Roethlisberger injury update

Pittsburgh Steelers quarterback Ben Roethlisberger added to his injury history Monday night when he suffered an unusual injury to his right throwing shoulder. According to coach Mike Tomlin, Roethlisberger suffered "an SC sprain," (a sternoclavicular joint sprain) and his status for this week is questionable.

The SC joint is located at the front of the chest, where the clavicle, or collarbone, meets the sternum, or breastbone. Although it might seem strange to classify this as a shoulder injury, the SC joint is part of the global shoulder girdle: the scapula (shoulder blade), upper humerus (arm bone) and clavicle. When the shoulder moves, it creates movement at the SC joint. If there is an injury to the SC joint, it can affect any movement of the shoulder girdle, making it particularly problematic for a throwing athlete such as Roethlisberger.

A sprain describes a ligamentous injury. The SC joint is reinforced by ligaments in front of and behind the joint. It also has ligaments that attach it to the first rib. The ligaments are particularly strong, and injury here is relatively uncommon. A fall on the arm usually results in an acromioclavicular (AC) sprain (often referred to as a separated shoulder if there is displacement of the collarbone away from the shoulder blade) or a fracture of the clavicle. If the forces are transmitted in just the right manner, however, the SC joint becomes the victim -- as was the case with Roethlisberger -- and the ligaments or joint capsule (fibrous tissue around the joint) become stretched or torn.

There has been no indication from the Steelers as to the degree of injury suffered by Roethlisberger, making it somewhat challenging to prognosticate. ESPN's Ed Werder reports that Roethlisberger also suffered a rib injury Monday night. It is unclear which of his 12 ribs is injured, but at the very least it adds to the pain problem for Roethlisberger.

Standard treatment for most SC injuries is nonoperative. The primary goal initially is to reduce the pain and inflammation to the point that the athlete can begin range-of-motion and strengthening work. The time frame for recovery can vary widely, from days to weeks. The key factor in returning to play will be when Roethlisberger can function effectively at the quarterback position. It's not just concern about contact from an opposing player or a takedown to the ground. Because the SC joint moves every time there is any motion in the shoulder, return to activity will test his pain tolerance. Then again, this is a quarterback who has shown he can play through significant pain. Whether he is able to be effective throwing the ball might be another matter, though.

There aren't many examples of comparable injuries, given how infrequently it occurs. St. Louis Rams wide receiver Danny Amendola suffered an SC injury in Week 5 this season but returned in strong fashion in Week 10. Amendola suffered a potentially serious posterior dislocation of his SC joint that required immediate medical attention to restore the joint to its proper position. Amendola initially was projected to miss six to eight weeks but was able to beat that timetable. Not only are their injuries not identical, but the functional demands of a receiver and a quarterback are quite different, making it difficult to draw any substantial comparison between Amendola and Roethlisberger.

Perhaps more relevant is the case of Brett Favre who, like Roethlisberger, was known for playing through significant pain. Yet even Favre could not maintain his consecutive start streak after he suffered an SC sprain in 2010 while with the Minnesota Vikings. Still, despite the expectation that he might be sidelined multiple weeks with that injury, Favre missed only one game before returning to start for the Vikings. His return was cut short when he suffered a concussion, and he was forced to miss the remaining two games of the season, making it impossible to know just how well the SC joint would have held up.

It seems highly unlikely that Roethlisberger will be available this Sunday, but he has yet to be officially ruled out. Even a return next week would be quick, given the nature of his injury and the degree of pain he reportedly is experiencing. But the Steelers have come to know that, when it comes to injuries, Roethlisberger has a history of defying expectations. Perhaps he will do so again.