Shoulder injuries in rugby players: mechanisms, examination, and rehabilitation.

Physical Therapy in Sport xxx (2014) 1e10

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Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp

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Shoulder injuries in rugby players: Mechanisms, examination, and rehabilitation Kevin Helgeson*, Paul Stoneman Rocky Mountain University of Health Professions, 122 East 1700 South, Bldg C, Provo, UT 84606, United States

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 March 2014 Received in revised form 5 June 2014 Accepted 9 June 2014

Background: The sport of rugby is growing in popularity for players at the high school and collegiate levels. Objective: This article will provided the sports therapist with an introduction to the management of shoulder injuries in rugby players. Summary: Rugby matches results in frequent impacts and leveraging forces to the shoulder region during the tackling, scrums, rucks and maul components of the game. Rugby players frequently sustain contusion and impact injuries to the shoulder region, including injuries to the sternoclavicular, acromioclavicular (AC), and glenohumeral (GH) joints. Players assessed during practices and matches should be screened for signs of fracture, cervical spine and brachial plexus injuries. A three phase program will be proposed to rehabilitate players with shoulder instabilities using rugby specific stabilization, proprioception, and strengthening exercises. A plan for return to play will be addressed including positionspecific activities. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Shoulder injury Rugby Rehabilitation Tackling injury

1. Mechanisms of shoulder injuries The sport of rugby or rugby union is characterized by frequent physical contact with other players and tackling that results in falls to the ground. (Crichton, Jones, & Funk, 2012; King, Hume, & Clark, che de, & Wolfe, 2010) Rugby 2012; McIntosh, Savage, McCrory, Fre players do not wear helmets and may have minimal padding to protect the upper extremities as found in American football. The incidence rate for upper extremity injuries during rugby matches has been estimated at 9.84 injuries per 1000 athletic exposures (95% CI 9.06e10.62), where each exposure is equal to one player participating in one match (Usman & McIntosh, 2013) Shoulder injuries make up half to two thirds of the injuries to the upper extremities and may involve a number of structures about the shoulder region with acromioclavicular and glenohumeral joints the most frequently injured. Many of these injures are significant resulting in lost match and practice participation for a 2e4 week period. (Headey, Brooks, & Kemp, 2007) The rate of injuries during

* Corresponding author. Tel.: þ1 801 734 6854. E-mail addresses: [email protected] (K. Helgeson), pstoneman@rmuohp. edu (P. Stoneman).

rugby practice have been estimated to be significantly less (.10/ 1000 of practice) than during matches but can still be prevalent during practice sessions that involve tackling and defensive drills. (Headey et al., 2007) The incidence of upper extremity injuries has been studied in different levels of rugby play with more shoulders injuries occurring at college and higher levels of play. (Usman & McIntosh, 2013) Players in back positions that require more frequent tackles and tackling of opponents who are running at top speed are at a greater risk of shoulder dislocations than players in forward positions. (King, Hume, & Clark, 2011; Sundaram, Bokor, & Davidson, 2011) The rate of injuries for female rugby teams is generally considered to be significantly less than male teams with more injuries to the lower extremities, especially the knee joint. (Taylor, Fuller, & Molloy, 2011) Rugby “League” and “Sevens” are variations on the game of rugby played with similar rules but with 13 players for League matches and only seven players for Sevens matches. Rugby league is predominantly played in England, Australia, and in Pacific Island countries. Rugby sevens is increasing in popularity in the United States and will be added as a sport for the 2016 Summer Olympic Games. The length of Sevens matches are shortened to two seven minute halves and are typically played during one or two day tournaments with a number of matches played each day.

http://dx.doi.org/10.1016/j.ptsp.2014.06.001 1466-853X/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Helgeson, K., & Stoneman, P., Shoulder injuries in rugby players: Mechanisms, examination, and rehabilitation, Physical Therapy in Sport (2014), http://dx.doi.org/10.1016/j.ptsp.2014.06.001

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K. Helgeson, P. Stoneman / Physical Therapy in Sport xxx (2014) 1e10

These games emphasize a faster style of play with more passing, open field running and tackling compared to rugby union. Rugby league matches result in injuries to the shoulder, but mostly to the head and neck region. (Gabbett, 2004) Limited data is available on injuries during rugby Sevens, surveys from collegiate and international tournaments also indicate a high injury rate with a majority of injuries to the upper extremities, head and face. (Fuller, Taylor, & Molloy, 2010; Lopez et al., 2012) A number of mechanisms have been identified for injuries to the shoulder and upper extremities. During a rugby match, tackling of an opponent can result in a number of impacts and forces to the shoulder and upper extremities (Figs. 1e5). McIntosh et al. identified six different tackling methods all resulting in impact or leveraging forces upon the shoulder. (McIntosh et al., 2010) A player being tackled can also sustain impact injuries or be injured by landing on the ground or bracing themselves with an outstretched arm. (McIntosh et al., 2010) The most common method for tackling is performed from a crouched position with the arms abducted in attempt to reach around the opponent's trunk. This usually results in an impact directed to the anterior-superior surface of the shoulder and arms. This mechanism can result in a posteriorly directed force resulting in horizontal abduction of the arms and leveraging forces over the glenohumeral joint. The mechanisms of direct impact and leveraging forces can result in glenohumeral dislocations, labral tears, acromioclavicular joint separations, and clavicular and scapular fractures. (Badge, Tambe, & Funk, 2009; Crichton et al., 2012) The other common tackling method is described as “arm tackling” where the players attempt to tackle the opponent by diving and reaching outwards to grab the ankle for a tripping tackle or grabbing the trunk to slow down or change the direction of the ball carrier. (McIntosh et al., 2010) Another method of tackling is described as “smothering” where the tackle is attempted from an upright position wrapping the arms around ball carrier's trunk and arm to trap the ball, so that the ball carrier is unable to pass the ball during the tackling maneuver (Fig. 4). Forces placed upon the shoulder during a rugby tackle have been measured to be over 1600 N, which is usually tolerated by che de, 2011) most tissues of the shoulder. (Usman, McIntosh, & Fre

Fig. 1. Tackling Mechanism for Shoulder Injuries: An arm tackle creates a leveraging force across the anterior shoulder.

Fig. 2. Tackling Mechanism for Shoulder Injuries: The tackler encounters an impact force to the anterior shoulder and a leveraging force across the shoulder.

Interestingly, tackling without shoulder pads results in similar levels of force applied to the shoulder structures as when tackling while wearing shoulder pads. (Usman et al., 2011). A number of other factors can come into play for injury risk during a tackling episode, including the relative size and speed of the opponent, the direction of movement of the tackler as they approach their opponent and the forces delivered by other team members who are also attempting a tackle. Fuller et al. and King et al. have identified greater risks for injuries when two tacklers are involved and when approaching the ball carrier from the side. (Fuller, Ashton, et al., 2010; King et al., 2012)

Fig. 3. Tackling Mechanism for Shoulder Injuries: Impact forces are sustained to the tackler and ball carrier.



Fig. 4. Tackling Mechanism for Shoulder Injuries: During a smothering tackle the tackler attempts to hold up the ball carrier and steal the ball.

The game of rugby creates a number of stressful positions for the shoulders related to tackling. A tackle to the ground will result in a “ruck” where players from each side attempt to gain control of the ball. The ruck takes place by players from each side forming up in front or behind the tackled players and then lunging over the tackled players to push the opposing players backwards. A player entering a ruck will bend forward at the waist with arms elevated in order wrap around a teammate's trunk as they both drive forwards with their lower extremities

Fig. 5. Tackling Mechanism for Shoulder Injuries: A ball carrier brought to the ground has impact forces delivered through the forearm.

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(Fig. 6). A “maul” takes place when a ball carrier is held up or is in smothering tackle. Players from each side will attempt to bind onto the runner and tackler in order to push them forwards or backwards. Again, a player may enter a maul by bending forwards and wrapping one or two arms around a teammate as they use their lower extremities to drive forwards. A scrum is a formation of eight players in three rows that is used to reset play during a rugby match. The position of a player within a scrum is referred to as binding, where a player's arms are elevated and wrapped around the back of a teammate. Players in different positions within the scrum will need to place their shoulder in varying elevated positions to create their binding position. Players from each side will engage each other in an attempt to drive forwards and maintain control of the ball (Figs 7 and 8). Although there is a potential for a great amount and types of stress on the shoulder during a scrum, this formation is not associated with shoulder injuries at the rate found with tackling, rucks, or mauls. (Crichton et al., 2012) A “shoulder charge” is a controversial defensive tactic where a defender collides with a ball carrier at top speed in order to stop the progress of the runner. This is a different tactic than a shoulder charge as used in soccer when two players are running side by side to attain control of the ball. This tactic has recently been outlawed by number of rugby associations due to highly publicized incidents that resulted in concussions and injuries to the face and upper extremities. To be a legal, a defender must wrap their arms around the ball carrier in an attempt to make a tackle and cannot leave their feet or launch them self at the ball carrier in order to stop them as often seen in American football. (International Rugby Board) Another mechanism that can result in a shoulder injury is when a player with the ball attempts to score points or “score a try“ by diving into the try zone holding the ball with the arms elevated above head (Fig. 9). This mechanism has been associated with rotator cuff tears and injuries to the glenohumeral joint. (Crichton et al., 2012)

2. Examination Shoulder injuries in rugby players most commonly occur during matches and will require on-field assessment to determine the

Fig. 6. Ruck: Players form up over the downed ball carrier assuming a crouched position and placing arms around a teammate's back in order to push the opposing players backwards. The position and motion create impact and leveraging forces upon the shoulder.


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Fig. 7. Scrum: Players bind together in three rows. Positions within the scrum require varying amounts of shoulder abduction and horizontal abduction that can create leveraging forces to the shoulder.

Fig. 8. Scrum: Players bind together in three rows. Positions within the scrum require varying amounts of shoulder abduction and horizontal abduction that can create leveraging forces to the shoulder.

seriousness of the injury. The sports trainer needs to make a rapid decision about whether the player can continue or be taken out for duration of the match. For a shoulder injury a screening of the motion, strength and sensation over the shoulder will identify serious injuries that require further assessments. Further

Fig. 9. Try Score: Diving into the try zone with arms elevated above the head creates leveraging forces across the shoulder.

assessment should determine if an emergent condition is present such as a fracture or shoulder dislocation as well as signs of cervical spine and brachial plexus injuries that may initially present as shoulder pain or dysfunction. The most common serious injuries to shoulder during a rugby match are glenohumeral dislocations/ subluxations and acromioclavicular separations. (Crichton et al., 2012; Horsley, Pearson, Green, & Rolf, 2012) These types of injuries need to be referred for imaging and follow-up care by a sports medicine physician to assess the extent of the injury and long term planning for overall management. A scoring system for shoulder injuries in rugby players has been developed and validated to identify factors for functioning and return to play after a shoulder injury. (Roberts & Funk, 2013) Contusions and bruising are the most common type of injury associated with rugby practices and match play. The initial examination for a player complaining of pain in the shoulder region should be to inspect the region for deformities and signs of swelling, especially over the anterior chest, biceps and deltoid regions. Inspection and palpation of the acromioclavicular and sternoclavicular joints, clavicle and acromion will assess for signs of joint sprains, ligament injuries, and bone bruising. Although rarely found in rugby players, clavicle and glenoid neck fractures should may be considered especially when the player has landed on the shoulder during a tackling event. Other acute soft tissues injuries to consider are muscle tears of the biceps and pectoralis



major that occur more frequently in a scrum where external forces from other players can result in forceful eccentric contraction of the muscle, especially in older players. (de Beer & Bhatia, 2009) Acromioclavicular (AC) joint injuries are also common injuries during rugby matches that occur mostly during tackling plays. This occurs when a player's arms are wrapped around the ball or an opponent and land upon the top of the shoulder. This mechanism can result in an AC joint ligament injury and joint separation. Players typically identify localized pain over the AC joint that started with landing on the shoulder. (Mazzocca, Arciero, & Bicos, 2007; Reid, Polson, & Johnson, 2012) The involved and uninvolved shoulders should be observed for signs of asymmetry and a noticeable step-off between the end of the clavicle and acromion. Palpation of the acromioclavicular joint ligaments over the AC joint line as well as the more proximal coracoclavicular ligaments will help locate the source of their symptoms and determine the extent of ligament injuries. Symptoms of AC joint injuries are reproduced with horizontal adduction of the shoulder and accessory joint motions of compression and posterior glide of the clavicular head. (Reid et al., 2012) AC joint injuries can be further assessed with imaging assessments of ultrasound, radiographs, and bone scans. AC joint separations have been classified using a three or six level classification system. (Mazzocca et al., 2007) Acute injuries should be assessed primarily to determine if the joint is unstable in order to provide protection for the shoulder and to make an appropriate referral for this condition. Chronic acromioclavicular joint pain can result from repeated injuries and chronic weightlifting, which can lead to arthritic changes or distal clavicle osteolysis. Rugby players may become susceptible to shoulder injuries due to training and conditioning practices that create postural imbalances from muscle strength and flexibility. Rugby players do considerable strength training and can develop imbalances typical of weightlifters. Assessments of professional rugby club players found signs of limited shoulder active range of motion and anterior shoulder tightness. (Horsley et al., 2012; McDonough & Funk, 2014) Another study of rugby player measured shoulder internal and external strength and did not find any imbalances that could possibly make them more susceptible to a shoulder injury. (Edouard, Frize, Calmels, Samozino, Garet, & Degache, 2009) Scapular dyskinesia has been identified as a persistent finding for players with shoulder instabilities. A player with a shoulder condition should be assessed for movement of the scapula during shoulder elevation and above head reaching activities. (McClure, Tate, Kareha, Irwin & , Zlupko, 2009) Excessive scapular elevation (Type III scapular dyskinesia) has been associated with these instabilities as the player performs active and resisted shoulder flexion and abduction movements. (Kawasaki, Yamakawa, Kaketa, Kobayashi, & Kaneko, 2012) Injuries of the glenohumeral (GH) joint may result in an acute subluxation or dislocation. This type of injury is associated with tackling method such as the arm tackle method previously describe or falling onto the ground landing on the hand or elbow that imparts excessive forces to the GH joint. (McIntosh et al., 2010) These types of injuries are best examined in the training room that should include a detailed history of any previous injuries and a description of the mechanism which caused the shoulder injury. A complete examination will include assessments of upper quarter posture, active and passive shoulder motions and accessory joint motions. The player's description of their injury and the mechanisms of forces on the shoulder will provide a good indication for the type of special tests that are needed to determine the type of injury or type of shoulder condition. These tests should be performed with an understanding of their known sensitivity and specificity for making an accurate assessment of shoulder conditions. (Hegedus et al., 2012; Tzannes, Paxinos, Callanan, & Murrell, 2004)

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Labral tears and detachment in rugby players may be better reproduced using test that create compressive force onto the labrum as this is a frequent mechanism of shoulder injury in rugby, not throwing which is usually the mechanism in overhead athletes. The active compression test, (O'Brien's test), passive compression test, and the modified dynamic shear test have all been well studied and when used in combination can provide information to confirm or disconfirm the hypothesis of a labral detachment. (Hegedus et al., 2012) The patient descriptions of the forces and mechanisms that create instability can be used to appropriately select the test which will reproduce these symptoms. Examination of players with persistent shoulder discomfort should focus on looking for signs of joint instability as these conditions are most prevalent in rugby players. Players may experience a minor injury that with continued play develops into a more chronic problem with more extensive joint injuries. (Herrington, Horsley, & Rolf, 2010; Herrington, Horsley, Whitaker, & Rolf, 2008; Horsley, Fowler, & Rolf, 2013; Horsley, Herringto, & Rolf, 2010) The player should be questioned for types of activities that create their symptoms with a focus on tackling, ruck and mauling mechanisms which may place increased stress and leveraging forces across the shoulder. (Roberts & Funk, 2013) Players should also be asked about the type of prescribed and non-prescribed medications they are taking to control their symptoms. Players with persistent shoulder instability may describe episodes of sudden sharp “paralyzing” pain in the shoulder and into the arm or describing the shoulder as feeling “loose” or “weak”. This has been described as “dead-arm syndrome” and typically occurs with a blow to shoulder or when the arm is forced into end-range positions. This syndrome is associated with glenohumeral joint capsuloligamentous injuries and labral detachments. (Rowe, 1987) Labral lesions and Hill-Sachs lesion with loss of glenoid bone have been identified in rugby players with chronic shoulder pain. Type II, IV and V superior labral (SLAP) lesions should be suspected and special test that combine GH joint compression and translational forces should be used to reproduce their symptoms of instability and discomfort. (Horsley et al., 2010, 2013) Avulsion of the GH ligaments is also possible source of GH joint instability that will result in subtle but persistent symptoms. (Crichton et al., 2012) 3. Rehabilitation Rehabilitation for acute shoulder injuries may begin with on field measures to protect injured tissues and promote the healing process. The control of symptoms and inflammation can be mediated with use of modalities and medications. Many shoulder injuries involve joint ligamentous structures that will benefit from the early use of an arm sling or sling with abduction pillow. (de Beer & Bhatia, 2009) The athlete should be encouraged to maintain supported positions for the shoulder to allow for proper healing of capsuloligamentous structures and to avoid aggravation of symptoms. Contusion injuries of the shoulder respond well to a few weeks of rest with restrictions on contact with a rehabilitation program to prepare for a return to play. (Headey et al., 2007) Players who have sustained a first time traumatic dislocation of the shoulder will benefit from an early arthroscopic procedure to stabilize the anterior shoulder. (Kirkley, Werstine, Ratjek, & Griffin, 2005) AC joint injuries are frequently found in rugby players and with many minor injuries responding well with a 2e3 week rehabilitation program. The athlete should be encouraged to limit the amount of load on the shoulder and across the AC joint with the use of a sling or resting the arm in a neutral position. The use of supportive taping is useful as the athlete progresses with rehabilitation


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Fig. 10. Taping for AC joint stability using rigid tape.

exercises and functional training (Fig. 10). The use of a foam or cotton felt pad placed over the AC joint is allowed for return to play and can help the cushion the impact from blows to the shoulder or a fall. (Harris & Spears, 2010) Players experiencing persistent AC joint line pain may benefit from an injection of a local anesthetic and steroid which allows for an earlier return to play. (Orchard, Steet, Massey, Dan, Gardiner, & Ibrahim, 2010) Players who have experienced shoulder injuries that result in glenohumeral and AC joint instability will benefit from a rehabilitation program designed to improve the neuromuscular control, joint position sense, and dynamic muscular responses for the shoulder. (Dark, Ginn, & Halaki, 2007; Escamilla et al., 2009; Wilk & Macrina, 2013) A training program should be designed with multiple phases to start and progress to more challenging levels of activities while maintaining shoulder stability. A three phase program will be proposed using the terms “Attain, Maintain, Sustain” to explain the purpose of each phase of the program. (Helgeson, 2009; Magee & Zachazewski, 2007) The Attain phase will emphasize placing the shoulder in optimally stable positions using active contractions of the shoulder and scapular muscles. Early exercises should emphasize rotator cuff control and scapular stability using manual resistance and PNF

diagonals. (Youdas, Arend, Exstrom, Helmus, Rozeboom, & Hollman, 2012) The player should be positioned to insure stability of the scapula on the rib cage and a neutral position of the glenohumeral joint. Rhythmic stabilization methods are appropriate to facilitate contraction of the scapular and rotator cuff muscles that are progressed to include rapid production of muscle tension to prepare them for rugby specific forces. Rotator cuff control with scapular stability can be progressed with use of theraband exercises that emphasize controlled concentric and eccentric contractions for shoulder internal/external rotation and abduction/adduction motions using 3e4 sets of 8e12 repetitions. (Reinold, Escamilla, & Wilk, 2009) The use of D1 and D2 upper extremity PNF patterns is useful to work on motions that involve pulling the arm towards to the trunk to replicate the type of forces which are needed to hold the rugby ball and for tackling. (Figs. 11 and 12) At this phase, joint position sense should be assessed and proprioception trained with the shoulder in elevated and horizontally abducted positions which includes assessment of scapular position in standing and crouching positions. (Goble, 2010; Herrington et al., 2008, 2010) Players can begin to work on a joint re-positioning activity where they attempt to reproduce the position of the shoulder and arm with the eyes closed into elevated positions in standing and then progressing to crouching positions that replicate tackling and binding positions (Fig. 13). The Maintain phase will emphasize developing isometric and eccentric muscle contraction in anticipation of external forces that may challenge joint stability. A stabilization program using upper extremity weight bearing activities can be initiated. Standing exercises with weight bearing through the hands on the wall or a rugby ball on the wall will allow for weight bearing along with closed kinetic chain motions through the shoulder region. (De Mey et al., 2014; Maenhout, Van Praet, Pizzi, Van Herzeele, & Cools, 2010) These motions can be progressed to kneeling position with the hands on unstable surfaces and then onto landing in stable positions to prepare the player the player for practice and game situations (Figs. 14e16).

3.1. Stabilization progression Stabilization and weight training exercises can be progressed with use of theraband or cable exercises that emphasize

Fig. 11. PNF Exercise: A D2 pattern is used to facilitate shoulder adduction, internal rotation and extension muscle forces to prepare them for return to play.



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Fig. 12. PNF Exercise: A D2 pattern is combined with core stabilization to protect the shoulder against leveraging forces.

maintaining good control through mid-range shoulder movements. This can be progressed into full shoulder elevation and reaching motions to replicate rugby related activities. Examples of these exercises include the bilateral “dynamic hug” exercise and the “Arm row” performed from a crouched position (Figs. 17 and 18). (Reinold et al., 2009) These exercises can be performed with slow controlled motion that are progressed to more rapid pace using multiple sets of 4e6 repetitions that replicate tackling activities. Shoulder exercises can also be progressed with dumb bell weights for unilateral exercises of shoulder to promote good scapular humeral motions and control of acceleration/deceleration motions through the shoulder region. Weight lifting activities using a barbell can be performed with front raises, bench press, and overhead presses. Players should be counseled to avoid end range positions that may over stress the anterior shoulder structures. Proprioceptive exercises at this phase can include placing the shoulder and arm into elevated positions that replicate tackling and binding positions. A manual resistance can be applied to the distal arm and proximal forearm using oscillating perturbations that are progressed to more rapidly delivered impulses that replicate forces

that are delivered to the upper extremity during tackling and rucking activities (Fig. 19). The Sustain phase will emphasize integrating neuromuscular responses that are needed to maintain joint stability during practice and match conditions. Players should begin with a return to play by participating in practice drills for tackling using good body mechanics which protect the shoulders from excessive forces. The use of tackling dummies and scrum sleds will help replicate the appropriate positioning of the shoulder and crouching posture that are needed to perform tackling and scrum activities. During tackling drills the player should focus on keeping the elbows close to the trunk as they engage another player and then use a downward and inward motion of the arms as they complete the tackle (Fig. 20). The practice drills should also work on “going-

Fig. 13. Proprioceptive Exercise: Player attempts to place shoulder in stable position with eyes closed to prepare for binding positions within rucks and scrums.

Fig. 14. Stabilization Progression: Player performs pushups with hands placed on unstable surface.


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Fig. 15. Stabilization Progression: Player stabilizes shoulder with arms in an elevated position using a less stable surface on the therapy ball.

to-ground” positions that are part of rugby play. Impact forces during tackles and scrums can be controlled with the use of a scrum sled or by practicing with hitting pads during running drills. Players should avoid arm tackle and ankle tap methods of tackling as these will be place excessive forces across the shoulder and place them at risk for re-injury. Players in forwards positions will need to work on engaging in scrum positions while avoiding or managing as able excessive forces across the shoulder. Players with shoulder instabilities may benefit from a brace or taping that restricts shoulder abduction and external rotation motions as they begin a return to practice and match participation. The player should be assessed for proper joint position sense as they begin practicing tackling and scrum activities to insure proper positioning the scapula and glenohumeral joint. The player needs to demonstrate that they can tolerate shoulder positions of elevation and horizontal abduction as the external forces from other players are placed across the upper extremities. Players to should be counseled to avoid tackling techniques that place the shoulder into end range positions.

Fig. 16. Stabilization Progression: Players practices plyometric landing while maintaining shoulder stability and minimizing leveraging forces across the shoulder.

Fig. 17. Dynamic Hug: Player performs scapular protraction exercises through midrange while maintaining stability in a crouched position used for tackling.

A return to play “practice without contact” will allow a player to return to practice session which allow for conditioning and timing with their teammates while protecting the shoulder. A sports trainer can supervise a return to practice allowing for a limited number of impacts and tackling, before allowing a full return to practice and match participation. Players must be ready to return to full play as substitutions are limited during rugby matches and players are not usually substituted for short term periods of time. At this phase of the rehabilitation program, communication between the player, coaches, team physicians and sports physical therapist

Fig. 18. Arm Row: Player performs scapular retraction exercises from a crouched position.



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or an overhead throw during a line out play (Fig. 21) (Easton & George, 2006). The player should understand that this phase of the rehabilitation program does not guarantee a rapid return to participation and sustaining a re-injury or new injury to the shoulder is possible. Players preparing to return to practice can start a running program to maintain conditioning and should include intermittent sprinting with jogging activities to replicate the types of physiological loads involved in match play. (Coughlan, Green, Pook, Toolan, & O'Connor, 2011; Reid, Cowman, Green, & Coughlan, 2013) An agility drill that incorporates aspects of sprinting with tackling, rucking, and passing should be constructed to match the demands of the players position. (Easton & George, 2006) Players in forward positions will encounter more frequent tackling, rucking and scrums, with backs needing to practice fewer tackling impacts but at high speeds along with passing and sprinting activities. (King et al., 2011) The sports physical therapist should develop rehabilitation programs for rugby players which are consistent with the types of forces and mechanism the player will encountered during rugby practice and matches. An emphasis should be placed on shoulder stabilization exercises and drills that are similar to movements needed during rugby play. The use of padding or bracing may be needed to protect the shoulder during early return to play. The rehabilitation program should include components of conditioning and on-field practices to insure the player is using good technique for tackling and other components of the game. Fig. 19. Binding Stabilization: Player places arms in a binding position while perturbations are manually applied to the shoulder to reproduce impact and leveraging forces.

and athletic trainers is paramount to insure a safe and successful return to play. (Herring, Kibler, & Putukian, 2012) The plan for return to play should include activities that are specific to a player's usual position. A general return to play plan should include the activities of tackling, passing, landing with the ball, and rucking. Position specific return to play may include performing in different positions within a scrum, lifting another player

Fig. 20. Form Tackle: A crouched position is maintained with impact to the anterior shoulder and chest. Stresses on the shoulder are minimized with a strong adduction and internal rotation muscle forces.

Fig. 21. Line out lift: Two players lift a teammate overhead to catch the ball during a line out play.


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Conflict of interest None declared. Funding None declared. Acknowledgment Game photos are BYURugbyPhotos.com.

courtesy

of

Paul

Meyers,

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Shoulder injuries in adolescent rugby players.

Oro-facial and dental injuries in club rugby union players.

Shoulder injuries in elite rugby union football matches: Epidemiology and mechanisms.

Orofacial injuries and international rugby players' attitudes to mouthguards.

Rugby injuries.

Shoulder injury incidence and severity through identification of risk factors in rugby union players.

Rugby injuries.

Rugby injuries.

Nonoperative and postoperative rehabilitation for injuries of the throwing shoulder.

Mild traumatic brain injuries in early adolescent rugby players: Long-term neurocognitive and academic outcomes.

Time-Loss Injuries in Sub-Elite and Emerging Rugby League Players.

Incidence and characteristics of injuries in elite Australian junior rugby league players.

The prevalence of dental injuries in rugby players and their attitude to mouthguards.

Surgical interventions for anterior shoulder instability in rugby players: A systematic review.

Rugby football injuries.

The Throwing Shoulder: The Common Injuries and their Underlying Mechanisms.

Injuries in Rugby Union football.

Acromioclavicular disruption in first class rugby players.

Rugby and Shoulder Trauma: A Systematic Review.

Rugby injuries involving the hand.

The incidence of injuries in rugby football.

Rugby injuries involving the hand.

Incidence of and risk factors for traumatic anterior shoulder dislocation: an epidemiologic study in high-school rugby players.

Body composition of rugby union football players.