Combat Arts Shoulder Injuries Overview
Every time a martial artist performs a throw, punches, or raises the arms, it requires the rotator cuff to engage. Rotator cuff injuries are hard on martial artists because they weaken the shoulder. Major fight events and heavy sparring load the shoulder hard, and it is the most mobile joint in the body — the ball sits against a shallow socket and depends on the joint capsule, the glenohumeral ligaments, the labrum and the surrounding muscles, including the four rotator cuff tendons, to stay where it belongs. That mobility is bought with stability, which is why this joint gets hurt.
The rotator cuff is the group of four muscles and their tendons that hold the head of the upper arm bone, the humerus, against the socket while letting you raise the arm. It is muscle and tendon, not bone. The shoulder complex around it is built from three bones that come together: the shoulder blade or scapula, the collarbone or clavicle, and the upper arm bone or humerus.
The rounded head of the humerus sits against a shallow socket on the shoulder blade, which is what gives the shoulder its huge range of motion. The four rotator cuff tendons wrap that joint and centre the head in the socket, working alongside the joint capsule, the glenohumeral ligaments and the labrum.
Shoulder Injury Causes
The shoulder is one of the most mobile joints in the body. MMA fighters typically put their shoulder joints under enormous stress every time they train or fight. Moves like arm bars, Americana, and Kimura exert tremendous pressure on the shoulder. A submission hold, an awkward landing, and forceful contraction all cause the shoulder joint to dislocate and experience tears. It’s for this reason, that the shoulder joint is vulnerable to injury.
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Shoulder Injury Symptoms
Types of Shoulder Injuries
Injury Specific
A rotator cuff tear or strain is a common injury, especially in combat sports. It may happen suddenly, from a fall or throw, or gradually from repeated stress. Most often the tear or strain will occur in the supraspinatus tendon.
The rotator cuff area is susceptible to bursa damage. The bursae are small lubricating sacs or pillows located between bones that help lubricate and protect against rubbing and grating. These bursa sacs emit protective fluid that ‘oils’ the rotator cuff tendons so they move easily and painlessly. When bursae are damaged they become inflamed or painful. Damage to the rotator cuff may also damage the bursa which intensifies pain and creates additional complications to the injury.
Two Types of Rotator Cuff Tears
Partial Tear. This type of tear is also called an incomplete tear. It damages the tendon but does not completely sever it.
Full Tear. The full tear goes all the way through a tendon or completely severs it from the bone.
Causes
Fraying or wear from repeated stress may be present in a rotator cuff tendon that is then injured during a sudden incident. This fraying may tear unexpectedly during normal activity, such as performing a powerful overhand throw or lifting a heavy object.
Acute Injury: Acute injury tears happen suddenly and usually will cause intense pain. A sense of something snapping in the upper arm or shoulder and immediate weakness or heaviness may be felt. Landing badly from a throw or fall or trying to lift/throw heavy objects can cause this injury. A broken collarbone or dislocated shoulder may create a tear in the rotator cuff tendons.
Degenerative Tear: This type of tear develops slowly, usually from repetitive overuse. It may not cause any pain or other symptoms initially. Someone with a degenerative tear on one side carries a higher risk of a tear in the opposite shoulder, even with no symptoms there — a raised risk, not a certainty.
Symptoms
These symptoms are indicative of serious rotator cuff issues. It is important to have a torn rotator cuff seen by medical experts. Serious problems may develop over time, such as arthritis or a frozen shoulder.
To learn how Torn or Strained Rotator Cuff is diagnosed, Click Here
The great majority of shoulder dislocations are anterior — the head of the humerus is driven forward out of the socket. The shoulder can also dislocate backward and downward, and it can come out partially or completely. Extreme rotation can pop it out of its socket. Fighters who dislocate once tend to dislocate again, because the capsule and ligaments are left lax or do not heal properly.
Symptoms
Causes
Anterior dislocations of the shoulder occur due to a blow to an abducted, externally rotated and extended limb. It can also occur when the fighter falls on an outstretched arm due to the force from the posterior humerus.
The arm remains abducted and externally rotated. The acromion looks prominent. Posterior dislocations happen due to a hit to the anterior shoulder. The adducted internally rotated arm bears all the load. The arm is usually in adduction, and internal rotation. Inferiors dislocations occur due to hyperabduction. It can also happen when the abducted arm is overloaded.
To learn how Shoulder Dislocation is diagnosed Click Here
The pectoralis major is a muscle that fans out over the chest and acts as adductor, flexor and internal rotator at the shoulder joint. Tears in this muscle are rare unless, a fighter attempts to lift an opponent or while lifting heavy weights or doing the bench press maneuver. It usually occurs when there’s a violent, eccentric contraction of the muscle.
The pectoralis muscle is a broad, fan-shaped muscle. It has two heads, a sternal head and a clavicular head. The muscle inserts into the humerus. It is responsible for adduction, forward elevation, and internal rotation at the shoulder joint.
Excess tension on a maximally contracted muscle can cause traumatic injury to this muscle. The most common injury is the ‘bench press’ maneuver. Here the arm is abducted and externally rotated. The muscle experiences maximum tension. The injury occurs when the fighter lowers the weight down to the chest. The muscle usually ‘brakes’ the motion. If this eccentric contraction is not smooth due to muscle fatigue, the weight/person slips to one side. It results in a sudden eccentric contraction of the pectoralis major which causes it to rupture.
The muscle also tears when force is applied to a maximally contracted muscle. This happens when a fighter attempts to break a sudden fall in a tackle. It has been observed that direct trauma tears the belly of the muscle. Excess tension causes avulsion of the humeral insertion of the tendon.
To learn how Pectoralis Major Tear are diagnosed, Click Here
Source: VladOrlov, Standard License, via Shutterstock
Common Shoulder Injuries
Read more about common shoulder injuries like bursitis by visiting our Common Injuries section.
Shoulder Injury Diagnosis
Injuries to the shoulder are mostly diagnosed via physical exam and imaging. Since the shoulder is a complex joint with many muscle, tendon and ligament attachments multiple views and imaging modalities are necessary to evaluate the bone, the cartilage, the muscles and ligaments.
Injury Related Diagnoses
Physical Exam
If degenerative tears or pain develops slowly a medical examination is required to ascertain the level of injury, best treatment, and ensure that there are no other complications such as inflamed bursa or other components such as arthritis or a “pinched nerve.”
Imaging
X-rays do not show the soft tissues of your shoulder such as rotator cuff but are used to assess bone alignment.
Magnetic resonance imaging (MRI) or ultrasound
Shows soft tissue problems such as tears in the rotator cuff tendons. They will help clarify if there is a rotator cuff tear, where it’s located, and the size of the tear. An MRI also shows the quality of the rotator cuff muscles, making it easier to ascertain whether the injury is an "old" one or "new" one.
To learn how Torn or Strained Rotator Cuff is treated, Click Here
Physical Exam
The physical exam is very diagnostic once the range of motion test is done and its observed that the shoulder has a diminished range. In anterior dislocations, the arm is abducted and externally rotated. In thin patients, doctors can palpate a prominent humeral head anteriorly. The posterior void is visible to the naked eye. In posterior dislocations, the arm is internally rotated and adducted. In thin patients, the prominent head is felt posteriorly. Fighters look like they’re guarding the extremity. A detailed neurovascular examination is done before reduction. It is repeated after the reduction as well. In inferior dislocations, the fighter holds his arm above and behind the head. He is unable to adduct the arm.
Imaging
A shoulder x-ray series is more than enough to diagnose a shoulder dislocation. A CT and MRI are required to assess for other fractures. This includes fractures of the glenoid rim or tendon injuries. On a plain film, anterior and inferior dislocations are seen as an incongruence between the humeral head and glenoid outline. If the humeral head is displaced medially and it overlies the glenoid, then it means the dislocation is anterior. Posterior dislocations are difficult to identify on a single AP view film as the congruence is maintained. All dislocations are easily seen on trans-scapular Y views. If bone loss is suspected, then a computed tomography (CT) scan and/or a CT arthrogram is done. Angiography is done if vascular compromise is suspected.
Lab Tests
Lab tests are not usually needed to diagnose a shoulder dislocation — the diagnosis is made on examination and x-ray. Blood work is ordered when surgery is on the table, or when another medical problem has to be checked first. Note that not every dislocation is handled without an operation: the fracture patterns and unstable joints described in the treatment section below are treated surgically.
To learn how Shoulder Dislocation is treated, Click Here
During the physical examination, doctors look for swelling and ecchymosis over the anterior chest, the axilla, and the arm. They look for chest asymmetry. Sometimes the muscle belly is prominent or it could be thinned-out. There might be a webbed appearance of the axilla. They will palpate the muscle to see any tenderness over the muscle. Abduction and adduction of the arm are done to 90 degrees to confirm injury to the pectoralis major. Doctors will test the strength of the muscle. The range-of-motion tests will demonstrate any limitation to motion.
X-rays are usually done first. However, they are of limited use. They are done to rule out any bone avulsion. On plain films, the usual shadow of the pectoralis major is lost. The normal anterior axillary fold is also lost.
Ultrasound is more useful due to the low cost and rapid availability. The tears are visible as an uneven echogenicity compared to the contralateral side. Magnetic resonance imaging (MRI) is the preferred imaging modality. This is because it can differentiate between acute or chronic tears. It can also indicate if the tear is complete or partial. MRI is now used to classify the grade and site of injury.
There are four types of injuries. Type I consists of muscle contusions and tears. Type II has partial tears and Type III has complete tears. Type III tears are categorized based on location into A: sternoclavicular, B muscle belly, C myotendinous junction and D insertion.
No lab tests are required for this injury unless surgery is warranted.
To learn how Pectoralis Major Tear are treated, Click Here
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Diagnosis of Common Shoulder Injuries
Refer to our Common Diagnoses section about how physicians assess shoulder injuries and test for them.
Shoulder Injury Treatment
The treatment of all shoulder injuries is based on the type of injury. Early identification and diagnosis is key. Often, fighters may choose to sleep off pain in the shoulder joints. Many pectoralis major tears are noticed after four weeks. Most fighters tend to have some tendon degeneration from the repetitive stress which further contributes to the injury. This prolongs and complicates healing.
Injury Specific Treatments
Emergency Treatment
Rest the arm and put it in a sling. Ice the area and get an orthopedic assessment — an acute tear needs looking at early. Over-the-counter anti-inflammatory medication can take the edge off the pain; follow the label, and check with a pharmacist or doctor first if you take other medicines or have stomach, kidney or heart problems. Steroid injections are not emergency care. They are a specialist decision later on, because steroid repeatedly placed around a tendon can weaken it. If the problem is chronic rather than acute, limit the aggravating activity and start a guided shoulder strengthening program.
Medical
A rotator cuff tear may cause further damage and get larger over time. It is very important to seek treatment immediately with an acute injury or if experiencing pain.
Surgery. For many partial tears and some degenerative full-thickness tears, a structured course of physical therapy produces results comparable to an operation, and plenty of people get back full function without one. That is not a blanket rule, and it is not an argument against surgery. Acute traumatic tears in fighters, large tears, and shoulders with genuine weakness and loss of function are the ones surgeons repair — see the indicators listed below. The call belongs to an orthopedic surgeon who has seen your imaging.
Nonsurgical Treatments. Most people with a rotator cuff tear get useful improvement in symptoms from nonsurgical treatment — physical therapy, stretches, and exercises built to add strength and flexibility to the muscles around the shoulder joint. Worth knowing: improved symptoms is not the same as a healed tendon. The tear itself does not knit back together.
Indicators that surgery, or other options such as PRP or stem cell injections, are worth discussing with an orthopedic surgeon — bearing in mind that the evidence for PRP and stem cell injections in rotator cuff tears is still limited, and that neither substitutes for a repair when one is indicated:
Home Treatment
Once the acute phase has passed, physical therapy built around core and scapular strengthening is the mainstay for anyone managed without surgery, and most of that work is done at home between sessions. Subacromial corticosteroid injections are not home treatment. They are given in the clinic at orthopedic follow-up, and they are used sparingly.
Emergency Treatment
Putting a dislocated shoulder back in is a medical procedure. It is done by a clinician — in an emergency department, or by a doctor with the training and the equipment to do it. Never by a coach, a corner, a training partner or the fighter, and never in the gym. Get the fighter to an emergency department. A dislocation is not reduced in the ED when an anterior dislocation comes with a fracture of the humeral neck, because of the risk of avascular necrosis, or when repeated unsuccessful attempts risk neurovascular damage.
For posterior dislocations, if the fighter has presented late or more than 6 weeks after the injury, the injury cannot be reduced promptly in the ED. If there are multipart or displaced fractures, then surgical treatment is better. For inferior dislocation, all humeral neck fractures must be reduced via surgery. If vascular injuries are present, surgery is preferred.
Medical
Clinicians have several techniques for reducing a shoulder dislocation. The descriptions that follow are here so you know what is being done to you, not so anyone can copy them. Every one of them is performed by a trained clinician, after a neurovascular examination and, in most cases, x-rays — a shoulder that is also fractured, or that has a nerve or artery trapped, can be permanently damaged by a well-meaning attempt at the side of a mat. Common techniques include scapular manipulation, external rotation, traction-countertraction, and the Cunningham, Milch, Stimson, Spaso, FARES and fulcrum methods. The choice depends on the type of dislocation, any associated fracture, and the clinician’s experience.
The Cunningham technique is done with the fighter seated facing the doctor, the fighter’s hand resting on the doctor’s shoulder while the doctor supports the elbow and massages the biceps, deltoid and trapezius, then asks the fighter to draw the shoulder blades together and straighten their posture. It works by getting the muscles to let go rather than by force, which is one reason a clinician may choose it. It is still a clinical procedure, not something to try ringside.
The Stimson technique has the fighter lying face down on a hospital bed with the injured arm hanging over the edge under a small weight, letting the muscles fatigue and release over roughly half an hour. It needs almost no equipment, which is exactly why it gets copied — do not copy it. Hanging weight off a shoulder that also has a fracture, or a trapped nerve or vessel, can cause permanent damage, and in hospital it is done with imaging, monitoring and someone watching the limb.
Pain control for these reductions is the treating clinician’s decision. Many are done without conscious sedation, using local anesthetic injected into the joint. Where sedation is needed it is given in a monitored setting, with drugs such as fentanyl, midazolam, ketamine, propofol or etomidate, and with the staff and equipment on hand to manage the airway. That requirement is one more reason reduction belongs in a medical setting.
Posterior dislocations are reduced differently, usually with sedation, and they are more often missed on first assessment, so specific x-ray views are needed to confirm the joint is back in place.
Home Treatment
After the reduction, the fighter is placed in a sling. A neurovascular exam is done and post-reduction imaging is advised at regular intervals. The fighter must follow-up with an orthopedic surgeon to ensure the reduction is successful.
There’s no emergency treatment except in recognizing that there is a tear in pectoralis major muscle. Since it is a huge muscle, the injury is deceptive. If there is pain, rest, ice, immobilization, and pain medication must be given until consult.
The treatment of a pectoralis major tear depends on how severe the injury is. It also depends on the activity level of the fighter. For complete tears surgery is preferred.
The fighter is put in a sling with the arm adducted and internally rotated. Within two weeks, passive and active range of motion exercises are started. Gradually, return to full range of motion in the next six weeks.
Eight weeks after the injury, progressive resistance exercises can commence. Four months post injury, full resistance training can resume.
Common Treatments
There are various treatments available for shoulder injuries in our Common Treatments section.
