Clinical Review

Upper Extremity Injuries in Soccer

Publish date: October 9, 2018

References

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THE SHOULDER

The majority of upper extremity injuries in professional soccer players are shoulder injuries.^1,2,4 Almost a third of these injuries (28%) are considered severe, preventing participation in training and matches for 28 days or more.⁶Ekstrand and colleagues¹ reported that shoulder dislocation represents the most severe upper extremity injury with a mean of 41 days of absence from soccer. When considering the position of the player, they further demonstrated that absence from full training and matches is twice as long for goalkeepers as for outfield players, which reflects the importance of shoulder function for goalkeepers.

In terms of the mechanism of shoulder instability injuries in soccer players, more than half (56%) of these injuries occur with a high-energy mechanism in the recognized position of combined humeral abduction and external rotation against a force of external rotation and horizontal extension.³ However, almost a quarter (24%) occur with a mechanism of varied upper extremity position and low-energy trauma, and 20% of injuries are either a low energy injury with little or no contact or gradual onset. These unique characteristics of shoulder instability injuries in soccer players should be accounted for during training and may imply that current training programs are suboptimal for the prevention of upper extremity injuries and shoulder injuries. Ejnisman and colleagues² reported on the development of a Fédération Internationale de Football Association (FIFA) 11+ shoulder injury prevention program for soccer goalkeepers as one of the ways to promote training programs that address the risk of shoulder injuries.

Reporting on the management of severe shoulder injuries requiring surgery in 25 professional soccer players in England, between 2007 and 2011, Hart and Funk³ found that the majority of subjects (88%) reported a dislocation as a feature of their presentation. Twenty-one (84%) subjects were diagnosed with labral injuries, of which 7 had an associated Hill-Sachs lesion. Two (8%) subjects were diagnosed with rotator cuff tears requiring repair, and 2 (8%) subjects had a combination of rotator cuff and labral injury repair. All patients underwent arthroscopic repair, except for 5 who had a Latarjet coracoid transfer. Post-surgery, all players were able to return to unrestricted participation in soccer at a mean of 11.4 weeks, with no significant difference between goalkeepers and outfield players and no recurrences at a mean of 91 weeks’ follow-up.

Up to one-third of shoulder instability injuries in soccer players are reported to be recurrences,^1,3 which emphasizes the need to carefully assess soccer players before clearing them to return to play. These data raise the controversy over the treatment of first time shoulder dislocators and may support early surgical intervention.^7-9 In terms of the preferred surgical intervention in these cases, Balg and Boileau¹⁰ suggested a simple scoring system based on factors derived from a preoperative questionnaire, physical examination, and anteroposterior radiographs to help distinguish between patients who will benefit from an arthroscopic anterior stabilization using suture anchors and those who will require a bony procedure (open or arthroscopic). Cerciello and colleagues¹¹ reported excellent results for bony stabilization (modified Latarjet) in a population of 26 soccer players (28 shoulders) affected by chronic anterior instability. Only 1 player did not return to soccer, and 18 players (20 shoulders, 71%) returned to the same level. One re-dislocation was noted in a goalkeeper 74 months after surgery.

An injury to the ACJ has been previously reported to be the most prevalent type of shoulder injury in contact sports.¹²In soccer, injury to the ACJ is responsible for 18% of upper extremity injuries, and the majority (72%) are sprains.¹Interestingly, but unsurprisingly, implications of such an injury differ significantly between goalkeepers and outfield players with up to 3 times longer required absence periods for goalkeepers vs outfield players sustaining the same injury.

ACJ injury is commonly the result of a direct fall on the shoulder with the arm adducted or extended. Six grades of ACJ injuries have been described and distinguished by the injured anatomical structure (acromioclavicular ligaments and coracoclavicular ligaments) and the direction and magnitude of clavicular dislocation.^13,14 Presentation will usually include anterior shoulder pain, a noticeable swelling or change in morphology of the lateral end of the clavicle (mainly in dislocation types), and sharp pain provoked by palpation of the ACJ. Radiographic imaging will confirm the diagnosis and help with identifying the specific grade/type of injury.

Decision making and management of acute ACJ injury should be based on the type/grade of injury. Nonoperative treatment is recommended for types I and II, and most athletes have a successful outcome with a full return to play.¹²Types IV, V, and VI are treated early with operative intervention, mostly due to the morbidity associated with prolonged dislocation of the joint and subsequent soft tissue damage.¹² Treatment of type III injury remains controversial. Pereira-Graterol and colleagues¹⁵ reported the effectiveness of clavicular hook plate (DePuy Synthes) in the surgical stabilization of grade III ACJ dislocation in 11 professional soccer players. At a mean follow-up of 4 years, they showed excellent functional results with full shoulder range of motion at 5 weeks and latest return to soccer at 6 months. The hook plate was removed after 16 weeks in 10 patients in whom no apparent complication was observed.

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