THE PROJECT
Should I Give
Shoulder?
Rugby
the
Cold
Project Aims:
• To gain understanding of shoulder anatomy, and the
pathophysiology of dislocation.
• To discover the incidence and prevalence of these dislocations
in contact sports.
• To research the various management strategies for these
injuries, and the application and effectiveness of different
treatment methods.
• Find out what factors determine an individual’s return to
contact sport after shoulder dislocation.
• Develop an algorithm based on our research to help the
decision making process of returning to contact sport after
shoulder injury.
This site was made by a group of University of Edinburgh
medical students, who studied this subject over 10 weeks as part
of the SSC. This website has not been peer reviewed. We certify
that this website is our own work and that we have authorisation
to use all the content (e.g. figures / images) used in this website.
We would like to thank Dr Sam Mackenzie (Trauma and
Orthopedics Department, Royal Infirmary) for his guidance
throughout this project.
Final Word-count: 5977
THE PROBLEM
This project researches glenohumeral instability, specifically
anterior dislocations and subluxations, in relation to the contact
sportsperson. We then consider the implications for return to
sport after the episode of instability. This will be done by firstly
reviewing the pathophysiology, epidemiology, and management
of shoulder instability. Secondly, we will reflect on the factors
influencing an individual’s return to sport. This will be
discussion on interviews carried out with various athletes that
have differing experiences of shoulder injuries, as well as a
physiotherapist and a consultant orthopaedic surgeon. As a
summary, we hope to provide information to those with primary
shoulder instability injuries to aid them in the decision making
process of return to contact sport.
Please click on the sub sections within the header, or the
hyperlinks above to read more on shoulder instability.
PATHOPHYSIOLOGY
Normal Anatomy of the Shoulder:
The shoulder is formed by the proximal end of the humerus
fitting into the pectoral girdle, which consists of the clavicle and
scapula. Although it is referred to as a ball and socket joint, the
socket is actually a near flat surface called the glenoid. The
shoulder region has three joints[1]; the sternoclavicular,
acromioclavicular and glenohumeral joints. The sternoclavicular
and acromioclavicular joints connect the clavicle and scapula to
each other and to the trunk. Together, these two joints increase
the reach of the upper limb. The glenohumeral joint allows
articulation between the scapula and the head of the humerus[2].
Right Glenohumeral Joint: articular surfaces. By Niall Brown
Glenohumeral Joint: referred to as the shoulder joint, this is a
ball and socket joint between the glenoid cavity of the scapula
and the head of the humerus. This multi-axial joint has the
widest range of movement of any joint in the body. However,
this mobility means the shoulder joint is less stable. Unlike the
acetabulum of the hip, the glenoid fossa is only a shallow
socket[3]. Therefore, the stability of the shoulder must be
provided by other structures- referred to as stabilisers[4]:
Passive Stabilisers: acting as restraints
• Bony geometry: the humerus inserts into the glenoid fossa
• The Labrum: fibrocartilagenous collar attached to the margin
of the glenoid fossa serves to deepen the glenoid cavity.
• Joint Capsule and Capsular ligaments:
Superior Glenohumeral Ligament: resists inferior
translation in the adducted shoulder
Middle Glenohumeral Ligament: resists inferior
translation in the adducted and externally rotated
shoulder
Inferior Glenohumeral Ligament: resists translation of
the humeral head anteriorly and posteriorly. This is
the most important stabiliser against anteroinferior
shoulder dislocation.
Active Stabilisers:
• Long head of Biceps Brachii: is located anterior and superior
to the humeral head to resist upward movement of the
humerus in the glenoid cavity.
• Tendons of the rotator cuff muscles: blend with the capsule to
form a musculotendinous collar enclosing the joint. This
increases stability whilst allowing full range of movement.
Anterior Shoulder Dislocation:
The glenohumeral joint is the most commonly dislocated joint in
the body[5], and over 95% of these glenohumeral dislocations
occur anteriorly. Just one quarter of the humeral head is in
contact with the glenoid at any point in the shoulder’s wide
range of movement, showing why it is so easy for the shoulder
to dislocate[6]. Dislocation occurs due to damage of the
structures that make up the shoulder joint, and the stabilisers
that hold it together.
The most common presentation is a Bankart lesion, which has
been recorded in up to 90% of anterior shoulder dislocations
related to trauma[6]. A Bankart lesion is detachment of the
anterior labrum, along with the section of the inferior
glenohumeral ligament that joins to the labrum anteriorly[7]. The
reason behind their high frequency is due to the most common
mechanism of shoulder injury: falling onto an abducted,
externally rotated shoulder. With the shoulder in this position,
the inferior glenohumeral ligament is the main structure
preventing the humeral head from dislocating anteriorly[6].
A Bony Bankart lesion is a variant of this, and occurs when the
anterior inferior glenoid rim fractures, with the anterior labrum
attached[6]. If dislocation reoccurs, the humeral head can cause
increased bone loss as it rubs against the glenoid rim, making
the shoulder increasingly unstable by reducing the concavity of
the glenoid[7].
A Hills-Sachs lesion can occur when the glenoid rim causes an
impression fracture on the posterior humeral head. This is due to
the pressure of the hard glenoid rim on the relatively soft
humeral head, happening exclusively after anterior shoulder
dislocation[7]. This type of lesion usually has a traumatic
mechanism as a cause, and is a frequent reason for recurrent
shoulder dislocation and instability[8]. A Hill-Sachs lesion of
2.5cm3 of more has been shown to cause recurrence in over twothirds of patients, emphasising the association with instability[9].
The stabilising effect of the rotator cuff muscles can be
compromised when their tendons tear in dislocation- a
phenomenon more common in elderly patients[7]. Further
stability is lost when these rotator cuff tendon injuries are
combined with disruption to the capsuloligamentous structures
across the joint. The anterior movements cause stretching of the
joint capsule, which can become detached from the glenoid rim
or, less commonly, the proximal humerus.
Nerve damage is common in shoulder dislocation and is a main
determinant in speed of recovery[10]. Neuromuscular damage
worsens the instability of the rotator cuff muscles, as these
muscles receive disrupted nervous feedback from the damaged
structures of the dislocated shoulder[7]. The axillary nerve,
which winds around the humeral head, runs in a close
relationship to the glenohumeral joint. During dislocation, it is
therefore the most vulnerable nerve of the brachial plexus.
Severe injury to the nerves at the shoulder can be identified by
testing for abnormal sensation in the lower arm.
Electromyography can also prove useful in identifying nerve
damage after shoulder dislocation[10].
Clinical Features:
An anterior shoulder dislocation can be seen on inspection by a
trained medical professional. The normal shape of the deltoid
over the shoulder is lost; the affected shoulder has a squarer
shape, compared to the usual round contour of the humeral head.
In addition, the humeral head may be palpable, sometimes even
seen anteriorly. The patient is likely to be holding their arm in
an abducted and externally rotated position, due to the nature of
the dislocation[5].
EPIDEMIOLOGY
Shoulder injury is very common in contact sports especially
those that involve a lot of tackling such as rugby which has 80%
of all injuries being related to the shoulder[1]. In fact it has been
shown that over the last ten years shoulder injury has been the
major reason for rugby retirement[2] and of all the severe
shoulder injuries experienced 80% are due to dislocation [3]. For
this reason several studies have been conducted to measure
dislocation’s incidence and prevalence and the determining risk
factors.
Within the tackle situation, the tackler is in fact the most prone to shoulder
dislocation anteriorly.
Determining Risk factor
Different situations on
the field pose different
levels
of
risk
for
dislocation; the most
likely being the ‘tackle’
situation and the second
most being ‘falling’.
Statistics
Of all causes of all
dislocation on the rugby
field:-35-68% are from
tackling-10.3% are from
falling[3]
Glenoid dislocation is the
third most common injury
accounting for loss of days
for the Back positions and
second most for the
Forward positions[4].
Specific positions on the Studies show that the
team
have
different position of flanker is most
levels of dislocation risk. susceptible to dislocation
while wingers are the
least[5].
‘Back’ or ‘forward’
position. Forward
positions are the more
likely of the two types to
dislocate[4].
Why?
In fact it is the tackler,
not the tackled, who are
most susceptible[3] . This
is because in a front on
tackle the player’s arm is
most likely to be
abducted
and
in
an externally
rotated
position and so is more
liable to dislocate.
It should be noted that
this is not to do with the
demanded tackle number
from each position but
rather the nature of the
tackles[5]. For example,
a flanker (a forward)
must tackle or engage in
contact with opposition
round the fringes of
rucks and mauls, thus
exposing themselves to
constant high-intensity,
short-range contact.
Wingers,
however, benefit from
the safety of engaging in
contact with speed as
well as plenty of
recovery time[3].
The age
and
experience of
the
player.However it should
be noted that different
studies
draw
conflicting conclusions in
this area.
Usman
&
McIntosh[6] show this in
their 2013 study reporting
that younger players have
a lower incidence of
shoulder injury to that of
elite
players
but
conversely have a higher
rate of glenoid dislocation.
However, this reasoning is
contested by Nicol et
al[7] who, by studying
high-school rugby rates,
concluded an increasing
dislocation
risk
proportional to increasing
age
Studies showing younger
players having higher
incidence
rates
are
believed to obtain their
results because said
players
tackling
technique is poorer[8],
while
older
more
physically
mature
players have enough
muscle bulk to avoid full
dislocation.
Studies
showing the opposite
however attribute their
results to older players
being more aggressive,
competitive
and
physical[7].
MANAGEMENT
The doctor patient relationship is key in managing the injury. The treatment has to be
specified to the patient and their lifestyle.
Aims of managing anterior shoulder dislocation revolve around
returning shoulder function to satisfactory standards for patient
lifestyle, whilst reducing recurrence risk.
Protocols surrounding management remain indecisive. This
originates from taking the patient’s lifestyle and expectations
into account, but also the fact that the body of evidence is
inconclusive. Differences in trial results come from sample
variations, such as patient characteristics to the disparity in
surgeons and recovery regimes used in each sample. The
following management review therefore attempts to discriminate
towards the use of literature which narrows parameters to the
study of the contact athlete.
Firstly, shoulder reduction is implemented. Traditional methods
include Hippocratic method, where the clinician placed their
heel on the patient’s and applied traction along the arm. This
method have been largely replaced[1], with methods such as the
Stimson method (weight is applied to patient’s wrist while lying
prone) and the Milch method (patient keeps hands behind their
head). This is often executed with appropriate analgesia and
muscle relaxation. Open reduction is very rarely needed,
however sometimes the shoulder can be irreducible; an example
would be when there is an interposition of the long biceps
tendon, caused by a greater tuberosity fracture. The tendon
therefore has to be relocated anteriorly to the humeral head and
the greater tuberosity stabilised.
Once shoulder reduction is complete, the shoulder is often
immobilised. 90% of cases in the UK are treated with
immobilisation in internal rotation (IR), which is maintained for
an average of 5 weeks[2]. IR is safe, as it prevents the shoulder
being subject to the vulnerable position of abduction and
external rotation, which maintaining stability. It also promotes
patient compliance, as the arm is rested in the comfortable
position close to the abdomen[3].
However, there has been an argument of immobilising the arm
at a small angle (often approximately 10o) of external rotation
(ER). ER maintains glenoid-capsule contact, and increases the
tension on the sub-scapularis muscle. This showed a major
improvement in the reduction of the Bankart lesion [4], however
this came with the downside of preventing the labrum from
returning to its original position. This has resulted in mixed
results returning from trials, however there has been evaluation
that authors need to better differentiate patient groups and
pathologies when trialling management strategies[5].
This differentiation has shown more coherent results in the
duration of immobilisation. Benefit was shown in
immobilisation up to three weeks after dislocation[6], however
analysis showed that this benefit was limited in immobilisation
over 1 week in patients under the age of 30[7]. Older patients
required the longer period of immobilisation, as this prevented
stiffness[8].
Regardless of immobilisation method, reported patient noncompliance remained high for every option, up to 47% in
cases[9]. This places the use of immobilisation in question,
particularly for long periods of time, which is still prevalent
within the UK.
Surgical intervention has shown undeniable evidence that it
reduces recurrence rates. One study showed a recurrence
reduction of 37-65% in young adults[10]. This is particularly
noted in athletes returning to contact sports, where the
recurrence risk is higher[11]. Some researchers even argue that
early arthroscopic stabilisation should be issued, even without
any form of immobilisation[12].
Arthroscopic lavage has been considered, with the theory that it
would decrease the volume of the capsule, thus allowing greater
adherence of the glenoid rim to the capsulolabral complex.
Initial trials showed promising reduction in recurrence rates, but
it was confirmed in larger sampled trials that these recurrence
rates remained between 38-55%- still higher than more radical
arthroscopic techniques[13]. These techniques often target and
repair the labral tears, as well as improve the capsular laxity.
This preserves the range of movement, and often boasts low
complication rates[14].
Before surgery is conducted, an early MRI is recommended,
specifically to diagnose rotator cuff tears, which has a high
prevalence in shoulder injury patients, especially as age
increases. Rotator cuff tears must be treated, to prevent
extension of the tear to the sub-scapularis tendon, which
increases the risk of recurrent instability[15].
Conventional open surgery remains widely used in shoulder
stabilisation. Arthroscopic method is becoming increasingly
popular amongst surgeons, however there has been no
significant difference found between the two methods, both in
recurrence rates, and also quality of life of patients at two year
follow up[16]. Inevitably though, the less invasive technique of
arthroscopy allows quicker recovery from the actual surgery.
In a case of recurrent shoulder instability, conservative
treatment is inadequate[17]. This is due to trends showing an
increase in frequency and severity of lesions within the
shoulder- Hills-Sachs lesion numbers increase three fold[18].
Due to the high momentum nature of recurrent shoulder
dislocation in contact athletes, bone erosion is often significant,
and if glenoid bone loss exceeds 25%, a bony reconstruction
procedure is recommended in the surgery[19]. The most popular
is the Latarjet-Patte procedure, which creates an osseous block
by pulling the coracoid process through the subscapularis
tendon[20]. If the osseous erosion is on the humeral head, a
remplissage process is often executed. These methods have been
found to be effective in reducing further recurrence and also
help avoid a lengthy return to sport[21].
This growing body of literature has changed the habits of
surgeons, with those favouring radical early surgical
intervention now doubled[22]. For the young athlete who is
anxious to return to rugby, it would not be wrong to pursue this.
Inversely, up to 56% of patients choose to adopt an initial
conservative approach, and only choosing surgery when
necessary[23]. This is down to economical, time and lifestyle
factors, which are yet to be fully investigated in such studies.
This comes with the finding that if all patients were surgically
treated, even in the high-risk group of those below 25 years old
30% of patients would undergo unnecessary operations[24]. This
highlights that despite the eager approach to surgery can be seen
as encouraged, it is important to consider the perspectives of the
unique patient. However, it is important to highlight the
extremely high recurrence rates associated with solitary
conservative treatment, and the risks of suffering further lesions
with a recurrent episode.
Once there is a return to contact sport regardless of treatment
choice, there is little to no viable options which effectively
reduce risk of recurrence when playing sport – the use of
padding reduces the force load on the shoulder by a mere
3%[25]. This makes it essential to provide effective treatment
after the first dislocation.
PERSPECTIVES
To further our understanding of return to contact sports after
shoulder injury, we spoke to individuals experienced in this
area. This included an interview with a consultant orthopaedic
surgeon, a sports physiotherapist and various students that have
injured their shoulders through rugby.
SURGEON
Ms Julie McBirnie – Consultant Orthopaedic surgeon
“My job is to treat the patients shoulder instability with the
end goal of getting them back to playing their primary
contact sport, to the same level and ability as they were preinjury”
To obtain a professionals viewpoint on treatment of shoulder
injury in the contact sportsperson and the consequent decision to
return to sport or not, we interviewed Ms Julie McBirnie, a
consultant orthopaedic surgeon with years of experience treating
shoulder instability, who also has a research interest in shoulder
instability in the contact sportsperson.
Ms Mcbirnie was able to give us valuable insight into the
decision making process from a professional standpoint.
Provided the patient still had desire to return to sport, the goal of
her treatment was to get them back to their playing level prior to
injury, as quickly as possible. She mentioned the risks of
recurrent injury after shoulder instability management, and the
potential complications of re-treatment if the athlete does have
recurrence. She is extremely cognisant of the risks which come
with certain management plans, and considers it seriously
important to talk through all relevant risks with each patient,
however she does not actively discourage return to sport
because of them.
One particularly important factor when deciding the best
treatment plan was the patients age; as younger athletes (e.g.2130 years old) tend to have a higher chance of recurrence after
primary instability than older people[1]. As a result of the
different risks associated with age, her treatment and
counselling on the decision to return to sport varies. So for
treatment of the younger athlete who has had shoulder
instability, for example, arthroscopic or bankhart repair is
normally opted for over conservative management because of
the increased shoulder stability, and the associated decreased
risk of recurrence. [2]
Having dealt with many professional athletes, with dense
muscle mass surrounding the shoulder, the surgical treatment
can be made somewhat more difficult, and this is another
component of discussion with her patients; if surgery is made
more difficult because of personal factors, the chance of surgery
failure increases. This must be considered when weighing up
conservative/surgical treatment plans.
Conflicting views between her and her patients are rare; and
although it is ultimately the patients decision, the plan of
treatment and decision to return to sport is made on a mutual
basis normally. She has only had to suggest retirement in two
athletes so far, however these patients were aware that any more
efforts to return to sport would be unwise, due to the extent of
their recurrent shoulder problems.
She emphasised that the decision of treatment and the advice on
return to sport is individually tailored to each patient throughout
the interview. The patients expectations and desires in terms of
management and recovery must be considered alongside their
relevant risk factors such as age, fitness and level of sport when
deciding treatment.
HYSIO
Janis Beattie – Physiotherapist
“The physiotherapist’s role is to build a strong, trusting
relationship with the patient by using clear, open
communication to ensure they have the confidence, both
physically or otherwise, to return to contact sport”
Throughout the interview with physiotherapist Mrs Beattie, a lot
of useful information about shoulder dislocation was obtained.
In addition, we gathered her viewpoints on and involvement
with a player injured from shoulder dislocation and their
subsequent decision to return to contact sport. The main focus
points of the interview were about the therapist’s role in a
player’s rehabilitation; namely encouraging and reassuring their
confidence and building a trusting relationship supported by
clear communication.
Firstly, confidence was a large talking point of the interview. An
individual’s amount of courage and self-assurance relative to
rehabilitation was stressed as crucial to their chances of
returning. This confidence is dependent on a large variety of
influences; the main one being the player’s experience from
dislocation to immediate treatment. This encompasses primarily
the experienced severity of pain but also the skill, empathy and
judgement with which the on-hand medical staff manage the
player. Therefore the quality of care immediately given by the
physiotherapist – who would be the most likely pitch-side help –
becomes key in limiting the player’s negative experience and so
can determine their want and confidence to return. It should also
be noted however that other influences can be detrimental to a
player’s experience, and so confidence, to return: the
care/attention given by the A&E department; the length of time
from injury to pain relief; if the injury was caused by something
self-inflicted, for example a diving try, as a measure of guilt my
affect confidence; and if the dislocation was a second or third
occurrence. The later affecting confidence as the player may
subsequently no longer possess the self-assurance in their body
to handle the sport and contact any longer. Furthermore Miss
Beattie commented that should a player return with decreased
confidence then in the tackle situation, where most dislocations
occur, a player is often more likely to reinjure due to lack of
physical commitment.
Secondly, the relationship and quality of communication
between clinician and patient were stated to be two more hinges
with which the player’s decision to return revolved around. Mrs
Beattie described how in the clinical setting a sufficient amount
of trust between the therapist and player is necessary for fullyfledged, successful rehabilitation. Should the therapist lack the
personal skills to build up a good rapport with the player, the
resulting lack of trust that can cause increased disregard for
treatment plans and protocols. This will lower the chances of
return. Furthermore it was explained that the physiotherapist’s
quality of communicating said treatment plans and protocols is
also determinant of rehabilitation. For example, if a therapist
fails to accommodate such characteristics as a player’s intellect,
style of learning and previous anatomical knowledge while
communicating the requirements for rehabilitation, the resulting
outcome would mean difficulty and confusion regarding the
players input to treatment, equating to decreased chances of
return to contact. In addition, if the support team around the
player (i.e. a coach and a physiotherapist) give different
instructions and information to the player, a successful return is
also less likely.
PATIENT
The patients interviewed had varying injuries and outcomes,
and by discussing their injury and decision to return to
sport, we gained an understanding into the factors that
influence this decision.
Patient 1: Callum Leese
Age: 21
Callum Leese – 3rd Year Medical student with recurrent shoulder instability
Position: Fly half
Injury sustained: Anterior shoulder dislocation with Bankart
lesion
What happened: Surgical management with bankart repair
followed by seven months of physiotherapy
Callum dislocated his shoulder in a rugby tackle, after which he
underwent 6 months of conservative management with the goal
to return to rugby. The physiotherapy required him to spend one
hour per day in the gym working on rehabilitating exercises.
Although he was aware of the risks of recurrence, his love for
the sport meant he was willing to accept this, and he wanted to
return as soon as he could. Shortly after his return to rugby the
shoulder dislocated again and the bankart repair failed. This
demoralised Callum as he had put so much effort into the
recovery only to be injured again.
His views on returning to sport have now changed as he doesn’t
want to experience another disappointment or painful injury
again. Currently he is considering moving to other non-contact
sports while waiting for a shoulder operation in several months
time.
Was it worth it? Callum maintains that despite the huge
disappointment of rapid recurrent injury and failure of the
surgery, he is glad he returned to rugby after his initial injury,
and loved every minute he was able to play. He remains
undecided on whether he will ever return to contact sports or
not, however thinks it unlikely because of his increasing risk
and past frustration with instability.
Patient 2: Greg Brown
Age: 21
Greg Brown – 3rd Year Medical Student with recurrent instability
Position: Inside center
Injury sustained: Subluxation followed by full anterior
dislocation of right shoulder
What happened: Conservative physio management, returned to
rugby and had another dislocation which was managed
surgically. (keyhole initially, followed by open when shoulder
remained unstable.)
Greg experienced a partial dislocation of his shoulder while
playing rugby. Investigation proved he partially dislocated, for
which he was managed conservatively with sling immobilisation
and physiotherapy. Soon, after dedication to strengthening
exercises, he returned to rugby but only to injure his shoulder
again; this time fully dislocating it as he could tell from a
lvisible displacement of his arm. Conservative management was
employed again until a consultation with a surgeon who told
Greg that to continue to play rugby, open surgery would be the
best option for his shoulder due to the procedure’s high success
rate and the associated increase in stability. The medical team
and his family both advised him to opt for surgery, however
with no desire to go back into a sling and miss several months of
rugby Greg delayed surgery; instead he continued to play,
resulting, in several more dislocations. Finally Greg underwent
open surgery and, though he is still not fully recovered, reports
that his shoulder is good and only weakens on occasion.
Greg’s enthusiasm to return to rugby has never faltered and so
he intends to return again as soon as he can. He attributes this
decision to a love of the sport, but did make sure to note that he
makes it with increased apprehension and that should he ever
dislocate again he thinks he will have to retire.
Was it worth it? Greg made great efforts to return to sport,
despite recurrent dislocations setting him back. His viewpoint
was that if he still has the ability to play rugby, it is worth the
risk, however with the recurrent injuries, this has been slightly
altered, and with another instance he will be forced to seriously
consider retirement.
Patient 3: David Barcroft
David Barcroft – 3rd year Medical student with recurrent shoulder instability
Age: 21
Position: Back row
Injury sustained: Anterior right shoulder dislocation
What happened: Bankart repair followed by physiotherapy
David had a minor episode of instability when his shoulder
subluxed aged 17, after which physiotherapists recommended
surgery as a course of management. Instead he opted for
physiotherapy as he thought surgery was too drastic. After he
dislocated the shoulder during a rugby game about a year later,
he was advised that since he wanted to return to playing rugby,
physiotherapy alone would not improve stability enough, and
surgery to improve his shoulder stability was the best course of
action. After the surgery, David was encouraged by the surgeon
and physiotherapist to return to rugby.
Despite this, he suffered several more dislocations roughly one
year after his Bankart surgery. He explained that the shoulder
dislocated easily on this occasion, suggesting high levels of
instability. He thinks that the second dislocation (post-bankart
repair) was due to physical weakness and poor fitness levels.
The muscles of shoulder were not strong enough to be going
back to rugby, and this contributed to the second dislocation. He
then had a lateiet operation, after which he decided to stop
playing rugby. Despite making a good recovery from the second
operation, he described it as slow and more painful than the
Bankart repair.
Was it worth it? David is glad he returned to rugby after the
first operation. Fortunately the good recovery after the second
operation means he is not restricted by his shoulder, and can still
participate in non-contact sports like skiing and rowing. He
doesn’t want to risk any further dislocations as his passion for
sport is not enough to justify more hassle and pain.
Peter eves – 2nd Year Medical Student with sternoclavicular joint dislocation and
recurrent following subluxations
Patient 4: Peter Eves
Age: 20
Position: Scrum – Half
Injury sustained: Anterior dislocation of sternoclavicular joint,
followed by recurrent subluxations of right shoulder
What happened: Physiotherapy followed
management after recurrent subluxations
by
surgical
While playing at scrum-half position for 1st XV schools Peter
dislocated his shoulder at the sternoclavicular joint while
tackling a member of the opposition team resulting in required
reduction and serve pain relief at a local accident and emergency
department. Initial management upon a surgeon’s consultation
consisted of conservative physiotherapy for strengthening;
however after several later subluxations while playing noncontact sports – football and basketball – Peter finally decided to
receive surgery .He has not yet returned prior to this.
Peter did not chose to return immediately to rugby after his
primary injury and instead played said other sports because they
offered little risk of further instability and were in keeping with
his physiotherapist’s treatment plan. In fact even after receiving
surgery he continues to play said sports rather than rugby
because of enjoyment and the relative lack of risk. He describes
differing opinions about his potential return to rugby from those
around him, his family wanting him to retire rugby while his
surgeon did not rule out his return as a possibility. However to
Peter neither of these viewpoints influence him very much;
instead stating that his decision to return revolves around both
his on research into the topic at hand as well as his own
confidence in the stability of his arm, and that thus far he
doesn’t believe it is ready to endure contact sport.
Was it worth it?: Peter is currently happy that he has not
returned to contact sports. He knows the risks of recurrence are
high and if he re-injures then he may develop life-long shoulder
instability issues. He still plays non-contact sports and his love
of rugby is not enough to warrant the risk of recurrent injury in
his eyes.
CLINICAL ALGORITHM
At the start of the project we had set out to make an algorithm to
help patients make a better informed decision about their
treatment, by presenting them with the different relative risks of
the possible management plans. However due to the
individualistic nature of shoulder injury, defining an individuals
relative risk cannot be done due to the amount of personal
factors which influence this risk. Categorisation of patients
based on broad characteristics can allow for a rough aid for
decision making, but the final treatment decisions must be
tailored to the individual.
We have formulated one such potential algorithm, not to instruct
definite choices, but to provide relevant information for a given
patient with shoulder instability. This could potentially increase
the chances for correct management decisions by allowing
clearer understanding on the individuals risks by using figures
on recurrence and instability from past studies. Previous studies
have attempted to make individual decision based models for
return to sport after injury, but none specifically for shoulder
instability issues.[1]
Admittedly, there are a number of limitations which cannot be
accounted for in such a treadmill format. These are briefly
acknowledged in the grey areas section. Despite this, we felt that
after observing poor decision-making in our patient perspectives
section, both on the patient and clinician part, a clear cut
formula, despite the case variation, could be useful. Even in our
small patient interview sample, one of the patients, Greg Brown,
continued playing rugby despite waiting on surgery to improve
stability in the shoulder, which resulted in further damage which
could have been avoided if he was better informed. The
characteristics of the patient displayed is not intended to
pigeonhole patients and definitively categorise their treatment
based on certain criteria, but to illustrate high risk factors which
should lean the decision making in a certain direction.
CONCLUSION
At the start of this project, we were shocked that over threequarters of injuries in rugby involve the shoulder. However,
when the immense force of contact sport collision is combined
with the inherent instability of the shoulder joint, it becomes
easy to see why anterior dislocation is such a common
issue[1,2]. Although we could identify no clear correlation of
shoulder dislocation incidence with age, we discovered that the
forward position ‘flanker’ is most likely to sustain this
injury[1,2,3], and overall most shoulder dislocations occur during
tackling. Early in the project we discovered that the hugely
varying personal factors between patients makes management a
very patient-specific process. For example, varying playing
levels, other leisure activities and desire to play contact sport
again. For the most, reduction and immobilisation are the
mainstays of immediate treatment [4,5], whilst subsequent
treatment is swayed heavily by the return to contact sports or
lack thereof. Dislocation reoccurs at a higher rate in those
participating in contact sports[6], and with each recurrent
dislocation more serious damage is done. This emphasises the
importance of the decision making process of returning to
contact sports and further reinforces the necessity of appropriate
treatment after the original injury.
Originally, we set about the project hoping to identify
individuals that fit certain criteria to return to contact sport.
However, by speaking to patients and professionals we now
realise that both treatment and decision making about playing
contact sports again are very personal processes that can’t be
replicated between individuals[7]. In terms of factors
determining return to contact sport, we found in the patient
cohort that the personal desire to play again is the most
influential component of the decision balanced against the
potential risk of recurrence and further time spent being injured.
In addition, the professionals involved in managing shoulder
injuries influence the way treatments are decided[8]. However, it
seems to require a very skilled surgeon to be able to fit the
unique needs of all the patients they encounter. For instance,
Miss McBirnie discussed how she doesn’t have a set
management routine, as each patient must be individually
considered and understood for optimal treatment. This was
replicated by the physiotherapist, further emphasising that
treatment is very much a case-by-case event requiring good
dialogue with the patient.
It was incredible how many patients decided to exercise a waitand-see approach with their treatment. Although this allows the
chance of avoiding extensive surgery, it can also increase the
risk of recurrent instability with other associated lesions. Better
dialogue and information provision regarding recurrence risk
and rehabilitation to a normal lifestyle may be what is required
to reduce this indecision.
As a group we have thoroughly enjoyed this project, which has
explored a very widespread issue in both medical treatment and
sporting injury. Our interest in rugby has made the topic
relevant, and our findings have allowed us to explore player’s
and professional’s experiences with anterior dislocation injury.
We hope to have fulfilled our aims, and all now have a far better
understanding of the factors involved in return to contact sport
after shoulder injury.
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Management:
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dislocation. Ghane MR, Hoseini SH, Javadzadeh HR,
Mahmoudi S, Saburi A. Chin J Traumatol. 2014 Apr 1;17(2):938.
2. Chong M, Karataglis D, Learmonth D. Survey of the
management of acute traumatic first-time anterior shoulder
dislocation among trauma clinicians in the UK. Ann R Coll Surg
Engl. 2006;88(5):454-458.
3. Klviluoto O, Pasila M, Jaroma H, Sundholm A.
Immobilization After Primary Dislocation of the Shoulder. Acta
Orthop. 1980;51(1-6):915-919
4. Hart W, Kelly C. Arthroscopic observation of capsulolabral
reduction after shoulder dislocation. Journal of Shoulder and
Elbow Surgery. 2005;14(2):134-137.
5. Kuijpers T, van der Windt D, van der Heijden G, Bouter L.
Systematic review of prognostic cohort studies on shoulder
disorders. Pain. 2004;109(3):420-431.
6. Bishop J, Crall T, Kocher M. Operative versus nonoperative
treatment after primary traumatic anterior glenohumeral
dislocation. Journal of Shoulder and Elbow Surgery.
2012;21(1):e17-e18.
7. Gamradt S. Prolonged Immobilization Does Not Reduce the
Rate of Recurrence After Initial Anterior Shoulder Dislocation.
J Bone Joint Surg Am Orthopaedic Highlights: Sports Medicine.
2013;3(6):e8.
8. Klviluoto O, Pasila M, Jaroma H, Sundholm A.
Immobilization After Primary Dislocation of the Shoulder. Acta
Orthop. 1980;51(1-6):915-919.
9. Robinson C, Dobson R. Anterior instability of the shoulder
after trauma. The Journal of Bone and Joint Surgery.
2004;86(4):469-479
10. Morrey B. Primary Arthroscopic Stabilization for a FirstTime Anterior Dislocation of the Shoulder: A Randomized,
Double-Blind Trial. Yearbook of Orthopedics. 2009;2009:113114
11. Gooding B, Geoghegan J, Manning P. The management of
acute traumatic primary anterior shoulder dislocation in young
adults. Shoulder & Elbow. 2010;2(3):141-146.
12. Morrey B. Prospective, Randomized Clinical Trial
Comparing the Effectiveness of Immediate Arthroscopic
Stabilization Versus Immobilization and Rehabilitation in First
Traumatic Anterior Dislocations of the Shoulder: Longterm
Evaluation. Yearbook of Orthopedics. 2006;2006:246-247.
13. Jakobsen B, Johannsen H, Suder P, Søjbjerg J. Primary
Repair Versus Conservative Treatment of First-Time Traumatic
Anterior Dislocation of the Shoulder: A Randomized Study
With 10-Year Follow-up. Arthroscopy: The Journal of
Arthroscopic & Related Surgery. 2007;23(2):118-123.
14. Bahk M, Karzel R, Snyder S. Arthroscopic Posterior
Stabilization and Anterior Capsular Plication for Recurrent
Posterior Glenohumeral Instability (SS-18). Arthroscopy: The
Journal of Arthroscopic & Related Surgery. 2009;25(6):e10e11.
15. Nevaiser R, Nevaiser T, Nevaiser J. Anterior Dislocation of
the Shoulder and Rotator Cuff Rupture. Clinical Orthopaedics
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16. Brophy R, Marx R. The Treatment of Traumatic Anterior
Instability of the Shoulder: Nonoperative and Surgical
Treatment. Arthroscopy: The Journal of Arthroscopic & Related
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first-time anterior shoulder dislocations. Orthopaedics &
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18. Kim D, Yoon Y, Yi C. Prevalence Comparison of
Accompanying Lesions Between Primary and Recurrent
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Sports Medicine. 2010;38(10):2071-2076.
19. Young A, Maia R, Berhouet J, Walch G. Open Latarjet
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the glenohumeral joint. Journal of Shoulder and Elbow Surgery.
2011;20(2):S61-S69.
20. Joshi M, Young A, Balestro J, Walch G. The Latarjet-Patte
Procedure for Recurrent Anterior Shoulder Instability in Contact
Athletes. Clinics in Sports Medicine. 2013;32(4):731-739.
21. Purchase R, Wolf E, Hobgood E, Pollock M, Smalley C.
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Engaging Hill-Sachs Lesion. Arthroscopy: The Journal of
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Associated with Traumatic Anterior Glenohumeral Dislocations.
The Journal of Bone and Joint Surgery (American). 2012;94(1).
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Surgeon’s Viewpoint:
1. Kralinger, Franz S., et al. “Predicting recurrence after primary
anterior shoulder dislocation.” The American Journal of Sports
Medicine 30.1 (2002): 116-120.
http://ajs.sagepub.com/content/30/1/116.short
2. Arciero, Robert A., et al. “Arthroscopic Bankart repair versus
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Clinical algorithm:
1. Creighton, David W., et al. “Return-to-play in sport: a
decision-based model.” Clinical Journal of Sport Medicine 20.5
(2010): 379-385.
Conclusion:
1. Sundaram A., Bokor D., Davidson A.; ‘Rugby Union on-field
position and its relationship to shoulder injury leading to
anterior reconstruction for instability.’ Journal of Science and
Medicine in Sport. March 2011; 14(2): 111–114
2. Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation.
Ann R Coll Surg Engl [Internet]. 2009 [cited 15 February
2015];91(1):2-7. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752231/
3. Mohammed K., Cadogan A., Robinson D., Roche J.; ‘The
shoulder in the collision athlete.’ Orthopaedics and Trauma.
2015.
4. Comparison between traction-countertraction and modified
scapular manipulation for reduction of shoulder
dislocation. Ghane MR, Hoseini SH, Javadzadeh HR,
Mahmoudi S, Saburi A. Chin J Traumatol. 2014 Apr 1;17(2):938.
5. Chong M, Karataglis D, Learmonth D. Survey of the
management of acute traumatic first-time anterior shoulder
dislocation among trauma clinicians in the UK. Ann R Coll Surg
Engl. 2006;88(5):454-458.
6. Gooding B, Geoghegan J, Manning P. The management of
acute traumatic primary anterior shoulder dislocation in young
adults. Shoulder & Elbow. 2010;2(3):141-146.
7. Simonet, William T., and Robert H. Cofield. “Prognosis in
anterior shoulder dislocation.” The American journal of sports
medicine 12.1 (1984): 19-24.
8. Robinson, C. Michael, et al. “Functional outcome and risk of
recurrent instability after primary traumatic anterior shoulder
dislocation in young patients.” The Journal of Bone & Joint
Surgery 88.11 (2006): 2326-2336.
Graphics:
1.Pictograms of Olympic sports – Rugby union
domain, http://commons.wikimedia.org/wiki/File:Olympic_pict
ogram_Rugby_union.png
http://commons.wikimedia.org/wiki/Commons:Reusing_content
_outside_Wikimedia
2. Shoulder drawing: by Niall Brown 20/02/2015.
3. A diving tackle in rugby union
http://creativecommons.org/licenses/by/2.0/
http://en.wikipedia.org/wiki/Tackle_(football_move)#/media/Fil
e:Rugby_tackle_cropped.jpg
4. Doctor greeting patient
https://creativecommons.org/licenses/by/2.0/
www.flickr.com/photos/59632563@N04/6104068209/