Shoulder advice

Long story, will try to make it short... I've had shoulder problems since being a teenager... comes with the territory of being a swimmer Over the past 5-ish years with my getting back into the sport, I have had some issues. The most recent was in November when I subluxed my shoulder (partial dislocation). I have done PT for it going back even before the injury as it had been causing me pain before. So after the Subluxation the Dr sent me for an MRI. Because there is such a wait time, I decided to get one privately.

The findings were: patulous anterior joint capsule that I suspect is secondary to capsular stripping from the scapular periosteum. This is a nonspecific finding but could account for the patients increased anterior translation on clinical exam. However the auxiliary recess is normally contoured with no evidence of tearing of the inferior glenohumeral ligament complex or HAGL lesion.
Normal glenoid labrum. No evidence of Hills Sachs lesion or bony Barnhart to confirm a previous anterior inferior location type injury.
Mild active supraspinatus and infraspinatus tendinopathy. No discreet rotator cuff tear.
So then I go in for my scheduled MRI in December the findings for that one was:

There is a cleft of contrast undercutting the glenoid insertion of the anterior band of the inferior glenohumeral ligament and the axillary capsule consistent with a GAGL injury. Posterior band of the inferior glenohumeral ligament is intact.
No labels tear is identified. No Hills Sachs and no bony Bankhart fracture.
Anterior cartilage is maintained.
Mild articular surface fraying of the supraspinatus tendon. Rotator cuff is otherwise intact.

In the past year it has popped out (and then gone right back in) 4 times. Not a full dislocation, but enough to want to barf and then put me out of commission for a couple of weeks.

When I went in to the sports med doctor in November he said based on the first MRI that the surgeon says he won't do surgery. He says I should try something different.. like water-jogging. It was all I could do to not punch him in the throat. My PT was surprised that they wouldn't do anything.

But all this is Greek to me. I just want to be able to consistently be able to get in the water and swim without having to keep taking weeks off at a time. I'm waiting to get in with someone else for a second opinion. But just thought I would throw this out to the armchair doctors out there or to some people that have had a similar issue and what they have done.

[GomerPile]

You’re much more on the lingo then I ever was. I can’t believe that there isn’t more damage in there from the dislocations. I’ve had three separate shoulder surgeries, with probably 100+ dislocations. The only thing that ever truly worked for me was getting a full rebuild done, doing the physio to the T and continuing with resitance band exercises for the small muscle groups in the shoulder, forever. I found whenever I got away from the resistance bands and focused on larger weight, my shoulders would feel weak even if I felt and presented stronger.

My arm chair Dr diagnosis, I have weak/loose shoulders (maybe you do to) and have to keep doing those exercises and had to change my habits. Ie - no more rugby, and limit falls on the ski hills. Keep asking questions, go to physio, and you’ll find something that works for you.

[AC]

I had 8 dislocations by the time I got my shoulder redone.

They opened me up and found even more damage than indicated by the MRI, including bone spurs. Well worth it.

I still get some discomfort occasionally, but I'm not in constant fear while working out, playing hockey, or even getting dressed or sleeping with my arm above my head (managed to dislocate my shoulder doing both).

Changing my habits might include not being able to swim and that is what freaks me out the most. If I can't do that, I'm just going to get fat and die.

And the pop out while you sleep happened to me 2 weeks ago. Woke up and couldn't lift my arm. So off to physio I go where he clicked it back in.

I don't think I need a full reconstruct. Just a tightening up of everything. And that GAGL things seems to warrant reattachment from what Dr. Google told me.

[redforever]

My daughter had a shoulder that kept popping out, due to a drunk driver hitting her while she was on her motorbike.

She did physio at Innovative Sports, something like that, in Mayfair Place.

They referred her for surgery in Banff, the doctors that fix up Canada's ski team's injuries.

It was day surgery. Her surgery was done arthroscopically, one stitch in the back of her shoulder , and one in the front. One was to repair her rotator cuff and the other was to shorten the tendons or ligaments that were stretched in her accident.

She too was a swimmer and went back swimming after her surgery.

[blankall]

The shoulder joint is very complex. I wouldn't do anything, except under the guidance of a trained professional. It sounds like the professionals aren't entirely sure what your issue is or what the proper course will be.

If your shoulders are at the point, where every time you do X activity, you risk partial dislocation, then, at least until your get some great therapy, your going to have to change the way you do that activity.

One thing to look out for is that "pops" may not be dislocations. You could be dealing with tendons and/or ligaments getting stuck on and then sliding over bones, which can create a popping sensation within the joint.

My shoulders are also a major issue, but in terms of impingement. It just kind of sucks. I have to accept that I cannot do physical activities the way I want to. For me, my activity is bench press and weightlifting. Whenever I get my bench press close to a competitive level, I begin to get impingement issues in at least one shoulder. Once those start, it leads to inflammation and swelling, that makes things worse. I've accepted that it's just part of sports. Limitations come not only from ability (aka speed and strength) and drive, but also durability and ability to avoid injury.

I'm also somewhat lucky. Although my limitations prevent me from competing, I'm also not prone to any actual tears in the joint. So I avoid the need for surgery or limitations on day to day use.

You might not have to go as severe as "water jogging", but you are likely to have to modify the way you swim. I used to love to swim, but a perforated ear drum prevents me from going into pools now....

Edit: I would also try some physio and active rehab too, assuming your doctors okay it. A lot of shoulder issues are caused by the shoulder being pulled out its normal place by muscle imbalances, that can be caused over time by bad posture or too much computer use and/or sitting. This is considered "conservative treatment", and may be what the surgeon had in mind, when he said surgery was not appropriate. A lot of minor tears will also heal over time. The physio/rehab people can show you exercises to minimize scarring.

[TheSutterDynasty]

Originally Posted by Puxlut

The findings were: patulous anterior joint capsule that I suspect is secondary to capsular stripping from the scapular periosteum. This is a nonspecific finding but could account for the patients increased anterior translation on clinical exam. However the auxiliary recess is normally contoured with no evidence of tearing of the inferior glenohumeral ligament complex or HAGL lesion.
Normal glenoid labrum. No evidence of Hills Sachs lesion or bony Barnhart to confirm a previous anterior inferior location type injury.
Mild active supraspinatus and infraspinatus tendinopathy. No discreet rotator cuff tear.
So then I go in for my scheduled MRI in December the findings for that one was:

There is a cleft of contrast undercutting the glenoid insertion of the anterior band of the inferior glenohumeral ligament and the axillary capsule consistent with a GAGL injury. Posterior band of the inferior glenohumeral ligament is intact.
No labels tear is identified. No Hills Sachs and no bony Bankhart fracture.
Anterior cartilage is maintained.
Mild articular surface fraying of the supraspinatus tendon. Rotator cuff is otherwise intact.

When I went in to the sports med doctor in November he said based on the first MRI that the surgeon says he won't do surgery. He says I should try something different.. like water-jogging. It was all I could do to not punch him in the throat. My PT was surprised that they wouldn't do anything.

Your MRI was an arthrogram, correct? There's zero reason why it wouldn't be, but I'm very surprised you don't have a labral tear, namely a SLAP lesion. The majority of dislocations have an associated SLAP lesion, and the fact that you've had 4 makes me wonder about the MRI. The radiologist hardly commented on it besides saying "no tear". The tear of the anterior capsule from the bone also suggests this.

The GAGL injury is the main ligament holding your shoulder in place in front has torn a piece of bone off of the "socket" of your shoulder joint and is no longer attached. This may be why your doctor has said that you're not a candidate for surgery. Many avulsion fractures (especially with this presumed chronic one) are inoperable.

Much of your pain will be from the tendinopathies of the two tendons. These will rehab well conservatively (there is no surgery for them).

The other good news is that you don't have a hills-sachs lesion, which is essentially wearing of part of the bone from dislocating it multiple times. It leads to further instability and a higher likelihood of dislocation.

It basically comes down to this:
-There are one or two things I think a surgeon can do (anterior capsule repair and ?GH ligament repair plus a debridement thrown in). I'm not at grounds to comment on you being a candidate or not, but you should probably see a surgeon for their opinion.
-You will need significant (proper) rehab including ++strengthening and manual therapy now. Significantly more if there's a surgery involved (that is a 9 month recovery).

Sports medicine doctors are gate keepers. They are meant to help triage patients to orthopaedic surgeons as needed. Your sports medicine doctor may certainly be right about the avulsion being inoperable, but given your MRI I would want the opinion of a surgeon. I also wonder about a labral tear.

So you have a few options. Your family doctor can put in a (generally slower) referral to a surgeon. You can get a second sports medicine doctor's opinion.
Or if you hurt your shoulder again you can play the system a bit.

I have been doing PT for the past 4 years. I'm pretty sure my PT and Chiro's kids are set up nicely for their post secondary costs because of me. I do the exercises and stretches. I've adapted both my stroke and training to minimize impingement possibilities (smaller rotations on freestyle, try not to kick with a board and no butterfly) I have my own TENS machine (doesn't really help much). Even my PT says there's not much he can do... come see him if slides out again or if the pain gets really bad and he can throw in some ultrasound.
All of my injuries have been subluxations, so no complete dislocations. Even my PT jokes I would be better off to make sure I do it completely next time. Many visits to the chiro results in a relocation of the shoulder to where it's supposed to be. It's not just a tendon out of place...
I have both copies of my MRI's (yes, arthrograms) and looking at them and doing research, there definitely doesn't seem to be an obvious SLAP tear. I think those are easy to see on the scan. Other stuff I'm not sure what I'm looking at... I'll see if I can post the good pics on here. My PT was surprised there wasn't one as well. He said the GAGL injury was the likely cause of my hypermobility (loosey-goosey was the term he used)
I appreciate all your guys input. It's just really frustrating not to be able to do what I love and what essentially is the main part of my job (although, knock on wood, I have never had to get wet!)

[OMG!WTF!]

Originally Posted by Puxlut

All of my injuries have been subluxations, so no complete dislocations. Even my PT jokes I would be better off to make sure I do it completely next time.

I wonder if there's something to that. I've dislocated my shoulders 6 or 7 times each but now I have no problems at all. I also think what you said about adapting your stroke is really important. It becomes all about finding a way to continue what you love doing. If you have to breast stroke forever I guess it beats not swimming at all.

Originally Posted by OMG!WTF!

I wonder if there's something to that. I've dislocated my shoulders 6 or 7 times each but now I have no problems at all. I also think what you said about adapting your stroke is really important. It becomes all about finding a way to continue what you love doing. If you have to breast stroke forever I guess it beats not swimming at all.

Ick. I would rather do fly lol. but seriously... in breast your arms are always positioned above your torso. That over head hurts even more than freestyle. It's funny; back stroke is the stroke that gives me the least pain.

[Robo]

Sorry to hear as someone who suffers from a bad right shoulder it can be frustrating to say the least

[OMG!WTF!]

I have a similarly frustrating ankle issue...done all the pt, watched all the videos, and sort of gave up on it. I still think though that somewhere there is a specialist who knows how to fix the issue. I suspect that person would be a trainer at a university in the States working on student athletes as kind of their lab rats. I was always amazed at the treatment student athletes received. Maybe you could contact a university with a major swimming program and see what they say. I'm sure they deal often, if not primarily with shoulder issues. You never know if someone may just point you in the right direction.

[TheSutterDynasty]

Originally Posted by Puxlut

I have been doing PT for the past 4 years. I'm pretty sure my PT and Chiro's kids are set up nicely for their post secondary costs because of me. I do the exercises and stretches. I've adapted both my stroke and training to minimize impingement possibilities (smaller rotations on freestyle, try not to kick with a board and no butterfly) I have my own TENS machine (doesn't really help much). Even my PT says there's not much he can do... come see him if slides out again or if the pain gets really bad and he can throw in some ultrasound.
All of my injuries have been subluxations, so no complete dislocations. Even my PT jokes I would be better off to make sure I do it completely next time. Many visits to the chiro results in a relocation of the shoulder to where it's supposed to be. It's not just a tendon out of place...
I have both copies of my MRI's (yes, arthrograms) and looking at them and doing research, there definitely doesn't seem to be an obvious SLAP tear. I think those are easy to see on the scan. Other stuff I'm not sure what I'm looking at... I'll see if I can post the good pics on here. My PT was surprised there wasn't one as well. He said the GAGL injury was the likely cause of my hypermobility (loosey-goosey was the term he used)
I appreciate all your guys input. It's just really frustrating not to be able to do what I love and what essentially is the main part of my job (although, knock on wood, I have never had to get wet!)

Well it sounds like you've done a lot of the right things.

I know there's probably a strong loyalty there, but you also mentioned some red flags. It is most certainly not better for you to completely dislocate your shoulder, ultrasound and TENS have no evidence for long term benefit for your condition, if you subluxed your shoulder there is nothing that needs to be "put back into place" (if it was still dislocated that is a medical emergency), and you've been going for four years with a plateau. Obviously they've helped you a lot but it may be time for another set of eyes.

You have some other options for interventional medicine, but I can't say if you're a candidate from this post. There are some PTs in the city who may have some different things that can help you and can also manage any further intervention or referrals you may need. (And if it means anything I have zero connection to them except knowing they're the best in the city).

Deleted

[TheSutterDynasty]

Well I'll leave that up to the radiologists. It makes more sense why you may not have one if you've only subluxed and not needed relocation. PS you may want to edit your photos to hide your personal info.

PM'd regarding the referral.

[Csquared]

Would definitely second going to see a different physio and chiro. Innovative Sports Medicine may let you see one of their sports physicians too even though it's not a recent injury

[manwiches]

I have had shoulder issues since I was 16. Subluxxed by right shoulder when I was 16 in gym class, then my left one when I was 21 and working in the field. After both of those, suffered many sublux episodes on both from hockey, snowboarding, and even working more. I did it a couple times sleeping too, and that is by far the worst feeling.

I was convinced I needed surgery, and got 3 different opinions for it. All 3 never made it past the primary assessments and followups, as I was never recommended an MRI for them. All 3 told me that I probably have partially torn rotator cuffs, but both my shoulders could be rehabbed IF i kept up with daily exercises. All 3 times, I started it, and gave up on the physio, only for it to creep up again and sublux again. I wore shoulder braces, monthly massages, etc, but I didn't want to do the work.

Eventually I got T-boned in a bad car crash with my wife 7 years ago, and my shoulders didn't feel hot. My physio then told me the same thing (he was one of the original 3 I saw previously), to get back on the exercises, as I wasn't a good candidate for surgery.
So I stayed with the daily exercises, weekly physio with active release and dry needling (which btw, is bloody terrible). Physio for a full year, plus keeping up with the exercises, and also changing how I sleep, how I play hockey, and basically my mindset when it comes to putting my shoulders in vulnerable positions.

Essentially, I rehabbed my shoulders to a point where I haven't had a sublux episode since. I think every case is different of course. My cousin had similar issues as I, but was told he needed surgery. Granted, he had a full dislocation when he finally was recommend for it.

All the best to your process though. Shoulder issues are terrible.

[NuclearFart]

MR arthrograms are decent, but known to miss labral pathology or be misinterpreted as anatomic variants. Not sure where you got your MRI done, but that report sounds lacking in detail and you could always have your referring doc order a second read on it.

Regardless, arthroscopy is the diagnostic gold standard, and it sounds like clinically you may have recurrent instability. There is enough here to justify an ortho consult, and I'd try for Richard Boorman.

[ooogabooga]

I empathize, I have had various Rotator Cuff injuries for around 15 years now. Last reinjury of it was in July. Partially tore my Supraspinatus and Subscapularis tendons. With those, I have now partially torn at some point all 4 of the tendons comprising of the Rotator cuff, and also bursitis in my shoulder. Have done tons of physio and it's thankfully stable, however whenever it gets cold it just ache's and ache's all the time with reduced range of motion in the cold. Not sure if there is anything else I can do, when it's warm out it's usually not too bad, as long as I don't throw something with effort

Originally Posted by NuclearFart

MR arthrograms are decent, but known to miss labral pathology or be misinterpreted as anatomic variants. Not sure where you got your MRI done, but that report sounds lacking in detail and you could always have your referring doc order a second read on it.

Regardless, arthroscopy is the diagnostic gold standard, and it sounds like clinically you may have recurrent instability. There is enough here to justify an ortho consult, and I'd try for Richard Boorman.

I had 2 arthrograms done. One in April, the other in December. April was private through CDC across from Chinook and the other one was public at Peter Lougheed.

So the second referral my physio was put through to Group 23 at Winsport. I see them tomorrow. I'll let you know what the verdict is