Shoulder Injuries
Shoulder Injuries

By Aaron Goldberg, MD, FAAEM

Shoulder injuries are among the most common race ending injuries.  They often involve surgical intervention and time off the road, wrecking a season.  Peraud and Renshaw were two of the victims this year.  Even a minor grade I acromioclavicular (AC) joint injury can force the cyclist off the road for a few weeks.  I am going to talk about shoulder injuries including acromioclavicular injuries (shoulder separations) and clavicle fractures (collar bone fractures).  We are going to skip the more rare (for road cycling) shoulder dislocations, and humerus fractures.

Shoulder injuries are extremely common in cycling.  When you fall off your bike going 25-30 mph some damage is going to occur.  When you land directly on the top of your shoulder instead of sliding, well I’m afraid your clavicle is likely to snap. If you are lucky maybe you will just rip up your AC joint.  These falls often occur as a result of crashing into a drainage ditch, trust me I know it well, or when tumbling over another fallen rider.  The fall mechanism is usually with the arm at the side, maybe while still holding onto the bars going endo.  If you manage to get your arm up over your head before hitting the pavement you are more likely to dislocate your shoulder.

Here is some advice for a quick self-assessment on the pavement.  Number one, I would be most worried about the head, neck and chest first.  Head, neck, and rib or lung injuries would all require an immediate, like 5 minutes ago, ER visit.  If it seems you are ok, other than that incredible tight feeling in your shoulder, we can move on to a brief self-shoulder exam to figure out just exactly what you might have messed up.  This exam is no substitute for a doctor exam, we go to school 12 years for a reason.  This is really a pretty simple process but you need to know a little anatomy first.

The clavicle is the S shaped bone that extends like a strut from the sternum (breastbone) to the acromion (a part off the front of the scapula).   The humerus rotates in a joint just beneath the acromion.    Start palpating (pushing) on your clavicle in small segments from the sternum on out to the shoulder.  You have another one to compare it to on the other side in case you forgot, hopefully that one is normal.  If you find a tender sharp edge or big bump that’s likely the problem, a nice new clavicle fracture.  If you find the clavicle is only tender at the end of the clavicle at the AC joint and maybe even seems to drop significantly at the shoulder with a step off, it probably is an AC separation.  If you are in horrible pain, can’t even rotate your arm a tiny bit, and you feel a fullness in front of your upper chest you might have a shoulder dislocation, but like I said earlier this usually occurs when you fall with your arm above your head.

So what to do now?  You’ve checked yourself out, no serious head, neck or chest injury.  You have found a problem with only your shoulder.  Again, your exam is no substitute for a doctor’s exam and the doctor’s exam is no substitute for an X-ray.  At this point fashion a sling out of something, or just hold your arm against your chest wall with your other arm supporting underneath your hurt arm’s elbow.  This would be the most comfortable position until you get to the ER.  If it’s just your shoulder you can probably save yourself the ambulance bill and have a friend drive you. Take some ibuprofen on the way and try to figure out just how you wound up on the ground in the first place.  In the ER they will likely get you a sling, something a little stronger for the pain, do an official exam, and order an X-ray.  There is just no way we can be absolutely sure without an X-ray.  The X-rays do typically confirm what the exam shows but sometimes there are surprises.  Luckily in most cases the treatment of clavicle fractures and AC separations in the cyclist is fairly straight forward.

The clavicle is divided up into thirds to classify the fracture sites.  Most (70%) are located in the middle third, the rest are the distal third (end) and very few proximal third.  The fracture, like all fractures, can then be further classified as displaced (broken parts not touching), as well as comminuted (lots of broken pieces).  Treatment of displaced middle third clavicle fractures has changed over the years.  Traditionally almost all middle third fractures were treated non-operatively even if they were significantly displaced and comminuted.  The fractures would eventually scar down and heal well enough to permit nearly normal shoulder use.  The problem is it takes a really long time and if it doesn’t heal they need to operate anyway.  For an active cyclist who wants to get back to training this approach is clearly suboptimal.  Early plating or a pin/rod/nail technique allows for faster healing, 16 weeks vs 28 weeks, quicker recovery and less pain in the recovery period.  Orthopedic referral for a surgical option may also be helpful even for less severely displaced middle third fractures.  Non-displaced middle third fractures often heal very well without surgery.  Displaced distal third fractures of the clavicle will likely also do better with surgical intervention.  It is typical to wear a sling until the fracture site is non-tender and arm movement is full with little discomfort, usually 4-6 weeks or so depending on the fracture.

AC separations (shoulder separation) are clinically classified into three grades.  Grade one is a stretched AC joint, which looks slightly swollen and tender on exam, but x-rays are normal.  With grade two separations the end of the clavicle is slightly prominent and tender on exam and x-rays show widening of the joint.  In grade three separations the end of the clavicle is really prominent and tender and the x-rays show complete disruption of the joint.  Treatment for grade one and two is a sling for comfort and resume normal activity when the pain improves.  This typically takes days to two weeks for grade one, and about two weeks for grade two.  Grade three is almost always non-operative as well but if pain continues past six weeks orthopedic consultation is appropriate.

3rd Degree AC separation, Notice the large step off at the end of the clavicle where it meets the acromion  (AC joint).  This clavicle is also straighter then typical due to an associated plating of a distal clavicle fracture.

3rd Degree AC separation, Notice the large step off at the end of the clavicle where it meets the acromion (AC joint). This clavicle is also straighter then typical due to an associated plating of a distal clavicle fracture.

Normal clavicle, note the relatively smooth contour and the mostly flat AC joint.

Normal clavicle, note the relatively smooth contour and the mostly flat AC joint.

Ouch.

Ouch.

Dr. Aaron Goldberg FAAEM is an Emergency Medicine Physician in Milwaukee WI. He is the director for Emergency Medicine resident education at St Lukes Medical Center. He is the team physician for IS Corp Cycling as well the My Wife Inc Cyclocross Team.  He races both road and cyclocross in the masters category.  He helps teach the Medical Emergencies in Cycling Course connected with the yearly Medicine of Cycling Course.  He would be glad to answer any further questions you may have.

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