Injury Prevention in Grappling Sports - Part IVa

Last week we started discussing another common area of injury in grappling sports, the shoulder.  In starting our discussion, we talked about the anatomy of the shoulder that is commonly involved or impacted in grappling.  This is important to know because the time that it takes you to recover can depend on the injury that occurs and what structures are involved.  Keep in mind, the information in this blog should never replace the advice of your medical provider.  Nothing can replace a physical examination with your health care provider.

In this week's discussion, we will start to look at how those structures are involved and what submissions or positions usually injure these areas.  Keeping in mind there are a lot of submissions that can injure the shoulder, this will not be an all inclusive list.  What we will do is go over the most common ones we see in the clinic and the tissues that are involved.

Arm Bar - obviously arm bars can be done from a lot of positions and the injury that can be sustained will be position dependent and depended on the opponents position.  For example, in the example depicted here, the opponent is standing when the arm bar is applied.  This will put a lot of pressure on the elbow with driving his hips forward.  However, if he drives his hips forward and kicks the legs back at the same time, this creates pressure on both the elbow and the anterior (front of) shoulder (specifically the labrum of the shoulder).

Couple things to keep in mind, if the opponent depicted here, steps back with the left foot, this will increase the pressure to the shoulder and can involve more pectoralis.  When I first started training >5 years ago, this was one of my first injuries.  An injury to my pectoralis major from resisting an arm bar and stepping back.

In addition to the stress applied by the arm bar itself, resistance to this position (especially as depicted above) is primarily provided by the biceps.  If the anterior shoulder is under pressure (as in the picture above) and a maximal resistance is given to the resist the arm bar, this can result in a a long head of the biceps pulling on an already stretched and stressed labrum.  This can cause the labrum to tear or the biceps tendon to tear.

In this scenario you may have one of 4 things:

• Pop in the shoulder and balling up of the muscle - typically this is associated with a biceps rupture.  This is a hard one to miss as there is typically a lot of pain, more diffuse pain, bruising in the arm (usually in the next 48-72 hours) and balling up of the bicep muscle (Popeye bicep).  In this case you should see your physician.        
• Pop in the shoulder with pain - this can be associated with a lesser of a degree of bicep tear or labral tear.  This will result in more localized pain, to the front of the shoulder.  If bruising occurs, more likely bicep.  If shoulder feels unstable (feels like comes in and out), this can be a sign of larger labral tear.  If this is the case, you should see your MD.  If no bruising in 24-48 hours, pain resides and shoulder feels stable, this can most likely be self treated with ice and shoulder exercises.
• Pop in shoulder without pain - there are a lot reasons you can get a pop in the shoulder.  However, if there is no pain, you have full range of motion and no change in strength, you should be good doing activities that do not bother you.  I would suggest take it easy and ice proactively.
• Shoulder pops out - this is shoulder dislocation.  If it self reduces (goes back in) you should have it checked out by your physician.  If it does not self reduce (stays out of place) this is considered a medical emergency and should be seen right away.  There is the possibility of compromised blood flow and neural input to the lower arm and should be relocated (put back in place) ASAP.   

*If you have constant and significant tingling and numbness down your arm, loss of sensation in your arm or loss of circulation in your arm, seeking a medical evaluation is strongly encouraged.* 

One common escape from an arm bar is turning the thumb down, bending the elbow and swimming around. This escape can also put the shoulder in a compromised position and can lead to shoulder injury.  With the arm extended and rotating in this position puts a significant amount of stress on the labrum and rotator cuff.  As a seasoned jiu jitsu athlete (5+ years training and 50+ years old) this is not an escape that I can do.  If in your training or drills you attempt this position and it bothers your shoulder, this should not be an escape you rely on to get out of an arm bar.  If it bothers you under lower load (drills and training) this should not be the one you resort to under higher loads and competition. 

Kimora, Americana, Key Lock, etc. - there are a lot of shoulder submissions we use in the sport and they are achieved in a lot of different positions.  Obviously these are shoulder submission and each will place a lot of stress on the tissues of the shoulder.  The tissues that are involved will not only depend on the submission itself but the position in which the submission.  As a sports medicine physical therapist, one of the most interesting things I first learned in Jiu Jitsu is that a lot of the submissions in the shoulder mimic special tests we use to determine what is wrong with the shoulder. 
For example, this test (internal rotation lag sign) looks like a badly performed kimora with a wrist lock.  The reason for pointing this out is that these submission positions are, sometimes, the same positions we use to stress the tissues of the shoulder to determine what is wrong.  This is why they work, they are designed to stress these tissues.  This is important to keep in mind because with constant stress we can outpace our bodies ability to repair these tissues.  This leads to injury.  As a practitioner, we have to be proactive in our shoulder health

With shoulder submission positions, the most common tissues involved are the rotator cuff, labrum and long head of biceps.  Injuries commonly occur due to the submission itself as well as when we try to resist the motion.

• Rotator cuff injuries.  >80% of rotator cuff injuries occur in the supraspinatus.  This will result in pin point pain on the outside of the shoulder (lateral aspect in the subacromial space) and may refer to your deltoid insertion (down the outside of your arm).  This will be painful to resistance to the external rotation (rotating the arm out) or raising your arm out to the side.  A physician visit is advised if you hear a pop in the shoulder with any of the following: significant pain in the shoulder (5/10 pain or greater), loss of range of motion of the shoulder (unable to move it overhead), significant pain (5/10 or greater) with moving your arm, tingling and numbness down the arm.
• Long head of biceps tendon.  Due to the attachment and crossing of the shoulder joint and the resistance we often give to avoid the submission, this is often involved.  A physician visit is advised if you have any of the following: pop in shoulder with bruising down the arm or balling up of the biceps, inability to flex the arm, significant pain (5/10 pain or greater) in the arm or with trying to raise the arm or significant pain (5/10 pain or greater) with turning door handles, screw driver or getting gallon of milk out of the fridge (all very active biceps activities). 
•  Labral injuries.  This is a common injury in Jiu Jitsu.  Most think if their labrum is torn that this will require surgery.  I can tell you that I have treated a lot of athletes (high level and not so high level) and this is really dependent on the location and severity of the tear.  Personally, I tore mine in my 30s.  As a weightlifter and someone that does Muay Thai and Jiu Jitsu and is over 50, I have not had my repaired.  If you have pain that limits your range of motion, prevents you from sleeping at night or your shoulder feels unstable (sensation comes in and out), then you should see a physician.  

As with cervical injuries (please refer to this previous blog), you can monitor your progress by how your pain is.  You should also start icing right away.  The more you ice and the more likely you are to return to the mat and full training quicker and with less problems.  

We hope you continue to enjoy this series and find the information valuable.  Next week, we will talk a few more injuries then move into some specific stretches and exercises for preventing injuries.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years.