Vince Lombardi once said football is not a contact sport. Dancing is a contact sport. Football is a collision sport. He was right. And when you or your family members are involved in collision sports like football (or soccer, wrestling, basketball, mountain biking, etc.) your shoulders may pay the price. Contact injuries to the shoulder are a common cause of down-time and occasionally result in surgery. What is the best management for these injuries?
Your shoulder is composed of three bones (humerus/upper arm, scapula/shoulder blade, and clavicle/collar bone) which connect at two joints (glenohumeral/main shoulder joint/ball & socket, and acromioclavicular/AC joint/point of shoulder). The most common collision injuries seen are shoulder dislocations, separations, labral tears, and fractures.
Shoulder dislocations occur when trauma causes the humeral head (ball at top of humerus/arm bone) to dislodge from the glenoid (socket of the scapula/shoulder blade). This inevitably injures the ligaments which hold these structures together, tears the labrum, which is the ligamentous attachment to the glenoid, and often fractures the edge of the glenoid bone +/- the edge of the humeral head. In most cases, first-time shoulder dislocations are treated non-surgically after reduction of the joint (putting the ball back in the socket), which may require anesthesia.
Most shoulder dislocations can be reduced on the field if a trainer can recognize and reverse it quickly. This becomes more difficult as time from injury to reduction increases. The risk of subsequent re-dislocation is approximately 50 percent, so most sports docs will treat these with reduction, initial immobilization, progressive flexibility and rotator cuff strengthening exercises, and a return to the sport when the athlete has full range of motion, full strength, and no instability. This may be as soon as a week or two, but may also take much longer. If recurrence occurs, surgical stabilization is indicated. This is generally accomplished with an arthroscopic (minimally-invasive) shoulder procedure where the labrum and associated ligaments are repaired and tightened with sutures and suture anchors (small absorbable screws which hold the labrum to the bone). The success rate in terms of recurrence is about 90 percent for surgical stabilization, but return to the sport is generally no sooner than four to six months.
Shoulder separations are injuries to the AC joint, the point/top of the shoulder where your clavicle meets your acromion (lateral tip of the scapula). This usually results from a fall or direct blow to the point of the shoulder, disrupting the ligaments which hold these structures together, and causing various levels of deformity. The arm hangs lower, and the end of the clavicle may project prominently through the trapezius muscle at the top of the shoulder. Injured players will often support their elbow with their opposite arm as they leave the field to decrease the pain of the deformity.
Non-surgical treatment is generally appropriate, with return to play when pain subsides and the athlete has full mobility and strength. This may be as soon as one to two weeks. Surgical treatment is appropriate for grade five injuries (extreme deformity) or patients who have persistent dysfunction after non-operative care. This is accomplished by reconstructing the coracoclavicular ligaments, which hold the clavicle to the scapula, and stabilizing this with strong sutures. Healing time for a ligamentous reconstruction is a minimum of three months, and return to play at least four to six months without excessive risk of re-injury. These injuries were treated surgically before the late 1980's, at which point clinical data showed that functional results were similar when treated either surgically or non-surgically. This data changed initial treatment to non-surgical in most cases. Surgical treatment was actually felt to be contraindicated in athletes involved in contact sports due to risk of re-injury of the surgically-repaired AC joint.
Over the past few years the trend in sports medicine has been to treat these injuries more aggressively surgically. Unfortunately, convincing clinical data justifying this trend is lacking at this point, so I would recommend a more conservative approach initially. My personal anecdote is that my brother-in-law was an NCAA D1 wrestler at the 190 lb weight class for four years, had bilateral grade 3-5 AC separations, never stopped, and is doing fine 30 years later without surgery. While his level of toughness may be unusual, his result is not rare.
Labral tears occur in a variety of sports activities and should be treated with rotator cuff rehab exercises and active rest, with return to sport determined by functional performance. If persistent pain or mechanical symptoms (catching/locking) persist, arthroscopic surgical repair/debridement as for shoulder dislocations is appropriate and highly successful. When repair is necessary, return to sport is a minimum of four to six months for contact sports, six to 12 months for the dominant arm of a throwing athlete. Key points to remember here are that non-surgical treatment is generally successful, involves less down-time than surgery, and MRI, while helpful, has an accuracy rate as low as 50 percent in some clinical studies. In other words a positive MRI does not mean surgery is necessary.
Finally, fractures most commonly involve the clavicle, but can occur throughout the shoulder. Treatment is dictated by fracture location, displacement, and age of the patient. Children can heal most displaced fractures with minimal long-term issues, while adults generally need intervention for similar injuries. Surgical treatment entails alignment of the fracture and stabilization with plates/screws. This has become more common for clavicle fractures, and medical data appears to justify this trend.
If you are athletically active, you will likely deal with shoulder injuries at some point. If this occurs, seek treatment from an orthopaedic surgeon with training in these areas and relax - most of the time, with guided rest, protection, and rehab, full recovery is possible without an operation.
Robert Wolf, MD is an orthopedic surgeon with Summit Orthopedics, Spine & Sports Medicine.
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