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Ask Dr. Rick – July 2010

July 7, 2010

Shoulder Instability

One of the most common problems seen in the shoulder during contact sports is glenoid humeral instability or what we call a shoulder dislocation. Most shoulder dislocations in contact sports are traumatic with the arm in a compromised position. Stress to the shoulder can cause instability
or dislocation.

The most common dislocations are anterior, but dislocations can be anterior, posterior or inferior, as well as any combination of the above. Athletes with multidirectional instability have looseness in the shoulder in multiple planes and can sublux. Subluxation occurs when the shoulder shifts in and out of the joint or dislocates when the shoulder stays out of the joint. Subluxation and dislocation can occur with minimal trauma. Therefore, the two types of instability in general are traumatic and atraumatic.

Most cases of traumatic instability are unidirectional. They are most often anterior and a much smaller percentage can be posterior. Anterior shoulder dislocations occur with the arm in the abducted external rotation position. We call this the stick-up position because the shoulder goes into the compromised position as if you are being held up with a gun. In this position, the arms are abducted and externally rotated. That position is a very bad position for an individual that has anterior instability. For posterior instability with the arm in front and forward flexed, the shoulder slides out the back. This is most commonly seen when the athlete is in a push-up position. So, when pushing in front or when there is a force vector pushing from anterior to posterior; from front to back, this predisposes the shoulder to slide out the back.

The most important factor is to reduce the dislocation without traumatizing the shoulder joint. Frequently, if the shoulder is reduced immediately after an instability pattern, it can easily return to normal anatomy and stay within the joint. The longer the joint is dislocated, the harder it is to “reduce.” If the shoulder is not put back in joint immediately, the athlete must then go to the emergency room and very probably have a significant anesthetic to then have the shoulder actively reduced.

For athletes that have had one episode of instability, they should be treated with physical therapy, strengthening and limitation of activity until the affected shoulder is stable. For athletes that have had multiple episodes of instability, arthroscopic reconstruction is frequently necessary. This is a very common problem in sports medicine and excellent results can be expected following an arthroscopic reconstruction. Full return to sports is expected.

“Dr. Rick, I very much enjoy reading your segment and have learned a great deal. I would like to ask you about my problem. When I start to exercise, I develop shortness of breath and start to wheeze, making it very difficult to continue. Any advice that you have would be
very helpful.”
– Francine G., Olivette, MO

This sounds very much like exercise-induced asthma. Exercise-induced asthma occurs when the small alveoli of the lungs collapse as you start to exercise, making breathing very difficult. This is a common problem among athletes and usually improves as the athlete gets older. Commonly, the exercise-induced asthma occurs on cold days and is generally very consistent meaning at a certain level of exercise, the asthma attack is induced creating shortness of breath and gasping for air. There are a number of medications that can be taken as well as inhalers to treat this problem. In general, the medications are taken on a routine basis and/or the inhalers are used at the first sign of shortness of breath. Athletes that have exercise-induced asthma need and usually remember to carry their inhaler with them at all times. If the shortness of breath episode cannot be controlled, the athlete should immediately be transported to an emergency room. Thank you very much for your question, Francine. That was an excellent question.

“Dr. Rick, I was playing basketball three weeks ago. When I went to catch a pass, the ball hit the tip of my middle finger, and now there is a large lump at the top of my middle finger. I am having trouble straightening my finger and it continues to be swollen. Please help!”
– Cale W., Washington, MO

Although this at the time probably seemed like just a jammed finger, this problem can cause deformity and long-term arthritis if not treated appropriately. You have torn the central slip of the main capsule of what is noted to be your proximal interphalangeal joint (PIP) and if not treated correctly, you will end up with what is called a boutonnière deformity. In short, what happens is that the finger starts to bend because of the tear in the dorsal capsule at the top part of the finger. This allows the extensor tendons to slide down, acting like flexor tendons bending your PIP joint. As the joint continues to be bent without the ability to straighten, the joint will become progressively arthritic and become rigid in a flexed pattern, i.e. ankylosis. Initial treatment is to wear a splint on your PIP joint, the middle joint of your finger. This is to hold the finger straight or in full extension so that this top portion can heal. In the event that this does not heal, the deformity will get progressively worse and the ability to straighten the finger will be limited. It is important for our readers to know that what may seem like a minimal finger injury can create problems forever. After these injuries occur, it is important to see your doctor within the next two days to evaluate the finger and determine if there is in fact a problem or it is just jammed and will get better on its own. Good luck and thank you for your question.

Dr. Rick’s medical tip for July: When hydrating, rather than using plain water, use replacements that have electrolytes in them to replenish lost salts and minerals. Drinks like Gatorade, Vitamin Water, Powerade, etc. are superior in their ability to replace the electrolytes, compared to simple water.

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