Shoulder Dislocation: Advanced procedures related to Rugby

Why have a “manual” on shoulder injuries}}} in rugby, and not simply use the standard references on shoulder injuries? The reasons are that certain injury patterns occur in rugby specific to the sport and that the players have varying requirements as far as rehabilitation is concerned and most return to this high contact activity within a relatively quick period.

THE BASIC ANATOMY OF THE SHOULDER:

• The Rotator cuff tendon, which is an important muscle and tendon to lift the arm and is situated deep to the deltoid.
• The Sterno-clavicular (SC) joint, the junction between the breast bone and collar bone on the upper front part of the chest.
• The Brachial plexus, the large set of nerves above the collar bone, which run from the neck to the shoulder and arm. They are quite shallow and can be palpated deep within the skin just above the collar bone.
• The Shoulder joint (Gleno-humeral joint) which is the primary ball and socket of the shoulder.
• The Pectoralis major (Pec Major), a large muscle on the front of the chest which draws the arm towards the body.

STRUCTURES MOST OFTEN INJURED
• The AC joint: This junction in the middle of the collar bone and shoulder bone is one of the most commonly injured structures during rugby games. It usually results from a fall directly onto the shoulder – usually slightly towards the back of the shoulder. This may result in either a sprain or an actual dislocation of this joint due to a rupture of the ligaments stabilising the AC joint.
• The SC joint: The junction between the breast bone and collar bone (upper front of the chest) is injured when the player falls directly onto the shoulder. The joint may be painful with swelling or dislocation.
• SLAP lesions: (“Superior Labrum Anterior to Posterior”): These are tears of the top part of the cartilage surrounding the glenoid (socket) of the shoulder joint. They may be caused by a fall upon elbow with an upward force into the shoulder joint

MECHANISMS OF INJURY MOST COMMONLY SEEN IN RUGBY
• Shoulder dislocation: The usual mechanism is when the arm is forced outwards and backwards. This would happen during a “straight arm tackle” or when another player falls onto the back of the shoulder forcing the upper arm backwards
• Brachial plexus injuries: These usually happen when the head is forced away from the shoulder and the shoulder downwards – the result is a severe stretch of the tissues between the shoulder and neck. This would happen when a player falls forward and downwards contacting the arm and the head at the same time. This leads to a stretch of the big nerves above the collar bone (brachial plexus).
• Collar bone: A fracture of this bone occurs during a direct fall onto the shoulder, but this is less common in rugby and mostly seen in younger schoolboy players.
After injuring a shoulder, an applicable medical or other attendants would assess the shoulder in the following manner. This assessment will lead to a decision as to the immediate further management.

GUIDELINES ON WHEN TO REMOVE THE PLAYER FROM THE FIELD SUBSEQUENT A SHOULDER INJURY:

• Deeper injuries of the rotator cuff and labrum: These may not be visible from the surface and a simple test would be to ask the player to lift his arm. If he can do this comfortably, then there is no pressing need to remove him from the field and he could be allowed to play if pain allows him to. If, however, he is unable to elevate the arm he should be removed from the field.
• Collar bone: If severe pain and deformity is evident over the collar bone, this may be a fracture and he should be removed for further medical attention.
• Biceps tendon injury/rupture: Although further damage with continued play is unlikely to cause more damage, the pain following the injury will usually be too intense to allow continuation.

FURTHER MANAGEMENT OF SPECIFIC ACCIDENTS FOLLOWING THE RUGBY MATCH:

• Soft tissue injuries: These could be treated conservatively by physiotherapists.

• AC joint injuries: These seldom, if ever, require immediate surgical intervention and can usually be managed conservatively by the physiotherapist and attending physician. Surgery is seldom, if ever, necessary in the acute phase and a rare few may require it in the longer run .Surgery does result in a very favourable outcome in those who have chronic AC joint pain and associated rotator cuff symptoms.

• Pec Major Rupture: This injury would require referral for specialist opinion as most of them may require surgical repair in order to return to a level of function in order to play rugby.

With the correct management of shoulder injuries in rugby players, most of the players will be able to return to the sport and not suffer any long term consequences to the well-being of this important joint, the shoulder.

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