Injuries in Contact Athletes

Fig. 3.1

Common mechanisms of shoulder injury in rugby (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

3.3 Clinical Evaluation

3.3.1 History/Presentations

A thorough investigation of relevant history and physical examination are essential for making the correct diagnosis. Baseline information including the patient’s age, dominant arm, type of the sport and playing position are first obtained. It is also important to ask about the history of previous injury or treatment of the shoulder, any events of dislocation of other joints and the presence of known connective tissue disorders in the patient or family.

The mechanism of injury should be investigated in detail. The athlete with a shoulder dislocation may recall a specific traumatic instability event or incomplete subluxating events. The magnitude of the impact or collision, the position of the arm at the time of the trauma, how the shoulder was reduced (whether the shoulder was manually reduced or spontaneously reduced) are important. Patients with posterior shoulder instability primarily have pain and weakness rather than frank instability. however, a recent large-scale epidemiologic study showed that 54% of patients presented with subluxation/instability as primary complaint [8]. For patients who complain of recurrent instability, the number and frequency of recurrent episodes should be investigated. Whether the injury is affecting their activities of daily living as well sports are important factors in considering the surgical treatment.

3.3.2 Physical Examination

The physical examination begins with inspection. Both shoulders need to be exposed for inspection of any deformity or muscle wasting. Active and passive range of motion testing must be performed and compared with the contralateral shoulder. Thorough palpation of the shoulder is carried out with special attention to the AC joint, biceps groove, rotator cuff insertion sites. Shoulder strength testing of each rotator cuff muscle must be assessed as well. It is essential to assess the neuromuscular status, with special attention to the axillary nerve (Deltoid muscle function and “regimental badge” paraesthesia). In addition, generalized ligamentous laxity has been associated with shoulder instability [9]. The Beighton score is used to determine the degree of generalized ligamentous laxity [10]. Special tests, including the Gagey’s test, sulcus sign, apprehension, relocation, and surprise tests may enable the physician to identify the shoulder instability pattern (Fig. 3.2).

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Anterior apprehension test (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

3.4 Imaging

Routine radiographic studies consist of orthogonal view of the shoulder joint: Anteroposterior (AP), axillary lateral and scapula Y view. The AC joint can be best visualized with a 15° cephalic tilt view known as the Zanca View. West Point axillary views often demonstrate the presence of a Hill-Sachs lesion of the humeral head and may demonstrate a loss of bone at the anterior surface of the glenoid. Stryker notch view can help detect humeral head bone loss (Hill-Sachs lesion).

Advanced imaging can be very helpful for defining the pathoanatomy and for planning the surgical approach. Magnetic resonance imaging (MRI) with arthrogram is an extremely useful tool to assess the soft tissue injuries. Classic Bankart lesion (Fig. 3.3), reverse Bankart lesion (Fig. 3.4), humeral avulsion of glenohumeral ligament (HAGL) can also be assessed (Fig. 3.5). The presence of a bone bruise or defect in the posterolateral aspect of humerus (Hill-Sachs lesion) may also be present. Rotator cuff tendon injury ranging from contusion to full thickness tear can be seen.

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Bankart tear on MR arthrogram (white arrow)

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Reverse Bankart tear and reverse Hill-Sachs lesion on MR arthrogram

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HAGL on coronal MR arthrogram (white arrow)

Computed tomography (CT) scan is best to detect bony injuries. Fractures of the clavicle, scapula, and proximal humerus can be better assessed. Three-dimensional (3D) CT reconstruction of the glenoid is useful to measure glenoid bone loss which has been recently understood to be a cause of failure of soft tissue surgery if not properly addressed.

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Rockwood classification for AC joint injuries (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

3.5 Management

3.5.1 AC Joint Injury

The AC joint is a diarthrodial joint, stabilized by the AC ligament and the coracoclavicular (CC) ligaments. The AC ligament, particularly the superior and posterior ligament, provides stability in the AP plane whereas CC ligaments provide stability in the vertical plane. Injuries are typically classified using the Rockwood Classification [11]. Type I injuries are isolated sprains of the AC ligament. Type II injuries are a torn AC ligament and sprained CC ligaments. Type III–VI injuries are torn AC and torn CC ligaments with differential severity and location of AC displacement (Fig. 3.6).

Traditional treatment of AC joint injuries is based on the Rockwood classification, but there is no high level evidence to support this. Generally Type I and II injuries are treated non-operatively with brief period of immobilization, analgesia, cryotherapy, and physical therapy. Return to play is dependent on the player’s comfort and ability to perform sport-specific activity. The management of type III injuries remains controversial. Type III, IV and V injuries can be treated non-operatively initially, as with Type I and II injuries. If the athlete is not coping or progressing with rehabilitation then surgical stabilization is indicated. The time of season and specific sporting requirements should be taken in to consideration when timing surgery. Previous studies have shown that most AC joint injuries in contact athletes are low-grade (Types I and II) and only a small proportion of the injuries (1.7–2.4%) required surgical management [12, 13].

Numerous surgical techniques have been described in the treatment of AC joint injuries. There is little published research focusing on the surgical treatment of AC joint injuries in contact athletes specifically. Marcheggiani Muccioli et al. [14] reported on the outcome of the AC joint reconstruction with the LARS ligament in contact athletes. After reconstruction, the athletes were able to return to full contact sport at median of 4 months using an anatomical artificial ligament technique. Athletes who sustained low-grade injury (Type I or II) may develop posttraumatic osteoarthritis of the AC joint. This can be managed with distal clavicle excision [15].

3.5.2 Rotator Cuff Injury

Injuries of the rotator cuff in contact athletes range from contusion to full thickness tear. A study of rotator cuff contusions in a North American professional football team found that contusions accounted for nearly half (47%) of all shoulder injuries, approximately 5.5 contusions per season [16].

The predominant mechanism of injury for full thickness tears is traumatic and usually associated with shoulder dislocations or subluxations [16, 17]. Tambe et al. [18] reported on the arthroscopic repair of full thickness rotator cuff tear in professional rugby players. They found about half of the patients had concomitant labral injuries or bony Bankart lesions (Fig. 3.7).

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Try scoring injury with anterior shoulder subluxation and rotator cuff tear (courtesy of Lennard Funk, http://www.shoulderdoc.co.uk)

Management of rotator cuff injury is dependent on the severity of the injury. Cuff contusions and partial tears can be managed with non-operative management including pain control and rotator cuff strengthening. Subacromial corticosteroid injections can be considered for athletes with persistent bursal inflammation and pain. Patients who do not respond to these conservative treatments, and those with full thickness cuff tears are indications for surgical management. Advancements in arthroscopic techniques has enabled the successful treatment of cuff tears in contact athletes with little soft tissue damage. A confident repair of rotator cuff and other associated pathology allows the athlete to participate in early return to sport rehabilitation programme. In the series by Tambe et al., 91.7% (ten of eleven) of the elite rugby players were able to return to their pre-injury level of competition early (4.8 months) after arthroscopic rotator cuff repair [18].

3.5.3 Glenohumeral Joint Instability

Glenohumeral joint instability is common and often a disabling injury for the contact athlete. The direction of instability is an important factor for deciding treatment plan. Anterior instability comprises majority of shoulder instability cases, but recent studies have suggested that posterior instability is increasing and consists as much as 10–30% of traumatic instability in contact athletes [5]. Posterior instability is often associated with anterior instability and superior labral tears [8, 19]

If the injury occurs close to the end of the season or during the off-season, surgical stabilization can be easily selected with minimum play-time loss. The choice of early surgery or non-operative treatment should be tailored to the individual athlete with the mid-season injury, taking the following factors into consideration: The type of sport, level of competition, position of the athlete, age of the athlete, pathoanatomy (e.g. glenoid bone loss, Hill-Sachs lesion), timing of the injury in the competitive season, the athlete’s career goal, expectation from the coaching staff or the family member. The orthopedic surgeon needs to gather all the necessary information, assess the risk of recurrence, and counsel the patient and family for the best treatment option.

Surgical stabilization can get the athletes side-lined for 4–6 months, which is usually season-ending. Athletes may be strongly motivated to play through the rest of the season, especially when external factors (contract, scholarship or personal goals etc) are involved. In this scenario, the decision to select non-operative treatment during the season with surgery reserved for the off-season is a viable option. For injured athletes who wish to return to play with non-operative treatment, accelerated rehabilitation protocols can be employed [20, 21]. The immobilization period is minimized (none to 7 days), and supervised rehabilitation program is initiated as tolerated from the first day after injury. At first, gentle ROM exercises and cryotherapy to ease the discomfort are commenced. Once the full range of motion without discomfort is possible, rotator cuff and periscapular muscle strengthening exercises are initiated. When ROM and strength are symmetrical, sport-specific drills are initiated and return to play with a motion-limiting brace is considered when all the following criteria are met [22].