An increase in the occurrence and severity of shoulder injuries in rugby has been noted and this realisation has prompted guidelines such as these to be drawn up as a specifically for coaches, physiotherapists and sport physicians caring for players on and off the field. Younger players are playing more competitively and aggressively and it is important to note the specific injury patterns in these players with immature skeletal structures.

BASIC ANATOMY

The most pertinent structures of the shoulder to recognise as far as injuries are concerned are:

• The trapezius, which is the large muscle running from the neck to the shoulder and back .

• The acromio-clavicular (AC) joint, which is the joint between the collar bone and shoulder bone.

• The Deltoid muscle: The large muscle at the upper and outer aspect of the arm which is the main muscle used to lift the arm.

• The clavicle (collar bone) which supports the shoulder and can be felt under the skin.

STRUCTURES MOST OFTEN INJURED

• Soft tissue around the shoulder: In the game of rugby, direct blows are common and soft tissue bruising of the trapezius muscle, the deltoid, the pec major and other soft tissue around the shoulder usually has long-term effects for the player.

• Rotator cuff: The rotator cuff tendon (mostly the supraspinatus tendon), deep to the deltoid, is usually injured when the abducted or extended arm is forced downwards or backwards especially during a fall or a tackle. The injury may be a simple sprain or a frank tear of the tendon. The latter is rare in young players and usually a sprain of the tendon is more common.

MECHANISMS OF INJURY MOST COMMONLY SEEN IN RUGBY

The most common mechanism of injuries includes:

• A direct blow to the shoulder: This may happen when a player falls or is hit on the shoulder from either the front or the back. This may result in a simple bruising of the shoulder or even dislocation.

• Falls directly onto the shoulder with the arm by the side: AC joint injuries often occur due to this mechanism – direct falls onto the shoulder often result in AC joint sprain or dislocation. In some instances rotator cuff injuries may also occur due to this mechanism.

• Rotator cuff injuries: These usually occur when the arm is forced downward when it is held up forwards or to the side or even from a fall onto the shoulder.

Obvious bruising or deformity:

• Swelling or deformity over the AC joint may indicate an AC joint injury / dislocation

• Bruising or swelling over the trapezius or deltoid may be the result of soft tissue bruising of these muscles

• Pain inside the joint could be linked to a labral or rotator cuff injury

GUIDELINES CONCERING WHEN TO REMOVE THE PLAYER FROM THE FIELD IN THE EVENT OF A SHOULDER INJURY:

If the shoulder is obviously dislocated the player should be taken off the field and managed by the medical practitioner on the side of the field or referred to a hospital for reduction of the shoulder displacement.

A deformity over the AC joint is a crucial area and pain can be the determining factor. Should the player be able to continue, he may do so without any serious results. On the other hand, should his pain be of such a nature that he is not able to play competently, he should be removed. Trying to play on does not have any serious or harmful effect though, but the pain and associated loss of function may limit his/her rugby playing performance from a team perspective.

In conclusion, with the appropriate management of shoulder injuries in rugby players most of the players should be able to return to the sport and not suffer long term consequences to the function of this important joint.