TigsTown Injury Analysis: Dislocated Shoulder

TigsTown continues its look at various injuries with impacts on the Tigers' organization, this time examining the details of shoulder dislocations and related shoulder maladies. Two Tiger prospects have suffered injuries in this vein in recent games, and its time we take an in-depth look at the problem.

Outfielder Wilkin Ramirez, and most recently infielder Michael Hollimon, have both suffered shoulder injuries diving for batted balls, and both injuries have parallels that are all too common in the sports world. The dislocation (whether full or partial) of the shoulder can be a serious injury for any athlete, but it can be more problematic for baseball players, given the nature of throwing and swinging motions required. Examining the details of the shoulder, how the injury occurs, and what the follow-on steps are, is the best way to fully understand the impact of such an injury, and how to evaluate the long-range concerns that may follow.

Basics: In this case, in order to fully understand the nature of a shoulder dislocation, it makes the most sense to begin with a detailed explanation of how the shoulder is constructed. The following figure details the individual components that make up the joint:


Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases

The most basic pieces of the shoulder are the two bones involved, the ‘ball' on the upper portion of the arm bone (humerus) and the socket of the shoulder blade (scapula). The socket contains a small rim of cartilage to provide additional depth, allowing for the ball to remain in the socket with greater ease. Surrounding the joint on all sides is a group of ligaments referred to as the joint capsule, which is in turn encompassed by a group of four tendons known as the rotator cuff. This grouping of ligaments and tendons provide strength to the shoulder from the top, front, and back; leaving the lower front portion of the shoulder most vulnerable to injury. Lastly, this entire compilation of bones, tendons, and ligaments is covered by the deltoid muscle extending over the outer part of the shoulder.

There are three varying injuries that can occur within the shoulder, and the terms are often used interchangeably, though they describe distinctly different things. A dislocation refers to an injury where the shoulder is often forced upward and backward, resulting in all joint surfaces losing what would normally be considered their typical contact (or a removal of the ball of the humerus from the socket). A subluxation is the most similar to a dislocation. In fact, a full subluxation is synonymous with a dislocation. Partial dislocations and partial subluxations can be used relatively interchangeably, implying that some joint surfaces may still be in normal contact with each other. The final term that is often bandied about in these cases is that of a shoulder separation. While a shoulder dislocation involves unnatural movement of the socket and upper end of the humerus, a shoulder separation involves the tearing of the acromioclavicular and/or coracoclavicular ligaments, resulting in the separation of the collarbone (clavicle) and the end of the shoulder blade (acromion).

Treatment: After the injury has been confirmed by x-ray, a shoulder reduction must occur. This process involves restoring the original structure of the joint, or ‘popping it back in,' and can be extremely painful. The arm is then placed in a sling to immobilize the joint for several weeks, and re-evaluations are done after a few days to inspect for additional trauma within the shoulder (i.e., rotator cuff tears, muscle or tendon tears, and/or labral tears).

As directed by a doctor or physical therapist, range of motion exercises then begin slowly, attempting to regain motion lost during the injury and prevent additional loss through immobilization. As progress is made with these exercises, strengthening work is often begun to re-establish lost muscle mass and stability within the shoulder. Once these steps have been completed, a throwing program can be initiated to begin reinstituting the normal activities required by baseball players.

In cases of severe trauma within the shoulder, surgery can be required to repair torn ligaments or tendons, and even to tighten or further stabilize the shoulder. Surgical procedures inevitably require additional recovery time, rehabilitation steps, and strengthening during the treatment and care process.

Timetable: The timetable for recovery and a return to the field is entirely dependent on the severity of the dislocation and any other potential problems created by the event. For a minor or routine dislocation, such short durations as four to six weeks may be required to complete the aforementioned steps, allowing a player to return to action in a relatively quick fashion. In cases where the injury is more substantial, or possibly involves minor (non-surgical) tears to tendons or ligaments, the rest and rehabilitation time can easily approach or exceed three to four months in length; costing a player the bulk of a season. In extreme cases where surgery is required to repair additional damage within the joint, rest and rehab times can often exceed six to eight months, and often approach a full year before a player is able to return to game action.

In the cases of both Ramirez and Hollimon, damage appears to have been on the milder side of things; leaving hope that both could return to the field within about six weeks of their respective injuries. Should things go smoothly during rehab, it appears at this time that both players should be able to participate in the majority of the 2008 season.

Future Concerns: Shoulder injuries in baseball players are never a good thing, no matter how minor their description; because all too often they leave the possibility or recurrence. With shoulder dislocations, subluxations, and even separations, instability or ‘loosening' of the joint is often (almost always) a result to some degree. This alteration in the mechanics or operation of the joint leaves the shoulder more prone to future problems.

When such injuries occur at younger ages (18-25), athletes can have very high probabilities of recurrence, and potential for increased vulnerability to other shoulder ailments. If injuries of this nature do recur within the same shoulder, there is also the increased risk of additional damage to other components of the joint. One additional problem created by dislocation injuries – though often overcome relatively quickly – is the loss of strength within the shoulder. This lost strength often returns through continued strengthening and general everyday use, but can be problematic for players pushed back into service quickly.

All signs point towards a return by Wilkin Ramirez on the shorter range of those timetables outlined above; possibly returning to the field in some limited capacity in time for Opening Day with Double-A Erie. Hollimon's case is still up in the air, as definitive results have not yet been reported. Early returns are positive, but a timetable cannot yet be established for his return to the lineup; though any expectation having him out of the lineup well into April and not likely to return to the lineup until much nearer the season's second month, would be reasonable.


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