The shoulder is the most commonly injured joint in surfing with dislocations and tears. You can understand why. With all that arm paddling and being bundled when we inevitably stack it, this ‘ball and socket’ joint is seriously working hard.
Shoulder dislocations and injuries can, at best, keep you out of the water for weeks. Its not until you dislocate your shoulder you appreciate how much you need it to swim. And how its possible to vomit from pain!
Basic Anatomy of the Shoulder
In order to get all that movement (unlike your knee which only moves in one plane, or at least it’s meant to – see Stokesy’s interview here!), its naturally pretty loose and inherently susceptible to being injured. There are a few clever tricks your body does to improve the shoulder’s stability through all those wipeouts, like enlarging the ‘cup’ (glenoid) with a fibrous lip (labrum) to hold the ‘ball’ of the upper arm bone better. Around that is strung tight ligament bands and then muscles – these are mainly the internal rotator cuff muscles whose job it is to keep that ball in the cup, but more about that in a bit. Finally, you’ve got the true movers of the shoulder, the deltoid, pectorals, trapezius and latissmus. Or for Ron Burgundy, the ‘ubulus muscle’ that connects to the ‘upper dorsinus’. There’s no point curling that 1012th rep if you’ve got an unstable (extra loose) shoulder, you may look ripped but it won’t help the stabilising structures: the lip, the ligaments, or the rotator cuff.
How do you know if you’ve got an unstable, or worse a dislocated, shoulder?
For a mildly loose shoulder its pretty difficult – you might hear cracking coming from the joint when you move it, but simple cracks with no pain are pretty common, especially as we get older, and are not usually associated with underlying problems (in fact, there’s an ongoing argument about where exactly these sounds are coming from, like the phantom trump in the van when you’re scoping out breaks). However, if you feel pain – there’s something wrong. Watch this session out and go get your shoulder looked at.
‘Clunking’ is feeling like the joint is just slipping out of the cup before popping back or feeling like it’s about to slip out but never quite does. This is a sign of actual or imminent ‘subluxation’, where the ball is riding up on the lip of the cup and getting close to popping out completely. This implies those big 3 stabilisers, the lip, the lig and the cuff are loose. Scroll down to ‘What now?’ to see what to do.
Then there’s the biggy, the ball is completely out the cup. Because of the strength of the big mover muscles, mainly the pectoral muscles behind your nips, the ball of the arm bone typically ends up forward, kind of sat in front of where your armpit used to be. This is a dislocation. If it’s the first time its happened, its gonna hurt. Really hurt. A friend descriped it as feeling like your shoulder is slowing being torn off.
In order for the ball to get out of the cup, its torn those stabilising structures, and if you’re really unlucky, it’s broken some small bits of bone with it too. Any movement of the upper arm hurts like hell because the joint isn’t intact anymore. If you compare the look of the dislocated shoulder to the other side, the ‘squareness’ of the shoulder will have gone, replaced by a one-sided rounded, shortened look.
So that’s: pain, dramatically reduced movement, and finding the ball out the cup, normally forwards.
When is it likely to happen?
Your shoulder has most of the stablisers around the top, back and sides, meaning angles of the arm that push the ball down towards your feet are the most likely to cause dislocation. This means that where your upper arm is at the top of a paddle stroke is the weakest, if you have a cracking or clunking you’ll most likely feel it here. However, in reality it can happen at any angle, and if you add in the leverage force that your arm produces, being bundled by a heavy sunblocker wave or dropping over the falls onto your board, the shoulder can pop out like Pringles. Interestingly, there’s an increase in the summer months in shoulder dislocations in the UK with carrying longboards in classic Cornish crosswinds – presumably worse with foamies as they’re lighter, massive and likely to be still going out when there’s all that wind about.
I’ve Popped it! – What now?
If you’re in the water, GET OUT. Keep the affected arm tucked in to your side, hugging you or even tucking your fingers in to your boardies’ waistband or wettie’s neck to keep that upper arm against your body and reduce movement in the shoulder. Getting out might mean bodyboarding a straight line to the beach through the breakers or a slow one-arm paddle back to the boat, but GET HELP. Raise awareness your in trouble by waving your good arm or slapping the water. If you can’t get on your board, just grab it with your good arm and use it as a flotation device and shout to get help – treading water with one good arm is sketchy, even if you’re Laird you’ll tire.
If you LOSE SENSATION in you hand, or your hand/lower arm go COLD and BLUE – this is an emergency. You need to see a doctor ASAP.
The dislocated ball has impaired blood flow or nerves to your arm and it needs sorting quick.
You might have seen or heard of people putting their shoulder back in, Mel Gibson in Lethal Weapon-style, called reducing the dislocation. If this isn’t the first time a shoulder dislocation has happened to you, the stabilising structures will be loose from the last time, and you may have enough laxity to bring the ball back round the edge of the cup and back in, increasing your chances of reducing it. This doesn’t come without its own risks though – if it didn’t damage blood vessels, nerves or bone on its way out, it might on the way back. Therefore we still recommend you see a doctor even if you don’t have the ‘emergency signs’ above. However, if there are no emergency signs and you are truly surfing out in the middle of nowhere and there’s literally no-one about – email us immediately with your good arm where the feck you’re surfing, we want in!! Joking (kinda) aside, if you’re willing to take the risk here’s how it might be done:
Pain is the enemy of muscle relaxation. As bruising and blood establish themselves, the area and any movement of the dislocated ball is going to get more painful and any muscles that are still intact, like those powerful movers, are going to go into tight spasm. Therefore you have a window of a few minutes after sustaining a dislocation when it’s most likely a reduction will be successful without muscle relaxants and uber strong pain killers. While it’s true there is no agreed best technique to get the ball back in, there are some general best principles:
Go slow – Gibsonian slamming it back is likely to cause further injury and pain, and worsening resistant muscle tightening, whereas gently easing the ball back will give the best chances of success with least risk of further injury.
Get the position correct – get the arm (gently) out in front of your body (where it’d be if you were pointing at something dead in front of you – this is called a flexed shoulder position).
Gentle pulling – this is the key. Gentle traction of the outstretched arm aims to lift the ball back forward and around what remains of the lip of the cup. However, your muscles will fight this, all they know is its painful and injured so their natural response is to clamp down. That’s why jerking the arm with your other intact arm is unlikely to work – instead with your good arm grab the wrist of your affected arm and apply constant firm traction (as if you’re trying to pull your hand off in the direction of the horizon). Stay patient, it can take several minutes. A way of doing the same force is to lie on the bonnet/hood of your car (or any surface with a vertical drop beside it) face down hanging your affected arm down over the side, and holding anything you can in your hand to weight the affected arm. Try and relax. And wait.
You should feel a ‘clunk’ as the ball sits in back in the cup. There will still be pain (remember those structures are still damaged) but it’s likely to ease off a bit and some degree of shoulder movement return. Again, if you look at the squareness of the shoulder silhouette in a reflection or you ask a mate, it should look even with the other unaffected shoulder. BUT remember, structures can be damaged as it goes back in! Recheck for the emergency signs above, if you know how to feel your pulse in the wrist beyond the affected shoulder, do it.
Remember – only try and reduce it if that’s the only way for you to get help (ie to drive yourself back to civilisation). If you’ve got it successfully back, go get it checked out. Don’t get back in for another surf! It’ll be loose, injured (bruised, ligament and muscle sprain/strain, torn lip cartilage, with or without bony injury) and is likely to stiffen up over the next few days because of what its been through.
So you’ve had it checked out/reduced, what know?
Typically, the beautiful spots surfing takes you have less than stellar rehab facilities or advice. Again, there are basic agreed principles to post dislocation care, and some recent research that’s changing our management.
First off – rest it. Immediately after the injury, an inflammatory storm is happening in there. There is no advantage to busting through pain at this stage for the future of your shoulder. And definitely, definitely, don’t surf with it.
We used to rest the shoulder with the arm held across the chest in a sling that supports the elbow, which if you haven’t got anything else is definitely better than nothing. However, it’s been proven that keeping the upper arm next to the body, flexing the elbow to 90-degrees and bringing the hand out away from the body (as if you’re hitting a backhand tennis stroke) brings those commonly injured stabilising structures back into the perfect healing position. This improves the likely future function of the shoulder and reduces the potential need for surgery.
How to do this in practice though, without complicated medical slings and with stuff you can find in your location, is difficult and open to Macgyver-like ingenuity. One way (video explanation coming soon!) is a bandage-type strap (strap 1) in a figure-of-8, with one loop around the lower chest/body and the other smaller loop around the arm just above the elbow, tied tight enough to keep the elbow/upper arm against the body. Another similar strap (strap 2) can then be looped around once around the wrist, and then around the lower-chest/body and tied onto strap 1 in a way that keeps the arm out in that tennis backhand position. (If the hand keeps dropping over time, a third strap can be looped around the wrist and diagonally up over the opposite shoulder to keep you in primo ‘teapot’ position). As well as being tied up in some crazed cats cradle, your arm will be exposed to getting bashed about as you go from boat to car to that Garuda flight. Not ideal. As always, the best option lies as a compromise somewhere between theoretical and practical ideals.
When you can, get it checked out by a doctor. It’s likely you’ll need x-rays to look for bony injury and may even need surgery, despite doing all the above. After this, it’s time start the long-haul of rehab, slowly regaining range of movement, strengthening and tightening those rotator cuff muscles and regaining function. Finding a good physio can make the world of difference and get you back to the surf.
Rehabilitation exercises are important. The video below demonstrates the important first steps,
Sounds grim – how can I stop this from happening?
Strengthening the important muscles and ligamnets is the key. It works!
We think this site is pretty good for basic body strengthening exercises for surfing. We’re planning to make our own videos/instructions at some point.
Author: Dr Chris Ireland
There is no substitution for being examined and treated by a medical professional. The intention of the articles on this website is to inform anyone who reads it of medical issues encountered on surf trips.
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