{"id":8647,"date":"2019-09-13T22:36:09","date_gmt":"2019-09-13T21:36:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=8647"},"modified":"2019-09-15T21:08:54","modified_gmt":"2019-09-15T20:08:54","slug":"the-impact-of-shoulder-injuries-in-rugby-what-can-we-control","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2019\/09\/13\/the-impact-of-shoulder-injuries-in-rugby-what-can-we-control\/","title":{"rendered":"The impact of shoulder injuries in rugby: what can we control?"},"content":{"rendered":"

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By Sam Blanchard @sjbphysio_sport<\/a> \u00a0& Paula Timpson @paulat_physio<\/a><\/strong><\/em><\/p>\n

Asia is not a region that would be traditionally synonymous with Rugby Union\u2026 until now. On the 20th\u00a0<\/sup>September 2019, Japan will host the 9th\u00a0<\/sup>Rugby World Cup and will see the greatest rugby nations on Earth collide\u2026 literally! The impacts reported in professional rugby have been likened to car crashes (1) and it is a sport that year on year becomes more physically advanced (2). With an increased physicality comes increased injury rates (3) and there is no larger mechanism for injury than tackling (4) with a reported 142-166 tackles per hour (1).<\/p>\n

\u201cConcussion\u201d and \u201cthe lower limb\u201d account for the main injuries that we see from tackling (3) and undoubtably it will be the management of the former that presents some major talking points this Autumn. Whilst those two injuries make up the majority of time loss in the professional game, an 8-year study of the under-20 program recorded a different prevalence of injury (5,6) with shoulders accounting for the highest injury incidence. This firstly suggests that younger players cope with the demands of rugby differently, but might also suggest that the majority of players travelling to this World Cup have suffered a shoulder injury in their earlier career. So what impact does previous shoulder injury have on rugby players and how can it be addressed?<\/p>\n

Shoulder injuries: not a complicated equation.<\/strong><\/p>\n

We are all told about how unstable the shoulder is, but when you consider 60-70% of the total glenohumeral joint (GHJ) stability is reliant on active stability from musculature (7) and you add in those high impacts, multiplied by the volume of tackles, you can see why shoulders pose a risk to both availability and health.<\/p>\n

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Not all tackles are text book. A number of moving parts can contribute to poor execution, mistimed landing and sometimes, just bad luck.<\/figcaption><\/figure>\n
<\/h6>\n

Now, lets consider some other variables for that equation.<\/p>\n

One thing we understand is that rugby players in particular with existing shoulder pathologies have altered joint position sense (JPS) compared to uninjured peers\u00a0with the outer range being significantly reduced when fatigued (8). On top of altered JPS, a lack of appropriate muscle recruitment in the stabilising muscles of the GHJ following injury can lead to decreased lateral rotation and protraction, contributing to anterior translation of the humeral head (9). Remember, the shoulder girdle is only attached to the axial skeleton via the clavicle, so our basis of support for the shoulder is a mobile scapular.<\/p>\n

So, we have a multi-planar joint that is heavily reliant on active structures for stability, yet post injury we lose the awareness of that joint in space and then, decreased stability potentially changes the position of the humerus (think proprioceptive feedback from the joint capsule). It becomes a vicious circle.<\/p>\n

Key principles to rehabilitation:<\/strong><\/p>\n

Maintaining stability in sporting tasks is going to help increase participation and performance. This stability, going into a big tackle, will require co-ordinated co-activation underpinned by both conscious (\u201cI\u2019m going in for a big hit, I best tense up\u201d) and reactive muscle efficiency (\u201cooosh he was going quicker than I thought, where\u2019s my arm gone?\u201d) (10). \u00a0This is something the Athletic Shoulder Test (11) allows us to measure and monitor. Looking at three potentially vulnerable positions for the shoulder, we can assess not only the peak force\u00a0<\/u>of a conscious contraction, but also the rate of force<\/u>; how quickly they can reach their peak. A quicker rate is going to help stabilise with that unconscious reactive contraction.<\/p>\n

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A potentially vulnerable position for a shoulder in a last gasp tackle.<\/figcaption><\/figure>\n
<\/h6>\n
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Measuring one component of the Athletic Shoulder (ASH) test.<\/figcaption><\/figure>\n

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The video below helps briefly (<2mins) describe some principles of rehab that look at:<\/p>\n

    \n
  • Control<\/strong>. Working on that joint position sense in both a loaded and unloaded manner.<\/li>\n
  • Strengthening<\/strong>. Especially in those outer ranges that can be easily fatigued (here\u2019s where the ASH test adds value).<\/li>\n
  • Dissociation<\/strong>. This is basically complex proprioception, distracting the brain with an opposing task, pretty much like patting your head and rubbing your tummy. Can one limb stabilise whilst the other mobilises? Can the trunk move about a fixed shoulder?<\/li>\n<\/ul>\n