Coming Back From: Shoulder Separation

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points: 

  • A “shoulder separation” is a different injury than a shoulder dislocation
  • The shoulder separation involves a sprain to the ligaments of a joint at the point of the shoulder near the end of the collarbone
  • We will often see these injuries when a player is tackled or falls to the ground on the point of the shoulder, with the arm at the player’s side
  • Most shoulder separations from sports injuries can successfully be treated without surgery

This week I’ll offer up some pre-World Cup injury recovery info, inspired by Egypt/Liverpool brilliant playmaker Mo Salah. There’s been much speculation about the nature of Salah’s recent shoulder injury, and I haven’t been able to find a clear diagnosis in publicly available sources. But if I had to guess (and this is a pure guess), given the way the injury occurred and the evaluation from the physician in the accompanying photo, I’d say he likely sustained a shoulder separation.

First, let’s look at some confusing terminology.

I’ve written previously about shoulder dislocation, a serious condition in which the ball portion of the shoulder (humerus) becomes completely dislodged from the socket. This week we’ll discuss a shoulder separation, another common shoulder injury.

A separated shoulder refers to an injury to the ligaments of the acromioclavicular joint (commonly known as the AC joint), which is the joint between the end of your collarbone and the upper part of your shoulder blade. It’s located near the point of the shoulder.

Most shoulder separations occur during some type of hard fall or contact, such as a player being tackled on to his shoulder, or a cyclist falling and landing on his shoulder. When I see a hard fall to the ground I’ll be suspicious for either a shoulder separation or a broken collarbone if the athlete fell with the arm tucked in to the side, and I’m suspicious for a shoulder dislocation if the athlete fell on to the outstretched hand.

There are six types of shoulder separations. Types 1 and 2 are the most common ones we see in sports injuries and are treated without surgery. Type 3 injuries are also reasonably common, and most of these are treated without surgery (although there is some debate about early repair for the throwing shoulder of an elite athlete…).  Types 4-6 are not seen very often in sports injuries and these will require surgery. I refer to these as “types” although some surgeons will call these “grades”.

  • Type 1 – The ligaments have a mild sprain without a tear.
  • Type 2 – The AC ligament tears, leading to a partial separation.
  • Type 3 – The AC ligament and other associated ligaments tear, leading to a complete separation.
  • Types 4-6 – These are complete separations, serious injuries often requiring urgent surgery. I have seen one type 4 separation in a D1 quarterback during my 23-year career.

Here are typical return to play times for the common types:

  • Type 1:You can usually return to play 2-3 weeks after the injury, depending on your sport and position. You should be comfortable, with full motion, normal strength, and ability to do sport specific motions. Treatment includes rest and anti-inflammatory medication.
  • Types 2 and 3:A Type 2 injury takes about 3-4 weeks to fully heal, and a type 3 injury takes about six to eight weeks to heal. We’ll almost always treat these without surgery, and we’ll use the same return to play criteria as indicated above for the Type 1 injury. If you’re in a collision sport (such as football) I’ll usually recommend you return to play with an AC joint pad to minimize the chance of another injury.Logo

Whether Salah will play is still speculative but most media reports indicate him as “probable”. When it comes time to lacing up the cleats for a possibly once-in-a-lifetime event with the eyes of the country on him, my guess is that he’ll find a way to work his magic from game 1.

Bone Bruise: What It Is And How It’s Managed

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A bone is a living tissue with a blood supply, and impact to the bone can cause bruising in the bone’s interior
  • Bone bruises are diagnosed on MRI scan
  • Bone bruises will predictably heal and allow the athlete to return to play, however the time frame for return is widely variable

Many people are surprised to learn that bone has a blood supply. It’s every bit a living tissue as skin, your brain, or your heart. And like any of those other tissues with a blood supply, a bone can be bruised.

Lots of people are familiar with a bruise on the skin. If you bump the outside of the skin hard enough it will cause tiny blood vessels in the skin to break, leading to some bleeding in the skin. This causes the common black/blue/green discoloration. If you hit a bit harder the force can be transmitted deeper, to the underlying muscle. And if you hit harder still that force can go straight to the bone.

A bone bruise is an injury to the interior of the bone (the bone marrow) with enough force to disrupt the internal blood supply but not enough force to crack the outside of the bone. A bone bruise is an injury that almost broke the bone but came up just short. There are several sports scenarios that can cause bone bruises. Common ones I see are direct impact injuries such as a fall onto a hard surface, or a bone bruise to the arm in a batter hit by a pitch. We’ll see a fair number from player to player contact, and there’s also a bone bruise pattern we see on an MRI of a knee with an ACL tear.

One of the key features of a bone bruise is that it can be extremely painful immediately after the injury. Severe pain after impact typically makes an orthopedic surgeon concerned for a fracture, and if the initial x-ray shows no broken bone a common next thought would be for a bone bruise. A bone bruise is diagnosed by MRI scan, and x-rays are typically normal.

The good news about a bone bruise is that the same system that causes the bruise- the internal blood supply- is also the system that creates the environment for healing. Like the bruise in the skin, the bone bruise will typically go on to heal. What’s usually required is limiting the impact loading that caused the problem. In the upper extremity the treatment may be and arm sling or brace followed by light activity until healing. In the lower extremity crutches, a brace, or a boot may be needed.

The tough part about a bone bruise is that they can be very painful, especially in the initial healing phase. The other key consideration for the athlete is that return to play can be highly variable, taking from a couple of weeks to several months.

There are several interesting variables about bone bruises. First, the long term implications of a bone bruise are unknown. We believe that the vast majority of bone bruises will go on to heal in the near term but there isn’t yet enough data to know whether there are any long term implications. Second, the extent of the bruise on an MRI is not necessarily correlated with pain. We see severe pain with fairly minimal bone bruising, and conversely we see some severe bruises on an MRI in people with only a small amount of pain.Logo

Because of the lack of clear correlation between bruising on the MRI, pain, and function, we will usually not repeat an MRI to assess healing but instead rely on how the injured athlete feels and how they are functioning. When pain is resolved and the function is restored we’ll usually allow the athlete to return to play.

Start ACL Injury Prevention Programs When The Players Are Young

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The FIFA 11 injury prevention warmup program has been proven effective in reducing lower extremity injury rates in soccer players
  • Pre-adolescent and adolescent female players are at particular risk for ACL injury, possibly due to risky movement patterns
  • A recent study shows that the pre-adolescent group may benefit most from training with the FIFA 11 program, although all groups show improvements in their movement patterns
  • This study suggests that starting the FIFA 11 program as early as possible would be beneficial

I’ve written and spoken about how much I believe in the value of the FIFA 11 program to reduce ACL and lower extremity injury rates, and make better soccer players. In fact the value of the FIFA 11 has been demonstrated in other sports too. I honestly can’t see why any coach wouldn’t implement this program. It’s part of the regular warmup you’d be doing anyway, and it’s better for your players. Please do it.

ACL tears tend to happen more frequently in teenagers rather than in younger players. Does that mean you should wait until the players are teenagers to start the FIFA 11? This recently published study suggests that the younger players will have greater improvements in body mechanics than the teenagers. The key study result: start the FIFA 11 program in the younger age groups.

This study was recently published in the American Journal of Sports Medicine. In the study, the authors investigated improvement in movement patterns and mechanics in two groups of young players from an 8-week FIFA 11 training program. They had one age group of female soccer players aged 10-12 and another group of female players aged 14-18. In each age grouping there were “intervention” players who participated in FIFA 11 and “control” who did not.  To be clear, this study evaluated the improvements in movement patterns and did not follow the players out to see whether they had reduced injury rates.

Some movement patterns have been shown to be particularly risky for possible ACL tear or lower extremity injuries. For example, landing in a “knock kneed” position is a risky pattern, as is landing with the knee fully extended. The study authors found that the preadolescent 10-12 year old age group started off with more of the high risk injury patterns than the older players. And the younger players had greater improvements in their movement patterns after the 8-week training.

I spoke with study author Dr. Jason Dragoo, who is one of my practice partners at LogoStanford orthopedic surgery. “A few earlier studies suggested that intervention training programs might have a greater effect on athletes classified as ‘‘high risk’’ for ACL injury (meaning that they had poor movement techniques to start with) as compared with those classified as ‘‘low risk.’’ What we found is that preadolescent athletes not only display riskier movement patterns than adolescent athletes but also benefit more from participation in the FIFA 11 program.  I’d start this as early as you can.”

For More Information:

FIFA 11+ poster ages 13 and up

FIFA kids poster ages 7-12

Long Distance Running Won’t Kill Your Knees

By Dev Mishra, M.D., President, Sideline Sports Doc , Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • There’s a common belief that running leads eventually to arthritis in the hips or knees but evidence shows that runners have no increased risk for arthritis and in fact may have lower risk than the general population
  • The biggest risk factors for developing arthritis are prior injury or surgery to the joint, family history, and high body mass index

I see a lot of folks in my clinical practice with hip and knee arthritis and many of them have extensive running histories. Most of these folks believe that it’s the long term running that eventually led to the arthritis, but the belief that running causes knee arthritis is probably a myth.

The idea that running can lead to arthritis makes sense. You run on a hard surface for long distances and over many years the impact leads to wear and tear. Seems pretty logical, right? Well the available evidence points us in a different direction.

There have been several good quality medical studies done over the years to study the relationship between running and arthritis. I want to highlight three that have some interesting and relevant points.

This study published earlier this year specifically studied marathon runners. These were experienced high mileage runners, average age 48 years, typically training about 36 miles per week. They’d completed an average of 76 marathons! About 47% reported hip or knee pain but only about 9% had arthritis. The strongest predictors of hip or knee arthritis were older age, family history of arthritis, and any prior surgery on the joint. But marathon running itself was not predictive of arthritis.

This study of about 75,000 runnersis pretty impressive for the number of people who participated. It’s incredibly difficult to get information on that many individuals. The author used the National Runners’ Health Study and the National Walkers’ Health Study. During a multi year follow up, about 2.6% of the runners reported arthritis, and about 4.7% of the walkers reported arthritis. These are pretty low numbers since the generally accepted prevalence of arthritis amongst all U.S. adults over 55 years of age is about 18%. The author believed that the most meaningful reason is that the body mass index (BMI) of the runners was less than the walkers, and presumably both are lower than the average BMI for the general population.

And here’s another interesting study titled “Why Don’t Most Runners Get Knee Osteoarthritis?”These authors used motion capture imaging and force plates in the ground to estimate forces across the knee joint with running and walking. They found as expected that there’s quite a bit more load across the knee joint with running (8x body weight) vs. walking (3x body weight). But the runners have longer stride lengths than the walkers, which meant that they took fewer steps over a given distance than walkers and had fewer impacts. The runners also experienced any pounding for a shorter period of time than when they walked, because their foot was in contact with the ground only briefly with each stride.

The net effect was that the amount of force moving through a participant’s knees over any given distance was equivalent, whether they ran or walked. It’s an interesting mechanical explanation.Logo

So these and other available scientific evidence indicate that running itself is not a risk factor for developing hip or knee arthritis. The strongest risk factors appear to be prior surgery or injury to the joint, a family history of arthritis, and a high BMI. If you start out running with a healthy joint there’s good reason to believe you can run healthy for many years. This myth is probably busted.