Most common rugby injuries in the shoulder affect the following structures:  

Soft tissue around the shoulder

The shoulder complex, which consists of the clavicle, scapula, and humerus, connects the upper extremity to the thorax by a carefully crafted arrangement of three joints- the glenohumeral, acromioclavicular, and sternoclavicular. The articular structures of the shoulder complex are largely intended for mobility, enabling us to move and position the hand within a large range of space.

While being a primary joint responsible for the movement of the upper limb, stability is very important for the joint. Passive stabilization is provided by the bony architecture, the ligaments, the capsule, and the labrum. Additionally, muscles around the shoulder complex also provide dynamic stabilization to the joints.

Figures 1 and 2 below show the soft tissues present around the shoulder. (Images taken from Magee, David J. (2014). Orthopedic Physical Assessment (6th. Ed). St. Louis, Missouri: Elsevier Saunders.)

Acromioclavicular joint (AC joint injuries)

The acromioclavicular (or AC joint) is a joint that connects the clavicle (collarbone) to the acromion (a bony projection on the top of the shoulder blade). It is a gliding joint that allows the shoulder blade to move up and down.

Acromioclavicular injuries are found to be the most common shoulder injury in rugby players.

Mechanism of injury

Most common mechanism of injury is a direct fall on the shoulder, especially with the area above the shoulder blade striking the ground first. This causes a dislocation of the AC joint as the ligaments that keep the joint in place get torn by the impact.

Symptoms

Pain, limited motion in the shoulder, swelling, bruising, tenderness at the top of the shoulder.

Rotator cuff injuries

Rotator cuff injuries encompass a range of severity, from mild cuff contusions to partial and full thickness tears and can all occur in players. Rotator cuff tendinitis is also a common issue in rugby players.

Mechanism of injury 

These types of injuries are mostly sustained by a direct blow to the shoulder from direct contact with an opposing player or a fall. Usually, the mechanism of injury is an impact or less commonly, could be an ABER (abduction-external rotation) dislocation.

Symptoms

Difficulty and pain caused by raising your arm, popping, or clicking sounds or when moving your arm, shoulder weakness and struggling to lift items.

Sternoclavicular joint

The sternoclavicular joint is a joint located in the middle of the chest, between the sternum (breastbone) and the clavicle (collarbone). It allows the shoulder to move up and down, and helps to keep the shoulder in its socket. The Sternoclavicular joint is also responsible for rotated shoulder movements.

Mechanism of injury

A compressive or violent force either directly over the medial clavicle or to the posterolateral aspect of the shoulder can cause a sternoclavicular injury.

Symptoms

Bruising, pain, swelling or tenderness over the joint, a deformity where the clavicle or scapula has moved, limited range of arm motion.

Glenohumeral joint

The glenohumeral joint is the primary shoulder joint, and is responsible for a wide range of motions. The glenohumeral joint is made up of three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone). The humerus is attached to the scapula at the shoulder joint, and the clavicle attaches to the scapula at the acromion process.

Mechanism of injury

Tackle injury is the most common cause of dislocation. The rugby player tackling are more prone to have a dislocation as opposed to the players being tackled. The five-eight position on the field are at the highest chance of enduring this injury. For all rugby players, player-to-player contact results in trauma with the elbow in an extended position forcing the shoulder to exceed the limits of the normal range of motion causing anterior shoulder dislocation. Trauma with the elbow in a flexed position and the direction of the injuring force along the longitudinal axis of the humerus causes posterior shoulder dislocation. Fall, ruck, and impact are the lesser common mechanisms of injury. 

Symptoms

A visibly deformed shoulder, inability to move your shoulder joint, excruciating pain, swelling, and tingling sensation from your neck that can radiate to your arms.

Superior labrum anterior-to-posterior lesion (SLAP) tears

The superior labrum is a cartilage that attaches the shoulder blade to the humerus (upper arm bone). It helps to keep the shoulder in its socket and allows for a wide range of movement. The superior labrum can be injured in a number of ways, including a direct blow to the shoulder.

Superior labrum anterior to posterior (SLAP) tears are the most common labral tears in rugby players.

Mechanism of injury

The typical mechanism of injury is usually a direct blow, consisting of a tackle where the shoulder is driven into an opposing player or, more commonly, landing on the ground directly onto the adducted shoulder while holding the ball or an opponent. Less commonly, an injury can occur if the arm is in an abducted internally rotated position for a tackle, with a direct blow to the upper arm, forcing the arm into hyperextension and internal rotation.

Symptoms

Shoulder pain along with mechanical symptoms such as locking, catching, popping, or snapping in the shoulder.

Biceps tendon injury

The bicep tendon attaches the bicep muscle to the shoulder blade. The bicep muscle is responsible for bending the arm at the elbow, and the bicep tendon helps to keep the muscle in place.

Mechanism of injury

Traction forces on a flexed elbow can cause injuries to the long head of biceps.

Symptoms

Swelling in the front of the elbow, bruising in the elbow and forearm, weakness in bending the elbow, weakness in twisting the forearm (supination).

Fractures

Fractures are a minority injury type in rugby players. However, upper limb fractures are more common than lower limb fractures in rugby players.

Mechanism of injury

Most commonly, a tackle injury causes a fracture. The clavicle (collar bone), proximal humerus, scapula (shoulder blade) are most commonly fractured.

Symptoms

Pain, swelling, discolouration at the site of the fracture.

Brachial plexus traction lesion

The brachial plexus is a network of nerves that runs from the neck to the arm. It controls the movement and sensation in the arm and hand.

The Brachial plexus traction lesion is a type of shoulder injury that occurs when the nerves that run from the neck to the arm are damaged. This injury is often caused by a direct blow to the shoulder, such as in a rugby tackle.

Mechanism of injury

Traction and/or compression forces acting on the brachial plexus are the primary means of injury, with traction accounting for 95% of injuries. Such injuries most commonly occur in players playing the fullback position. The injuries result from a tackle causing a depression of the shoulder and lateral flexion of the head to the contralateral side. Less commonly such an injury can occur from a direct compressive force onto the supraclavicular region. 

Symptoms

Numbness or loss of feeling in the hand or arm, inability to control or move the shoulder, an arm that hangs limply, burning, stinging or severe and sudden pain in the shoulder or arm.

Pectoralis major tears

A rare but serious injury is a rupture of the pectoralis major muscle. Given the demands placed on the shoulders of these players, when such an injury occurs, it will usually require surgical repair, and an extended period of rehabilitation before return to professional play is possible.

Mechanism of injury

A tackle that involves a relative increase in the amount of shoulder abduction, a higher point of contact on the attacking player, and an initial point of contact from the defending (injured) player more distal on the arm than is usual.

Symptoms

Pain in your chest and upper arm, weakness when you push your arms out, bruising in your chest and arm, a dimpling, or pocket, just above your armpit where the tear is located.

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Volleyball is one of the most popular team sports in the world and played by 200 million people worldwide (Kilic et al., 2017), being played recreationally or professionally. During volleyball practice, the athlete can perform tasks such as jumping, blocking, landing and spiking the ball, where these activities must be performed quickly, increasing the demand on the musculoskeletal system. As a result of this requirement, there is a risk of injury to the musculoskeletal system, such as pain, tendinopathies in the shoulder and instabilities in the shoulder. Such factors interfere in the athlete’s practice and performance, leading to a reduction in the athletes’ time on the game.

The simplicity of using hands in volleyball, actually makes for more complex movements for athlete’s shoulders. 

The hand during an attack in volleyball plays an important role as the athlete needs to hit the ball very fast and as fast as possible. During an attack, the hand speed can reach up to 120km/h. In order to reach high speeds, the shoulder needs the stabilizing musculature to work dynamically in order to maintain the integrity of the glenohumeral joint (Harput et al., 2016).

Most common injuries 

The most common shoulder problems in volleyball players are impingement syndrome, rotator cuff tendinopathy, glenohumeral instability, suprascapular neuropathy and SLAP injury (Miura et al., 2020).

Implications of injuries on performance 

Studies highlight the need to identify risk factors and develop strategies to prevent injuries in athletes, based on risk factors. Biomechanical factors involving alteration of shoulder mobility, alteration of coordination and failure during the execution of the technique, can also be risk factors for the shoulder, implying in alteration of the athlete’s performance. Other factors such as deficits in glenohumeral internal rotation, scapular dyskinesis, and biomechanical changes during ball strike contribute to the development of shoulder problems. In addition, changes in range of motion, muscle strength ratio, and scapular position in volleyball players with and without shoulder dysfunction also contribute to the loss of athlete performance.

How would reduced ROM impact performance? 

Reducing ROM can affect performance due to joint overload due to biomechanical changes. Demanding more of the stabilizing and mobilizing muscles of the shoulder. Long-term loss of ROM can contribute to the emergence of shoulder problems, which can lead to withdrawal from sports activity.

Different hand positions/strike movements demand a lot from shoulders 

Shoulder musculoskeletal syndromes affect both athletes and the general population, in the general population shoulder pain has a prevalence of 7-26%, in volleyball players injuries have a proportion of 8-20% (Harput et al., 2016). In this way, an inadequate contact with the ball during the attack can increase the risk for shoulder problems, due to the high number of repetitions that the athlete needs to perform between training and the game. In addition, different ball impact positions require different levels of activation for the glenohumeral and scapular muscles. During the volleyball attack, the more posterior and lateral positioning in the hand position during the impact of the ball can cause an increase in muscular activity reducing the centralization of the humeral head (Miura et al., 2020).

Therefore volleyball players must take care of their shoulders

The athlete should maintain an exercise program that involves activities to improve shoulder range of motion, exercises for intrinsic shoulder musculature (rotator cuff) and trunk and scapular musculature.

References

Kilic, O., Maas, M., Verhagen, E., Zwerver, J., & Gouttebarge, V. (2017). Incidence, aetiology and prevention of musculoskeletal injuries in volleyball: A systematic review of the literature. Eur J Sport Sci, 17(6), 765-793. https://doi.org/10.1080/17461391.2017.1306114 

Harput, G., Guney, H., Toprak, U., Kaya, T., Colakoglu, F. F., & Baltaci, G. (2016). Shoulder-Rotator Strength, Range of Motion, and Acromiohumeral Distance in Asymptomatic Adolescent Volleyball Attackers. J Athl Train, 51(9), 733-738. https://doi.org/10.4085/1062-6050-51.12.04 

Miura, K., Tsuda, E., Kogawa, M., & Ishibashi, Y. (2020). The effects of ball impact position on shoulder muscle activation during spiking in male volleyball players. JSES Int, 4(2), 302-309. https://doi.org/10.1016/j.jseint.2019.12.009 

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