Shoulder Strain and Sprain

Fantasy impact

NFL teams will often report minor shoulder injuries as a strain or a sprain and often will not provide any more detail unless the injury is more severe. The ambiguity of this reporting makes it difficult to track who exactly has suffered a shoulder strain or sprain and makes it difficult to differentiate the two when assessing how this impacts fantasy performance. Because of this, we will look at strains and sprains as one when evaluating the data, and we will describe the two injuries below.

Overall, shoulder strains or sprains do not appear to largely impact players’ performance when they return. More serious shoulder injuries, such as labral tears, more severe rotator cuff tears, and AC joint injuries, are more likely to impact performance and may require surgery, leading to missed games.

Players who have had a shoulder strain/sprain

Quarterbacks

Quarterbacks	Games Missed	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Carson Wentz (2022 week 5)	0	21	N/Aψ	N/Aψ	N/Aψ
Tom Brady (2022 week 4)	0	18.9	19.8 (+0.9)	12.7 (-6.2)	16.4 (-2.4)
Drew Lock (2021 week 17)	0	12.2	22 (+9.8)	N/A	N/A
Dak Prescott (2021 Preseason)	0	27.7	28.4 (+0.7)	14.3 (-13.4)	25.5 (-2.2)
Drew Lock (2020 week 2)	3	14	5.5 (-8.5)	17.9 (+3.9)	17.8 (+3.8)
Dak Prescott (2019 week 15)	0	21.7	11.3 (-10.4)	29.6 (+7.9)*	N/A
Ryan Tannehill (2018 week 5)	5	14.3	17.6 (+3.3)	19.5 (+5.2)	7.2 (-7.1)
Average	1.3		-0.7	-0.5	-2
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			4/6 (66%)	6/6 (100%)	6/6 (100%)

Running Backs

Running Backs	Games Missed	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Zach Charbonett (2023 preseason)	0	NA	1.1
D’Andre Swift (2022 week 3)	3	11.1	11.8 (+0.7)
Jamaal Williams (2019 week 16)	1	7.8	1.7 (-6.1)ρ	1.7 (-6.1)*ρ	N/A
Kenyan Drake (2018 week 10)	0	12.6	24.1 (+11.5)	12.9 (+0.3)	8.1 (-4.5)
Average	1
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			2/3 (66%)	1/2 (50%)	1/2 (50%)

Wide Receivers

Wide Receivers	Games Missed	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
River Cracraft (2023 week 3)
Brandon Aiyuk (2023 week 2)	1	14.9	17.8 (+2.9)
Devin Duverney (2023 week 2)	0	6.2	0 (-6.2)
Jaylen Waddle (2022 week 6)	0	15.4	10.8 (-4.6)	22.8 (+7.4)	7 (-8.4)
Kyle Philips (2022 week 1)	0	N/A (rookie)	-1	0.6	0
Tre’Quan Smith (2022 preseason)	2	6.9	12.5 (+5.6)	2.2 (-4.7)	6.7 (-0.2)
Dionte Johnson (2022 preseason)	0	13.4	9 (-4.4)	11.6 (-1.8)	6.1 (-7.3)
Nico Collins (2021 week 2)	3	1.2*	6.4 (+5.2)	5.7 (+4.5)	3.1 (+1.9)
N’Keal Harry (2021 Preseason)	3	3.3	1.5 (-1.8)	2.4 (-0.9)	3.2 (-0.1)
Jerry Jeudy (2020 week 9)	0	7.6	8.8 (+1.2)	2.6 (-5)	2.9 (-4.7)
Auden Tate (2020 week 5)	1	4.3	0 (-4.3)	6.7 (+2.4)	0.5 (-3.8)
Average	1.3
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			4/9 (44%)	4/7 (57%)	4/7 (57%)

Tight Ends

Tight Ends	Games Missed	PPG Prior to Injury	PPG 1st Game After Injury	PPG Games 2-3 After Injury	PPG Games 4-6 After Injury
Darren Waller (2022 week 4)	0	6.5	N/Aψ	N/Aψ	N/Aψ
Jonnu Smith (2021 week 9)μ	1	3.8	2.2 (-1.6)	4.5 (+0.7)	1.3 (-2.5)
Jonnu Smith (2021 week 7)	0	4.6	2.3 (-2.3)	N/Aμ	N/Aμ
Noah Fant (2019 week 15)	0	9.1	2 (-7.1)	0.9 (-8.2)*	N/A
Vance McDonald (2017 week 14)	1	2.7	7.2 (+4.5)	8.6 (+5.9)ρ	N/A
Average	0.5		-1.6	-0.5	-2.5
Number of Players Who Have Met Their Baseline at Current or Previous Time Points			1/4 (25%)	2/4 (50%)	2/4 (50%)

Anatomy of shoulder strains and sprains

Before jumping into the anatomy of shoulder strains/sprains, it is important to discuss the difference between them. Simply, a sprain is an injury to a ligament, and a strain is an injury to a muscle. The most common shoulder injuries are rotator cuff strains, pectoralis muscle strains, lat muscle strains, AC joint sprains, and glenohumeral ligament sprains.¹ 

Shoulder Strains

The rotator cuff, the pectoralis major, and the latissimus dorsi muscles are commonly strained or torn muscles.

Rotator cuff

Rotator cuff injuries are the most common shoulder strain, accounting for 12% of all shoulder injuries.² The rotator cuff comprises four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus functions to abduct or raise the arm from the side and attaches from the top of the shoulder blade to the top side of the humerus (arm bone). The infraspinatus and teres minor function the rotate the shoulder outward and attach from the back side of the shoulder blade to the side of the top portion of the humerus. The subscapularis functions to rotate the shoulder inward. It attaches from the front portion of the shoulder blade to the inside and upper portion of the humerus.³

If severe enough, an injury to the rotator cuff will require surgery. Discussion on rotator cuff surgery can be found on our Shoulder Repair Surgeries: Rotator Cuff and Labrum page. This page will focus on non-surgical rotator cuff injuries. 

Pec major

The pectoralis major (pec) is a massive muscle with many functions and is highly involved in blocking and tackling motions.  The pec’s primary job is to press the arm forward (like a bench press) and bring the arm across the body (like squeezing a ball carrier while making a tackle).  

Lat muscle

The latissimus dorsi (lat) is another massive muscle. It helps extend the shoulder, which is the movement in the backward portion of a bowling throw. It also rotates the shoulder inward and brings the arm toward the body, similarly to pec major.^3. Like other tissue injuries, shoulder strains can be graded to help classify the severity of the injury.

• Grade 1: Mild pain with minor tearing of the muscle causing little to no strength loss._⁴
• Grade 2: Significant pain, moderate to maximum tearing of the muscle without a complete rupture causing significant loss of strength. A palpable defect can sometimes be felt with this grade of strain.⁴
• Grade 3: Severe pain with complete rupture of the muscle with full loss of strength. A palpable defect can be easily felt with this grade of strain.⁴

Shoulder sprains

Shoulder sprains are incredibly common and generally occur to the anterior or posterior (front or back) ligaments of the shoulder. These ligaments attach from the front and back of the humerus to the front and the back of the scapula. They all work together to prevent the humerus bone from dislocating. There are three different ligaments in the front of the shoulder that stabilize throughout different degrees of shoulder motion.

The superior glenohumeral ligament is most taught when the arm is in neutral and limits outward rotation and translation of the head of the humerus downward. The middle glenohumeral ligament is most taught at 45 degrees of shoulder elevation and prevents outward rotation and translation of the humeral head forward. The lower glenohumeral ligament has portions on the front and back of the shoulder. The front portion is most taught at 90 degrees of shoulder elevation. It limits outward rotation and translation of the humeral head up and forward, making it most at risk for injury when a quarterback is throwing. Conversely, the posterior portion helps prevent inward rotation and backward translation of the humeral head.

Another commonly torn ligament is the acromioclavicular or AC ligament, which attaches the acromion of the scapula to the clavicle (collar bone).³ In fact, the AC joint is the most common shoulder injury in football players, accounting for 41% of all shoulder injuries.² More information on AC joint injuries can be found on our AC joint injury page. 

Shoulder instability is a condition that can occur when the shoulder ligaments (as well as other tissues) are too loose and struggle to stabilize the arm in the shoulder socket properly. Instability typically occurs following trauma to the ligaments, muscles, or even labrum but can also occur naturally. There are two types of instability, anterior and posterior, with anterior occurring in 20% of all shoulder injuries and posterior occurring in 4% of injuries.² Like other tissues, shoulder sprains can be graded to help classify the severity of the injury.

• Grade 1: Minimal damage to the ligament, without any laxity or loss of function.⁵
• Grade 2: Further tearing of the ligament presents with some laxity and loss of function. Generally more painful than grade 1.⁵
• Grade 3: full ligament tear with severe instability and loss of function.⁵

Cause of shoulder sprains and strains

Rotator cuff

There are multiple causes for rotator cuff injuries, including overuse, impingement, or direct impact. 47% of rotator cuff injuries are reported to be simple contusions, which occur from direct impact.¹ In football, rotator cuff tears are typically due to forceful contact. This can happen when a player lands hard on their hands from a dive, their arm gets caught under their body when landing or being tackled, or can even be a quarterback’s arm being restrained while attempting to throw.  

Pec major injury

The main cause of injury is forcing the arm away from the body against resistance.¹ This most commonly occurs when a player has their tackle broken as they are trying to wrap up and is less likely to occur in fantasy-relevant players. 

Ligament sprains

Ligament injury occurs from direct or indirect trauma to the shoulder. Based off the ligament anatomy, we can infer the different angles of the shoulder that put each glenohumeral ligament at most risk for tearing. When a force causes the upper part of the arm to move forward relative to the rest of the arm, a sprain of these ligaments can occur. This type of force is often seen when a player reaches out to make a catch and is hit in the shoulder from behind. This can also occur when a quarterback is winding up to throw and is hit in the shoulder from behind. 

As mentioned above, a consequence of ligament injury (as well as injury to other tissues) can be the development of instability within the shoulder joint. Depending on the tissues injured, this instability can occur either anteriorly (to the front, most common) or posteriorly (to the back) and is often seen as a dislocation.

AC joint sprain

For information on the cause of an AC joint sprain, see our AC joint page.

Shoulder strain and sprain rehab process

Although strains/sprains are different in that they are injuries to different tissue types, they have very similar rehabilitation processes. Rehabilitation for muscle strains depends mainly on the grade of the injury. However, most rehab protocols follow a common pattern unless the strain/sprain was a grade 3 that required surgery, which would then have a surgical rehab protocol specified by the surgeon. 

Acutely, the injury is treated with ice, anti-inflammatories, manual therapy, electric stimulation, and other pain-relieving modalities, and a period of immobilization depending on the severity of the sprain/strain.⁷ Also, within the early phase of rehab will be the restoration of normal range of motion (ROM), which will start with passive range of motion (PROM) and progress to active (AROM).

Decreasing pain is the most important step here because it will allow the athlete to progress quickly to later phases, which involve more strengthening and sport-specific exercises.⁷ Dry needling can also decrease pain, increase range of motion, and improve function. Later in the early phase, neuromuscular electrical stimulation (NMES) can be used to improve motor coordination of the rotator cuff. Pain-free isometric exercises are also important to begin the neuromuscular re-education process, which precedes higher-level strengthening exercises.

During the intermediate phase, strengthening is progressed to include rotator cuff and scapular strengthening. Blood flow restriction (BFR) can also be beneficial for increasing strength because BFR requires less weight for the same strength gains, though proper training and supervision with BFR is advised.⁷ Cervical and thoracic mobility are also important due to the interaction between the scapula and the thoracic spine/rib cage.

The late stage of rehab continues to progress strength as mentioned above. It also incorporates more dynamic stabilization exercises, plyometrics, and sport-specific drills.⁷ Finally, the player will be able to initiate contact drills starting with position-specific drills, then unit drills, then full participation.⁷ Another critical role of all stages is to address issues that may have contributed to the injury in the first place, such as improving technique, altering mechanics, or improving range of motion in other areas.

Phases of Rehab	Treatments	Criteria to Enter Phase
Early Phase	Ice, NSAIDs, immobilization, pain-relieving modalities (electric stimulation) PROM, AAROM, AROM. Isometric strengthening. Manual therapy, dry needling. NMES.	N/A
Intermediate Phase	Progress strength for RTC and scapular muscles. Blood flow restriction (with proper training and supervision). Postural retraining Thoracic and cervical ROM exercises.	Pain-free ROM
Sports-Specific Phase	Continue strength exercises for RTC and scapular musculature. Incorporate dynamic stabilization drills. Plyometrics. Sport-specific activities, progress to contact drills.	Full and pain-free strength and ROM

References

1. Gibbs DB, Lynch TS, Nuber ED, Nuber GW. Common Shoulder Injuries in American Football Athletes. Curr Sports Med Rep. 2015;14(5):413-419.
2. Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football Players. Am. J. Sports Med. 2005;33(8):1142-1146.
3. O’Reilly, N. Shoulder. Physiopedia. Retrieved June 22, 2022, from https://www.physio-pedia.com/Shoulder 
4. Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr Rev Musculoskelet Med. 2010;3(1-4):26-31. Published 2010 Jul 30.
5. Mulcahey, M. (2020, June). Sprains, strains and other soft-tissue injuries – orthoinfo – aaos. OrthoInfo. Retrieved June 22, 2022, from https://orthoinfo.aaos.org/en/diseases–conditions/sprains-strains-and-other-soft-tissue-injuries/
6. Kelly BT, Barnes RP, Powell JW, Warren RF. Shoulder Injuries to Quarterbacks in the National Football League. Am. J. Sports Med. 2004;32(2):328-331.
7. Weiss LJ, Wang D, Hendel M, Buzzerio P, Rodeo SA. Management of Rotator Cuff Injuries in the Elite Athlete. Curr Rev Musculoskelet Med. 2018;11(1):102-112.