Simon Kelly – Shoulder Dislocation

Mark: Hi, it's Mark from top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. One of Vancouver's best physiotherapy clinics, many time winners of best physio therapy clinic in Vancouver as voted by their customers. And Simon's a physiotherapist there. He's actually from Ireland of all places originally so, love the accent, love what he's got to say. He's an expert at getting you feeling better. And we're going to talk about shoulder dislocation today. A really painful subject. What was going on with this client Simon? 

Simon: Cheers Mark, thanks for having me again. This client was a snowboarder, a 30 year old. He came in, I think it was two weeks after the injury. Had lots of shoulder pain was sort of cradling his arm across the chest kind of like in a sling position. And his wrist was kind of hanging down like so. Pretty limp. 

And so we had a discussion what happened obviously? So he was snowboarding, so it was pretty traumatic. He said his shorter dislocates pretty frequently. I think he said  like anywhere between 20 and 25 occasions in his lifetime, but generally it just goes back in and he started rehabs himself he says. But this time was a little bit different because he had like no use of his wrist. That's why his wrist was hanging down like so. A lot of the nerves that supply those muscles had been damaged, which was kind of a new presentation to him. 

So he was pretty worried when I first saw him actually. So we went through this objective that was pretty important stuff to know. And there definitely was some nerve damage. I had to clear the neck first because sometimes the nerve roots come from the neck, so the neck seem to be intact.

But we have a lot of nerves that pass through our top of our shoulder. You call your brachial plexus. And before they go under the clavicle on top of the first rib, and they can sometimes do damage going down into the arm and into the forearm and into the wrist. So first protocol for him was actually to send him for an X Ray and make sure he hadn't fractured the top of the humerus. Because one of the nerves, the radial nerve, brings the wrist up. So it extends the wrist. In other words, that's why his wrist was down. So I was hoping that he had fractured the top of his arm. 

Good news for him, that differential diagnosis was ruled out because he didn't have any fractures. No Hill-Sachs fractures is a fracture in the humerous and no humerous fracture in a different part of the humerour. So that was all good. In theory, we should of probably sent him for a MRI at that moment, but it was going to take a long time and he just wanted to start rehab. So we got right into it basically. 

So, first protocol was to really get his nerves firing up again. We done that by putting on electrical muscle stimulation. It's called EMS kind of like jumping a car is the analogy I would use. We're just kind of getting electrical nerve impulses firing from the muscles to the brain. In other words, to get this wrist moving. So, like he also had no triceps, so he couldn't extend his arm above his head, which means against gravity. So very, very weak at that moment in time. So then we just started firing up with the electrical muscle stimulation and got it working. And then his wrist started to come back moving again which was fantastic. 

So most of the work early on was getting his nervous system back working, I suppose the wiring from his brain to his forearm. And then rest of the treatment was really just stability in the shoulder. And he had to avoid the high-five position initially because the shoulder can come out forwards. So we avoided that initially, but then we do eventually have to go into that as the weeks progress, because he clearly has to use his arm in functional positioning if he wants to go back snowboarding again. 

So we did rehab. We got him back. I did send them to a neurologist just to be extra safe a few weeks in just to be sure to the nerves weren't completely damaged. And he said it's all okay. It should come back in three to six months, which it did. And he was back on the slopes within five or six months after that injury.

However, I did say to him based on the 20 dislocations that he did that previously, that he might want to go and see an orthopedic specialist just because . It was pretty stable when I left him, but I really wanted him to get it checked out even further, just to be sure. He may need surgery at some point in the future, but he really wasn't a big fan of going under the knife.

So that's kind of where I left him. We definitely stabilized and it was definitely pretty good when I left but I would have liked another opinion from a specialist. Which is what he was going to do. 

Mark: So would that be because the ligaments have been stretched or /and tendons have been stretched too far?

Absolutely Mark. Like when, like someone who's dislocated his shoulder that many times. You know, it's highly likely that it's going to kind of continue to dislocate unless you get a surgery. So those ligaments and tendons are going to be overstretched. It's going to be too lax in your shoulder and it's going to continue to fall.

And in his case, he was actually starting to damage some of his nervous system. So that was something I really wanted to get across to him, even though he was young and a 30 year old male, and he was clearly an adrenaline junkie. He wanted to get back on the mountains. I had to give them that information, expert advice to be like, look I think you still need to see an orthopedic surgeon just to tighten up their shoulder and you might be looking at surgery. In your own best interest, if you want to stay on just slopes for the coming few years. 

Is there any, ongoing protocol that you would have recommended to him to try and help with that? 

Simon:  Absolutely Mark. Yeah. I would've of given him a huge amount, not a huge amount, but a couple of very important exercises to kind of standardize the shoulder. Sometimes we do closed kinetic chain exercises like wall pushups the where hand is actually fixed. That's a bit safer because the bottom of the hand is fixed. And then we do open kinetic chain, which is when your hand is free in space like mine. But I would have been going into this position eventually, which we were doing actually and he was coping pretty, pretty well. 

It's just on this occasion based on his history, clinically, he seemed pretty stable, but just that many dislocations. For me, I was like, maybe he needs to see a specialist too at the end. But yeah, for sure, we gave him lots of stuff to work on in his own time. Which he should be doing actually every couple of weeks for numerous months after that, based on his history.

Yeah because if he's snowboarding, he's probably going to fall again. He's probably going to fall on his shoulder one way or another, whether it's with his arm outstretched or just directly on the shoulder and that ballistic impact. Could easily, if it's loose already, it's going to dislocate it again. Right?

Absolutely. Like he kind of appeared to think it was kind of okay, because it just kept relocating, but I was trying to tell him that you can't just continue to go on like this forever. But I liked his enthusiasm and his positivity. Is probably why he got better so well but, same time he may have been looking at surgery at some point. And that was my opinion when he left.

But very interesting case with the nerves and that in his arm. Seeing him progress against gravity was pretty, pretty interesting. And it can come back. That's what I would like to get across with this video. Pretty scary when you're in your wrist is hanging down like that. And you're wondering, is it severed or is it ever going to come back. Nerves usually regrow one millimetre a day, when they're damaged. So it can grow back in other words, we just have to make sure it grows back correctly, and you get all the movement back into your arm. 

Mark: There you go. If you need some help with your shoulders. Got shoulder issues and you don't want to be 80 years old and still have, you can't sleep on your side because your shoulder is so buggered from not looking after it. The guys to see Insync Physio, give Simon Kelly a call. You can reach him at the Vancouver Cambie Street office (604) 566-9716. Check it out. If you want to book insyncphysio.com. You can book for both Vancouver and the Burnaby office, or if you're in Burnaby, give them a call there at (604) 298-4878. Call. Get in there. Get after it. Get looked after sooner rather than later, so that you can enjoy the rest of your life. Thanks Simon. 

Cheers, Mark. Thanks very much. See you soon.