Shouldering the load

Thursday, February 22, 2007

I am always humbled when press releases presume that medicine can produce miracle cures for injuries that take time to heal. Dwayne Wade dislocates his shoulder on February 20th and is listed as doubtful for a game 5 days later. I have been amazed at how driven elite athletes are to return to play but shoulder dislocations take forever to heal. Still, I think of Daunte Culpepper playing 6 days after arthroscopic knee surgery, a time frame when most humans are barely able to ride an exercise bike in that same week. But I digress.

Shoulders are the most common joint in the body to dislocate and the mechanism is just as you saw in the highlights of Wade’s injury. The arm is moved away from the body (abducted) and externally rotated (turning the forearm, palm side up). The joint gives way and the humeral head, or the ball of the joint, is ripped out of the socket. The structures that hold the shoulder together are torn, including the joint capsule, cartilage and the ligaments of the rotator cuff.

In the real world, people present to the ER in a fair amount of pain and pain control is the first priority. The usual sequence of events begins with drugs to help with the pain, a quick exam by the doc, followed by x-rays to make sure no bones are broken and then the shoulder can be reduced. There are different ways of doing things, but most people prefer to be aggressively sedated for the procedure. After the shoulder is back in place and another x-ray confirms the fact, the patient is allowed to wake up and go home in a sling or shoulder immobilizer.

Since the joint has been damaged and is unstable, the shoulder immobilizer will be a friend for a few weeks. At the same time, the therapist and orthopedic surgeon may decide to do some range of motion exercises to balance getting the joint stable with minimizing the loss of function. It does no good to have a solid shoulder that doesn’t move.

Unfortunately, in young people and athletes, the redislocation rate is high (up to 90%) and the nonsurgical approach that can work for the older person may not work as well for somebody who wants to use the arm aggressively. The conservative, nonsurgical approach can take more than 3 months until return to full activity can be expected.

That brings us back to Dwayne Wade. A shoulder dislocation should be a season ending injury requiring surgery, but perhaps the gods of medicine can bequeath a miracle and allow him to suit up for February 25.

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