Shoulder dislocation in Swedish ice hockey players LENNART HOVELIUS,*M.D., Gävle, Sweden From the Department of Orthopaedics, Gavle Hospital, Gavle, and University Hospital, Linkoping, Sweden
Shoulderjoint injuries sports
are frequent in contact such as American football, rugby and ice hockey. The material presented here consists of data from 63 ice hockey players with primary, recurrent, and operated dislocations of the shoulder joint. The purpose of the study has been to map the pattern of injuries in this team game, to investigate whether the duration of immobilization after the first dislocation is of any significant importance for recurrence, and to determine whether a postoperative loss of outward rotation affects the player’s performance. Furthermore, left and right players have been analyzed for the importance of the stick grip in relation to the injured side. The study shows that dislocation of the shoulder is a very common injury in ice hockey, particularly among the top players. The time during which the first dislocation is immobilized seems to be of no sure importance for later recurrence. The age seems to be most important in this respect. Dislocation of the shoulder that is dominant in ice hockey (usually the left) causes more trouble for the player and results more often in an operation; but even when the postoperative loss of movement is relatively marked, the result is tolerated well.
MATERIALS AND METHODS
During the period 1976 to 1977, a study was made of 63 ice hockey players with dislocated shoulders; 53 were active players, 23 in the first (highest) league and 30 in the second league (Table 1). Of *
Address requests for reprints to: Department of OrthoGavle Hospital, Gavle, Sweden.
paedic Surgery,
players, 48 had dislocated their shoulders three times and were diagnosed as recurrent cases; 32 had been operated on (Table 2). The primary dislocations had not recurred and were 63
or more
as a rule, for more than two seasons. The stick grip of a left player is illustrated in Figure 1. Of the 59 forwards and defensive players in this material, 44 were left players and 15 were
observed,
right players (Fig. 2). The first league in Swedish ice hockey involves 12 teams, of which each is comprised of about 25 players, all of whom (12 x 25 300) were questioned by their doctors concerning any shoulder dislocations as junior players or later. In the case of second leagues about 1,000 players in 50 teams were covered by the study. The questions of par=
ticular interest concerned the duration of immobilization after the first dislocation, the number of recurrences, the side of the dislocation, whether the person was left or right player, as well as whether an operation had been performed and, if so, the degree of postoperative shoulder mobility. The record of the operation was obtained in 30 of the 32 operated cases. RESULTS
All of the players were younger than 30 when they first disocated the shoulder. Other data are listed in Table 3. Of the 300 players in the first league who were asked whether they had dislocated a shoulder, 23 replied in the affirmative, an incidence of 8%. In the lower leagues this type of injury is considerably less common. The duration of immobilization after the first 373
Composition
TABLE 1 of the matenal
Breakdown between
1 80%
Fig. over
by class of player
TABLE 2 and recurrent dislocations
primary
Grip for a left player, right hand on top, of all ice hockey players.
ference (P < 0.05) for recurrence in the group that under 20 at the first dislocation, compared with the group 20 years of age and older. The overall incidence of recurrences, irrespective of age and the duration of immobilization, is 76%. The methods of operation that were used in the 32 players concerned are listed in Table 6. The left shoulder had been operated on in 24 and the right in 8. By confining the analysis to the 30 forwards and defensive players, 19 of the 23 who were operated on in the left shoulder are left players and 5 of the 7 operated on in the right shoulder are right players. In other words, 24 of the 30 was
used by
Fig.
2
movement
Grip for a right player, left hand on top, so that occurs primarily in the right shoulder, which
with this grip
dislocation is related to recurrences in Table 4, from which it is seen that the incidence of recurrences is much the same in all three groups. A breakdown of the material according to the player’s age at the first dislocation is shown in Table 5. Recurrences are reported for 90% of the players who were under 20 at the time of the first dislocation, whereas the corresponding figure for the players who were over 25 is only 50%. The statistical x2 test shows an almost significant dif374
ice
is
considered
to
be the dominant shoulder
hockey.
TABLE 3 Breakdown between forwards, defensive players, and goalkeepers, and between right and left shoulders
in
TABLE 4
The material is divided into three groups according the duration of immobilization after the first dislocation and later recurrences
&dquo;
to
Over-all incidence of recurrences, 76%.
forwards and defensive players had the dislocation in the shoulder that predominates for them in ice hockey. A postoperative observation time of more than 1 year was obtained in 28 cases. A recurrence was noted in five of these and a re-operation was performed in three cases, with good results. Of the five recurrences, three belonged to the Putti-Platt group. After the operation, two of the players had been obliged to stop playing ice hockey, in one case because of recurrences 1 year after the primary operation and in the other case because a bone-block operation using Kieler bone led to greatly impaired mobility and pain. One of the players with postoperative recurrence was able to go on playing ice hockey without reoperation. All of the others were very pleased with the result of the operation. The players tolerated the postoperative loss of mobility fairly well; none of them were troubled by outward rotation being restricted up to 40 degrees (Fig. 3). Although two of the players could not abduct above the horizontal plane, this did not inconvenience them either. The 16 players with recurrent dislocation but no operation are presented in Table 7. An operation is being planned for 2 of these but does not appear to be necessary in the other 14, i.e., in 33% of all of those with recurrent dislocation of a shoulder.
recommends immobilization for 8 weeks in the of young persons. In the present material the maximum duration of immobilization was 3 to 4 weeks, and there is no evidence that this reduced the risk of recurrence compared with shorter periods, a finding that agrees with Rowe. Rowe’s opinion that age is most important for the prognosis in a primary dislocation-recurrences were noted in about 80% of primary dislocations in 20-year olds-is borne out very well by the present results in Table 5, which clearly illustrate the decreasing frequency of recurrence with increasing age. A Xz analysis also shows an almost significant difference ( P < 0.05) for recurrence in age under 20 compared with ages 20 or older. A series of operated humeroscapular dislocations does not usually contain a definite difference between the left and right sides. 1,As mentioned earlier, most ice hockey players use the left grip (Fig. 1 ), which means that for about 80% the left shoulder is dominant in this game. In the present material there is a difference between sides, in that the operation was performed on the left shoulder in as many as 24 of 32 cases and on the dominant side for ice hockey in 24 of 30. The corresponding figures for 27 of the unoperated forwards and defensive players are presented in Table 8. Here, there is nothing like the same dominance for one side, no doubt because the extent of the movement in the right or left shoulder will vary greatly with the grip used by the player. In a left player, abduction and outward rotation occur chiefly in the left shoulder, while the right functions as a support. This means that case
TABLE 5
Age
at the first dislocation and recurrence
DISCUSSION
Opinions differ about the appropriate duration of immobilization after a primary humeroscapular dislocation. Low age is considered by Rowel to be the chief determinant of recurrence and he attaches no defmite importance to the duration of immobilization. His study was based on more than 500 primary and recurrent shoulder dislocations during the period 1934 to 1954. On the basis of an equally large Hungarian material, Kazar and Belovszky2 consider that, in order to improve the prognosis in a primary dislocation, immobilization3 should last at least 3 weeks, whereas DePalma3
TABLE 6
Surgical procedures used
375
Fig. 3. Postoperative 40 degree restriction of outward rotation In the left shoulder: not a subjective impediment for ice hockey. TABLE 7 Outcome for the 16
quence,
unoperated players with recurrent dislocations
presumably
is
players
a left player with injured left shoulder is liable to dislocate this each time he shoots, while a left player with a similar injury in the right shoulder has considerably less trouble. The postoperative outward rotation in the left shoulder of a left player is illustrated in Figure 3. The 40 degree restriction of outward rotation in this and other operated patients was of no conse-
376
a
player
compensated by turning the body instead.
The present material is too small for any defmite on the various methods of operation, but it is notable that two of the recurrences in the Putti-Platt group occurred without trauma less than 2 years after the operation. The surgical repair in these two cases consisted of tendon duplication and a firmer technique is certainly required at these ages. It may seem surprising that so many players are able to continue with ice hockey despite an unstable shoulder (see Table 7). One explanation for this may be that their dislocations tend to be in the nondominant shoulder, which causes less discomfort. Furthermore, this group includes three cases of spontaneous healing, which has been reported by DePalma,3too. One of the present trio will be described in more detail. This player, who is now 50 years old, used to represent Sweden in the National Hockey Team. In the early 1960’s his shoulder dislocated very easily, even when he sneezed, and he was advised to choose between an comments
TABLE 8 Side of dislocation in the 27 unoperated
because when such
shoots, for instance, the defective outward rotation
operation
or
ice
shoulder has
hockey. Preferring
the latter, his
dislocated,
though
never
even
no
since 1964, i.e., during an observation time of 13 years. Outward rotation is reportedly restricted in the position of abduction, no doubt due to fibrosis of the joint capsule ¡ and tendons.3
operation
was
performed,
SUMMARY
l.
Humeroscapular dislocation, primary
or re-
current, is found in 8% of elite ice hockey players in Sweden. 2. The dislocation recurs in 90% of
Shoulderjoint injuries sports
are frequent in contact such as American football, rugby and ice hockey. The material presented here consists of data from 63 ice hockey players with primary, recurrent, and operated dislocations of the shoulder joint. The purpose of the study has been to map the pattern of injuries in this team game, to investigate whether the duration of immobilization after the first dislocation is of any significant importance for recurrence, and to determine whether a postoperative loss of outward rotation affects the player’s performance. Furthermore, left and right players have been analyzed for the importance of the stick grip in relation to the injured side. The study shows that dislocation of the shoulder is a very common injury in ice hockey, particularly among the top players. The time during which the first dislocation is immobilized seems to be of no sure importance for later recurrence. The age seems to be most important in this respect. Dislocation of the shoulder that is dominant in ice hockey (usually the left) causes more trouble for the player and results more often in an operation; but even when the postoperative loss of movement is relatively marked, the result is tolerated well.
MATERIALS AND METHODS
During the period 1976 to 1977, a study was made of 63 ice hockey players with dislocated shoulders; 53 were active players, 23 in the first (highest) league and 30 in the second league (Table 1). Of *
Address requests for reprints to: Department of OrthoGavle Hospital, Gavle, Sweden.
paedic Surgery,
players, 48 had dislocated their shoulders three times and were diagnosed as recurrent cases; 32 had been operated on (Table 2). The primary dislocations had not recurred and were 63
or more
as a rule, for more than two seasons. The stick grip of a left player is illustrated in Figure 1. Of the 59 forwards and defensive players in this material, 44 were left players and 15 were
observed,
right players (Fig. 2). The first league in Swedish ice hockey involves 12 teams, of which each is comprised of about 25 players, all of whom (12 x 25 300) were questioned by their doctors concerning any shoulder dislocations as junior players or later. In the case of second leagues about 1,000 players in 50 teams were covered by the study. The questions of par=
ticular interest concerned the duration of immobilization after the first dislocation, the number of recurrences, the side of the dislocation, whether the person was left or right player, as well as whether an operation had been performed and, if so, the degree of postoperative shoulder mobility. The record of the operation was obtained in 30 of the 32 operated cases. RESULTS
All of the players were younger than 30 when they first disocated the shoulder. Other data are listed in Table 3. Of the 300 players in the first league who were asked whether they had dislocated a shoulder, 23 replied in the affirmative, an incidence of 8%. In the lower leagues this type of injury is considerably less common. The duration of immobilization after the first 373
Composition
TABLE 1 of the matenal
Breakdown between
1 80%
Fig. over
by class of player
TABLE 2 and recurrent dislocations
primary
Grip for a left player, right hand on top, of all ice hockey players.
ference (P < 0.05) for recurrence in the group that under 20 at the first dislocation, compared with the group 20 years of age and older. The overall incidence of recurrences, irrespective of age and the duration of immobilization, is 76%. The methods of operation that were used in the 32 players concerned are listed in Table 6. The left shoulder had been operated on in 24 and the right in 8. By confining the analysis to the 30 forwards and defensive players, 19 of the 23 who were operated on in the left shoulder are left players and 5 of the 7 operated on in the right shoulder are right players. In other words, 24 of the 30 was
used by
Fig.
2
movement
Grip for a right player, left hand on top, so that occurs primarily in the right shoulder, which
with this grip
dislocation is related to recurrences in Table 4, from which it is seen that the incidence of recurrences is much the same in all three groups. A breakdown of the material according to the player’s age at the first dislocation is shown in Table 5. Recurrences are reported for 90% of the players who were under 20 at the time of the first dislocation, whereas the corresponding figure for the players who were over 25 is only 50%. The statistical x2 test shows an almost significant dif374
ice
is
considered
to
be the dominant shoulder
hockey.
TABLE 3 Breakdown between forwards, defensive players, and goalkeepers, and between right and left shoulders
in
TABLE 4
The material is divided into three groups according the duration of immobilization after the first dislocation and later recurrences
&dquo;
to
Over-all incidence of recurrences, 76%.
forwards and defensive players had the dislocation in the shoulder that predominates for them in ice hockey. A postoperative observation time of more than 1 year was obtained in 28 cases. A recurrence was noted in five of these and a re-operation was performed in three cases, with good results. Of the five recurrences, three belonged to the Putti-Platt group. After the operation, two of the players had been obliged to stop playing ice hockey, in one case because of recurrences 1 year after the primary operation and in the other case because a bone-block operation using Kieler bone led to greatly impaired mobility and pain. One of the players with postoperative recurrence was able to go on playing ice hockey without reoperation. All of the others were very pleased with the result of the operation. The players tolerated the postoperative loss of mobility fairly well; none of them were troubled by outward rotation being restricted up to 40 degrees (Fig. 3). Although two of the players could not abduct above the horizontal plane, this did not inconvenience them either. The 16 players with recurrent dislocation but no operation are presented in Table 7. An operation is being planned for 2 of these but does not appear to be necessary in the other 14, i.e., in 33% of all of those with recurrent dislocation of a shoulder.
recommends immobilization for 8 weeks in the of young persons. In the present material the maximum duration of immobilization was 3 to 4 weeks, and there is no evidence that this reduced the risk of recurrence compared with shorter periods, a finding that agrees with Rowe. Rowe’s opinion that age is most important for the prognosis in a primary dislocation-recurrences were noted in about 80% of primary dislocations in 20-year olds-is borne out very well by the present results in Table 5, which clearly illustrate the decreasing frequency of recurrence with increasing age. A Xz analysis also shows an almost significant difference ( P < 0.05) for recurrence in age under 20 compared with ages 20 or older. A series of operated humeroscapular dislocations does not usually contain a definite difference between the left and right sides. 1,As mentioned earlier, most ice hockey players use the left grip (Fig. 1 ), which means that for about 80% the left shoulder is dominant in this game. In the present material there is a difference between sides, in that the operation was performed on the left shoulder in as many as 24 of 32 cases and on the dominant side for ice hockey in 24 of 30. The corresponding figures for 27 of the unoperated forwards and defensive players are presented in Table 8. Here, there is nothing like the same dominance for one side, no doubt because the extent of the movement in the right or left shoulder will vary greatly with the grip used by the player. In a left player, abduction and outward rotation occur chiefly in the left shoulder, while the right functions as a support. This means that case
TABLE 5
Age
at the first dislocation and recurrence
DISCUSSION
Opinions differ about the appropriate duration of immobilization after a primary humeroscapular dislocation. Low age is considered by Rowel to be the chief determinant of recurrence and he attaches no defmite importance to the duration of immobilization. His study was based on more than 500 primary and recurrent shoulder dislocations during the period 1934 to 1954. On the basis of an equally large Hungarian material, Kazar and Belovszky2 consider that, in order to improve the prognosis in a primary dislocation, immobilization3 should last at least 3 weeks, whereas DePalma3
TABLE 6
Surgical procedures used
375
Fig. 3. Postoperative 40 degree restriction of outward rotation In the left shoulder: not a subjective impediment for ice hockey. TABLE 7 Outcome for the 16
quence,
unoperated players with recurrent dislocations
presumably
is
players
a left player with injured left shoulder is liable to dislocate this each time he shoots, while a left player with a similar injury in the right shoulder has considerably less trouble. The postoperative outward rotation in the left shoulder of a left player is illustrated in Figure 3. The 40 degree restriction of outward rotation in this and other operated patients was of no conse-
376
a
player
compensated by turning the body instead.
The present material is too small for any defmite on the various methods of operation, but it is notable that two of the recurrences in the Putti-Platt group occurred without trauma less than 2 years after the operation. The surgical repair in these two cases consisted of tendon duplication and a firmer technique is certainly required at these ages. It may seem surprising that so many players are able to continue with ice hockey despite an unstable shoulder (see Table 7). One explanation for this may be that their dislocations tend to be in the nondominant shoulder, which causes less discomfort. Furthermore, this group includes three cases of spontaneous healing, which has been reported by DePalma,3too. One of the present trio will be described in more detail. This player, who is now 50 years old, used to represent Sweden in the National Hockey Team. In the early 1960’s his shoulder dislocated very easily, even when he sneezed, and he was advised to choose between an comments
TABLE 8 Side of dislocation in the 27 unoperated
because when such
shoots, for instance, the defective outward rotation
operation
or
ice
shoulder has
hockey. Preferring
the latter, his
dislocated,
though
never
even
no
since 1964, i.e., during an observation time of 13 years. Outward rotation is reportedly restricted in the position of abduction, no doubt due to fibrosis of the joint capsule ¡ and tendons.3
operation
was
performed,
SUMMARY
l.
Humeroscapular dislocation, primary
or re-
current, is found in 8% of elite ice hockey players in Sweden. 2. The dislocation recurs in 90% of
