A primer on chronic injuries

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A primer on chronic injuries
By Dr. Dan Silver
Sep 22, 2002, 00:36

Even the most highly trained, conditioned and agile hockey players sustain injuries that at times do not go away. Injuries that occur and last more than six months are technically considered "chronic." "Acute" injuries, on the other hand, are those that last less than six months. Chronic injuries occur frequently to the shoulder and upper extremities, the back, neck and to the lower extremities, especially around the groin, the hamstring and knee areas.

Interestingly, ailments to the the knee, which are a common source of acute injury, are usually so disabling that the hockey player cannot skate easily and therefore has to rest his injured knee. As such, the knee usually does not become chronic as do other body areas.

It is the other body areas that were mentioned that, although they do not stop the player from engaging in his sport, are a chronic nuisance that can cause a low-grade pain or discomfort in most activities. When these injuries come to the point where they interfere with sleep and eventually with performance, then the player usually seeks medical advice.

The nature of many of these chronic injuries is a low-grade inflammation. An area that has been sprained or contused or a muscle that has been partially torn and still not healed, are typical of chronic injuries. Also, as the years go by, many of these chronic injuries occur because the acute (short-term) injuries have not been allowed to properly heal by the player. Because aging acute injuries take longer to heal, the active and impatient senior hockey player often resumes playing before the injury is completely healed. This almost guarantees that the injury will become chronic.

We are going to explore the specifics of some of these chronic injuries and give some advice both in how to self-diagnose and how to self-treat the ailments. We'll also give recommendations as to when orthopedic or other medical advice should be sought. In this article, I'll discuss the shoulder area.

Chronic Shoulder Inuries

There are two primary portions to the shoulder area that need to be addressed: There is the acromioclavicular joint, commonly called the AC joint, that is the connection between the tip of the clavicle, which is the collar bone, and the tip of the shoulder blade, which is called the scapula. This AC joint is seen in the diagram below. This joint has ligaments that connect one bone to the other in two different locations. The most common injury is a first or second degree separation, which is a tearing of the ligaments that connect the clavicle to the acromion (noted by the letter A). These acromioclavicular ligaments partially tear and will continue to be painful and irritated from the multiple collisions and impacts during a hockey game.

The shoulder can be injured in several ways. One way is to fall directly onto the point of the shoulder, but this is not the most common mechanism of injury. By far, it seems that hitting the boards or having a collision shoulder-to-shoulder or shoulder-to-body with another player is much more common. It is this hard impact that causes the partial tear of these AC ligaments. Repetitive impacts through collisions or falls where the player simply uses his hand or outstretched arm to break his fall to the ice or to actually push himself off the ice when getting up from a fall, will continue to irritate and aggravate the shoulder.

A first- or second-degree separation, and even a third degree, which is a complete tearing of these ligaments plus the conoid and trapezoid ligaments (noted by "B") are not disabling to a hockey player and therefore the player usually continues his sport. Eventually, however, it is interference with sleep and the need for anti-inflammatory medication, possibly even a cortisone injection to reduce pain after the game or in between games, that brings the player to the point of becoming a patient and having to undergo orthopedic care.

Typical Treatment

Treatment for this condition generally is anti-inflammatory medicine and icing. If the pain continues and there is a popping or clicking or grinding of this AC joint, then an arthroscopic removal of the tip of the clavicle will be required which will relieve the pain without creating any further weakness or disability of the shoulder.

The other part of the shoulder joint, called the glenohumeral (part C) is where the head of the humerus, which is a large round ball, sits in the glenoid which is a shallow small cup. The ball is held in the cup by a capsule, ligaments and muscles. In a fall, where the arm gets pulled back forcefully, the head of the humerus can be shoved forward out of the cup, tearing the anterior capsule and stretching the muscles of the front of the shoulder joint. This condition, when it occurs, is called a shoulder dislocation, or if the head does not come all the way out of the cup, then it is called a subluxation or partial type of dislocation. In any event, once a shoulder dislocation occurs, it is common for it to occur many times thereafter unless it is initially properly treated in a sling for about four weeks.

Many shoulders that are sore and feel unstable or in fact go out of place frequently, can become chronically sore and disabling to a hockey player. If the shoulder is extremely unstable and coming out frequently then an arthroscopic shoulder stabilization using a variety of techniques is required. Occasionally an open tightening of the entire capsular structure is required as well. The bursa (part D), can get chronically inflamed with either condition or alone and may require medication, injection or even an arthroscopic "clean-out" of swollen tissues.

An active hockey player, Dr. Dan Silver is a board certified orthopedic surgeon and founder of the Institute for Arthroscopic Surgery and One Stop Brace Shop in Los Angeles.