Mohamed Salah’s Type 1 AC Joint Sprain: World Cup in Jeopardy?

In the 25th minute of the Champions league final between Liverpool and Real Madrid, Mohamed Salah hit the ground (pulled to the ground?) shoulder first while jockeying for hold-up position against Real Madrid’s centreback Sergio Ramos, likely suffering a type 1 AC joint sprain in his left shoulder.

Here’s video of the incident:

The Liverpool dynamo and player of the year tried to play through the type 1 AC joint sprain, but was in too much pain to continue after a Liverpool corner in the 29th minute.  The realization of Salah’s shoulder injury set in – he would miss the rest of the final and his status for the World Cup – only 19 days away at that point – was up in the air.

Through my lens as a DPT, Doctor of Physical Therapy, I’ll delve into Salah’s type 1 AC joint sprain and his possible return for the World Cup, by answering the following questions

  • What’s the anatomy & function of the shoulder joint?
  • What role does the shoulder play in soccer and for Salah specifically
  • What exactly happened during Salah’s type 1 AC joint sprain? Is Ramos to blame?
  • What is the recovery and rehab process for type 1 AC joint sprain?
  • Will Salah’s shoulder be healed in time for the World Cup?

The Liverpool medical staff has been very vague, commenting on the Salah shoulder injury only as a “shoulder sprain, with no signs of fracture or severe dislocation“.  However, the mechanism of injury (the way he hit the ground), the on-field reaction from Salah, on-field assessment from the physio, and optimistic timetable for return inform us on the the extent and severity of injury.

Lets start with the anatomy and function of the shoulder:

I. What’s the anatomy and function of the shoulder?

A. The general anatomy and function

The shoulder complex is rich in anatomy – multiple bones, muscles, ligaments, and 4 distinct joints. For the sake of this piece, we’ll focus on the AC joint and shoulder movement.

The AC joint – also known as the acromioclavicular joint – is a joint at the top of your shoulder. It joint forms the junction between your acromion (part of the scapula aka shoulder blade) and the clavicle (the collarbone). Take a look:

type 1 AC joint sprain
Credit – Harry Brownlow

The AC joint is stabilized by 4 different ligaments (think of ligaments like rubber bands that are tensioned during movement and help keep the joint in place) but for our purposes, we can categorize them into 2 major ligaments – the acromioclavicular (AC) and coracoacromial (CA) ligaments.

Take a closer look:

type 1 ac joint sprain
Credit – shoulder and elbow

When the AC joint takes on excess force and gets shifted out of place, these ligaments can stretch/tear (sprain), and with enough force, they can rupture (full tear).  A type 1 AC joint injury indicates a mild sprain in the AC ligaments.

To understand the function of the AC joint, we have to first understand a little bit about the mechanics of the shoulder.

Whenever you move your shoulder, the head of your humerus (your upper arm) moves around in your glenoid cavity.  The glenoid is like a socket that the head of the humerus fits into, hence the glenohumeral joint is termed a “ball and socket joint”.

Here’s a basic video:

And a visual of shoulder movements:type 1 ac joint sprainCredit – Sequence Wiz

However, what that video and picture don’t show is how the scapula simultaneously moves and aides with shoulder movement. This is called scapulohumeral rhythm.

Here’s a video:

Additionally, depending on what range the shoulder motion is taking place in, there’s a certain ratio of movement between the scapula and glenohumeral joint.  This visual shows the ratios:

type 1 ac joint sprain
credit – Simon Atkins

I like to say that that the scapula “sets the stage” for shoulder movement.  Without the scapula moving, shoulder movement is going to be limited – especially when moving the arm and shoulder up overhead.

The AC joint, as I touched on earlier, is a major junction and bridge that allows this rhythm to occur. When that joint is disrupted, like in the case of Salah’s type 1 AC joint sprain, that disrupts scapulohumeral rhythm, mechanics, and overall shoulder function.

(To note: there are 2 other joints that also contribute to shoulder motion but I have left them out for the sake of brevity and clarity)

Now that we’ve covered the anatomy and general function of the shoulder, lets take a sport and player specific look at function…

B. Soccer-specific function

Soccer is obviously lower body dominant, but still involves a considerable amount of shoulder mobility, strength, and leverage which can irritate a type 1 AC joint sprain.

Players are constantly fighting for position in the run of play or off a dead-ball, trying to gain leverage with their upper bodies by leaning in with the shoulder or using their arms, overhead during throw-ins, and bringing the arm up as a counter-balance during kicking movements.

For Salah’s role as a #9 in Liverpool’s system – he’s constantly leveraging and hand-fighting while at high pace since Liverpool’s front 3 constantly interchange to create confusion and gaps, he gets into the opponent with his body and arms due to Liverpool’s incessant pressing (I say that with complete admiration – as an Arsenal fan, I’m really excited to see Unai Emery’s tactical pressing), and jockeying for position with defenders in the final 1/3 to create incoming passing lanes for himself or gain possession.

This hold-up and jockeying play is how Salah got hurt during the CL finals. Let’s take a look at what exactly happened…

II. Salah’s Type 1 AC joint sprain

A. The Mechanism of Injury and Reaction

Let’s start with a picture-by-picture breakdown of what happened and led to Salah’s type 1 AC joint sprain:

type 1 ac joint sprain
Credit – ESPN FC

The encounter between Salah and Ramos starts when the ball is played into the middle of the pitch.  Ramos is tracking Salah and both are jockeying for position with Salah leaning into Ramos and hooking under his arm to gain initial leverage.

type 1 ac joint sprain
Credit – ESPN FC

As Salah gains leverage and Ramos is pushed off his line to the ball, Ramos begins to fall to the right. He hooks his elbow and arm under Salah’s which pulls Salah down as well.

type 1 ac joint sprain
Credit – ESPN FC

As Salah goes to ground, his left arm is tucked underneath. This puts his shoulder in a flexed-adducted-internally rotated position (remember that) and his left shoulder is headed for direct contact with the ground.

Split-seconds later, Salah’s shoulder makes contact with the ground, taking it full-on:

type 1 ac joint sprain
Credit – ESPN FC

And the reverse angle:

type 1 ac joint sprain
Credit – ESPN FC

_____________

Before we go any further, there’s a heated question that needs to be addressed: Is Ramos at fault for Salah’s shoulder injury by hooking Salah as he fell to the ground?

Based on Ramos’ history and reckless behavior, I have to lean towards yes.  He’s like the Cobra Kai of centre-backs at this point (having learned from the master, Pepe).

Don’t get me wrong, Ramos is a great player- he’s one of the best CB’s of this generation in my opinion – but there’s a fine line between being physical and being reckless.  Ramos has crossed that line too many times and put players in danger.  I can’t give him the benefit of the doubt.

When there’s a clear pattern of dangerous behavior, you have to take that into consideration.  Fool me once, shame on you..fool me twice, shame on me….try to fool me for the 50th time, lol cmon.

For what it’s worth, Liverpool’s physio Ruben Pons alleges that Salah does not blame or hold any ill will towards Ramos.

“Salah has not told me anything about Sergio Ramos…I (Pons) don’t think he is angry with him. It was an accidental challenge.”

Anyways, back to our regularly scheduled programming.

__________

Although Liverpool hasn’t released the specifics of the injury, the position of Salah’s shoulder at contact, Salah’s reaction, the on-field assessment by the Liverpool physio, and optimism for Salah’s return inform me that Salah’s shoulder injury is most likely a type 1 AC joint sprain – a slight displacement of the AC joint resulting in a slight stretch and tear of the AC ligaments.

AC joint injuries are often caused by falling directly onto the shoulder with the shoulder flexed, adducted, and internally rotated (aka the arm up and across the body).  Take a look at the moment of injury again:

type 1 ac joint sprain
Credit – ESPN FC

You can clearly see how Salah’s moment of impact checks all those boxes – direct hit to the shoulder with an arm that is up and across his body.

With enough force, contact in that specific position can disrupt the AC joint and the ligaments:

type 1 ac joint sprain
Credit – BrisbaneShoulderClinic

Additionally, Salah’s reaction and the physio’s immediate assessment points to an AC joint injury as well.  With an AC joint injury – unlike many other injuries where location of pain is not a reliable indicator – the location of pain can be very localized and often the person will be holding that spot of the AC joint or can point directly to it.

As we saw with Salah, immediately following the point of contact:

type 1 ac joint sprain
Credit – ESPN FC

After the corner on the 29th minute:

type 1 ac joint sprain
Credit – ESPN Fc

And with the Liverpool physio feeling for tenderness in that same spot (Salah’s face gives us that answer):

type 1 ac joint sprain
Credit – ESPN FC

Generally, AC joint sprains are relatively common – accounting for about 9% of shoulder injuries.

Now that we’ve covered how the injury happened, what are some of the symptoms that Salah may have been feeling….

B. Symptoms of an AC joint sprain

The initial symptoms are:

  • Pain over the AC joint
  • Possible pain referral to the trapezius muscles
  • Loss in range of movement
  • Tenderness to touch over the AC joint. Right here:
type 1 ac joint sprain
Credit – LeadingEdgePT

Additionally, after Salah went off in the 29th minute, the medical staff likely completed a handful of tests to rule injuries in or out and determine the extent of damage…

C. Testing

1 – Manual Testing

To assess the injury and potential severity, there’s a series of tests (called a “test cluster”) that if positive gave a very high likelihood that Salah indeed had an AC joint injury and based on specific findings, inform the medical staff of how severe the injury was.

Here’s a video of this test cluster (go the :55 mark):

Additionally, observation of the shoulder gives valuable information as well.  In more severe AC joint injuries, there’s obvious displacement.  Here’s an example:

type 1 ac joint sprain
Credit – Stack

In general, there are 6 different types (with some of those having sub-types) of AC joint injury, each corresponding to a different level of ligament damage and possible displacement or fracture of associated bones (like the clavicle).

Here’s a chart with those 6 classifications:

type 1 AC joint sprain
Credit – PhysioPedia

And a visual representation of each:

type 1 ac joint injury
Credit – CoreEM

With manual testing complete, Salah would be taken in for imaging…..

2 – Imaging

X-rays were taken to confirm the extent of the AC joint injury.  The key indicators are if there’s any separation between the AC joint and displacement of the clavicle.

For reference, here’s an x-ray of a type 3 AC joint injury with an overlay of a normal clavicle position:

type 1 ac joint injury
Credit – Michael Codsi

 

III. Salah’s type 1 AC joint sprain rehab and recovery process

Immediately following the type 1 AC joint sprain, Salah’s arm was immobilized and put into a sling:

This is to allow his ligaments to heal and not put excess strain on the shoulder.  Think of it like wearing an ankle brace or wrap for the first few days after a minor ankle sprain.

Three days later, Salah was at the airport not wearing a sling and actively using the left arm:

type 1 AC joint sprain
Credit – El Chiringuito TV

This short time period of immobilization and active use is a great indicator that Salah’s shoulder injury indeed a type 1 AC joint injury and not that serious.

Now that he’s out of the sling, what does his treatment consist of?

I categorize the rehab process into a micro (tissue), mezzo (systemic), and macro (emotional/social/contextual) model.  Lets start with the micro:

A. Micro (the tissue)

1 – Reduce pain

The first task is to reduce pain because pain changes movement, leads to compensatory patterns, and interferes with subsequent rehab.

This is done by initially protecting the shoulder via immobilization. Once that phase is complete, treatments like soft tissue work, ice, e-stim, and a TENS unit are introduced.

2 – Restore mobility

The second goal is mobility.  Gentle passive range of motion and active range of motion, as tolerated, will be introduced as soon as possible to keep the muscles active and the joint from stiffening and losing range of motion.

3 – Improve strength

The third goal is strength.  Once the shoulder has or is near full range of motion, Salah can start strengthening the surrounding musculature. 

Strengthening is always important in rehab but it’s of particular importance when rehabbing a shoulder injury, including a type 1 AC joint sprain.  The shoulder has so much range of motion which makes it less stable and puts increased onus on the ligaments and muscles to provide stability.

With a type 1 AC joint sprain, the ligaments are still healing so there’s increased onus on the muscles to help control and direct shoulder motion appropriately.  This means strengthening both the shoulder muscles and scapular (shoulder blade) muscles because, as we learned way up at the top, scapular movement and control is intricately linked with shoulder movement.

The progression for strengthening is as follows:

  • Isometric holds (muscle contraction against resistance, without movement).  Like these:

  • Closed-chain exercises.  Some examples:
shoulder subluxation
Credit -AccessPhysioTherapy
  • Open-chain exercises.  Another video:

  • Within these categories, Salah will progress from concentric to eccentric strengthening (the latter puts significantly more load on the muscle).  Here’s a visual explaining the difference, using a biceps curl as the example:
shoulder subluxation
Credit – PitchMechanics

If you’re interested, I created a full shoulder injury prevention and warm-up progression.  I do it every day and before any upper body activity.  Check it out:

4 – Sport specific

Once Salah is able to clear fundamental strengthening without a significant pain response, he’ll be cleared to return to the pitch and incrementally take on more contact, until he’s able to tolerate full-on contact and intensity.

B. Mezzo

1 – Bio-Mechanics

There are bio-mechanical factors – other than the AC joint itself – that can affect how the scapula moves.

There’s something known as “scapula dyskinesis”, or altered movement of the shoulder blades, which can occur for a variety of reasons but commonly due to muscular imbalances.

Check out this example of severe scapular dyskinesis (focus on his shoulder blades, especially when the arms are coming down):

Additionally, the scapula sits on the backside of your ribcage. If the ribcage position is altered, that alters scapular position (in turn, altering shoulder movement).

Anecdotally, I’ve noticed that many of my clients have a ribcage that is tipped backwards with accompanying rib cage flare, kinda like this:

shoulder subluxation
Credit – Jessica Reale

And in standing:

shoulder subluxation
Credit – PreHab Exercises

I’ve had success alleviating this by coaching and changing breathing patterns to include a more effective and deeper exhale.  When you have a shallow exhale (commonly due to being stressed  or a learned habit), that leaves more air in your lungs and tips the ribcage posteriorly.

Additionally, this shallow breathing pattern can make you “stuck” in an extension pattern (shoulders hiked and scapula retracted) which reinforces the tipping of the rib cage.  The next time you see someone who’s obviously stressed, look at the way they’re holding their body.

By training and conditioning deeper breathing (click here for some techniques I use) to help reduce over-inflation of the rib cage, decrease stress, and extension patterning – I can help alleviate that backwards tipping of the ribcage. This improves scapular movement leading to improved overall shoulder movement.

In rehabbing Salah’s type 1 AC joint sprain, it’s imperative to work on and restore these bio-mechanics to ensure optimal shoulder movement.  Here’s an example of restoring scapular mobility (go to the 1:20 mark):

2 – Proprioception

The proprioceptive system is an unconscious sensory feedback systems that provides information to your brain about where your body is in space. It consists of receptors in your muscles and tendons that provide information and feedback about joint angles and joint velocity. Based on this feedback, the body makes micro adjustments to make movement more efficient, effective, and safe.

The simplest way to understand the proprioceptive system is to imagine if we didn’t have it. Try this: close your eyes and move your hands around up and down side to side. If you didn’t have a proprioceptive system, you wouldn’t be able to feel what your hands were doing.

In Salah’s rehab, proprioception training will be implemented in the later stages as his shoulder gets near full range of motion.

3 – The nervous system

Neuromuscular control

Neuromuscular control (aka motor control) is the unconscious process through which muscles are timed and activated to control dynamic joint stability.

Since the shoulder has such expansive range of motion, it relies heavily on neuromuscular control for stability. Therefore, it’s really important for Salah to train and restore it during rehab.

This type of training is often referred to as reactive neuromuscular training (RNT) or reflex neuromuscular stabilization (RNS).

Here’s a video of it:

Autonomic Nervous System (ANS)

The ANS is comprised of two systems:  the sympathetic nervous system (SNS) which creates the stress or “fight or flight” response, and the parasympathetic nervous system (PSNS) which creates the relaxation or “rest and digest” response.

To put it simply, stress kills healing.  A ramped up SNS makes injury rehab more difficult by affecting Salah cognitively, physically, and emotionally:

  • Cognitively:  The brain’s main role is to anticipate and prepare for threat.  When you’re stressed, the brain is on high alert which creates a heightened sense of threat and fixation on problems.  In turn, the brain sends out more pain signals (aka MORE PAIN) to alert the body
  • Physically: Stress results in a multitude of physical changes including increased systemic inflammation, increased muscle tension, deregulated immune response, etc.  Each of these negatively impacts healing.
  • Emotional/Behavior: Stress can alter major health drivers like sleep, nutrition (“binge-eating” for example), and exercise patterns.  Changes in these key areas exacerbates all other existing issues.

Addressing and managing the CNS is key in creating an optimal healing environment for Salah.

C. Macro

1 – Team, family, and social support

Rehabbing from an injury as a professional athlete can be a very lonely place. It’s just you and the medical staff (often times the same person) for long periods of time, days on end.  Therefore, it’s really important to stay connected and have a support system to keep the spirits and motivation up.

Based on early accounts, it looks like Salah has great support from his Liverpool and Egypt teammates, coaching staff, and medical staff.

Here some examples:

“He is the hero of the (Egyptian national) team”

2 – Resiliency and mindset

I can’t emphasize enough how a resilient mindset can completely alter the course of therapy and rehab.  The mindset of viewing an injury as a depressing obstacle vs viewing it as a new challenge alters the lens of recovery, commitment, and motivation.

Fortunately, Salah’s mentality seems to be the latter, as evidenced by his quotes and pictures since the injury:

It was a very tough night, but I’m a fighter. Despite the odds, I’m confident that I’ll be in Russia to make you all proud. Your love and support will give me the strength I need.

And very recently on Twitter:

3 – Pressure

There’s a lot of pressure on Salah to return – he’s the star player for Egypt and the catalyst for them having a decent showing in the World Cup.

This type of pressure can be a doubled edged sword.  It could be detrimental to Salah’s recovery as it adds an extra layer of stress but, on the flip side, it could also be very motivating if he embraces shouldering the weight of Egypt’s World Cup hopes…

shoulder subluxation
Credit – Atlas and the Hesperides by Singer Sargent, John (1925)

Speaking of the World Cup…

IV. Will Salah be back in time for the World Cup?

Short answer: Barring a setback, I’m confident the type 1 AC joint sprain will be fully healed and Salah will back for the start of the World Cup.

Long  answer: I think he’ll be back for the start of the World Cup because the average return to play timeline for a  type 1 AC joint inury is around 10-14 days which puts him on track for Egypt’s first group stage game on June 15th (vs Uruguay) .

Factor in his personalized 24/7 elite level of medical care and rehab, great team support, and a very positive & resilient mentality – that all adds up to creating a great healing environment and returning even earlier than the average timeline.

Additionally, there’s taping and bracing that can be used to help stabilize his shoulder in the short-term to help give him extra support for the World Cup.

Taping like this:

type 1 AC joint sprain
Credit – HumanKinetics.com

And bracing:

shoulder subluxation
Credit – BetterBraces.com

All in all – I expect Salah’s type 1 AC joint sprain to be fully healed and for Mohamed Salah to be ready to go for the start of the World Cup.  Rejoice Egypt and Liverpool fans.

Thanks for reading and until next time.

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