Clinical Practice Guidelines for Grade III ...

Clinical Practice Guidelines for Grade III Sternoclavicular Joint Sprains in Wrestlers

By: Karilyn Barber, Amy Guidinger, & Monika Nievergelt

Anatomy/Structure

- The SC joint is a diarthrodial (saddle) joint. - It is the only connection between the upper extremity

and the axial skeleton. - Incongruent articulation of clavicle with

manubrium & first rib --> inherently unstable - Joint capsule provides primary stabilization. - Capsule is weak inferiorly; capsular ligaments provide

secondary stabilization in superior, anterior, and posterior directions. - Muscle insertions help to stabilize the joint: trapezius, sternocleidomastoid, and pectoralis major. - Major structures directly posterior to SC jt: trachea, subclavian artery & vein, common carotid artery, vagus &

Purpose:

1) Does early recognition and intervention of Grade III SC joint sprains reduce the incidence of chronic instability?

2) Do strength and ROM exercises used in treatment of Grade III SC joint sprains reduce incidence of re-injury of the joint?

3) What are the long term effects of proper management of Grade III SC joint sprains (re: pain & ROM)?

Prevalence

- Shoulders are among the top two body parts injured in wrestling. - SC joint dislocations are rare --> 3% of shoulder girdle injuries. - Anterior dislocations are 20x more common than posterior. - Posterior dislocations are more serious --> 25% complication rate.

Mechanism of Injury

- Contact sport is one of the two most common causes of SC joint sprains or dislocations. - Posterior dislocations are usually causes by a direct blow to the medial clavicle. - Indirect blow can cause both anterior or posterior dislocations depending on the direction of force on the shoulder (see picture below). - Most common position of injury in wrestling is the takedown position.

phrenic nerves, esophagus, brachial plexus and apex of lungs



Rockwood & Green 1996

Clinical Practice Guideline

HOPE On-Field Management 1 Post Reduction 3,5

?History: mechanism of injury; subjective symptoms: deep boring pain; increased pain with movement, coughing, sneezing, and deep breathing. specific to posterior dislocation: SOB, dysphagia, pressure on great vessels, "funny feeling" in throat.

?Observation: swelling, possible deformity, affected shoulder appears shortened and thrust forward, head may be tilted to affected side.

?Palpation: extreme pain over SC joint.

?Evaluation: manual stress testing is often impossible due to pain and/or fixed dislocation, increased pain with lateral force to shoulders.

?Management: Support arm in sling and apply ice.

?Immediately refer to emergency if above HOPE principle presents positive for S&S.

A CT scan is required to fully diagnose an SC jt. dislocation.

? Stabilize shoulders with a soft figure 8 tensor,

clavicle strap harness, or plaster figure 8 cast.

? Support arm in a sling

? Day 1-3, ice for pain and swelling.

Anti-inflammatory meds if prescribed by doctor.

? Immobilization period: 4-6 weeks for stable joint,

minimum 6 weeks for unstable joint.

? Protection period: 2 weeks post immobilization

Arm protected in sling.

? Begin active ROM: Week 8 post injury:

1. Standing chest stretch :

Hold 10 sec ; Repeat 5 times

2. Standing shoulder flexion

Repeat 10 times

Goal of post-immobilization: 1. Painfree stable SC joint (symptom free unstable) 2. Pain-free chest stretch 3. Pain-free shoulder flexion

Rehab Exercises 3

Start with 1 set of 10 repetitions 1. Shoulder Abduction: 2. Shoulder External Rotation:

Stand, elbow flexed 90o, arm at side Externally rotate shoulder 3. Shoulder Horizontal Abduction/Adduction: 4. Supine Shoulder Retraction Supine lying, abduct arms to 90o Retract scapulae & horizontally extend arms 5. Sitting Shoulder Flexion: 6. Prone Horizontal Flexion Prone lying, abduct arms to 90o Horizontally flex arms 7. Prone Shoulder Extension: Progression: ? Add a dumbbell: weight ? Increase number of sets (up to 3)

Return to Play 2,3

Criteria for Return to Practice:

1. Pain-free joint at rest and with activity.

2. Full shoulder ROM.

3. Comparable strength to opposite side.

Rehab Program:

? Wrestling Specific Strengthening Exercises:

1. Push-ups

3. Lateral Raise

2. Shoulder Press

4. Horizontal & Upright Row

? Return to Practice: Move to next step if no exacerbations occur.

Step 1: Warm-up & Standing Drills

Step 2: Warm-up & All Drills (includes takedowns)

Step 3: Full Practice minus live scrimmage

Step 4: Full Practice

References:

1. Bicos, J., Nicholson, G.P. (2003). Treatment and results of sternoclavicular joint injury. Clinics in Sports Medicine, 22, 359-370.

2. Hines, R.F. (1998). Shoulder Injuries In Wrestlers. Wrestling USA, 34(5), 24.

3. McKesson Clinical Reference Systems: Sports Medicine Advisor 2002.1. Sternoclavicular Joint Separation. Retrieved from the Sept 28, 2003: .

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