Shoulder Dislocation: The Paddlers Perspective

Updated 4 April 2001

[Note: I am indebted to the author of this page, Chris Walters, for his kind permission to let me host (entirely in its original content - in what follows, "I" means "Chris" not "me"!) these very useful notes and tips. My club, too has several members who've suffered - and in many cases, continue to suffer - the effects of shoulder dislocations. So I hope this material may continue to serve as a useful resource for the paddling community as a whole.
David Pearson, Secretary, CSCC.]

Being a veteran of shoulder dislocations achieved through paddling, I have amassed plenty of experience which may be of benefit to other paddlers, primarily those who have not (yet) suffered a shoulder dislocation. Although I do not have a medical background (there are many medical sites available on the web which give much detailed information on the reduction and consequent surgery on a shoulder dislocation), I have experienced at first hand the medical profession and their handling of traumatic shoulder injuries. I have also undergone surgery and physiotherapy to correct recurrent shoulder dislocations and am in a good position to comment on what worked for me !

Who is susceptible?

The Bones in a ShoulderWell the bad news is that all paddlers who paddle in a reactive environment (especially kayak surfers, white water paddlers and slalomists) seem to be susceptible. The problem is that the physiology of the shoulder was not best designed for canoe sports. The shoulder joint is a ball-and-cup joint stabilised by ligament and muscle. At the full range of movement, the head of the humerus is no longer located in the shoulder, and hence is very susceptible to trauma. This could come from a paddle striking a rock, a high brace in turbulent water or any other jarring shock. That's not the end of the bad news for paddlers though. Your own anatomical makeup will have a great bearing on the situation too. Are your shoulders muscly ? Do you have short arms (compared with Mr. Average) ? Well, you're the lucky one. According to the laws of mechanics, more force is required to de-stabilise your shoulder if you exhibit these physical traits. Are you double jointed (a good test, apparently, is to try to bend your thumb back to touch the inside wrist of the same arm) ? Bad news - this means that your ligaments are either stretchier or longer than normal and that your shoulder joint is likely to be less stable as a result. The bottom line is that if (like me) you're a long-limbed paddler, with weedy shoulders and a tendency towards double-jointedness, you could well suffer a dislocation during your paddling career.

What is a dislocation like ?

Well the first thing that you notice after the initial force, is the inability of your arm to function exactly the same as before. This may be stating the obvious, but it takes a moment or two for the realisation to set in that all may not be well. There are two types of dislocation: the anterior (where the head of the humerus is pushed forwards and downwards out of the front), and the posterior (where it is pushed backwards). I have read statistics that reckon that around 90% of paddler dislocations are of the anterior type, which I can speak about with authority as all of mine were. If at this stage you were to look at the shoulder, it would appear deformed, with that arm appearing slightly longer, and by now the patient will have realised that something is wrong. Generally they will try to support the shoulder with their other arm if the situation allows. First-aiders will struggle to tell whether this is a dislocation or a break of the collar bone. Without wanting to be alarmist, the pain starts at around the five minute mark after the incident. The pain starts as a dull throb, and gets progressively worse. The shoulder has now reached a very stable position (out of the socket), with the muscles tense (later going into spasm) and the patient unlikely to find any position of comfort. Eventually (after 2/3 hours of non-treatment), the pain can be overwhelming, leading to possible blackouts (a temporary respite).

Evacuation

The treatment of shoulder dislocations seems to be a paradox to me, with unfortunately no real solution. Quick treatment is the primary goal to prevent long-term damage to the shoulder. However unqualified and inexperienced treatment can also cause problems with the potential for trapped nerves and blood vessels in the shoulder joint. Another complication is that the patient is often a long way from anywhere, making quick relocation (reduction) impossible. I would recommend taking a course in emergency shoulder reduction if you're part of a trip going to an isolated area. Otherwise, aim for the speediest possible evacuation to an emergency medical facility. Bear in mind the mobility of the casualty. One of my dislocations was in a swimming pool. It was difficult getting out of the pool using the ladder and handrail. Add the complications of a casualty in a gorge, and the situation gets correspondingly more serious.

Treatment

X-Ray of dislocated Left ShoulderMost treatment methods hinge around getting the shoulder back in the way it came out. These are likely to include traction, external rotation and brute force. The shoulder will almost certainly be generating excruciating pain by now from the muscles which are in spasm. In my experience the three methods listed above will cause more pain and possibly damage to the shoulder joint. In all of my dislocations, forceful methods of reduction were tried for varying amounts of time (up to 3 hours - with no success) before the last resort was used. General anaesthetic has the advantage of relaxing the muscles to the point where, on three out of my four dislocations, I can remember the shoulder slipping back in of its own accord as the anaesthetic was working through my body. However, trying to persuade a young house officer in the emergency room that you want a general anaesthetic while you're in agony is not the easiest task... especially when you're in a foreign country and your command of the native tongue barely stretches beyond asking for a couple of beers !

Surgery

Unless you have a good private health plan, you're unlikely to get the option of surgery after the first dislocation. However, you'll probably have done enough damage to your shoulder joint that, unless you're careful with your rehabilitation, it'll happen again sooner or later. After my initial left shoulder dislocation, I had two further dislocations in eight weeks, thus securing my place on the waiting list for surgery. It's well worth getting to know an orthopaedic surgeon who has empathy with sportsmen (and women), as you're more likely to get surgery which enables you to continue your paddling career. I got lucky in 1984 and had my left shoulder rebuilt by a surgeon who took the trouble to find out about the movements involved in canoeing before he did the reconstruction work. In the last ten years or so there have been major advances in non-intrusive (keyhole) surgical techniques which appear appropriate to the fixing of loose shoulders. I do not propose to comment any further in this area (as I am not qualified to do so), apart from to enthuse about the stability of my left shoulder since I underwent surgery.

Rehabilitation

Solid and sensible rehabilitation is the key to shoulder injuries of this type, whether operated on or not. One of the key factors in shoulder stability appears to be muscle strength. This will undoubtedly decrease in the immobilisation period after the injury (I was generally spending three weeks with my upper arm totally immobilised), which gives the main area for work. The most damaged part of the shoulder is likely to be the ligaments which take a long time to heal due to their lack of blood supply. The longer you can leave the shoulder without stress on the joint, the more fully you stand a chance of recovery. Paddling should not be on the agenda for at least three months and possibly longer. It is imperative to follow medical advice in this stage. Physiotherapy with trained practitioners will help focus the exercises on recovery without aggravation. They will also be able to give advice on which canoeing strokes are mechanically unsound for the shoulder and worth avoiding ! The good news is that since surgery, I have had no recurrence of my left shoulder problems. I built up my upper body using weights in the three years following which stood me in very good stead for when I dislocated the right shoulder in 1988. Rest and strengthening has kept the right shoulder intact (without surgery) until this day.

Avoidance

Many of the classically taught paddling strokes are potentially hazardous for the dodgy shoulder. The basic principle to aim for is to avoid hyper-extending the shoulder. Full stop. Newer paddling techniques have evolved to minimise the risk of injury as awareness has increased. The list below details the risk strokes and their avoidance:

Other scenarios to watch for are during rope rescues, which involve large weights and high velocities (meaning high forces). If you're the swimmer, never let your arms go straight before the rope has tightened ! It sounds obvious, but this happened to me when I dislocated my right shoulder.

Further Resources


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