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J Orthop Sci (2011) 16:389397

DOI 10.1007/s00776-011-0087-6

ORIGINAL ARTICLE

Video analysis of the mechanisms of shoulder dislocation


in four elite rugby players
Umile Giuseppe Longo Polydoor Emile Huijsmans
Nicola Maffulli Vincenzo Denaro
Joe F. De Beer

Received: 25 August 2010 / Accepted: 6 April 2011 / Published online: 13 May 2011
 The Japanese Orthopaedic Association 2011

Abstract
Background Shoulder injuries are common in rugby, with
the most severe match injury being shoulder dislocation
and instability. A limitation of epidemiological studies is
that the injury information is based on player interviews
after the injury or reports from the medical staff. The
objective of this study is to describe the specific injury
mechanisms for shoulder dislocation using video recordings in a consecutive series of 4 elite male rugby players
who sustained an episode of shoulder dislocation during an
official match.
Methods Videotapes were reviewed to identify the
mechanism of the injury. The incidents, including the play
leading up to each incident, were analysed. A shoulder
dislocation mechanism score was developed to describe the
injury mechanism and the events leading up to the injury.
Results For all the athletes, player-to-player contact was
responsible for the shoulder dislocation. Three of the four
injuries resulted from trauma with the elbow in an extended

position forcing the shoulder to exceed the limits of the


normal range of motion, causing anterior shoulder dislocation. One injury resulted from trauma with the elbow in a
flexed position and the direction of the injuring force along
the longitudinal axis of the humerus causing posterior
shoulder dislocation.
Conclusions This study provides preliminary evidence
that thorough video analysis can provide detailed information about the mechanisms of shoulder dislocation in
elite rugby players. Knowledge of the common mechanisms of injuries in these athletes may potentially lead to
improved sports technique to attempt to reduce the occurrence of shoulder dislocations. Further studies with a larger
number of patients are required to better clarify the exact
mechanism of shoulder dislocation in rugby players, and
how these results may be applied in training and matches to
prevent shoulder dislocation in elite rugby players.

Introduction
U. G. Longo (&)  V. Denaro
Department of Orthopaedic and Trauma Surgery,
Campus Bio-medico University, Via Alvaro del Portillo,
200, Trigoria, 00128 Rome, Italy
e-mail: g.longo@unicampus.it
P. E. Huijsmans
Department of Orthopedics, Haga Hospital, Sportlaan 600,
2566 MJ The Hague, The Netherlands
N. Maffulli
Centre for Sports and Exercise Medicine, Barts and The London
School of Medicine and Dentistry, Mile End Hospital,
275 Bancroft Road, London E1 4DG, UK
J. F. De Beer
Cape Shoulder Institute, PO Box 15741, Panorama 7506,
South Africa

Shoulder injuries are common in rugby, accounting for


915% of all acute injuries [1, 2] and for a high proportion
(15%) of missed days from playing and training due to
injury [1, 2]. Because the revenue from most famous sports
events worldwide is linked to sponsors and media coverage, physicians are often faced with the pressing requirements of the athlete, the coach, the team, the media, the
sponsors, and the supporters [36].
The most common match injury is acromioclavicular joint
injury (32%), but the most severe is shoulder dislocation and
instability, which also causes the greatest proportion of
absence and has the highest rate of recurrence [7]. Several
epidemiological studies are available on the incidence of
acute injuries in rugby players [1, 2, 812], but a limitation of

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U. G. Longo et al.

epidemiological studies is that the injury information is based


on player interviews after the injury or reports from the
medical staff [13]. Determining the mechanism of the injury
on the basis of reports from the injured player or their medical
staff is difficult, because injuries happen quickly, and the
player may not be able to provide an accurate description of
how the injury occurred. Moreover, because, often, two or
more players are usually involved in the injury, the injured
player may not always be fully aware of what actually caused
the injury [13]. A more revealing approach may be to examine
videotapes of actual shoulder injury situations to describe the
mechanisms leading to injury [1321].
Despite the relevance of the problem, to our knowledge,
no study has addressed the specific issue of video analysis
of the mechanisms for shoulder dislocation injuries in
rugby players. Because rugby is a contact sport requiring a
variety of skills, the mechanisms of shoulder dislocation
may differ from those commonly proposed for shoulder
dislocation in other situations.
The objective of this study is therefore to describe the
specific mechanisms of shoulder dislocation injury using
video recordings for a consecutive series of elite male
rugby players who sustained a shoulder dislocation during
an official match.

3.
4.

Dislocation was defined as instability requiring manual


reduction [22].
Patients were excluded from the study if they had:
1.
2.
3.
4.
5.

Videotapes were collected with permission from the South


African Professional Rugby Federation during the 2001
and 2003 seasons. We were allowed to search the archive
of the South African Rugby Federation to collect the videotapes of the injured elite rugby players. The videotapes
were reviewed to identify the mechanism of injury. The
incidents, including the play leading up to each incident,
were analysed.
Each recording was edited to include three sequences:

We performed a retrospective study of a consecutive series


of elite rugby players from the South African professional
rugby league who sustained an episode of shoulder dislocation between 2001 and 2003, and were operated on at our
institution. All athletes gave informed consent to participate into the study.

1.
2.

they sustained a glenohumeral dislocation during a


match;
they had no previous episode of shoulder dislocation;

the entire playing situation, including the play leading


up to the injury at normal speed;
one repetition of the injury; and
a slow-motion close-up repeat of the injury.

A shoulder dislocation mechanism score was developed


to describe the injury mechanism and the events leading up
to the injury. The questionnaire included the case number
and the side injured in each case. The variables used in the
questionnaire were defined as follows:
1.

Athletes were included in the study if:

previous surgery for multidirectional instability;


multiple revision surgery or previous reconstructive
surgery on the affected shoulder;
voluntary instability;
previous episode of shoulder dislocation; and
unclear videotape of the injury.

Video analysis

Materials and methods

Eligibility criteria

they had no previous surgery on the affected shoulder;


and
they had developed unidirectional instability.

2.
3.

the primary position of the hand: on the ground or in


the air;
the primary position of the shoulder: on the ground or
in the air;
the primary position of the elbow: on the ground or in
the air;

Table 1 Patients demographics


Patient

Shoulder

Dominant
side

First
episode

Direction of
dislocation

Withdrawn
from match

Surgical diagnosis

1 (Fig. 1)

Left

Right

Yes

Anterior

No

Bankart lesion and humeral avulsion of the


glenohumeral ligament

2 (Fig. 2)

Right

Right

Yes

Posterior

Yes

Humeral avulsion of the glenohumeral


ligament and rotator cuff tear

3 (Fig. 3)

Left

Right

Yes

Anterior

Yes

Bony Bankart lesion

4 (Fig. 4)

Right

Right

Yes

Anterior

Yes

Bankart lesion

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4.
5.

No

Posterior
Anterior

Anterior
No

Abduction, extension and


external rotation

Posterior

No
No

Forward flexion and internal rotation Yes


Abduction, extension and
No
external rotation

7.
8.

Yes

Forward flexion and internal rotation Yes

6.

9.

extension or flexion of the elbow;


whether the injured player was actively tackling an
opponent (active) or whether he was being tackled by
an opponent (passive);
whether it was a late tackle (that is, whether the tackle
occurred after the ball had been passed by the injured
player);
point of contact with another player: mainly anterior,
lateral, or posterior;
the main direction of shoulder motion: forward flexion
(internal, external rotation, neutral position), extension
(internal, external rotation, neutral position), flexion in
the plane of the scapula (internal, external rotation,
neutral position), abduction (internal, external rotation,
neutral position); and
falling of the opposing player on the back of the
injured player: yes or no.

The videotapes were analysed independently by two


experienced specialists in orthopaedic sports medicine
(UGL and PEH). Disagreements were discussed in a consensus meeting during which the video recordings were reevaluated and a final decision was made.

Results

Active
Extension
In the air
In the air
4 (Fig. 4) In the air

Flexion
Extension

Passive
Active

Extension

On the ground
In the air

On the ground
In the air

On the ground

2 (Fig. 2) On the ground


3 (Fig. 3) In the air

On the ground

Active

Patients demographics

1 (Fig. 1) On the ground

Primary position Primary position Primary position Extension or Active or


Late Main point of Main direction of
of the hand
of the shoulder of the elbow
flexion of the passive tackling tackle contact with
shoulder motion
elbow
another player
Patient

Table 2 Shoulder dislocation mechanism score for every elite athlete

Falling of the opposing


player on the back of the
injured player

Video analysis of shoulder dislocation

Four patients (mean age 23.7 years; range 2226) met the
inclusion criteria. All patients had undergone primary surgery at our institution (Table 1). The dominant arm was
involved in 2 patients. In all four patients the dislocation had
been caused by trauma. The detailed shoulder dislocation
mechanism score is reported in Table 2 for every athlete.

Discussion
This study evaluated the mechanisms of shoulder dislocation in four South African professional elite rugby players
on the basis of analysis of video recordings of injuries from
official matches. For all the athletes, player-to-player
contact was responsible for the shoulder dislocation. Three
of the four injuries resulted from trauma with the elbow in
an extended position forcing the shoulder to exceed the
limits of the normal range of motion and causing an
anterior shoulder dislocation. One injury resulted from
trauma with the elbow in a flexed position and the direction
of the injuring force along the longitudinal axis of the
humerus, causing a posterior shoulder dislocation. Generally, it is assumed that anterior shoulder dislocations occur
with the arm in abduction and external rotation. However,

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U. G. Longo et al.

Fig. 1 a Close-up of the


injured player falling on the
ground with another player on
his back, b overview of the
playing situation, c the extended
upper left arm of the player
touches the ground, d, e the arm
of the injured player is extended
and the opponent falls on his
back, f the moment just after the
shoulder injury

this is not necessarily the case in elite rugby athletes, as


shown in this preliminary retrospective study.
We are fully aware of the weaknesses of our study. First,
the number of athletes included is limited. Therefore, further studies including more patients are warranted.

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However, it can be difficult to collect a large number of


videotapes of traumatic shoulder dislocations. In fact,
although it is a common injury in elite rugby athletes, it
may also occur during unofficial matches or during training
activities, where no cameras are available and the exact

Video analysis of shoulder dislocation

393

Fig. 2 a Overview of the


playing situation, b close-up of
the injured player (with the ball
in his hands) falling on the
ground with another player on
his back, c the opponent falls on
the back of the injured player,
d the flexed upper right elbow
of the player touches the
ground, e the opponent falls
with his weight on the back of
the injured player who has the
flexed arm and makes contact
with the ground with his elbow,
f the moment just after the
shoulder injury

moment of injury is therefore not recorded [1, 2, 8, 12].


Also, it would be interesting to compare the mechanism of
shoulder dislocation between training and match injuries,
although we would expect fewer late tackles and less foul
play during training than in match play [7]. Moreover, the
assessment was subjective and qualitative, and in some
cases based on tapes of less than optimum quality with a
limited number of views available. However, the evaluations were independently performed by 2 assessors and a
correlation between the mechanism of injury and the surgical diagnosis was available. Systematic video analysis of
injuries seems to be the obvious approach toward a more
detailed understanding of the mechanisms of sports

injuries, providing more reliable information than retrospective player interviews; to the best our knowledge, no
studies reported in the literature have used this approach to
study the mechanism of shoulder dislocations in elite rugby
players [13, 16, 1820].
This study was conducted on elite male rugby players.
There may be differences in injury mechanisms between
rugby and other contact sports, and between these players
and other player populations (for example, younger players, female players, and amateur players) that warrant
attention in future studies [13].
Another limitation of this study is that we do not report
the position of the athlete in the field, the training

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394
Fig. 3 a Overview of the
playing situation, b close-up of
the injured player with the fully
extended left arm tackling the
opponent, c, d anterior impact
of the fully extended left arm of
the injured player with the
opponent, e, f the injured player
falls, g, h the moment just after
the shoulder injury

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Video analysis of shoulder dislocation

395

Fig. 4 a Overview of the


playing situation, b close-up of
the injured player with the fully
extended right arm tackling the
opponent, c, d impact of the
opponent against the fully
extended upper right arm of the
injured player

programme, and the number of matches played during the


season by the injured player. Unfortunately, these data
were not made available to us despite repeated attempts
with the clubs to obtain them. We acknowledge that
accumulation of microtrauma, such as occurs with tackles,
rucks and mauls, scrums, and line outs may cause deficiencies in active and passive control systems around the
glenohumeral joint. Moreover, the objective of our study
was not to find risk factors for shoulder dislocation, but to
provide a detailed description of the mechanism of such
injuries on the basis of video analysis.
Suboptimum glenohumeral alignment, attributable to
poor technique, during anticipated contact may be a cause
of injury [7, 23]. Poor technique might reasonably be
expected to be a risk factor for such injuries. Our preliminary video analysis of shoulder dislocations may be the
basis for larger studies to improve technique in rugby
athletes [7].
All the shoulder dislocation in our series of elite rugby
players resulted from contact with an opponent. Observational studies have demonstrated that during matches,
forwards spend more time in contact situations (competing

for the ball) than do backs [24]. However, no difference in


the incidence of shoulder injuries between forwards and
backs has been found [7]. Tackling has been proposed as
the main cause of match shoulder injuries and of most
dislocation/instabilities [7].
The tackle was responsible for all shoulder injuries in
our series. Dislocations occur when the tackled players
arms are caught in the tackle and the resulting fall is on
to the point of the shoulder [2533]. In our small series
of patients, acute anterior dislocations occurred in the
tackle, to either the tackler or the tackled player. The arm
can be forced either by the weight or momentum of
the player. Often, excessive forces are responsible
for levering the humeral head out of the glenoid fossa
[2534].
Players who make contact with the greatest momentum
tend to incur the largest forces on impact [35], which might
in part explain the higher incidence of shoulder injury for
these players. This supports the case for prehabilitation
or training that specifically prepares different players for
the different contact-related demands they incur during the
game [7].

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Prevention of shoulder injuries in elite rugby athletes is


far from effective. Taping of the shoulder seemed an
interesting option, but in asymptomatic Australian football
players it did not protect against re-injury of the shoulder
[36]. A thorough knowledge of the common mechanisms
of injuries in these athletes may have the potential to lead
to the development of effective preventive measures
enabling avoidance of the injuries [4, 3743].
In conclusion, this study provides preliminary evidence
that thorough video analysis can furnish detailed information about the mechanisms of shoulder dislocation in elite
rugby players. Knowledge of the common mechanisms of
injuries in these athletes may potentially lead to improved
sports technique in an attempt to reduce the occurrence of
shoulder dislocations. Further studies with a larger number
of patients are required to better clarify the exact mechanism of shoulder dislocation in rugby players, and how
these results may be applied in training and matches to
prevent shoulder dislocation in elite rugby players.
Acknowledgment Many thanks to Charles King for help in collecting videotapes.
Conflict of interest No benefits of any form have been received or
will be received from any commercial party related directly or indirectly to the subject of this article.

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