuromuscular facili­ tation (PN F ) techniques (Knott 1968) o f the scapula in side lying. This can be followed by improvement of scapula control in progressive ranges of flexion and ele­ vation in the scapular plane (Fig. 6). Free active exer­ cises in prone are added, emphasizing rhomboid and lower and middle trapezius muscle strengthening (Fig 7). Exercises are progressed by adding light weights or using elastic bands. Stability exercises include the closed kinetic chain exercises, for example push-upa These facilitate joint compression and stimulate neuromuscular propriocep­ tors to enhance static control (Dickoff-Hoffman 1994). The serratus anterior muscle plays an important role in proximal stabilization o f the shoulder girdle, and is strengthened during press-ups “with a plus” , i.e. adding full protraction o f the scapula. These are initially per­ Fig. 5. Rhythmical stabilization techniques for the rota­ tor cuff are used in the eariy phases o f rehabilitation. Scapular position is monitored constantly. Fig. 6. Re-education o f the muscle firing pattern. Scapular stabilization is monitored while adding flexion o r abduc­ tion o f the glenohumeral joint. SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Fig. 7. Free actiue exercises emphasizing interscapular muscle contraction. The arms are horizontally extended while controlling the scapular position. Fig. 8. Press-up exercises are progressed by using an ex­ ercise ball in the final stages o f rehabilitation. formed against the wall, and progressed to the floor. Performing them on a balance board or exercise ball (Fig. 8) requires maximum proximal stabilization and should be used in the last phases o f rehabilitation. 5. Strength training Straight arm exercises in flexion and abduction should never be employed before these movements cannot be controlled sufficiently by the proximal stabilizers, viz. scapular and rotator cuff muscles. PNF patterns, espe­ cially the diagonal flexion/abduction/extemal rotation, can be used in preparation of these, utilizing manual resistance. This has the advantage o f constantly moni­ toring control o f the movement and resistance can be accommodated accordingly. Both concentric and eccen­ tric contractions should be included. Using these tech­ niques in the seated or standing starting position repli­ cates the activity needed during sports. Weight train­ ing on apparatus can be commenced, monitoring sca­ pular control constantly. Isokinetic apparatus should be regarded only as an adjunct to functional rehabilitation as movements are isolated to specific directions. Progression o f exercises is determined by the con­ trol o f movement, presence o f pain or related symp­ toms, and never by time. Further, pelvic control is im­ portant for optimal timing during any biomechanical sequence. Pelvic position whilst performing any exer­ cises should therefore be monitored and corrected. Trunk strengthening, including abdominal setting ex­ ercises, and lower extremity strength and endurance work should be included into the programme. 6. Functional rehabilitation As the aim o f rehabilitation is to return the athlete to previous performance levels, exercises involving the bio­ mechanics o f the specific activity must be incorporat­ ed into the programme. Gymnasts will need weight­ 22 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) bearing exercises in various positions. Swimmers can work against resistance in the prone position. Plyomet- rics must be introduced gradually for throwers and rac­ quet sports (Fig. 9). A complete programme has been recently described elsewhere (Wilk et al 1993). Fig. 9. Throwing is gradually introduced. Emphasis should be placed on muscle Tiring pattern and scapular stabilization. Rehabilitation of the shoulder may appear very com ­ plex, but if the functional biomechanics are followed and restored, it is very logical and poses a great chal­ lenge. Throughout the programme, the normal re­ straints o f healing must be considered, and signs and symptoms must be re-assessed constantly. The pro­ gramme should employ synchrony o f muscle firing and correct movement patterns to prevent return o f symp­ toms and for improved performance. Therapists need (From page 18) Other Lesions There are other problems which may not be particular to athletes but can trouble them: Calcific tendinitis In resistant cases arthroscopic removal o f calcific deposits from the rotator cuff is the method o f choice. Frozen shoulder (adhesive capsulitis) Arthroscopic debridement and capsulotomy can be very effective. Conclusion From the above it is evident that the arthroscope has becom e an effective tool when dealing with shoulder to be aware o f all possible causes of dysfunction and if patients do not respond to treatment within expecta­ tions, they must be referred for further investigations as soon as possible. For the earliest possible return to optimal performance levels, communication between all members o f the medical team remains o f paramount importance. REFERENCES Ayub E (1992) Posture and the upper quadrant In: DonateUi R (Ed) Physical therapy of the shoulder. Churchill Livingstone. Butler DS (1991) Mobilization o f the nervous system. Churchill Livina- stone. Cyriax J (1980) Textbook of orthopaedic medicine Volume 2. Baiillere Tindall. Dickoff-Hoffman (1994) Neuromuscular control exercises for shoulder instability. In Andrews JR, Wilk KE (Ed) The athlete's shoulder. Churchill Livingstone. DUlman CJ, Fleisig GS, Andrews JR (1993) Biomechanics o f pitch­ ing with emphasis upon shoulder kinematics. JOSPT 18: 402-408. Jobe FW, Pink M (1993) Classification and treatment o f shoulder dys­ function in the overhead athlete. JOSPT 18: 427-432. Kamkar A, Irrgang JJ. Whitney SL (1993) Nonoperative management o f secondary shoulder impingement sundrome. JOSPT 17- 221-224. Knott M, Wbss DE (1968) Proprioceptive neuromuscular facilitation. Harper & Row. Litchfield R et al (1993) Rehabilitation for the overhead athlete JOSPT 18: 433-441. Magarey M, Jones M (1992) Clinical diagnosis and management of minor shoulder instability. Austr J Physio 38: 269-280. Maitland GD (1991) Peripheral Manipulation. Bulterworth Heineman. Maitland GD (1987) Vertebral Manipulation. Butterworth Heineman. Malone TR (1994) Elements of a standardized shoulder examination. In Andrews JR, Wilk KE (Ed) The athlete's shoulder. Churchill Livingstone. Pappas AM et al (1985) Rehabilitation of the pitching shoulder. Am J Sports Med 13: 223-235. Traueli JG, Simons DG (1983) Myofascial Pain and Dysfunction. The trigger point manual Volume 1. Williams & Wilkins. Wilk KE, Arrigo C (1993) Current concept in the rehabilitation of the athletic shoulder. JOSPT 18: 365-378. Wilk KE et al (1993) Stretch-shortening drills for the upper extremi­ ties: theory and clinical application. JOSPT 17: 225-239. □ problems. It has becom e essential for a surgeon deal­ ing with the athlete’s shoulder to master arthroscopic techniques. SUGGESTED READING Burkhart SS: Reconciling the Paradox of Rotator Cuff Repair versus Debridement Arthroscopy 1994; 10: 4-19. Bigtiani LU: Arthroscopic Resection of the Distal Clavicle. Orthopaedic Clinics of North America 1993; 24: 133-141. Kay SP: Arthroscopic Distal Clavicle Excision. Clin Orthop Ret Res 1994; 301: 181-184. Re LP: Management of Rotator Cuff Calcifications. Orthopaedic Clinics of North America 1993; 24: 125-131. Snyder SJ: SLAP lesions of the Shoulder. Arthroscopy 1990; 6: 274.0 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A survey to determine types and dosages of Anabolic Androgenic Steroids used by competitive bodybuilders in South Africa S D Titlestad BSc (Physio) BSc (Med) Hon (Physio) M I Lambert BSc (Agric) BA (Phys Ed) (Hon) MSc PhD M P Schwellnus MBBCh MSc (Med) MD FACSM Abstract A questionnaire was sent to all bodybuilders affiliated to two Provincial Bodybuilding Associations (n = 249). Out o f the 80 completed returned questionnaires, 30 bodybuilders admitted to using anabolic androgenic steroids (AAS). From this sample the A A S which were most frequently reported used were nandrolone decano- ate (Deca-durabolin® ) (83%), oxymetholone (Anapo- lon-50® ) (63%), testosterone cypionate (Depo-testoste- rone® ) (57%), ethylestrenol (Orabolin® )(47% ), methe- nolone enanthate (Primobolan® ) (30% ) and testoster­ one propionate (Sustanon-250® ) (40%). The maximum reported dosages used by the bodybuilders exceeded the maximum recommended clinical dosages by up to 18 times. Ninety-seven percent o f the users o f A A S reported significant increases in body weight and strength while on a course o f AAS. Most users obtained the A A S from peers in the gymnasium (63%). Seventy- three percent used more than one drug simultaneous­ ly (“stacking”) and increased and then decreased their dosages (“pyramiding”). Forty percent o f the users were in favour o f A A S production being limited to prevent anyone having an unfair advantage in body-building competitions. This suggests there is pressure for body­ builders to use these drugs This study confirms the anecdotal evidence that A A S are used by bodybuilders in doses which greatly exceed the recommended clini­ cal doses Introduction Anabolic androgenic steroids (A A S ) were reportedly first used to enhance athletic performance in the mid 1950’s 1 Since that time the use o f A A S has increased, being used by athletes in a wide variety o f sports,2, M l Lambert M RC/U C T Bioenergetics o f Exercise Research Unit Department o f Physiology University o f Cape Town Medical School Observatory, 7925 particularly bodybuilders and powerlifters.3 Although it has been reported that powerlifters in South Africa self- administer anabolic steroids in suprapharmacological doses,4 not much is known about the use o f A A S by bodybuilders in South Africa. Secrecy surrounds the use o f A A S in bodybuilders not only because o f the possibility o f large fines and possible prison sentences (South African Parliament, Act 101 o f 1965), but also because o f the controversy surrounding the use o f A A S .1 Negative publicity has also made bodybuilders secretive about the types and dosages o f A A S used (Underground Steroid Handbook). Therefore, little is known about the types and dosages o f A A S used, although it is apparent that bodybuilders in the USA and Europe use A A S in dosages which ex­ ceed dosages for clinical use5’673,910 Furthermore, it has been shown in these studies there is no consisten­ cy in either the type or dosage o f A A S used by body­ builders. This is possibly because bodybuilders obtain their information on A A S from either non-scientific sources (Underground Steroid Handbook) or from peers in the gymnasium.3 In South Africa, there are no data available about the different types and dosages o f A A S used by body­ builders. Therefore, the aim o f this survey was to de­ termine the types and dosages o f A A S used among bodybuilders affiliated to two Provincial Bodybuilding Associations in South Africa. Methods The population surveyed in this study were all the mem­ bers affiliated to either the Western Province (n = 80) or Natal Bodybuilding Associations (n = 169). A questionnaire developed in English and Afrikaans was validated in a pilot study. Th e questionnaire was then sent to all members in the target population. A covering letter explaining the reason for the survey and ensuring anonymity and confidentiality was also in­ cluded. The questionnaire was divided into a general section 24 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) and a section to be completed only by those body­ builders that claimed to have, or were using, AAS. Four weeks after the questionnaire was sent, a follow up let­ ter was sent to ail members o f the two associations to encourage those who had not returned their question­ naires to do sa A question about the respondent’s body mass and maximal strength (bench press and squat) before and after a course o f A A S was included with the question­ naire. Values are expressed as the mean ± standard devi­ ation. A paired t-test was used to detect significant dif­ ferences in the reported body weight pre- and post-AAS use, and differences in the reported maximum bench press and squat pre- and post-AAS use. Values were ac­ cepted as being different when p < 0.05. Results O f the 169 questionnaires sent to the members o f the Natal Bodybuilders Association, 12 (7% ) were returned uncompleted because o f unknown addresses, and 49 (29% ) were returned completed. O f the 80 question­ naires sent to the members o f the Western Province Bodybuilding Association, 6 (8 % ) were returned un­ completed because o f unknown addresses and 31 (39% ) were returned completed. It was decided that the two regions could not be separated or compared be­ cause o f the low percentage response. Therefore, all the respondents (n = 80) were grouped and analysed together (35% o f the total). Ninety-eight percent o f the respondents stated they had competed in a bodybuilding contest, and 50% had achieved a 1st place in their weight category. Fifty per­ cent o f the respondents had com peted at provincial level, 15% had competed at national level, and 6% had competed internationally. Seventeen percent o f the to­ tal sample were female (n = 14) and 83% (n = 6 6 ) were male. The average number o f body-building training sessions per week was 5 ± 1 (mean ± SD). O f the 80 completed questionnaires, 30 respondents (28 men and 2 women) admitted to having used A A S (38% o f responders). The average cost per month o f A A S for one user was R500 (range R70 to R2 000) (n = 28). The average age that A A S were first used by the sub­ jects in this study was 27 ± 9 years (range 18 to 53 years). The reasons for the respondents using A A S are shown in Table 1. Most bodybuilders (83% ) used A A S to increase their physical size (Table 1). A number o f respondents indicated more than one reason for usinq AAS. The type and dosages o f A A S used by the respon­ dents in this study are shown in Table lla and lib with the percent respondents reported using these drugs. In this table the dosages used by bodybuilders are com ­ pared to the maximum recommended doses for clini­ cal use. Nandrolone decanoate (Deca-durabolin® ) was the most com m only used A A S (83 % ) followed by oxy- rnetholone (Anapolon-50® ) (6 3 % ) and testosterone cypionate (Depo-testosterone® ) (57%). All the users o f nandrolone decanoate (Deca-durabolin® ) methenolone enanthate (Primobolan® ) and testosterone propionate TABLE 1 Reasons for bodybuilders in this sample using A A S (n = 30 ) REASON % o f users Increased physical size 83 To remain competitive 70 Increased strength 43 Improved endurance 30 Increased resistance to injury 23 Improved resistance to fatigue 17 (Sustanon-250® ) exceeded the maximum recommend­ ed dose for clinical use. Other A A S reportedly used in this study were: methandrostenolone (Dianabol® ), ox- androlone (Anavar® ) and stanozolol (Winstrol® ), but these were not reported in Table 11 because dosages were not given. These drugs are not available in South Africa so it can only be assumed that they were brought into the country. Nine o f the respondents reported using the veterinary anabolic steroids nandrolone decanoate (Tribolin® ) and boldenone undecylenate (Vebenyl® ). These have not been included with Table II because the dosages were not reported. Drugs were also used by the respondents to prevent the feminising effects during or after A A S use. Tamox­ ifen (Nolvadex® and Neophedan® ) was used by 34% o f the respondents and human chorionic gonadotropin (APL® and Pregnyl® ) was used by 30% o f the respon­ dents. The reported subjective changes and negative side effects experienced by the bodybuilders using A A S in this study are shown in Table HI. Nearly all users (97% ) reported an increase in body size and muscular strength. Both the female respondents reported deepen­ ing o f their voices and increased ditoral size. Seventy-three percent o f the respondents stated they “stacked” the drugs and “pyramided” the dosages Seventy % o f the respondents used oral and injecta­ ble forms o f A A S concurrently. Bodybuilders use A A S in cycles which last between 8-10 weeks, although this may vary (Underground Steroid Handbook). The bodybuilders using A A S in this survey had each taken an average o f 5 ± 4 cycles (mean ± SD) (n = 30). The average reported body weight o f the respondents before a cycle o f A A S was 79 ± 13 kg. Subjects report­ ed that their weight after a cycle o f A A S increased to 88 ± 13 kg (p < 0.05, n = 28). There was also a reported increase in strength fol­ lowing a cycle o f AAS. Average maximum bench press reported before a cycle o f A A S was 104 ± 28 kg which increased to 133 ± 32kg after a cycle (p < 0.001; n = 28). The reported average maximum squat before a cycle o f A A S was 135 ± 42 kg, which increased to 177 ± 54 kg after a cycle (p < 0.005; n = 27). Table IV depicts the source where the A A S users in this study obtained their drugs. Most users o f A A S ob­ tain their drugs from peers in the gymnasium (63%). More than one source was often used to obtain the A AS (Table IV). SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 25 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) TABLE Ha . Types, % users, and the range of doses of oral A A S used in the sample of bodybuilders (n — 30). The drugs are classified into anabolic or androgenic according to MIMS Desk Reference. Doses in this sample of bodybuilders are compared to the maximum recommended clinical dose (Mims Desk Reference) and the per­ cent of responders exceeding this dose are listed. NAM E O F AA S % users Reported dose range (mg/day) Min Max Max recommended clinical dose (mg/day) % body­ builders exceeding clinical doses ORAL ANABOLICS (per day) Anapolon-50® (50mg/tab) (oxymetholone) 63 50 350 400* (for 80 kg person) 0 Orabolin® (2mg/tab) (ethylestrenol) 47 2 20 4 79 Primobolan® (5 and 25 mg /tab) (methenolone acetate) 30 10 125 20 79 ORAL ANDROGENIC (per day) Proviron® (25mg/tab) (mesterolone) 33 25 100 75 11 Androxon® (40mg/tab) (testosterone undecanoate) 20 40 200 160 17 Halotestin® (5mg/tab) (fluoxymesterone) 7 - 10 10 0 TABLE lib Types, % users, and the range of doses of injectable A A S used in the sample of bodybuilders (n = 30). The drugs are classified into anabolic or androgenic according to MIMS Desk Reference. Doses in this sample of bodybuilders are compared to the maximum recommended clinical dose (Mims Desk Reference) and the per­ cent of responders exceeding this dose are listed. NAM E O F AA S % users Reported dose range (mg/week) Min Max Max recommended clinical dose (mg/week) % body­ builders exceeding clinical doses INJECTABLE ANABOLICS Deca-durabolin® (25 and 50mg/ml) (nandrolone decanoate) 83 25 300 17 100 Primobolan® (lOOmg/ml) (methenolone enanthate) 30 100 200 50 100 Durabolin® (25mg/ml) (nandrolone phenylpropionate) 23 50 300 50 71 INJECTABLE ANDROGENIC Depo-testosterone® (lOOmg/ml) (testosterone cypionate) 57 100 400 100 65 Sustanon-250® (250mg/ml) (testosterone propionate) 40 250 750 83 100 26 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) TABLE III Subjective effects experienced by the users o f A A S in this sample (n = 30). SUBJECTIVE EFFECTS % of users Increased strength 97 Improved size and appearance 97 Improved resistance to fatigue 73 Increased endurance 70 Increased appetite 70 Increased sex drive 60 Increased water retention 60 Disturbance o f normal sleep pattern 40 Less prone to injury 37 Increased body hair 37 Decreased sex drive 33 Testicular atrophy 33 Greater number o f headaches 27 Increased acne 23 Deepening o f voice 20 Gynaecomastia 17 Pins and needles 17 Nosebleeds 7 Stopped growing 3 Increased clitoral size (n = 2) 100 In 1992, A A S were re-classified to schedule 5 drugs. Penalties for an infringement o f drugs in this class may be up to a R40 000 fine or 10 years in prison (South African Parliament, Act 101 o f 1965). O f the respon­ dents using A A S in this study, 37 % stated this change in the law had affected their decision to take A A S and 60% stated A A S were now m ore difficult to get. Forty percent o f the users felt that A A S production should be stopped completely. TABLE IV The sources used by bodybuilders in this study (n = 3 0 ) to obtain A A S . SOURCE % of users Gymnasium friends 63 Doctor (other than family doctor) 27 Pharmacist 23 Family doctor 17 Gymnasium owner/instructor 3 Discussion The most important finding from this study was that except for oxym etholone (Anapolon-50® ) and fluox- ymesterone (Halotestin® ), bodybuilders in South Africa use doses o f A A S which exceed the recommended dose for clinical use. This is comparable to bodybuilders in the USA who used up to 4 times the recommended clin­ ical doses.10 Furthermore, this study confirmed that most body­ builders reported to “pyramid” the dosage and “stack” types o f steroids which agrees with previously report­ ed information (Underground Steroid Handbook,5’ 10). The use o f tamoxifen (Nolavadex® and Neophe- dan® ) by 34% respondents and human chorionic gonadotropin (APL® and Pregnyl® ) by 30% o f the re­ spondents indicates that bodybuilders try to avoid side- effects such as gynaecomastia and testicular atrophy during and after A A S .11 Mesterolone (Proviron® ) was also used by 33% o f the respondents to reduce the feminising effects o f A A S (Underground Steroid Hand­ book). In reported clinical trials there is no consensus on the effect o f A A S on body mass and strength changes.12 Despite this controversy in the scientific press, bodybuilders believe that A A S improve strength and body mass (Underground Steroid Handbook). In this study both the reported body mass and strength increased significantly after a cycle o f AAS. Although these are subjective data, it does indicate that body­ builders do believe A A S cause an increase in body mass and strength. According to the literature5 som e most commonly used A A S are veterinary preparations. In this survey veterinary preparations (Tribolin® and Vebenyl® ) were used by 30% o f the bodybuilders. These drugs are mar­ keted for use in horses. The reason for bodybuilders using them is that the preparation Tribolin® (veterinary preparation) for ex­ ample, contains nandrolone decanoate, which is also in Deca-durabolin® (human preparation). Furthermore, the veterinary drugs are cheaper. However, veterinary preparations are considered to be highly toxic and dan­ gerous to humans (Underground Steroid Handbook,5) because o f the impurities which may occur in these drugs resulting from the less stringent quality control in their manufacture. All the results o f this study were based on the respon­ dent’s (35 % ) answers to the questionnaire. The anony­ mous nature o f the questionnaire made it impossible to characterize the non-responders in the study. It can therefore not be assumed that the bodybuilders in this study are necessarily representative o f bodybuilders in South Africa. In summary this study documents the reported use o f anabolic androgenic steroids in a selected sample o f bodybuilders in South Africa, and describes the types and dosages o f drugs used. This study agrees with re­ ports from the USA that doses o f A A S used by body­ builders exceed recommended maximum doses for clinical use. Clearly users o f A A S believe the drugs are offering them som e advantage at these high doses. Although the adverse side-effects o f A A S in these high doses have been well characterized,14A61112 this does not seem to deter the users. This can possibly be ex­ plained by the fact that although the bodybuilders are well informed about the side-effects o f A AS, they are pressurized into using the drugs to remain competitive. This is confirmed by the respondents in this study (40% ) who were in favour o f A A S production being limited to prevent a possible unfair advantage by A A S users in bodybuilding competitions. Although the new legislation on A A S has had some effect on their avail­ SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 27 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ability, tighter regulation in the production and distri­ bution o f use o f A A S is needed. The South African Bodybuilding Association also needs to take a firmer stance against the use of AAS by bodybuilders affiliated to their organization. REFERENCES 1. Haupt HA and Rouere GD. Anabolic Steroids: A review of the liter­ ature. Am J Sports Med 1984; 12: 469-484. 2. ElashoffJD, Jacknow AD, Shain SG and Braunsteln GD. Effects of anabolic-androgenic steroids on muscular strength. Ann Ini Med 1991; 115: 387-393. 3. Goldman B, Bush P and Klatz R. Death In the locker mom. Steroids and Sport Icarus Press Inc, South Bend, Indiana, USA, 1984. 4. Cohen JC, Moakes T and Benade AJS. Hypercholesterolemia in male power lifters using anabolic-androgenic steroids. Phys Sportsmed 1988; 16: 49-55. 5. Wilson JD. Androgen abuse by athletes. Endocrine Reo 1988; 9: 181-199. 6. Wilson JD and Griffin JE. The use and misuse of androgens. Metabolism 1980; 29: 1278-1294. 7. Alen M and Hakkinen K. Physical health and fitness of an elite bodybuilder during 1 year of self-administration of testosterone and anabolic steroids. A case study. Int J Sports Med 1985; 6: 24-29. 8. Forbes GB. The effect of anabolic steroids on lean body mass: The dose response curve. Metabolism 1985; 34; 571-573. 9. Alen M, Hakkinen K and Komi PV. Changes in neuromuscular per­ formance and muscular fibre characteristics of elite power athletes s e lf administering androgenic and anabolic steroids. Acta Physiol Scand 1984; 122: 534-544. 10. Burkett LN and Falduto MT. Steroid use by athletes in a metropoli­ tan area. Phys Sportsmed 1984, 12: 69 74. 11. Fried! K and Yesalis CD. Self treatment of gynaecomastia in bodybuilders who use anabolic steroids. Phys Sportsmed 1989; 17: 67-79. 12. Hickson RC, Ball KL and Falduto MT. Adverse effects o f anabolic steroids. Med ToxicoL Adverse Drug Exp. 1989; 4: 254-271. D CICT SPORTS MEDICINE INFORMATION SERVICE SPORTS MEDICINE is a relatively new discipline of Medicine. There is hence a rapid expansion of knowledge in the areas o f exercise physiology, exercise biochemistry, medical aspects related to physical activi­ ty and sports related injuries Obtaining the informa­ tion may be difficult because o f limited access to library services, excessive cost of international journal subscrip­ tions and limited tim e for literature searches by busy pharmacists. The UCT Sports Medicine Information Service can solve these difficulties for you. YOG WILL BENEFIT FROM THE UCT SPORTS MEDICINE INFORMATION SERVICE if you are a phar­ macist interested in Sports Medicine. THE UCT SPORTS MEDICINE INFORMATION SERV­ ICE PROVIDES YOU WITH: — annual subscription to a specialised sports medicine information service at a cost lower than subscription to one international journal — a monthly list of important recent publications which have been identified by experts — the option o f requesting a copy o f any o f the listed publications at a minimal cost per page — an income tax certificate is available. A PPLIC ATIO N FORM S A N D FURTHER INFORM A­ TIO N C AN BE OBTAINED FROM: U C T SMIS P O Box 38567 Pinelands 7430 OR please phone Dr M P Schwellnus at (021) 406-6504. WlvotlarenlS T A B L E T S Diclophenac sodium 7 5 mg _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ d f c c s ] l/9< Diclophenac sodium 75 mg § § m m jif Voltaren 75 i I Q Tafttoa 28 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A profile of Biokinetic Services in South Africa from 1988 to 1991 MF Coetsee M A (Phys Ed) (Stell) PhD (ClPE) Abstract A survey was undertaken to establish the nature and extent o f Biokinetics services in the Republic o f South Africa for the years 1988-1991. Questionnaires were sent to all Biokinetic centres and practices The results show that Biokineticists willing to enter full time practice (as oposed to those working part-time) increased from 45% in 1988 to 73% in 1991. A growing trend in patient numbers was also experienced i.e. from 5 736 (286/centre) in 1988 to 11 241 (750/centre) in 1991. O f the patients seen by Biokineticists, 41% were referred by other medical disciplines The highest proportion of referrals came from Orthopaedic Surgeons (34,9% in 1991) followed by General Practitioners (18,2% in 1991) and Physiotherapists (13,0% in 1991). These results il­ lustrate the growth o f Biokinetics as a member o f the multi-disciplinary health team. Introduction On 9 September 1983, the profession Biokinetics was formally announced in the Government Gazette.1 It can therefore be regarded as a relatively young m em ­ ber o f the health profession. Biokinetics is defined as “The profession that deals with scientifically founded and controlled physical activities with regard to the fol­ low ing: 1. P ro m o tin g physical perform an ce; 2. Prevention o f ailments; 3. Final phase rehabilitation; and 4. Physical selection.”2 Biokinetics thus aims to promote quality o f life by means o f physical assessment and prescription o f rehabilitative and preventative ex­ ercise. The benefits o f physical exercise has been well researched and documented notably, on 19 February 1992 the American Heart Association issued an offi­ cial position statement recognising inactivity as a risk factor for coronary artery disease.3 Department o f Human Movement Science University o f Zululand Private Bag X1001 KwaDlangezwa 3886 The aim o f this research project launched, in 1988, is to monitor the growth o f Biokinetics and the sup­ port it has gained from other members o f the medical profession. The results o f the last four years are now available and this article attempts to summarize these findings Methods and procedures In January o f each year, from 1989 to 1992, question­ naires were sent to all Biokinetic centres and practices Respondents were requested to fill out the question­ naires using patient/subject data pertaining to the previ­ ous year. Over the four years o f the study the number o f responses were as follows 1988 = 20; 1989 = 8; 1990 - 16; and 1991 = 15. Because some centres and practices employed more than one person the actual number o f Biokineticists and Assistant Biokineticists that were involved were: 1988 = 33; 1989 = 19; 1990 = 37; and 1991 = 37. The reason for the drop in re­ sponses in 1989 may be attributed to a change in the questionnaire i.e. in addition to the existing question­ naire respondents were asked to categorise orthopaedic cases according to the site o f injury and information on referral o f patients It seems as if the respondents had difficulty in completing the more comprehensive questionnaire the first year it was introduced. Since 1989 the questionnaire remained unchanged and the number o f responses increased possibly due to better record keeping during the previous year. The questionnaire involved four categories i.e. 1. To determine the ratio o f full time and part time practices; 2. To determine the patient numbers seen by Biokineti­ cists; 3. To determine the extent and nature o f referrals to Biokineticists from members o f the medical profes­ sion; and 4. To determine the nature o f services ren­ dered by Biokineticists Results and discussion Ratio of full-time to part-time practices The ratio o f part time vs full-time practices changed appreciably over the four years since 1988. The 1988 survey showed that 45% o f all practices were full-time SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 29 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) practices and 55% part time practices. After a drop to 38% in 1989 (possibly due to the low response rate as discussed in the previous section) the full time prac­ tices increased to 56% in 1990 and 73% in 1991. This points to a growing confidence in the viability o f Bi­ okinetics as a full time profession despite the high costs o f setting up a practice. Patient numbers seen by Biokineticists The total number of patients seen at the respective Bi­ okinetic centres that responded over the 4 years was as follows: 1988 - 5 736; 1989 = 1 122; 1990 = 9 582; and 1991 = 11 241. The average number o f pa­ tients seen per centre was calculated as follows: 1988 = 286; 1989 = 140; 1990 = 599; and 1991 = 750. Apart from 1989 (possibly the results are affected by the low response) these results point to a growing de­ mand for Biokinetic services. Referrals from other m em bers o f the medical profession Being part o f a multi-disciplinary team, Biokineticists place a high emphasis on cooperation with other med­ ical and para-medical professions. The survey for 1988 showed that 31,1% o f the total patients seen by Bi­ okineticists were referred by other medical professions. The figures for the following years were: 1989 = 39,8%; 1990 = 49,6%; and 1991 = 43,1%. This indicates posi­ tive cooperation between Biokineticists and other med­ ical professionals. In response to the questionnaire, views regarding the cooperation between Biokinetics and other disciplines varied from excellent to poor, sug­ gesting that although many members o f the medical profession cooperate with Biokineticists, a lack of awareness still exists It is hoped that this article might help to promote greater cooperation in order to benefit the patient Knowledge regarding the type o f patient referrals Bio- Profile o f patient cases seen by Biokineticists during 1988-1991.____________________ 1988 1989 1990 1991 (% ) (% ) (% )__________ (% ) 20,7 30,6 37,5 3,2 4,4 6,5 7,1 12,8 13,4 0,6 1,5 1.8 7,1 7,8 9,3 1,7 2,6 4,2 0,6 0,5 1.2 0,4 1.0 1.1 O RTH O PAED IC Foot/ankle Knee Hip Back Shoulder Hand/arm Neck CARDIAC CO ND ITIO NS Coronary risk Documented coronary condition PRE-PARTICIPATION EVALUATION H YPO K IN E TIC CONDITIONS Hypertension Cholesterol Obesity Posture OTHER Asthma Diabetes . Arthritis Osteoporosis Emphysema Psychological Neurological Gynaecological SP O R T EVALUATIONS 9,3 14,3 12,4 5,8 10,8 7,2 2,2 3,5 5,2 3,6 23,8 21,5 18,6 18,9 19,9 25,3 23,1 17,1 0,6 13,5 4,8 5,8 0,4 1.9 6,2 3,7 10.9 9,1 7,8 4,4 8.0 0,8 4,3 3,2 0.8 4,7 5,0 6,6 0.3 1,1 0,9 0,6 0 1,0 0,9 0,7 0,5 2,6 3,2 2,2 0 0 0 0,2 0 0 0 0,1 0 0 0 1,2 0 0 0 0,6 0 0 0 1,0 10,6 13,5 103 14,1 30 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) kineticists receive, is very important for upgrading the type o f Biokinetic training that will be offered in the future. Table 1 gives a profile o f referrals to Biokinetic practices from 1989 to 1991. The highest number o f referrals came from Orthopaedic surgeons followed by General Practitioners and Physiotherapists. TABLE I Profile o f referrals for Biokinetics from 1989 to 1991 1989 <%) 1990 <%) 1991 (% ) Orthopaedic surgeons 13,4 26,3 34,9 General practitioners 41,0 25,3 18,2 Physiotherapists 23,9 15,8 13,0 Coaches 6,7 14,1 8,6 Cardiologists 3,5 6,6 7,1 Dieticians 1,2 2,0 6,3 Specialist physicians 1,2 5,6 4,6 Gynaecologists 1,8 0,3 3,2 Psychologists/ Psychiatrists 0 0,1 2,1 Podiatrists 0 0 0,6 Occupational therapists 0 0 0,6 Nursing sisters 7,3 0,1 0,5 Chiropracters 0 0,8 0,2 Neuro-surgeons 0 3,0 0,1 Interesting trends were revealed regarding the type of work most prevalent in a Biokinetics practice (Table II). Biokineticists are predominantly engaged in orthopaed­ ic rehabilitation, particularly rehabilitation of the knee. Another major area is the physical evaluation o f in­ dividuals, prior to their engagem ent in any activity, in order to assess the safety o f their participation. The third area Biokineticists are actively involved in, is the prescription o f exercise as a m ode o f rehabilitation for individuals exhibiting certain hypokinetic problems such as hypertension, high cholestrol, obesity and bad posture. The last, but progressively more demanding area o f involvement, is the assessment o f sportsmen in an attempt to identify possible shortcomings, op­ timize training, monitor progress and in so doing im­ prove performance. Conclusion The research data collected thus far, clearly demonstrat­ ed that Biokinetics has gained acceptance as a m em ­ ber o f the multi-disciplinary health team in both re­ habilitative and preventative medicine. It has been es­ tablished that a variety o f other medical disciplines cooperate with Biokineticists. Biokinetics, being a fair­ ly young discipline, is showing an escalating growth rate in the number o f patients making use o f its services. REFERENCES 1. Strydom G L. Bioldnetika: A s Professioneie Dissipline — Htstoriese O orsig en Ontwikkeling (uitgawe 2 ) Pbtchefstm om P U uir C H O , 1989. 2. Biokinetic activities as approved b y the Professional Board for M e d ­ ical Scientists in 1993 and submitted for publication in the G overn ­ m ent Gazzette. 3. Fletcher G F et aL 1992. A H A M edical/Scientific Statements, State­ m ent on exercise. Circulation Vol 86, H o 1. □ ERRATUM TABLE 1 Basic Skeletal muscle fibre type classifications Skeletal Muscle Fibre Types Nomenclature Type 1 11A 1IB slow fast oxidative- fast oxidative glycolytic glycolytic SO FOG FG Characteristics: Colour red red white Twitch slow fast fast ATPase activity low high high lost at pH 9.4-10.4 4.4-4.6 4.4 Glycogen content low high high Fatigue resistance high high low Oxidative capacity high high low An error inadvertently occured in Table 1 in the review article by K.H. Myburgh, “Muscle proteins and the con­ tractile properties o f muscle fibres” . (SA Journal o f Sports Medicine Vol 1 No 1: 13, 1994). Th e corrected table appears below. SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 31 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) READERSHIP SURVEY If you w ish to con tin ue receivin g this journal, free o f charge, p lease fill in the form b elow and return it to: Glenbarr Publishers cc Private Bag X I4 Parklands 2121 Name:.................................................................................................................... Address:................................................................................................................. Code:............ SPECIALITY: 32 SA JOURNAL OF SPORTS MEDICINE NOVEMBER 1994 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )