Shoulder injuries are quite common in rugby players. This is because rugby is a multiple high-energy contact sport with tackles accounting for 49-72% of injuries. Among these, shoulder dislocation is the most common and severe injury, leading to considerable time off training and games. It is highly likely for players to experience recurrent dislocations if the shoulder is not properly rehabilitated. It is therefore crucial for physiotherapists to provide proper treatment and rehab to ensure a smooth return to sport.
Shoulder dislocation occurs when the humeral head (ball of the upper arm bone) is completely forced out of the glenoid of the shoulder blade at the glenohumeral joint (shoulder socket). Shoulder subluxation is another term used to describe a partial shoulder dislocation. Interestingly, the shoulder joint is the most mobile joint in the body. Yet, the large amount of range of motion is at the expense of its stability due to the shallow socket. According to the British Journal of Sports Medicine, the most common mechanisms of dislocation that have been identified in Rugby players are:
1. Try scorer
This happens while ‘diving and reaching the ball-carrying hand forward to score a try’. This involves the shoulder going into flexion above 90 degrees. When the player hits the ground, the shoulder is forced into further flexion and drives the arm backwards.
2. Tackler
The arm of the tackling player is held in abduction (out to the side) at 90 degrees whereby a ‘posterior directed force is exerted from contact with the ball-carrying player’. This further extends the abducted arm, forcing the ball out of the socket.
Signs & Symptoms
Without surprise, shoulder dislocation is extremely painful. Some of the other signs and symptoms include:
obvious deformity with the ball protruding out of the socket
weakness
inability to move the arm
significant swelling
Management & Treatment Following Shoulder Dislocation
Immediate management of shoulder dislocation is pivotal for an optimal patient outcome. Research has established that leaving an untreated shoulder dislocation for over 24h significantly increases the risk of an unstable reduction, muscle spasms, and damaged neurovascular structures. Thus, in terms of medical management, shoulder reduction needs to be performed by a medical professional following appropriate analgesia and sedation. X-rays may be required to exclude potential fractures and check neurovascular integrity. This is then followed by a period of immobilisation, generally 4-8 weeks, to allow adequate capsular healing.
Roles of physiotherapists in Shoulder Dislocation Rehab
When it comes to physiotherapy management, there is no consensus across the board. Because of the great variability following immobilisation and at which stage each type of exercise is introduced, most clinical recommendations are based on the individual experience.
At Breathe, we are committed to providing you with a tailor-made treatment plan based on your past experience, goals, an efficient return to sport plan with minimal risk of re-injury and the most recent evidence-based practice. We focus on achieving milestones and meeting certain criteria rather than relying on a timeline before moving onto the next phase. This ensures that the body is ready for the next phase. It is also essential to maintain flexibility and strength of the healthy shoulder throughout the whole rehab period.
We find that our Roadmap to Recovery works best for most of our patients. Below is a rough guide to how we approach shoulder dislocation rehab:
Stage 1: Pain Reduction
For a successful rehab and an eventual return to normal function and sport, we focus on reducing muscle wasting and maintaining the range of motion of other joints during the immobilisation period.
During this stage, the goal is to maintain the range of motion of adjacent joints such as the elbow, wrist, and hand with gentle movements. Pain is managed using ice packs, acupuncture, soft tissue massage, and manual therapy such as gentle mobilisation of the shoulder joint for pain control. Isometric exercises are also incorporated for rotator cuff, forearm, and elbow musculature activation. These include:
Pain-free submaximal isometrics at 0 degree abduction of internal and external rotation
Submaximal elbow flexion and extension
Stages 2 and 3: Activation and Movement
Once there is minimal pain and inflammation, and static shoulder stability, stage 2 can commence with an aim to reduce pain, improve flexibility, and maintain and restore neuromuscular control of muscles.
Manual therapy is required post-immobilisation as the joint can develop secondary stiffness. This involves soft or deep tissue release of tight muscles, mobilisation of the shoulder joint for pain control and improves flexibility of the capsule.
The exercises are aimed to further activate the rotator cuff muscles for more dynamic stability of the humeral head, regain range of motion, as well as working on proprioception (awareness of the joint in space). These include:
External rotation walkouts, internal rotation with cable
Body blade oscillations
Shoulder proprioception with ball
Stage 4: Strength Building / Sports Performance
The final stage is reached once the athlete has a full pain-free range of motion and has no apprehension of the shoulder. The term ‘apprehension’ means that when the shoulder is placed into certain position (100 degrees abduction + maximum external rotation), the athlete feels like the shoulder is going to ‘pop out’ again. This is an indication that the baseline strength of the rotator cuff muscles is not sufficient to progress to a higher level.
The previous exercises are progressed to a higher level to continue to build strength.
In this stage, we also focus on maintaining and building the strength and endurance of other parts of the body such as the core and the lower limb, with these exercises:
Dynamic external rotation with band in different flexion ranges
Shoulder IYT, straight arm lat pulldown
Back body (posterior chain) with ball
Tidal tank is a great tool to use in this stage. It is essentially designed to maximise the movement of the weight. The water and air-filled container present with certain advantages such as training your core, activate more muscles and enhances motor learning and coordination which are key elements for return to rugby. The science behind this is that the tidal tank is “alive” and the water reacts to your slightest movement. This requires maximum effort to adjust well, keep control of the weight and of your body. Some examples of exercises include:
Single leg balance with tidal tank
Dynamic lunge with tidal tank
Jump squats
Compound movements (crab walk + shoulder press)
We also aim at incorporating sport-specific skills such as tackling, passing, receiving, catching, and kicking the ball.
The criteria to be met for a return to play are:
No pain at rest or with activity.
Absent apprehension sign.
Symmetrical shoulder range of motion.
67% external: internal rotation ratio within the affected extremity.
No apprehension with loading with bodyweight. 7. 90% strength ER and IR compared to the uninjured side.
In summary, shoulder dislocation in rugby players is rife. Recurrence is very likely after the first time you dislocate your shoulder. Physiotherapy management consists of providing the appropriate treatment and rehab such as advice and education, manual therapy, and shoulder exercises to prevent future adverse events while also focusing on maintaining and building the strength of the other parts of the body for a quicker return to sport.
References
Abrams R, Akbarnia H. Shoulder Dislocations Overview. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459125/
Anterior glenohumeral dislocation rehabilitation guideline - sanford health. (n.d.).
https://www.sanfordhealth.org/-/media/org/files/medical-professionals/resources-and-education/anterior-gh-dislocation.pdf
Crichton, J., Jones, D. R., & Funk, L. (2012). Mechanisms of traumatic shoulder injury in Elite Rugby players. British Journal of Sports Medicine. https://bjsm.bmj.com/content/46/7/538
Gaballah, A., Zeyada, M., Elgeidi, A., & Bressel, E. (2017). Six-week physical rehabilitation protocol for anterior shoulder dislocation in athletes. Journal of exercise rehabilitation, 13(3), 353–358.
https://doi.org/10.12965/jer.1734976.488
Hasebroock, A. W., Brinkman, J., Foster, L., & Bowens, J. P. (2019). Management of primary anterior shoulder dislocations: A narrative review - sports medicine - open. SpringerOpen. https://sportsmedicine-open.springeropen.com/articles/10.1186/s40798-019-0203-2
Patrick M Withrow, Judith L Stoecker, Karen Stevens, Kelly Clark. (2010) Nonoperative management of a patient with a two-part minimally displaced proximal humerus fracture: A case report. Physiotherapy Theory and Practice 26:2, pages 120-133.
Watson S, Allen B, Grant JA. (2016). A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health, 8(4):336-341. doi:10.1177/1941738116651956