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“I’ve worked hard the whole off season lifting and running. The next season will have a lot to do with whether I get offered a scholarship or not – am I going to be able to play?”
A minute earlier, when I walked into the exam room, Ryan and his parents were fairly somber. I attempted to lighten the mood by teasing him about his selection of college sports jerseys to little benefit. As we visited, he said that in late February he dove for a ball and experienced a sharp pain in his left shoulder immediately afterward. He was unable to move his arm without significant pain. Friends gave him a ride to the emergency room where X-rays showed that his shoulder was dislocated. After receiving pain medication through an intravenous line, the doctor was able to “pop it back in” relatively easily and the pain relief was immediate. He was given a sling and told to make this appointment. The fact that his shoulder was able to be put back in easily is not necessarily a good sign and may indicate that the supporting tissues are lax or stretched and may permit the shoulder to dislocate easily once again.
“Have you had any previous episodes like this”, I asked?
“Not really” he said.
“Remember, Ryan, last football season when you said your shoulder felt funny and seemed to slip out a little bit”, his father offered?
When a joint partially separates but doesn’t come completely out and remain dislocated, it is called a subluxation and can either be from an injury or generalized underlying shoulder (capsule/ligament) laxity.
I asked if he had any numbness after the injury or if he had any now and he said he hadn’t. When the shoulder dislocates, one of several nerves can become stretched and create numbness along the outside of the shoulder or along the forearm.
“Are you right-handed?”
“Mostly”, he said, “but I write left-handed”. Overhead and throwing activities put greater stress on the unstable shoulder if it has dislocated out the front and may affect the patient’s choice of treatment.
“Doc, I know you have to ask all of these questions, but can you just tell me when I can go back to lifting and if I’ll be able to play – I don’t want to go into camp weak?”
“It’ll help if I can take a look at your shoulder, why don’t you slip off your shirt.”
His range of motion was moderately limited which is not unusual and primarily due to pain. During the exam, the ball (humeral head) could be shifted outside the cup (glenoid) farther than normal toward the front and when his arm was put toward the overhead position, he became very apprehensive (see below).
“Let’s see about your strength”. His rotator cuff was moderately weak compared to his uninvolved shoulder. While it is important to regain normal strength to support and protect the shoulder, in and of itself it will not assure that the shoulder won’t subluxate or dislocate again.
His mother had been quiet, but asked, “I know football is important to him, but we don’t want him to damage his shoulder for later in life – should he give up football?”
“It’s important to complete his evaluation before discussing his treatment options”, I said. “Even though the X-rays from the ER show that his shoulder has been relocated, a special view will help us determine whether he has a rim fracture of the cup or not – it shouldn’t take long.”
The next post will look at the value of imaging studies and treatment considerations for Ryan.
Watch a Before & After Video of an Instability Repair
For minimally-invasive treatment of Shoulder Disorders in the Seattle, Bellevue, and Greater Eastside regions see Dr. Richard Angelo or go to our website: www.jointlife.com for further information.