A Shoulder to Cry Over

For two reasons, shoulder injuries are common in derby: 1) derby is a full contact sport often involving trauma to the shoulder and 2) the shoulder is a complicated, somewhat delicate joint. A brief overview of the some commonly seen injuries follows.

1. A/C separation

One of the more common shoulder problems we’ve seen over the years is an A/C separation (Acromion - a bony extension of shoulder blade to the front and top of the shoulder, Clavicular - collar bone). This is a partial or complete tear of the ligament that connects these two bones on the top of the shoulder. Common causes are direct trauma to the side or front of the shoulder (e.g. falls or blocks) or forceful elevation of the arm.

The symptoms are pain on the top and back of the shoulder, local tenderness, pain on raising the arm, and, on occasion, a lump on top of the shoulder. Immediate treatment is ice and immobilizing the arm (slings, ace wrap, or taping). X-rays may be needed to rule out a fracture.

Partial tears usually heal in 2 - 4 weeks. Complete tears are less common. If they don’t heal, resulting in chronic pain or impaired use of the arm, they may need surgical repair . Shoulder rehabilitation should begin as soon as pain allows to prevent a “frozen shoulder” (reduced mobility due to inactivity). Even after resuming full contact, continued protection may be needed with wrapping, taping, and/or padding.

A rarer variation of this is seen when the clavicle separates from the sternum (breastbone). This injury is treated in the same way as A/C separations.

2. Shoulder dislocations

The second injury seen fairly often is a partial or complete dislocation of the ball top (head) of the upper arm bone (humerus) out of the cup of the shoulder. The usual dislocation is to the front of the shoulder; dislocation to the rear is much less common. Dislocation occurs with direct trauma (falls onto the shoulder, especially with the arm outstretched) or sudden forceful wrenching of the arm. Some people naturally have loose ligaments in their shoulder which allow dislocation recurrently with no or minimal trauma; this may require a surgical repair.

When dislocation happens, there is severe pain in the shoulder, inability to move the arm, and a deformity where the normal rounded contour of the side of the shoulder is flattened with a bulge in front of the shoulder.

If trained medical staff are on site and can reduce the dislocation immediately, the shoulder is then immobilized and iced, and the skater sent to the ER. X-rays are often needed to rule out a fracture. If immediate reduction is not possible, the shoulder should be immobilized and iced, and the skater should go right to the ER.

Healing time depends on the ease of reduction, associated injuries (i.e., fractures, ligament tears), and any pre-existing shoulder problems. Healing time can vary from a few weeks to a few months. Rehabilitation is crucial to maintain range of motion and strengthen the support muscles of the shoulder. Your medical team should be involved in establishing your ability to return to contact.

Even after returning to play, the skater may need measures to restrict the motion of the shoulder to prevent re-dislocation. This might involve shoulder immobilizers or taping. If there are ligament injuries or recurrent dislocations, surgery may be needed.

3. Rotator cuff injuries

Injuries of the rotator cuff (the ligaments, muscles, and cup that support the shoulder joint) are another common problem. The topic is quite complicated and not suitable for a short article. I’ll try to touch on some of the important points. Rotator cuff problems are caused by both acute trauma (such as a sudden forceful pull on the arm or dislocations) and, more commonly, chronic repetitive trauma (e.g., repeated overhand motions or whips, bone spurs in the shoulder).

In the chronic use injury, the pain commonly develops gradually over time and, in time, persists even at rest. With a sudden forceful injury (e.g., jerking up a heavy weight) the pain comes on quickly and more intensely. The person finds that certain specific movements of the shoulder may cause or increase the pain. Lying on the shoulder may increase the pain. There may be a crunching or clicking in the shoulder associated with pain. The person with a rotator cuff injury may have the feeling the shoulder is not “stable” or feels that it “catches.”

Since the larger number of rotator cuff injuries develop gradually over time and since there are a number of structures making up the rotator cuff, evaluation by an orthopedist and often MRIs are needed for an accurate diagnosis.

The treatment depends on the structures damaged as well as the degree of damage. Conservative treatments such as physical therapy, pain medications, icing, immobilizers, or steroid injections are usually tried first and are successful for many people. If pain or loss of function are not relieved or if rapid return to work or sports is necessary, surgical repair may be indicated.

One final injury that causes pain near and in the shoulder is a biceps tendon tear. The biceps tendon runs from the top of the cup of the shoulder down through a groove in the head of the humerus. The tendon may be injured acutely with a sudden forceful stress (jerking up a heavy weight or falling on an outstretched arm) or chronically with repeated heavy lifting. Partial and complete tears are seen.

With this injury, there is pain in the area of the tear. A snap or pop may be heard or felt. Cramping and weakness of the biceps is found along with bruising of the upper arm. With a complete tear, an indentation of the area just below the shoulder with a bulge lower down is seen - the “Popeye” muscle. Since the biceps has two tendons, the long (the one usually injured) and the short, some function may be preserved.

Treatment for biceps tears, if partial, is usually conservative, especially for relatively inactive people. If there is a complete tear resulting in poor function of the biceps in athletes or laborers, surgery is indicated.

Hopefully, you will be able to use your shoulder for someone to cry on, not cry over.