Dr Gavin Nimon Glenelg Orthopaedics
Orthopaedic Shoulder Surgeon
At the end of the AFL season, players often present with shoulder issues. I thought it would be useful to outline the management for 3 of the most common semi-elective conditions (i.e. the ones that haven’t already been treated urgently).
Whilst these are conditions that you already treat, outlining the non-operative and operative treatments, including my thoughts on prehab and rehabilitation can be useful.
1. Anterior Shoulder Dislocation and Subluxation
These are particularly common in AFL and relate to the overhead marking, tackling and falling with the arm externally rotated.
Initial reduction is obvious but it is the further management that can be confusing.
Immobilization for comfort and then physiotherapy focused on range of motion restoration, strengthening the rotator cuff, and scapular stabilization exercises.
This can be a useful strategy for patients retiring from sport and for older individuals. However, it often proves unsuccessful in younger, active patients.
Definite Indications for Surgery
- This relates to
- Bankart lesions (large tears off the labrum off the glenoid)
- Significant bone loss evident on imaging (bony bankart or large Hill-Sachs lesion – dent of the posterior humerus) which can engage on anterior glenoid to dislocate out of joint
Early Stabilization of First-Time Dislocations
Recent studies have suggested that early surgical intervention after a first-time dislocation can reduce the risk of recurrent dislocations, especially in young, active individuals. These studies highlight that athletes under the age of 35 have a particularly high risk of recurrence when treated conservatively. Early surgical stabilization can also potentially minimize long-term joint damage and lead to better functional outcomes.
While the evidence tilts in favour of early intervention for a specific demographic (young, active athletes), it’s essential to consider individual patient factors, including their activity level, age, and personal preferences, before making a decision.
Surgery involves repairing the labrum to the glenoid or supplementing the repair of the labrum with a piece of bone taken from the coracoid (Latarjet procedure).
2. Rotator Cuff Injuries
Within the broader spectrum of shoulder injuries, rotator cuff issues stand out, particularly when we analyze their occurrence in the world of Australian rules football.
Footballers, especially as they age, seem predisposed to these injuries due to the demands of the sport and age-related tissue changes. The vast majority are just episodes of bursitis and are treated non-operatively, but can be assisted with a steroid injection (should be used very sparingly).
The Rotator Cuff: A Quick Recap
The rotator cuff is a group of four tendons and muscles converging around the shoulder joint. These muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) play pivotal roles in shoulder movement and stabilization.
Footballers, irrespective of their age, often endure high-impact tackles and routinely engage in overhead throwing and sudden arm movements. Such activities subject the rotator cuff to repetitive stress, micro-trauma, and potential injury.
The Ageing Aspect
Rotator cuff tears, while possible in younger athletes, are more common in older individuals. Here’s why:
- Tissue Degeneration: As athletes age, tendons naturally lose elasticity and blood supply, making them more susceptible to tears even from minor strains.
- Wear and Tear: Years of playing exacerbate the accumulated micro-damage within the shoulder joint. With reduced healing capacity in older tissues, these minor injuries can culminate in significant tears.
- Bone Spurs: Older athletes might develop bone overgrowths (spurs) under the acromion bone. These spurs can rub on the rotator cuff tendon, leading to tendonitis or even a tear – a condition known as impingement syndrome.
Presentation and Diagnosis
Footballers with rotator cuff injuries often complain of:
- Pain when lifting the arm or lying on the affected shoulder.
- Weakness, especially during overhead activities.
- A crackling sensation upon moving the shoulder in certain positions.
Physical examination, combined with imaging (like X-Ray and ultrasound), can provide a definitive diagnosis.
Both conservative treatment and surgical options can be explored.
Given the higher propensity for age-related tears, initial management often includes
- Rest, NSAIDs,
- (Rarely) a steroid injection
Physiotherapy is a first-line treatment for all injuries. It emphasizes pain management, range of motion restoration, and strength exercises targeting the rotator cuff and scapular stabilizers.
Modalities might include resistance bands, isometric exercises, and functional training.
Indicated for larger tears, significant functional impairment, or failure of conservative treatment.
- This involves minimally invasive arthroscopic repairs
- A video of Dr Nimon performing a cuff repair can be found here
For our ageing footballers, prevention is key. Regular rotator cuff and scapular strengthening exercises, combined with flexibility routines, can help maintain shoulder health.
- Diagnostic Clues: Night-time pain, pronounced weakness, and limited range of motion.
- Non-operative Management: Physiotherapy aimed at pain control, rotator cuff strengthening, and improving shoulder mechanics. Modalities might include resistance bands, isometric exercises, and functional training.
- Indications for Surgery: Large or full-thickness tears, persistent pain despite conservative management, and significant functional impairment.
3. AC Joint Injury
The acromioclavicular (AC) joint, where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion), is vulnerable, especially in contact sports like football.
Why Footballers are at Risk
Footballers are often subject to falls on the shoulder or direct impacts during tackles. Such high-energy collisions can cause anything from mild sprains to complete disruption of the AC joint.
Grading and Presentation of AC Joint Injuries
AC joint injuries are graded from I to VI based on severity:
- Grade I: Mild sprain without noticeable deformity.
- Grade II: Partial tear of the AC ligament with some joint misalignment.
- Grade III-VI: Complete rupture of AC and coracoclavicular ligaments, with progressive severity and displacement.
Symptoms typically include:
- Localized shoulder pain and swelling.
- A noticeable bump above the shoulder (more pronounced in higher-grade injuries).
- Reduced shoulder strength and range of motion.
Management of AC Joint Injuries
- Grade I and II: Rest, ice, compression, and elevation combined with pain relief medication. Immobilization with a sling can provide comfort. Physiotherapy focusing on restoring range of motion and strength is essential once the initial pain subsides.
- Grade III: Treatment can be non-operative or operative based on the patient’s activity level, pain, and functional requirements. Many athletes opt for early surgical intervention for optimal functional recovery, but conservative management can also be successful.
- Grade IV-VI and Select Grade III: Due to significant displacement and instability, surgical intervention is often recommended.
- Dr Nimon performs a repair of the coracoclavicular ligaments for acute injuries
- Delayed ones may require a ligament reconstruction.
Physiotherapy is crucial post-surgery, beginning with gentle range of motion exercises and progressing to strengthening activities.
In Summation: Operative vs. Non-operative
The role we play in discerning between operative and non-operative treatments, especially post-AFL season, is fundamental.
- Operative Indications:
- Persistent pain despite conservative treatment.
- Significant structural anomalies noted on imaging.
- Recurrent instability events.
- Injuries that inherently have poor healing without intervention.
- Physiotherapy Protocols for Non-operative Care:
- Early phase: Emphasize pain control, swelling reduction, and protection of the injury.
- Intermediate phase: Gradual introduction of range of motion and basic strengthening exercises.
- Advanced phase: Focus on functional rehabilitation, proprioceptive training, and sport-specific drills.
Armed with knowledge and a collaborative approach, we can ensure that our patients receive optimal care tailored to their needs. That includes information to help them understand their condition. Dr Nimon has written a number of patient education blogs, including:
- Shoulder pain after shoulder surgery-what to expect and how to manage it
- Shoulder surgery reconstruction vs replacement
- Driving with a shoulder injury or after surgery
As always, open dialogue between GPs and specialists ensures that our shared patients receive the best of both worlds. Dr Nimon is always available for advice at Glenelg Orthopaedics on 8376 9988. To access our GP Advice Line, please complete this form.