By: Esther Ebuehi, Human Development major, Nutrition Science minor ’16
“This narrative case report describes an athlete’s shoulder injury and explores the way injuries are treated in the world of collegiate athletics. While I was writing this piece, I recognized just how little time non-athletes spend thinking about the impact of sports injuries. Many NCAA athletes have life-long sports injuries, but we rarely talk about this issue as a campus community. There’s a national discourse revolving around injury prevention in football, and I believe this is a topic college students (athletes and non-athletes alike) should be thinking critically about.”
On a sunny October afternoon in 2012, Coolidge Evans, running back for an NCAA Division I football team, stepped on the field with a smile on his face. His team had traveled to South Dakota to play South Dakota State, and he was starting for the first time. A football player since the age of 6, Coolidge was always in tune with the vibe of the field before a game. On this particular day, he could tell he was about to “go off”. “‘Go off’ basically means I had full composure and control of the game,” Coolidge explains.
A sophomore at the time, Coolidge was excited to play well and make his parents (who had traveled from California to see him) proud. The players were running the spread offense, which is Coolidge’s favorite play. He had experience with this play in high school, so he knew exactly what he needed to do. Coolidge knew that the defense was aggressive and would act on quick assumptions, so he successfully tricked the defense by going left and breaking into the open field ahead of him. The safety tackled him as he was running, and he fell to the ground. “I was moving the ball but then I was like ‘Ah, this is all bad,’” Coolidge recalls. Instead of bracing for the impact, Coolidge relaxed his body as he came down to the ground.
Lying on the ground in a state of shock, Coolidge couldn’t feel anything. He was on the ground for all but a couple of seconds, though, and found that he could get up without any help. He told the physical trainers on the sideline that his shoulder didn’t feel normal. He wanted the trainers to cut through his jersey and remove his shoulder pads to get a good look at his shoulder. The physical trainers refused, despite the fact that his shoulder was clearly causing him pain. The trainers gave Coolidge some painkillers and he sat out for the rest of the game. Coolidge left the field to shower and put his arm in a basic sling. He was later given ice for his shoulder. He was in pain on the bus ride from the stadium and on the flight home. “Sleeping on that plane was the most uncomfortable sleep I’ve ever had,” Coolidge recalls.
Coolidge had injured his acromioclavicular (AC) joint during the game. The AC joint is located between the clavicle and the scapula. While the AC joint is strong, its location makes it vulnerable to injury from direct trauma (Koehler et al. 2015). The muscles that attach to the bones in this region rotate, flex, and extend the arm. In American football, shoulder injuries account for 10% to 20% of all musculoskeletal injuries, and in a cohort of intercollegiate football players, AC joint injuries accounted for 41% of all shoulder injuries (Lynch et al. 2013). The prevalence of these injuries comes as no surprise; football players are constantly tackled on the field and are given little time to recover, and these injuries are diagnosed and treated with a nonchalance that is quite commonplace in the field of athletics.
When he returned home, Coolidge realized just how much he needed his shoulder for daily tasks. Showering, wearing a backpack, and driving his manual car proved to be difficult with his impaired shoulder. Coolidge accommodated for this by using his good arm. Physical trainers said he had a third-degree AC separation, but that he would be fine. “In football language, ‘fine’ means ‘good enough to play,’” Coolidge clarifies. A third-degree AC separation refers to the complete dislocation of the joint between the shoulder blade and collarbone, an injury so severe that it can result in a permanently deformed shoulder.
Before heading out to practice, Coolidge would get an air cushion taped around his shoulder and his shoulder pads would be placed on top. The physical trainers recommended that Coolidge do weekly physical therapy, but he felt like they were downplaying his injury. He was still in pain, but for a month and a half, he tried to convince himself that he was okay.
If a player’s injuries are not properly treated, players might have to face the physical and mental burden of dealing with serious complications. Dr. Danielle Campagne, an emergency medicine physician, states that these complications may threaten life or limb viability or cause permanent limb dysfunction (Campagne, 2014). This may sound overly dramatic for a fairly common sports injury, but failing to let an injured joint properly heal can greatly increase the risk of permanent damage. Joint injuries can disrupt neurovascular structures in the body. Blood vessels and nerves from the hand and arm drain into a main artery and nerve plexus (respectively), both of which are located in the shoulder region, so an injury in this area can be especially debilitating. Long-term complications can result in general joint instability, torn ligaments, or fractured bones. In most cases, a physical examination will be done, x-rays will be taken of the affected area and, if the injury is deemed mild, the patient will be sent home with a list of rehabilitative arm exercises. In more serious cases, an MRI scan will be administered and surgery may be necessary.
One weekend, Coolidge flew to Los Angeles and got an MRI scan through his personal physician. The MRI scan confirmed that he had a torn labrum in addition to the third-degree AC separation. A labrum tear refers to a rupture of the cartilage that stabilizes the shoulder joint, and it is a common injury for athletes who engage in tackle sports. His shoulder was, as athletes call it, “blown”. He returned to campus and showed the physical trainers his MRI results. They agreed that surgery was necessary. Throughout December of that year, Coolidge did not train with the football team, but instead took time off to let his shoulder heal.
Coolidge went in for shoulder reconstruction surgery the following January. The ligament of his left clavicle bone and the tendons of his left bicep were reattached to his scapula. His torn labrum was reattached to his shoulder socket with sutures. He was prescribed Vicodin for the pain and his healing shoulder was encased in a heavy duty sling for four months. Two months after the surgery, he began daily rehabilitative exercises. He continued to do physical therapy with an athletic trainer for the rest of the year.
Anywhere from 11% to 81% of student athletes will sustain an injury over the course of their football careers (Dragoo et al. 2012). Only 3.6% of AC joint injuries are diagnosed as severe enough to require surgery. In a retrospective study that assessed the pathology of AC injuries in NFL players, orthopedic surgeon Dr. Bryan Kelly states, “Surgery has rarely been necessary. We have treated several NFL quarterbacks non-operatively.” Dr. Kelly does go on to mention that more serious cases will need surgical treatment (Kelly et al. 2004). Surgery and post-operative care are both time-intensive and costly. The process can be emotionally jarring for student-athletes specifically, many of whom want to simply get playing time on the field. Recovering from a severe injury can also affect other aspects of a student-athlete’s life; balancing academic responsibilities in addition to physical rehabilitation may prove to be too much to handle.
In more recent years, there has been a bigger push to prevent football players from having to deal with the physical pain and mental burden of injuries. Researchers have analyzed extensive databases containing injury diagnoses of NFL and NCAA athletes. In a study that assesses data from the NCAA Injury Surveillance System, Dr. Jason Dragoo and his colleagues found that rates of AC joint injuries are 11 times greater during football games than during practices (Dragoo et al. 2012). The study posits that game conditions are less predictable and produce heightened speeds and intensity, which contribute to an increased risk of injury (Dragoo et al. 2012). Reevaluating how players train and how injuries are treated might lead to a lower incidence of these severe injuries occurring during games. Results from injury prevention trials in other sports show that a structured and progressive warm-up can help prevent general sports injuries, but there is a lack of research that assesses the effectiveness of this training tactic in football specifically (Kirkendall et al. 2010). As far as treating joint injuries, the American Academy of Orthopedic Surgeons suggests that the player must have no pain, no swelling, a full range of motion, and normal strength before returning to play (AAOS 2013).
Football players look practically superhuman on the field. That’s why fans enter stadiums in droves to support their favorite players. Unfortunately, many fans do not know how common it is for players with sustained injuries to continue playing when they shouldn’t. Football players might seem indestructible, but it is crucial to remember that, even in all their might, they have very vulnerable and fragile bodies.
By the end of the year, Coolidge felt like he had fully recovered. He remained on the team and continued playing football for two more years. Now, at twenty-two and still as athletic as ever, Coolidge appears to be in good health. When asked what triggers his shoulder pain he pauses for a moment and mumbles, “Thinking about it triggers the pain.” He says he doesn’t even like touching the scar. When asked if he feels like his shoulder is back to normal he responds, “No, but it’s a new normal.”
References[AAOS] American Academy of Orthopedic Surgeons. Football Injury Prevention [Internet]. American Academy of Orthopedic Surgeons c2013 [cited 2016 Feb 1]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00113
Campagne, D. 2014. Overview of fractions, dislocations, and sprains [Internet]. Merck Manual; [cited 2015 Oct 18]. Available from: http://www.merckmanuals.com/professional/injuries-poisoning/fractures-dislocations-and-sprains/overview-of-fractures-dislocations-and-sprains
Dragoo JL, Braun HJ, Bartlinski SE. 2012. Acromioclavicular joint injuries in National Collegiate Athletic Association football. Am J Sports Med [Internet]. [cited 2015 Oct 18]. Available from: https://vpn.lib.ucdavis.edu/content/40/9/,DanaInfo=ajs.sagepub.com+2066.full.pdf+html
Kelly BT, Barnes RP, Powell JW, Warren RF. 2004. Shoulder injuries to quarterbacks in the National Football League. Am J Sports Med [Internet]. [cited 2015 Oct 18]. Available from: http://ajs.sagepub.com/content/32/2/328.full.pdf+html
Kirkendall DT, Junge A, Dvorak J. 2010. Prevention of Football Injuries. Asian J Sports Med [Internet]. [cited 2016 Feb 1]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289174/pdf/ASJSM-1-081.pdf
Koehler SM, Fields KB, Grayzel J. 2015. Acromioclavicular joint injuries [Internet]. Up to Date; [cited 2015 Oct 18]. Available from: www.uptodate.com
Lynch TS, Saltzman MD, Ghodasra JH, Bilimoria KY, Bowen MK, Nuber GW. 2013. Acromioclavicular joint injuries in the National Football League. Am J Sports Med [Internet]. [cited 2015 Oct 18]. Available from: http://ajs.sagepub.com/content/41/12/2904