A large variety of shoulder injuries may occur during sports or athletic activities:
Common sporting injuries of the shoulder include dislocations, Acromioclavicular joint (ACJ) injuries, rotator cuff injuries, labral tears, thrower's shoulder, biceps injuries, bursitis and fractures. Dislocations and ACJ injuries are more common in contact sports, such as rugby and wrestling, whilst rotator cuff tears and biceps lesions are common in sports involving explosive heavy weight-lifting. Fractures around the shoulder are seen with sports involving crashes and falls from heights (of which there are many).
It is often quite difficult to adequately assess the severity of a shoulder injury and the structures damaged following sports injuries, as simple muscle strains look very similar to more serious injuries. Thus early assessment from a skilled Shoulder Therapist or Surgeon is essential for early appropriate management. This may involve x-rays, and a special scan.
Because the shoulder joint is the most mobile joint in the body it is potentially unstable. It is therefore the most common joint to dislocate in the body. In some people only minor trauma can cause the shoulder to 'pop out' of joint. If your shoulder does dislocate it needs to be 'put back' as soon as possible and you then require physiotherapy.
Over 50% of dislocations can recur, especially in young sports people. Repeated dislocations lead to more instability and stretching of the shoulder joint, leading to long periods off sports and poor performance. We therefore recommend early surgical fixation. Keyhole repair offers the advantages of less pain, less complications and an earlier return to sports.
The hard small lump you feel on the top of your shoulder is your Acromioclavicular Joint (ACJ). This joint is very important for overhead and throwing athletes. It is commonly sprained by repeated falls on the shoulder and tackling. It can also dislocate resulting in a more prominent painful lump on your shoulder.
Sprained joints tend to cause more long-term pain than true dislocated joints. Injections and physiotherapy often improve the pain, but surgical removal of the joint is often required for persisting pain. This operation can be done by keyhole (arthroscopic) surgery, which has the advantages of less post-op pain and an early return to sport. Traditional open surgery can also weaken the shoulder, by dividing important ligaments. This is avoided with arthroscopic ACJ excision.
Subacromial Impingement (also known as Bursitis, Impingement Syndrome, Rotator Cuff Tendinitis, Supraspinatus tendonitis) occurs with repeated use of your arm overhead and in older athletes who develop small bony spurs which trap the rotator cuff tendons above the main shoulder joint. Injections and physiotherapy often improve this condition, but repeated steroid injections should be avoided (especially in athletes).
Surgery involves keyhole 'cleaning' of the subacromial bursa with removal of the bony spur. This is called arthroscopic Subacromial Decompression.
The rotator cuff is a very important group of tendons that provide movement and stability for your shoulder. Therefore when it is damaged pain and weakness can be significant. Tears caused by injury, especially in athletes, benefit from early repair because the tears can get bigger and more difficult to repair later on. Rotator cuff repair can be done by keyhole surgery or open surgery. We repair most tears by keyhole surgery with the same success rate as for open surgery.
Superior Labral Antero-Posterior (SLAP) tears of the shoulder are more common in overhead throwing, heavy lifting and tackling sports. The biceps insertion in the shoulder is forcibly peeled or pulled off its bone attachment by a large pulling or peeling force. This can occur during a heavy lift, hard throw, tackle or fall. The symptoms are pain deep inside the shoulder with lifting and sports. Some people complain of a clicking sensation and pain extending down the upper arm. It is often difficult to diagnose without actually looking inside the shoulder with an arthroscope (keyhole surgery), which is the recommended treatment for this.
The weak points of the biceps muscle is where the tendon attaches to the bone at the elbow and the junction between the biceps muscle and it's tendon. The biceps usually ruptures at the elbow in athletes. You will usually feel a pop and notice a lump in the front of your arm. In athletes and manual workers prompt early repair is advisable, as it can be very difficult to repair these later. The biceps may also rupture at the shoulder - this is usually in older people and associate with rotator cuff tears - if surgery is needed the tendon is attached to the humerus (this is called a tenodesis).
The labrum is a cushion surrounding the socket of the shoulder joint (similar to the meniscus of the knee). Likewise, it can tear like the knee meniscus with injuries of the shoulder. Labral tears usually follow falls or direct blows to the shoulder, but may also occur with throwing or pulling injuries. They can be diagnosed with MR Arthrograms (MR scan with special dye injected into the shoulder joint), and confirmed at keyhole surgery (arthroscopy). Large tears are associated with shoulder dislocations and called Bankart tears.
The shoulder is commonly injured and a detailed article by Prof Len Funk explains the detail (see in other notes)
Swimming involves repetitive overhead activity, with particular muscular imbalances occurring around the shoulder complex to accommodate this. Thus swimmers are prone to shoulder pain, with over two thirds of elite swimmers suffering this at some stage. Treatment usually involves addressing the muscular imbalance by an experienced shoulder therapist. Arthroscopic surgery may be required for subacromial impingement and shoulder instability.
Fractures around the shoulder have always been difficult to treat operatively, thus the results of shoulder fractures have not been as good as other fractures. With new fixation devices and safer surgical techniques we are able to fix difficult fractures early and allow early return to sports better than in the past.
True frozen shoulder (a very stiff painful shoulder with no obvious cause) is very rare in athletes. However, a stiff painful shoulder following an injury (sometimes, quite minor) is not rare. In these cases it is essential to treat the stiffness early and then also treat the underlying injury that caused the stiffness. The joint teamwork of an experienced physiotherapist and shoulder surgeon is very useful for an early recovery.
Arthritis is when a joint wears with age or overuse. The lubricant is reduced and the joint becomes stiff and painful. Keeping the shoulder active and the muscles toned is of benefit, along with painkillers. However, when the pain is severe enough to affect daily life and sleep a joint replacement is of benefit.
Overhand throwing places extremely high stresses on the shoulder, specifically to the anatomy that keeps the shoulder stable. In throwing athletes, these high stresses are repeated many times and can lead to a wide range of overuse injuries.
Although throwing injuries in the shoulder most commonly occur in baseball pitchers, they can be seen in any athlete who participates in sports that require repetitive overhand motions, such as volleyball, tennis, and some track and field events.
In addition to the ligaments and rotator cuff, muscles in the upper back play an important role in keeping the shoulder stable. These muscles include the trapezius, levator scapulae, rhomboids, and serratus anterior, and they are referred to as the scapular stabilizers. They control the scapula and clavicle bones — called the shoulder girdle — which functions as the foundation for the shoulder joint.
When athletes throw repeatedly at high speed, significant stresses are placed on the anatomical structures that keep the humeral head centred in the glenoid socket.
– The phases of pitching a baseball
When one structure — such as the ligament system — becomes weakened due to repetitive stresses, other structures must handle the overload. As a result, a wide range of shoulder injuries can occur in the throwing athlete.
The rotator cuff and labrum are the shoulder structures most vulnerable to throwing injuries.
(Left) The labrum helps to deepen the shoulder socket.
(Right) This cross-section view of the shoulder socket shows a typical SLAP tear.
(Left) The biceps tendon helps to keep the head of the humerus centred in the glenoid socket.
(Right) Tendinitis causes the tendon to become red and swollen.
Rotator cuff tendon tears in throwers most often occur within the tendon. In some cases, the tendon can tear where it attaches to the humerus.
Problems with the rotator cuff often lead to shoulder bursitis. There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.
The muscles and tendons of the rotator cuff.
Pain and loss of throwing velocity will be the initial symptoms, rather than a sensation of the shoulder "slipping out of place." Occasionally, the thrower may feel the arm "go dead." A common term for instability many years ago was “dead arm syndrome.”
Shoulder injuries can often be prevented, by following simple guidelines. Pre-season screening of athletes by an experienced physiotherapist can help prevent common sports injuries. This should include assessment and management of the following key areas: