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Shoulder Injuries

The shoulder is one of the most frequently injured joints in the body...

Perhaps one of the most readily injured joints in the body, the shoulder often takes the brunt of the force generated by the tackle in contact sports; with dislocations common in both codes of rugby.

The nature of rugby football as a contact sport means that traumatic injury to the shoulder is common, with a high percentage of these injuries reported as dislocations.  


Wen (1999), in fact, reported the shoulder as the most frequently dislocated joint in the body.  In football goalkeepers, shoulder dislocations are frequent and are well reported; but literature addressing shoulder injuries of any type in outfield players is scarce. 

Exposure to contact situations has been shown by Orchard (2003) to play a significant part in athletes missing playing and training time accordingly.   With reference to contact situations, Kaplan et al (2005) reported that the shoulder joint had a high tendency to be injured in American Football players with increasing exposure. 

In soccer football, injuries to the shoulder constitute a relatively small number of injuries by comparison to the lower limbs. 


Only 80 shoulder injuries were recorded by Ekstrand et al (2011) in the UEFA study of 2008 in which 4483 injuries were audited in total; the vast majority of these being to the lower limb (87%).  Earlier work by Hawkins et al (2001), underpinned Ekstrand’s findings.

Longo et al (2012) studied shoulder injuries in football but did not differentiate between goalkeepers and outfield players.  Shoulder injuries to outfield players often occur as the result of landing after a fall; and in general this might be because most outfield players are often unprepared for the impact.

Volpi (2006) argues that goalkeepers are much better than outfield players at learning how to hit the ground safely, thus giving themselves the minimal risk of ground-contact injuries. 

Basic Anatomy

The shoulder itself consists of the gleno-humeral joint; which is a ball and socket joint formed of the articulation between the ball of the upper arm known as the humeral head, and the socket of the scapula – or shoulder blade - known as the glenoid fossa. 

The scapula is the main bone involved in the shoulder joint; and the instability arises from the small contact area between the glenoid fossa of the scapula and the humeral head, leading to increased injury risk.

Rowe & Zarins (1981) provided the classic and often-referred to description of the shoulder joint by likening the relationship between the humeral head and the glenoid cavity to a seal balancing a ball on its nose.

The gleno-humeral joint is the most mobile joint in the human body and is also the most unstable (Richards, 1999).   Such mobility, however, leads to greater instability as a result of the small contact area between the glenoid cavity and the humeral head, which allows movement to take place in all directions.  

Anatomically, static stabilisation of the shoulder arises from the gleno-humeral ligaments, the articular capsule and the fibro cartilaginous glenoid labrum, which effectively deepens the glenoid cavity by 50% (Park et al, 2002).  

In addition to serving as an insertion point for the gleno-humeral ligaments, a negative intra-articular pressure within the labrum contributes to gleno-humeral stabilisation by creating a relative vacuum (Wilson and Price, 2009). 

Stability of the shoulder is also provided the rotator cuff muscles and their ability to dynamically position the scapula and maintain its position during activity and at rest, together with the functional restraints of the individual gleno-humeral ligaments, biceps, and the scapular muscles (Seade and Jossey, 2008).

Injury mechanics

It can be seen from the above, therefore, that the shoulder as a joint is easily injured.  As the most mobile joint in the body this also has a negative impact since the increased mobility provided by the low contact ratio illustrated by the example of the seal and the ball leads to greater instability. 

As with all other joints, injuries to the shoulder and the associated acromio-clavicular joint (ACJ) will vary in nature and incidence.  Injuries to the shoulder can comprise of bony injuries, traumatic dislocations, ligamentous sprains of gleno-humeral ligaments, soft-tissue muscle strains and tears including injuries to the rotator cuff, tendinitis, tendinopathy, and injuries to the joint capsule. 

Injuries can arise in several ways, either through direct contact or a fall on the outstretched arm or point of the shoulder, or as a combination of both. 

Direct contact injuries can occur through the arm being pulled or twisted; as in the so-called and illegal “chicken-wing tackle” in rugby league, while non-contact injuries are often the result of a sudden loss of control such as in weight-lifting for example, when the athlete loses control of the overhead bar.

Additionally, injuries may be the result of overuse – or underuse – mechanisms; and symptoms of one kind of injury or condition can lead to another.  A typical example of this is when an inflammatory injury to the rotator cuff leads to reduced range of movement and this then develops into a secondary adhesive capsulitis – aka the familiar “frozen shoulder”.

Dislocations are most frequently the result of forced abduction together with external rotation; while injuries to the rotator cuff will be discussed in a separate article.

Injuries to the ACJ arise primarily as a result of a falling and landing on the outstretched hand, the point of the elbow, or on the point of the shoulder.  Viewed from the front, the classic presentation is an obvious ‘step’ or ‘gap’ between the end of the collar bone and the top of the arm. 

This is an injury that arises frequently in both codes of rugby.  In a study at professional level in Rugby Union in England, ACJ sprains accounted for 32% of all shoulder injuries and was the most common of all the upper limb injuries sustained in matches (Headey et al, 2007). 


In the 13- a – side Rugby League code, King et al (2010) also noted that the shoulder was the most common area injured of all the body segments recorded.

Discussion

Clearly sports including American Football, Rugby League and Baseball place a huge emphasis on research into shoulder injuries since these are known to be among the most commonly sustained; but with the incidence of upper limb injury in football reported to be relatively low, there is a lot less information available. 

As mentioned earlier, there were only 80 shoulder injuries recorded by Ekstrand et al (2011) out of 4483 injuries in the UEFA study of 2008.  As a direct result of this, Longo et al (2012) were concerned that shoulder injuries were being overlooked in soccer, and carried out an extensive search into the origins, mechanisms, and management of shoulder injuries in football. 

However, due to the lack of previous research studies available, most of which only recorded the type of shoulder injury sustained, they were unable to differentiate between injuries to the goalkeepers and outfield players. 

Further research into the less frequent injuries is essential.  Piero Volpi (2006) discusses this in his excellent book, Football Traumatology, and stresses that just because certain injuries are less prevalent than others, these do occur; albeit only in lesser numbers. 

The topic of shoulder injuries is huge and as such there are many websites devoted solely to the management and treatment of these.  It is not the intention of this website, to simply replicate the contents of other specialised websites and consequently will focus on the practical aspects of shoulder injury management, drawing on examples from professional sport.


References:

Ekstrand J, Hagglund M, Walden M (2011).  Injury incidence and injury patterns in professional football -  the UEFA injury study.  British Journal of Sports Medicine.  Vol 45 (7); 553 – 558.

Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M (2001).  The association football medical research programme: an audit of injuries in professional football.  British Journal of Sports Medicine.  Vol. 35; 43 – 47.

Headey J, Brooks JH, Kemp SP (2007).  The epidemiology of shoulder injuries in English professional rugby union.  American Journal of Sports Medicine.  Vol. 35 (9); 1537 – 1543.

Kaplan LD, Flanigan DC, Norwig ATC, Jost MS, Bradley JB (2005).  Prevalence and variance of shoulder injuries in elite collegiate football players.  American Journal of Sports Medicine.  Vol. 33; 1142 – 1146.

King DA, Hume PA, Milburn PD, Guttenbeil D (2010).  Match and training injuries in rugby league: a review of published studies.  Sports Medicine Australia.  Vol. 40 (2); 163 – 178.

Longo UG, Loppini M, Berton A, Martinelli N, Maffulli N, Denaro V (2012).  Shoulder Injuries in soccer players.  Clinical Cases in Mineral and Bone Metabolism.  Vol. 9 (3); 138–141.

Orchard J (2004).  Missed time through injury and injury management at an NRL club.  Sports Medicine Australia.  Vol. 22 (1): 11 – 19.

Park M, Blaine T, Levine WK (2002).  Shoulder dislocation in young athletes.  The Physician and Sportsmedicine.  Vol. 30 (12).

Richards D (1999).  Injuries to the glenoid labrum.  The Physician and Sportsmedicine.  Vol. 27 (6).

Rowe CR, Zarins B (1981).  Recurrent transient subluxation of the shoulder.  Journal of Bone and joint Surgery of America.  Vol. 63 (6); 863 -872.

Seade and Jossey, (2008). Shoulder dislocation.  Available from www.emedicine.medscape.com/article/93323-overview      Accessed 20th March, 2017.

Volpi P (2006). Football Traumatology; Current Concepts from Prevention to Treatment.  Milan, Springer.

Warner JJP, Higgins L, Parsons IV IM, Dowdy P (2001).  Diagnosis and treatment of antero-superior rotator cuff tears.  Journal of Shoulder and Elbow Surgery.  Vol. 10 (1); 37 – 46.

Wen DY (1999).  Current concepts in the treatment of anterior shoulder dislocations. American Journal of Sports Medicine.  Vol. 17 (4); 401 – 407.

Wilson SR and Price DD (2009) Shoulder dislocation in emergency medicine, E-medicine specialities. Available at:

http://emedicine.medscape.com/article/823843-overview. 

Accessed 21st March, 2017.


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