Surgical management of large rotator cuff tears combined with instability in elite rugby football players

Large rotator cuff tears are extremely uncommon in young people and when they occur they may be associated with shoulder instability. This paper reports on a series of six elite rugby union and rugby league footballers who presented with shoulder instability and large rotator cuff tears. They were treated with a two stage procedure: an open rotator cuff repair followed by an open shoulder stabilisation some 10 weeks later. All had successful outcomes. The paper also highlights the risk of tearing the rotator cuff when a patient continues to play contact sport with an untreated unstable shoulder.     

Spinal cord concussion in rugby players

During an analysis of a group of 40 rugby players who had sustained cervical spinal cord injury, 9 players were identified who had sustained only transient paralysis. These players showed no radiologic evidence of any injury to the cervical spine. We did a retrospective analysis of the clinical and radiological findings in this group of rugby players. The cervical spine radiographs were analyzed for evidence of spinal stenosis, congenital anomalies, and degenerative disk disease. Using the ratio method of assessment for spinal stenosis, we found spinal canal narrowing maximally at C-3 and C-4 in five of the nine players. In the remaining four players, one showed evidence of osteoarthritic change at two levels while another had congenital fusion of two vertebral bodies. In two players, no radiologic evidence of any abnormality was detected. The mechanism of transient disturbance of the spinal cord function after trauma is discussed here.     

Mechanics of glenohumeral instability

The glenohumeral joint is designed for mobility and is normally lax. It is stabilized in its midrange by its limited joint volume and concavity-compression. It is stabilized at the extremes of motion by its ligaments. An enhanced understanding of these stabilizing mechanisms helps us in the diagnosis and management of glenohumeral instability.     

Cervical joint position sense in rugby players versus non-rugby players

ObjectiveTo determine whether cervical joint position sense is modified by intensive rugby practice.DesignA group-comparison study.SettingUniversity Medical Bioengineering Laboratory.ParticipantsTwenty young elite rugby players (10 forwards and 10 backs) and 10 young non-rugby elite sports players.InterventionsParticipants were asked to perform the cervicocephalic relocation test (CRT) to the neutral head position (NHP) that is, to reposition their head on their trunk, as accurately as possible, after full active left and right cervical rotation. Rugby players were asked to perform the CRT to NHP before and after a training session.Main Outcome MeasurementsAbsolute and variable errors were used to assess accuracy and consistency of the repositioning for the three groups of Forwards, Backs and Non-rugby players, respectively.ResultsThe 2 groups of Forwards and Backs exhibited higher absolute and variable errors than the group of Non-rugby players. No difference was found between the two groups of Forwards and Backs and no difference was found between Before and After the training session.ConclusionsThe cervical joint position sense of young elite rugby players is altered compared to that of non-rugby players. Furthermore, Forwards and Backs demonstrated comparable repositioning errors before and after a specific training session, suggesting that cervical proprioceptive alteration is mainly due to tackling and not the scrum.     

Evaluation of shoulder internal rotator muscle strength in baseball players with physical signs of glenohumeral joint instability

OBJECTIVES: To identify whether subjects with glenohumeral translational instability present with a strength deficit in their internal rotator musculature, and therefore to determine if general strengthening exercises are warranted for the management of this condition. METHODS: Eighteen male baseball players were allocated to two groups on the basis of expert clinical evaluation of the presence (n=8) or absence (n=10) of shoulder translational instability. A strain gauge was used to calculate the force generated during maximal isometric internal rotation contractions in neutral shoulder rotation and 30 degrees of internal rotation. RESULTS: The Mann-Whitney test identified no significant difference in force production during the maximum contractions in neutral rotation between the two subject groups. In the position of 30 degrees shoulder internal rotation, subjects with glenohumeral translational instability produced significantly greater force than the control group (p<0.05). CONCLUSIONS: High load strength testing cannot be used as a diagnostic tool to identify people with glenohumeral instability. Similarly, heavy resistance strengthening exercises for the internal rotator musculature are not warranted during rehabilitation.     

Arthroscopic management of glenohumeral instability

There has been substantial development of techniques for performing arthroscopic surgery of the shoulder over the past 20 years. A multitude of arthroscopic techniques have been developed in an attempt to manage the unstable glenohumeral joint while decreasing surgical morbidity. The results obtained with arthroscopic stabilization have been widely variable. This review will examine the current status of arthroscopic management of glenohumeral instability. The techniques and results of arthroscopic stabilization for primary anterior glenohumeral instability, recurrent anterior instability, and multidirectional instability will be discussed. A brief discussion on thermal capsulorrhaphy is included.     

Effectiveness of post-match recovery strategies in rugby players

Objectives

To examine the effectiveness of four interventions on the rate and magnitude of muscle damage recovery, as measured by creatine kinase (CK).

Methods

23 elite male rugby players were monitored transdermally before, immediately after, 36 hours after, and 84 hours after competitive rugby matches. Players were randomly assigned to complete one of four post‐match strategies: contrast water therapy (CWT), compression garment (GAR), low intensity active exercise (ACT), and passive recovery (PAS).

Results

Significant increases in CK activity in transdermal exudate were observed as a result of the rugby match (p<0.01). The magnitude of recovery in the PAS intervention was significantly worse than in the ACT, CWT, and GAR interventions at the 36 and 84 hour time points (p<0.05).

Conclusions

An enhanced rate and magnitude of recovery was observed in the ACT, CWT, and GAR treatment groups when compared with the PAS group. Low impact exercise immediately post‐competition, wearing compression garments, or carrying out contrast water therapy enhanced CK clearance more than passive recovery in young male athletes.     

Incidence of injury in semi-professional rugby league players

OBJECTIVES: To investigate the site, nature, cause, and severity of injuries in semi-professional rugby league players. METHODS: The incidence of injury was prospectively studied in one hundred and fifty six semi-professional rugby league players over two competitive seasons. All injuries sustained during matches and training sessions were recorded. Injury data were collected from a total of 137 matches and 148 training sessions. Information recorded included the date and time of injury, site, nature, cause, and severity of injury. RESULTS: During the two seasons, 1,694 playing injuries and 559 training injuries were sustained. The match injury incidence was 824.7 per 1,000 player-position game hours and training injury incidence was 45.3 per 1,000 training hours. Over 20% of the total training (17.4 per 1,000) and playing (168.0 per 1,000) injuries sustained were to the thigh and calf. Muscular injuries (haematomas and strains) were the most common type of injury sustained during training (22.0 per 1,000, 48.7%) and matches (271.7 per 1,000, 32.9%). Playing injuries were most commonly sustained in tackles (382.2 per 1,000, 46.3%), while overexertion was the most common cause of training injuries (15.5 per 1,000, 34.4%). The majority of playing injuries were sustained in the first half of matches (1,013.6 per 1,000, 61.5% v 635.8 per 1,000, 38.5%), whereas training injuries occurred more frequently in the latter stages of the training session (50.0 per 1,000, 55.3% v 40.5 per 1,000, 44.7%). Significantly more training injuries were sustained in the early half of the season, however, playing injuries occurred more frequently in the latter stages of the season. CONCLUSIONS: These results suggest that changes in training and playing intensity impact significantly upon injury rates in semi-professional rugby league players. Further studies investigating the influence of training and playing intensity on injuries in rugby league are warranted.     

Magnetic resonance imaging in glenohumeral instability

The glenohumeral joint is the most commonly dislocated joint of the body and anterior instability is the most common type of shoulder instability.Magnetic resonance (MR) imaging,and more recently,MR arthrography,have become the essential investigation modalities of glenohumeral instability,especially for pre-procedure evaluation before arthroscopic surgery.Injuries associated with glenohumeral instability are variable,and can involve the bones,the labor-ligamentous components,or the rotator cuff.Anterior instability is associated with injuries of the anterior labrum and the anterior band of the inferior glenohumeral ligament,in the form of Bankart lesion and its variants;whereas posterior instability is associated with reverse Bankart and reverse Hill-Sachs lesion.Multidirectional instability often has no labral pathology on imaging but shows specific osseous changes such as increased chondrolabral retroversion.This article reviews the relevant anatomy in brief,the MR imaging technique and the arthrographic technique,and describes the MR findings in each type of instability as well as common imaging pitfalls.     

MR imaging in sports-related glenohumeral instability

Sports-related shoulder pain and injuries represent a common problem. In this context, glenohumeral instability is currently believed to play a central role either as a recognized or as an unrecognized condition. Shoulder instabilities can roughly be divided into traumatic, atraumatic, and microtraumatic glenohumeral instabilities. In athletes, atraumatic and microtraumatic instabilities can lead to secondary impingement syndromes and chronic damage to intraarticular structures. Magnetic resonance (MR) arthrography is superior to conventional MR imaging in the diagnosis of labro-ligamentous injuries, intrinsic impingement, and SLAP (superior labral anteroposterior) lesions, and thus represents the most informative imaging modality in the overall assessment of glenohumeral instability. This article reviews the imaging criteria for the detection and classification of instability-related injuries in athletes with special emphasis on the influence of MR findings on therapeutic decisions.     

Intra-articular volume assessment in glenohumeral instability

It is commonly claimed that instability of the shoulder is associated with an enlarged joint volume. The purpose of our study was to assess the intra-articular volume in acute and chronic glenohumeral dislocation. Sixty-seven patients were examined by intra-articular infusion of saline solution. Three groups could be formed. Group 1 (n = 51) consisted of patients with first time traumatic dislocation, group 2 (n = 8) of cases with recurrent post-traumatic dislocation. The patients of group 3 (n = 8) suffered from impingement syndrome and served as the control group. The joint volume was correlated to the body surface area (BSA). We found a strong correlation between height, sex and intra-articular joint volume. There was no statistically significant difference in joint volume correlated to BSA between the three groups. There is no statistically significant difference in joint volume correlated to BSA in patients with traumatic anterior instability, chronic instability and individuals without glenohumeral instability.     

Soft tissue neck lumps in rugby union players

Dorsal neck masses are well recognised in front row rugby union players. Previously undescribed in the medical literature, they may present in the primary or secondary care setting when they become symptomatic. Often misdiagnosed as lipomata, they may in fact be fibrous and deeply connected, with the consequences of embarking on surgery subsequently underestimated. This paper describes an epidemiological study using the rugby union media and gives key points for healthcare professionals involved in the management of such masses.     

Acromioclavicular disruption in first class rugby players.

In a random sample of 105 first class rugby players, 45% gave a history of injury of the acromioclavicular joint. All continued to play at the highest level. The effects of the injury appeared to be minimal. Supraspinatus impingement syndrome commonly associated with acromioclavicular pathology was sought, but not found.     

Epidemiology of injuries in Australian junior rugby league players

ObjectivesConduct a large-scale epidemiological study of injury characteristics (location, type, mechanism, severity, burden) and incidence in community junior rugby league.DesignProspective cohort epidemiology study.MethodsInjury surveillance was conducted in three district leagues (Penrith, Canberra, Melbourne) in under 6 (U6) to under 18 years (U18) age groups across the 2016 season. Club sports trainers recorded all match/training medical-attention injuries using a commercial electronic application which recorded injury circumstances and characteristics.ResultsA total of 13,169 players from 897 teams participated and 408 (89% male) players sustained 485 injuries, 94% of which were match related. The overall injury incidence was 5.9 injuries/1000 player hours and highest in U13–U18 female players (22.2 injuries/1000 player hours). The mean injury severity of 16 ± 31 days missed training/match-play caused an overall injury burden of 94.2 days missed/1000 player hours). Tackles accounted for 84% of injuries. Joint and contusion injuries were the most prevalent injury type and the head (35% total injuries, primarily bruising and bleeding) was the most injured body site.ConclusionsThis is the first study to report injuries across a large cohort of all-age Australian community junior rugby league players over one season. Injury prevalence was lower than previously reported in junior rugby league suggesting the sport has not become more dangerous for junior players. These findings provide an evidence-base to inform or revise policy, training and injury prevention programs and athlete development pathways in relation to game-wide safety and develop best-practice protocols in injury management for rugby league athlete support personnel.