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Rugby and the shoulder

13 November 2018

With the rugby season now firmly underway and having already seen several rugby players with injuries to their shoulder, Mr Richard Baker, one of our leading Consultant Plastic Surgeons here at Spire Thames Valley, discusses two of most common rugby shoulder injuries, their consequences and potential treatment options:

Shoulder instability

Your shoulder is the most mobile joint in your body.  The price for this motion is that it is fairly easy to dislocate the shoulder. Shoulder instability is common in rugby, especially in younger players (15-25 years). The joint can either fully dislocate, or partially come out and self-relocate (subluxation). Both injure structures that render the shoulder more vulnerable to recurrent problems.  Indeed, recurrent instability is a main reason why people undergo shoulder stabilisation surgery.    

What to do if your shoulder comes out?

Of course, if your shoulder has dislocated, it is important you get it relocated urgently; this is best done in hospital. After the joint is relocated, you will be put into a sling that you should wear for a week before you begin to restore motion and function to your shoulder. It is then a good idea to seek the opinion of a shoulder specialist. This will allow you to organise imaging (MRI or CT scan) to assess the damage inside your shoulder and to discuss your rehab and risks of future problems.

Do you need surgery?

Each dislocation causes progressive structural damage inside your shoulder and makes it sequentially less stable. Success rates from surgery are better if done after only one, rather than several dislocations. Without surgery, re-dislocation is much more likely. If you are under 20 and a sports player, your risk of re-dislocation is extremely high – above 80% in two years. There is good evidence to support early surgery to stabilise the shoulder in active young sports players.

Your personal risk of re-dislocation and your functional limitations from your injury will be discussed with you to help guide your decision-making about whether or not to have an operation. If you choose to have surgery, there are two broad options: keyhole repair or open surgery. The better option for you will depend on your age, sporting level and the damage you have sustained inside your joint. Your surgeon will discuss these options with you.

If you do go ahead with surgery, you will need to wear a sling for about four weeks after your operation and follow a prescriptive rehabilitation programme to allow you to regain function whilst protecting your surgical repair.  Return to rugby usually takes 7-9 months.

Can you prevent shoulder instability in rugby?

While you cannot completely remove risk from rugby, there are some simple things you can do to minimise the chance of you suffering a shoulder dislocation. 

Conditioning is important in the modern game.  Many players are very strong in their chest, legs and arms, but the core and posterior shoulder muscles may be overlooked.  Your shoulder-blade positions the ‘golf-tee’ of your shoulder socket. Control is achieved through your core and co-ordination of your muscles in the back and rotator cuff.  If you can focus on achieving a solid core, strong rotator cuff and back, you are optimising your chances of avoiding injury. Your trainer or coach should be able to help with this.

Tackle technique is taught at all levels of the game, but, as with all sports, some of us still adopt incorrect techniques.  If you engage an opponent in the wrong position, it renders you more vulnerable to injury in your shoulder as well as your head and neck.  

Neoprene, tape or snug-fitting clothing can improve your joint-position-sense and may make your shoulder feel more stable. This can improve your muscle co-ordination but it cannot stop a shoulder from coming out.

Specific braces are available that are designed to prevent your shoulder entering the most vulnerable position for dislocation. They incorporate a strap restraint and fit beneath your normal shoulder padding and shirt. These may reduce your chance of primary or recurrent instability. An example is the flawless motion brace (www.flawlessmotion.com).

Acromioclavicular joint injury

This is the joint between the outer end of your collarbone and the acromion (which is part of your shoulder-blade). Again, this is commonly injured in rugby players, as a blow to the shoulder disrupts the joint and the ligaments that support it. Injury may be just a mild sprain, where no significant deformity arises. A more significant injury will dislocate the joint causing a noticeable step at the top of your shoulder. These injuries are always sore to start with, but many however, become pain-free fairly quickly. 

Do you need surgery?

The degree of joint disruption (termed the ‘grade’) does not necessarily determine whether you will need an operation, but those with more damage are more likely to need surgery to re-stabilise the joint. 

In the first few weeks, your symptoms and how you are progressing with rehab are a good guide as to whether you might wish to opt for early surgery. You do not have to rush into surgery if you think you are recovering well at this stage. However, if you are not coping there is the option of keyhole repair - this can be done up to four weeks after your injury. Very strong sutures are passed through tiny drill holes in your collarbone and your shoulder-blade and these hold your collarbone in place while your body heals the damaged ligaments.

If you had an AC joint dislocation a while ago and still have pain and loss of function, then you may need a reconstruction. Here a very strong polyester braided rope (LARS ligament) is used to reconstruct your ligaments and stabilise your joint.  This is an open operation. The success rates are very high with over 80% of patients returning to their same level of sport.

Do you have any shoulder concerns? Mr Richard Baker is a Consultant Plastic and Hand Surgeon here at Spire Thames Valley Hospital. If you would like to make an appointment, learn more about any procedures or have any questions, please call us on 01753 665 404 or email us.

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