Author(s): Timothy Tiu, MD, Dylan Wood, MD, Azmeer Khamisani, MD
Originally published: September 20, 2014 Last updated: December 17, 2025
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Disease/Disorder

Definition

Traumatic sports injuries of the shoulder include external forces that compromise the structural integrity of the surrounding tissues, bones, and joints of the shoulder complex. These injuries can include the glenohumeral (GH) joint, acromioclavicular (AC) joint, sternoclavicular (SC) joint, clavicle, proximal humerus, and/or scapula. Soft tissue injuries include the surrounding musculature of the rotator cuff muscles, biceps, or labrum. Careful assessment of the brachial plexus is also important to consider in any traumatic injury of the shoulder region.

Etiology

Shoulder dislocations are a common traumatic shoulder injury seen in sports. Anterior GH dislocations are the most common type and occur from forcible abduction, external rotation with extension and can be seen in falls, overhead activities, or blocking. Posterior GH dislocations are much less common and often arise from sudden muscle contraction such as during seizure or electric shock, or if seen in sports, from a fall with flexion, adduction, and internal rotation. 48.6% of shoulder dislocations within the emergency department were sports-related.1 AC joint injuries, otherwise known as shoulder separations, arise from direct falls onto the lateral shoulder with the arm adducted, and are classified by the Rockwood Classification. Sternoclavicular (SC) joint injuries are infrequent and classified as anterior and posterior, and are often caused by high energy collisions.2

Fractures of the shoulder area often include the clavicle, proximal humerus, and less commonly the scapula. Clavicular fractures can occur from a direct blow to the lateral shoulder or fall from an outstretched hand. Proximal humerus fractures (PHFs) are often from direct hits to the region in contact sports. Scapular fractures are rare but can occur from high-energy trauma.

Other injuries to the shoulder include rotator cuff tendon or muscle tears (including supraspinatus, infraspinatus, teres minor, and subscapularis) or brachial plexus injuries that occur due to compression, traction, or direct trauma to the upper trunk of the brachial plexus, and are otherwise known as ‘stingers’.3

Epidemiology including risk factors and primary prevention

Within the United States, the annual incidence of shoulder dislocation was 24 per 100,000 persons. The peak incidence age group was 15-20 with 70% of these individuals being male compared to female counterparts. 44% of these dislocations were from sports and recreation.4

AC joint separations occur at an overall incidence rate of 3.1 per 100,000 persons with the highest rate in individuals aged to 10-30 years old with 84% of the population being male and sports constituting 32% of the injuries.5 SC joint injuries represent 3-5% of all injuries to the shoulder girdle.6

Fractures of the clavicle occur at a rate of 18.7 per 100,000 persons with a disproportionate amount of these injuries occurring in the male population and aged 10-19 years old. The most common sports that occur in descending prevalence include football, soccer, snowboarding, cycling, wrestling, and skiing.7

The incidence of PHFs are much rarer and often occur in an older population from trauma or falls.8

Injuries to the labrum of the shoulder often occur in overhead athletes (baseball pitchers, volleyball, swimming) and contact sports. Young males aged 15-30 are the most affected due to higher shoulder forces.9

Rotator cuff tears are also an important consideration in any athlete with a traumatic shoulder injury. Higher prevalence is seen in skiers and overhead activities with approximately 4% of acute sports-related shoulder injuries being either a partial or full-thickness rotator cuff tear.10

Athletes who play football or hockey, or participate in boxing, gymnastics, or weightlifting are at increased risk of stingers; however, due to the transient nature, athletes tend to underreport them, making it difficult to ascertain the true incidence. There is an estimated injury rate of 2.04 stingers per 10,000 among American football players.11

Primary prevention of the above injuries should come from education regarding the risks of contact and overhead sports. Teaching proper skills such as tackling techniques in football and throwing mechanics in baseball could help lower the incidence of these injuries. Shoulder strengthening, flexibility, and stretching has been associated with decreased injury risk specifically in overhead athletes.12 Further research has shown that core stability and lower limb strengthening (specifically hamstrings and balance training) are also essential to prevent injury in the overhead athlete.40

Patho-anatomy/physiology

There are three primary types of GH joint dislocations: anterior, posterior, and inferior. Anterior dislocations are the most common caused by anteroinferior capsulolabral injury, which can lead to posterior lateral humeral head compression (Hill Sachs lesion). The second most common type of GH joint dislocations are posterior dislocations which can be encountered through seizures or an electrical shock. An inferior dislocation occurs when the arm is forced into hyperabduction, causing the abutment of the humerus against the acromion with subsequent separation of the humeral head from the glenoid.9

Proximal humeral fractures (PHFs) are classified using the Neer system, which is based on fracture location relative to the greater tuberosity, lesser tuberosity, head, and shaft, and divided into either: “2-part,” “complex 3-part,” or “4-part fractures”. PHFs are considered non-displaced if no segment is displaced more than 1 cm or angulated more than 45 degrees, while displaced fragments are classified according to the number of displaced fragments.8

The anatomic sites of clavicle fractures are typically described using the Allman classification, which divides the clavicle into thirds (proximal, midshaft, and distal), with midshaft fractures representing approximately 75 to 80% of all clavicle fractures. Lastly, 50% of scapular fractures occur in the body or spine of the scapula.9

Traumatic rotator cuff injuries have symptoms pertaining to the specific tendon that is injured. The most common rotator cuff injuries in descending prevalence include the supraspinatus, infraspinatus, subscapularis, and teres minor. These injuries are graded as partial-thickness, full-thickness, and complete tears.

Stingers can occur due to direct blow to the nerve causing compression from a hit at Erb’s point, a traction injury due to an increased neck-shoulder angle, or cervical nerve root compression caused by extreme flexion or extension of the neck. Per the Seddon and Sunderland classification, acute stinger severity can be categorized into neuropraxia (grade 1), axonotmesis (grade 2), or neurotmesis (grade 3).3

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

The initial presentation of GH dislocations is severe pain, deformity, asymmetry, and limited ROM. For isolated first-time anterior dislocations, recurrence is highest in young, active males; recent analyses show recurrence rates remain substantial in adolescents and young adults.13 Persistent apprehension, inability to return to sports, glenoid bone loss, and post-traumatic arthritis are other outcomes that may be present in those with history of shoulder dislocation.14,15

AC separations classified as types I-II are managed conservatively with good outcomes, and higher grades (III-VI) have variable recommendations depending on the athlete’s needs.13 SC joint dislocations are described as anterior or posterior and the Stanmore Triangle has been used to classify SC joint dislocations: type 1 (traumatic structural), type 2 (atraumatic structural), or type 3 (muscle patterning, non structural), and treated with closed reduction with conservative therapy or open reduction and stabilization on a case-by-case basis.2

The overall prognosis for PHFs depends on numerous factors: fracture pattern, patient age, associated comorbidities, and willingness of the patient to undergo lengthy rehabilitation.16 Most clavicle fractures treated non-operatively heal, although with variable amounts of cosmetic deformity.17 In scapular fractures, if no significant associated injury exists, complete or near complete recovery is expected.10

Rotator cuff tears are often treated with relative rest, rehabilitation, and load management. These tears are often preceded by underlying tendinopathy. Athletes may return to sports within weeks to months. If full thickness tears are encountered, these could require surgery.

Stingers generally occur unilaterally and acutely with sharp pain and reduced neck range of motion, with associated weakness, numbness, tingling, or paralysis for seconds to hours. Often, they are transient, though they may be associated with prolonged weakness. Should there be involvement of an additional extremity or any persistent symptoms, further workup is warranted.3

Specific secondary or associated conditions and complications

In patients less than 24 years old with anterior dislocation, anterior inferior labrum disruption (Bankart lesion) is described in the literature to occur in 87-97% of patients, posterolateral humeral cortical compression fracture (Hill-Sachs lesion) in 67-89% of patients, and superior labrum anterior-posterior (SLAP) tears in 10% of patients. In patients older than 30 years old, there is a 53% incidence of rotator cuff tears associated with anterior shoulder dislocations. Bankart and Hill-Sachs lesions occur in 73-100% of patients, and humeral avulsion of the glenoid ligament occurs in up to 9.3% of patients.15 Other complications include axillary nerve and artery injury, and brachial plexus injury.13 The “terrible triad” has been described in the literature, and includes a GH dislocation with a fracture, rotator cuff tear, and brachial plexus injury.2,16

Complications with AC or SC injuries include residual pain, arthritis, brachial plexus or vascular injuries, pneumothorax, esophageal ruptures, and tracheal compression. Certain injuries are emergencies including open AC joint injuries or those with subclavian or greater vessel compromise. Emergent SC joint injuries include posterior SC dislocations, which can lead to pneumothorax, or laceration of esophagus, trachea or great vessels.6,18 Complications associated with PHFs include neurovascular injury, avascular necrosis of the humeral head, and adhesive capsulitis. In displaced or comminuted clavicle fractures, complications include subclavian vessel injury, hemopneumothorax, brachial plexopathy, nonunion, malunion, posttraumatic arthritis, and recurrent fracture.

Essentials of Assessment

History

Essential components include time of onset, location, mechanism of injury, associated symptoms (e.g., neurovascular), modifying conditions, history of prior shoulder injuries, and previous interventions. Pain, swelling, loss of function and strength, locking/snapping/cracking sensation, instability (e.g., shoulder feeling loose), and possible deformity over the affected area may be described. It is important to ask about seizure history for posterior dislocations.

Physical examination

The examination should include inspection, assessing for atrophy, asymmetry, deformity, ecchymosis. Palpation should be used to assess for tenderness, crepitus, or bony abnormalities. Assess both passive and active ROM. A comprehensive neurovascular exam is essential and should include manual muscle testing, reflexes, and sensory testing to evaluate for brachial plexus or central injury as well as palpating for peripheral pulses. Special testing should include evaluation for radiculopathy (e.g., Spurling’s), rotator cuff strength (e.g., empty can, external rotation, belly/lift-off), impingement testing (e.g., Hawkins sign and Neer’s test), long head of biceps tendon testing (e.g., Yergason’s and Speed’s Tests), laxity/instability testing (e.g., load and shift, apprehension/relocation, and sulcus sign), and labral testing (e.g., O’Brien’s and biceps loading).

Functional assessment

Shoulder functional status can be evaluated through active and passive ROM, muscle strength, and joint mobility assessment. Limitations in sport-specific exercises are important to evaluate. The American Shoulder and Elbow Surgeons have adopted a standardized form that contains visual analog scales (VAS) for pain and an activities of daily living questionnaire to measure shoulder function and outcome.19

Laboratory studies

Labs are not routine for acute injuries unless metabolic bone disease, rheumatologic conditions or systemic contributors are suspected. In older adults with low energy pituitary-hypothalamus-axis, consider evaluation for osteoporosis and secondary causes using Dual-energy X-ray absorptiometry (DEXA) scan, vitamin D, calcium, or parathyroid hormone as indicated.

Imaging

Radiographs are the preferred initial test to detect GH dislocations and fractures (AP, Axillary or Velpeau, Stryker, Grashey views). Ultrasound can help evaluate rotator cuff tears and AC joints separations dynamically. AC joint separations can be evaluated with standard Zanca view on radiographs.  The need for advanced imaging (e.g., CT or MRI) is mainly dependent in part on initial radiographic findings and for those who are surgical candidates, those with PHF, and quantifying glenoid or humeral osseous or cartilaginous defects.9 MRI Brachial plexus may be helpful in evaluating a brachial plexus injury.

Supplemental assessment tools

Multiple assessment tools are utilized as a standard method to determine shoulder functionality in patients with shoulder injuries. Outcome measures include evaluation of pain, functionality, ROM, symptomatology, level of independence, and treatment satisfaction. Multiple questionnaires are currently available: Quick DASH scores, Constant Scores, Visual Analog Scale scores, Simple Shoulder Test, Short Form-36, and the Oxford Shoulder Scores.20 The 2022 BERN Consensus provides framework for load progression and return to sport decision making in shoulder rehab21.

Early predictions of outcomes

Younger age is a significant predictor for shoulder dislocation recurrence. Several studies have found the recurrence rate to be as high as 90% over two years in patients less than 25 years old.22-24 Associated risk factors include number of prior dislocations, activity level, male sex, history of bony defects, capsular deformation, or ligamentous injuries/laxity. Conversely, recurrence is less than 10% in older populations, largely due to the predominance of concomitant rotator cuff injuries as opposed to bony or ligamentous injuries as with younger populations. Outcomes in shoulder fractures are dependent mostly on the patient’s age, comorbidities, associated complications, and location and nature of the fracture. For clavicle fractures, displacement and comminution raise nonunion risk and affect functional outcomes.13 A positive correlation between stinger frequency and level of athletic competition has been shown. Collision athletes are more likely to sustain stingers due to the nature of the sport; however, older athletes may be more predisposed due to cervical spine degeneration secondary to aging and repeated microtrauma.3

Social role and social support system

Treatment outcomes involve the cooperation of the patient, the parents of young patients, and the athletic trainers and coaches in those involved in sports injuries. Sport psychologists can address coping with the natural process of the disease, the timing of recovery, and the treatment expectations.

Professional issues

The return to premorbid activities, such as the return to play in athletes and return to work in professional individuals, are important aspects in the management of shoulder injuries. There should be a multidisciplinary approach, with discussion of the natural process of the injury, treatment options, and the patient’s goals to make an informed decision. The Bern Consensus recommends individualized return to play decisions guided by staged load progression and functional milestones. Surgical timing in-season for athletes requires balancing recurrence risk, time lost, and team needs.21

Rehabilitation Management and Treatments

Available or current treatment guidelines

Acute reduction of GH dislocations should be prompt as delay greater than 24 hours increases risk of recurrent instability. There are several techniques, but consensus states that the physician should perform the techniques in which he or she is most proficient. Post reduction strategies vary and evidence supports individualized immobilization with early protected mobilization to reduce stiffness while minimizing recurrence. The arm may be placed in a sling and immobilized for at least 1 week. After this period, early gentle ROM is recommended to minimize capsular contraction. Restrictions for the first 4-6 weeks include no abduction and external rotation at 90° or greater of abduction to prevent recurrent dislocation. Scapular strengthening will be introduced at the 6-week mark.25,26

Patients with brachial plexus injuries should be removed from competition and have an initial neurovascular assessment with the contralateral extremity as a baseline. 85% of collision athletes who experience stingers do not miss subsequent games, and most resolve within seconds without intervention, though there are no standardized return to play protocols for those with persistent symptoms. They may return to play with demonstration of recovery including absent to minimal pain, completely intact neurovascular function, full cervical spine and shoulder range of motion and negative Spurling’s test. Further workup is necessary for persistent symptoms.3

Management of fractures depends on the patient’s age, activity level, location, and whether the fracture is displaced, non-displaced, or comminuted. Nonoperative care remains the standard for nondisplaced clavicle and many PHFs in low demand patients. For clavicle fractures, a sling, figure-of-eight splint, or a combination of both may be used; currently there is no consensus on the optimal duration of immobilization, but it ranges from 2 to 6 weeks.20,27  Higher grade AC or SC separations, displaced midshaft clavicle fractures in active patients, and complex PHFs, or those with recurrent instability or neurovascular compromise often require surgery.28

Rehab is staged: early protected ROM progression to strengthening and then sport specific loading. Typical RTS timelines vary by injury and intervention. Many athletes begin sport specific drills at 3 months and return fully between 4-6 months depending on severity, surgery, and sport. The Bern consensus and recent reviews emphasize criteria-based progression over time-based progression.21

At different disease stages

The patient should be referred to an orthopaedic surgeon if the following conditions are diagnosed: glenoid osseous defect greater than 25%, displaced medial clavicle fractures, humeral head articular surface osseous defect greater than 25%, PHF meeting surgical criteria, irreducible dislocation, failed trial of rehabilitation, continued pain and mechanical symptoms after conservative management, inability to tolerate shoulder restrictions, and inability to perform sport-specific drills without instability. While not absolute, orthopaedic referral should be considered in young patients with more than two shoulder dislocations during a season, overhead or throwing athletes, contact sport athletes, and injury near the end of a season.25,26

Coordination of care

Improved outcomes are obtained when patients are managed in a multidisciplinary manner. Communication between the patient, family members, coaches, orthopedic surgeon, physiatrist, physical and occupational therapist, nursing staff, case manager, and others is especially important for athletes returning to competition.

Patient & family education

The patient, parents, coaches, and trainers should be fully involved in care. They should be educated about the findings, expectations, and recommendations. Patients should be educated on the various operative and non-operative treatment options, possible complications, and the recovery timeline for their injury for a shared decision making opportunity.

Emerging/unique interventions

There are multiple cutting-edge concepts that are being used in the treatment and prevention of acute traumatic shoulder injuries. Identifying individuals who are at higher risk of injuries through motion analysis can help adjust mechanics to prevent future injury. Dynamic ultrasound and 3T MRI with AI models can assess for instability. Blood flow restriction (BFR) training can be used to create a metabolic high stress environment in a low load environment.

Recent studies suggest that conservative interventions for shoulder dislocations reveal unsatisfactory results, primarily in the young and athletic patients. Some advocate for orthopedic surgery referral after an initial dislocation to minimize risk of further glenoid bone loss. Early arthroscopic remplissage has demonstrated to be an effective technique with respect to recurrence rate, ROM, and shoulder function.29

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

When deciding the optimal treatment intervention in patients with a shoulder fracture or dislocation, factors to take into consideration include the patient’s age, activity level, dominant side, possible associated complications, and location of the fracture as well as other patient specific measures. Whether the injury is managed surgically or non-surgically, early motion is crucial in obtaining adequate functional outcomes.

Cutting Edge/Emerging and Unique Concepts and Practice

A 2024 systematic review compared arthroscopic stabilization versus immobilization in external rotation showed lower recurrent instability (8.8% vs 21.3%) and fewer subsequent stabilization surgeries in the operative group.30

Predictive risk modeling through player demographics, shoulder ROM, pitching velocity, and workload is being used to predict labral or rotator cuff injury risk. 3T MRI and MR arthrogram can help with risk stratification as it pertains to cartilage thickness and labral placement with microinstability that conventional MRI could miss. This has also been used with artificial intelligence algorithms to improve accuracy and faster diagnoses, which is essential in return-to-play decisions. Dynamic ultrasound helps assess glenohumeral translation during motion, which detects subtle instability not otherwise seen. BFR training has emerged as a promising technique that creates a metabolic stress environment for muscle hypertrophy in the setting of low-load resistance exercise to prevent high stress lifting or training. This is often initiated to allow for early strength and hypertrophy training in a low mechanical stress environment to allow earlier return to sports. This has been used after shoulder stabilization surgery with significant improvements in range of motion.31

Motion analysis and neuromuscular with kinetic chain rehabilitation has been utilized as a way to track shoulder loads, throwing mechanics, and fatigue in order to identify injury-prone mechanics and optimize rehabilitation. This can help stratify people who are at high risk for injury. Platelet Rich Plasma (PRP), stem cells, and collagen patches have been postulated to support labral and rotator cuff tears in athletes with poor tissue quality. Genomics and individual biomarkers are still being studied to further identify people at risk for injuries.

Gaps in the Evidence-Based Knowledge

Despite decades of research, there is still no consensus regarding the optimal management of shoulder dislocations and instability.

Traditionally managed with post-reduction immobilization, this approach is increasingly questioned due to high recurrence rates. Recent evidence demonstrates that arthroscopic stabilization significantly reduces recurrent instability compared with immobilization strategies. A 2024 systematic review found recurrent instability in 8.8% of surgically treated patients compared with 21.3% after immobilization in external rotation, with fewer subsequent surgeries in the operative group.30 A 2023 meta-analysis confirmed that arthroscopic Bankart repair reduces repeat dislocation, subluxation, and apprehension while improving return-to-sport rates compared with conservative care.32 A Cochrane review found insufficient evidence to inform choice of immobilization and recommended further high-quality trials on the subject.33 Nevertheless, immobilization practices remain variable: a 2024 RCT reported that omitting immobilization entirely yielded superior functional outcomes at 6 and 12 weeks without increasing redislocation rates.34

For chronic post-traumatic instability, long-term outcome data are sparse. Ten-year follow-up of arthroscopic repair for extensive (270°) labral tears demonstrated durable improvements, although failure rates approached 14%.35 Posterior shoulder instability remains a challenge, with long-term follow-up studies showing improved pain and function, but only modest return-to-sport rates; revision outcomes are less favorable, with recurrent instability and dissatisfaction common.36

Most PHFs are treated nonoperatively, and current evidence suggests surgery does not provide superior long-term outcomes in older patients, while increasing complication rates.37 However, reverse total shoulder arthroplasty is gaining traction for complex displaced fractures with tuberosity comminution or rotator cuff deficiency; newer fracture-specific stem designs may improve results.38 High-quality comparative trials remain lacking.

The optimal rehabilitation timeline after shoulder stabilization or fracture management is poorly defined. Trials are underway to determine whether sling immobilization is necessary after procedures such as the Latarjet surgery.39

Although the majority of fractures are treated non-operatively, the most appropriate form of management (surgical vs. conservative) is currently less clear when it comes to elderly patients. In addition, few guidelines are currently available as to staging physical therapy interventions to maximize ROM, strength, and optimize activities of daily living in these patients.27

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  40. Moiroux-Sahraoui A, Mazeas J, Delgado N, Le Moteux C, Acco M, Douryang M, Bjerregaard A, Forelli F. Prevention of Overhead Shoulder Injuries in Throwing Athletes: A Systematic Review. Diagnostics (Basel). 2024 Oct 30;14(21):2415. doi: 10.3390/diagnostics14212415. PMID: 39518380; PMCID: PMC11545345.

Original Version of the Topic

Jason L. Zaremski, MD, Daniel C. Herman, MD, PhD, Kevin Vincent, MD. Shoulder fractures, separation-dislocation, and other soft tissue injuries. 9/20/2014.

Previous Revision(s) of the Topic

William Micheo, MD, Brenda Castillo, MD, Jose R. Vives, MD, Javier González, MD. Shoulder fractures, separation-dislocation, and other soft tissue injuries. 9/6/2018.

Daniela Mehech, MD, Nirmal Maxwell, DO, Claire Cooper, DO. Traumatic Sports Injuries of the Shoulder: Fractures, Separations, and Other Injuries. 12/14/2022

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Timothy Tiu, MD
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Dylan Wood, MD
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Azmeer Khamisani, MD
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