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Explaining Sergio Ramos' injury

Should Real be careful with his recovery?

Gonzalo Arroyo Moreno/Getty Images

Footballers don't usually get shoulder injuries too often with the exception of goalkeepers, but the injury to Sergio Ramos on Tuesday is quite a common one in sport.   In football, the outfield players tend to be more susceptible to this kind of injury since these are almost always the result of landing after a fall and they are often unprepared for the impact.  Goalkeepers, however, tend to ‘roll' with the landing and learn how to hit the ground safely, thus giving themselves the minimal risk of ground-contact injuries.

Most of the research to date into shoulder injuries in football has focused on injuries to the actual shoulder joint itself.  This is known as the gleno-humeral joint in anatomical terms, and with the shoulder being the most mobile joint in the body, with that mobility comes an increased risk of injury through instability.  The shoulder itself is a ball and socket joint; formed of the articulation between the ball of the upper arm known as the humeral head, and the socket of the scapula - or shoulder blade - known as the glenoid fossa.  The scapula is the main bone involved in the shoulder joint; and the instability arises from the small contact area between the glenoid fossa of the scapula and the humeral head, leading to increased injury risk.

In Sergio's case, however, the injury is reported to have been sustained to the acromio-clavicular joint (ACJ); which is a small joint at the top end of the clavicle - or collar bone - attaching the clavicle to an area at the top of the scapula known as the acromion.  Anatomically, the ACJ is very easy to find and easy to injure.  To find the ACJ, just run your fingers along the length of your collar bone until you get to the end near the shoulder.  You will then find a slight ‘step' where the collar bone ends; and this area is where the ligaments of the ACJ keep the collar bone in place.  When the ACJ ligaments are torn, the collar-bone effectively ‘springs up'; leading to a visible deformity and the player will grip the arm to support it; often at the elbow.

A sprain of the ACJ is simply a tearing of the acromio-clavicular ligaments; and these are graded in the same way as ankle and knee ligament sprains.  These vary from a simple disruption of a few fibres being a Grade 1 sprain with an average 14 - 21 days recovery time; to a moderate Grade 2 sprain which is when a fair proportion of the ligaments are torn and can take around six weeks to fully recover.  A Grade 3 sprain, which is a complete tearing of the ACJ ligaments will take a lot longer and may require surgery.  In Grade 3 separations, a visible ‘step' is usually evident where the ligaments retaining the collar bone to the upper aspect of the acromion / shoulder blade have been ruptured.  In medical terms, therefore, a true ACJ dislocation is a Grade 3 sprain and may require surgery.

ACJ injuries arise primarily as a result of a falling and landing on the outstretched hand, the point of the elbow, or on the point of the shoulder.  Viewed from the front, the classic presentation is an obvious ‘step' or ‘gap' between the end of the collar bone and the top of the arm.  This is an injury that arises frequently in both codes of rugby.  In a study at professional level in Rugby Union in England, ACJ sprains accounted for 32% of all shoulder injuries and was the most common of all the upper limb injuries sustained in matches (Headey et al, 2007).  In the 13- a - side Rugby League code, King et al (2010) also noted that the shoulder was the most common area injured of all the body segments recorded.

Clearly other sports including American Football and Baseball place a huge emphasis on research into shoulder injuries since these are known to be among the most commonly sustained; but with the incidence of upper limb injury in football reported to be relatively low, there is a lot less information available.

There were only 80 shoulder injuries recorded by Ekstrand et al (2011) out of 4483 injuries in the UEFA study of 2008.  As a result of this, Longo et al (2012) were concerned that shoulder injuries were being overlooked in soccer, and carried out an extensive search into the origins, mechanisms, and management of shoulder injuries in football.  However, due to the lack of previous research studies available, most of which only recorded the type of shoulder injury sustained, they were unable to differentiate between injuries to the goalkeepers and outfield players.

This is disappointing, since if we are going to manage injuries correctly in football, further research into the less frequent injuries is essential. Piero Volpi (2006) discusses this in his excellent book, Football Traumatology, and stresses that just because certain injuries are less prevalent than others, these do occur; albeit only in lesser numbers.  However, football in general isn't renowned for opening it's doors to researchers at club level and collating relevant information for statistical purposes can often be difficult.

This past 48 hours will have been the key period for Sergio Ramos.  During this time the injury will have begun to settle and Madrid's medical team will soon be able to make a clearer decision as to whether any surgical interventions are required.  Normally an MRI scan will be performed within the first few days after the injury in order to ascertain the full extent of the damage; and based on the results of that together with a clinical examination, a more accurate prediction of how long the recovery period is likely to be can then be made.  This will be variable depending on the extent of the injury and also on how well the injury settles over the next few days.  Examination and assessment will be an ongoing process with progress duly monitored

Although painful and limiting in the early stages, injuries to the ACJ are normally the lesser of two evils when compared with injuries to the shoulder joint proper.  These can potentially bring a whole list of added problems and associated injuries to accompany what may appear to be a relatively straight-forward injury.  However, like any other injury, injuries to the ACJ have the potential for recurrence and the medical team will be well aware of this.  Sergio Ramos is unlikely to be rushed back into the team on that basis.  Additionally, the emphasis that Rafa's new fitness team place on researched evidence should reassure everyone - particularly Sergio himself (!) - that this is unlikely to happen.


Eckstrand J, Hagglund M, Walden M (2011).  Injury incidence and injury patterns in professional football -  the UEFA injury study.  British Journal of Sports Medicine. Vol 45 (7); 553 - 558.

Headey J, Brooks JH, Kemp SP (2007).  The epidemiology of shoulder injuries in English professional rugby union. American Journal of Sports Medicine. Vol. 35 (9); 1537 - 1543.

King DA, Hume PA, Milburn PD, Guttenbeil D (2010).  Match and training injuries in rugby league: a review of published studies.  Sports Medicine Australia. Vol. 40 (2); 163 - 178.

Longo UG, Loppini M, Berton A, Martinelli N, Maffulli N, Denaro V (2012).  Shoulder Injuries in soccer players.  Clinical Cases in Mineral and Bone Metabolism.  Vol. 9 (3); 138-141.

Volpi P (2006). Football Traumatology; Current Concepts from Prevention to Treatment. Milan, Springer.

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