That's Not Humerus
Well, actually it is the humerus that sees all the action when one dislocates a shoulder.
The shoulder anatomy is based on giving the joint extreme flexibility including very close to a 360 degree arc of motion. To achieve this enhanced level of function, mother nature drew up a ball and socket joint with an extremely shallow socket (the glenoid, which is the joint component of the shoulder blade or scapula).
The comparable joint in the lower extremity is the hip which is also a ball and socket joint but with a much deeper socket. The hip doesn't need the same arc of motion for function. The trade off for less motion is much better stability.
A shoulder dislocation shouldn't be confused with a "separated shoulder" which is what is medically known as an injury to the A-C (acromio-clavicular) joint between the clavicle (collarbone) and the acromion (the shoulder blade's bony projection that connects it to the clavicle).
Given that the shoulder gets extreme arc of motion, it pays the price in stability. Rather than the bony stability from the socket/glenoid, the shoulder stability is dependent on soft tissues to keep the ball (humeral head) in the socket (glenoid). To prevent the most common (over 90%) anterior dislocation, the front of the shoulder has adapted several structures including the labrum which is a fibrous-cartilage ring to reinforce the ligaments and capsule that attaches to the glenoid/socket. There are 3 (glenohumeral) ligaments that are embedded in the capsule and when these are torn in an injury the capsule is stretched and usually the entire attachment to the socket is pulled off giving the ball shaped humeral head a pathway to push through this opening and dislocate into the tissues in front (anterior) of the shoulder blade.
Once these ligaments are torn, they tend to stay stretched. If there is a detachment from the glenoid/socket it tends not to heal back in place leaving a larger capsule and the stabilizers aren't able to function so recurring dislocations are common. Strengthening the muscle directly in front of the shoulder (the subscapularis, which is the front part of the four muscles of the rotator cuff) can help but it's not helping any laxity of the anterior joint capsule, glenohumeral ligaments or labral detachment. It's been shown that for a first time dislocation in a 20 year old the recurrent dislocaton rate can be as high as 90%. That gets a little less frequent as one gets older and dislocations are much less frequent (but fractures are more common). If the initial trauma is extreme, indentations can occur on the humeral head (like a beat up ping-pong ball) as it gets whacked from the front rim of the glenoid and this is known as a Hill-Sachs lesion. This indentation can be something like a divot that adds to the instability when the shoulder is positioned where the roundness of the ball is now concave.
Traditional treatment pre-MRI and arthroscopic shoulder surgery was that a first time dislocation was reduced (ball realigned in the socket) ASAP followed by a period of rest to let the inflammation calm down then physical therapy to get range of motion and strength back. No surgery was considered back then for first time dislocators. Recurrent dislocation situations were treated differently. Given the nuisance factor, surgical techniques were developed to stabilize the shoulder when recurrent dislocations were happening. Some older techniques were pretty clever including moving bone/muscle attachments from an adjacent part of the shoulder blade (coracoid process) and fixing them to the front of the socket (ie. Bristow procedure). Many operations were created before the advent of MRI imaging and shoulder arthroscopy which made it much more obvious what the damaged anatomy was. These were big operations with a lot of soft tissue dissection...eventually, the Bankart procedure became the standard procedure even pre-arthroscopy. It was a larger open dissection to repair the anterior capsule back in place but it was the operation that fixed the heart of the damaged anatomy.
With the advances in arthroscopic surgical techniques and better implants to anchor the tissues to the front of the shoulder it became possible to do this operation with small incisions and reasonable restoration of the original anatomy.
Now back to the status of the Aramis Ramirez injury.
Information provided now (Bruce Levine's blog and ARam's agent Paul Kinzer) indicates this is his first dislocation but he's had some significant episodes of instability putting him in the category of recurrent instability.
Ramirez had suffered a partial dislocation of his left shoulder on Aug. 28, 2000 (with Pittsburgh), Levine reported. He missed the remainder of the season. On August 9, 1998, Ramirez hyperextended his left shoulder. He returned to the lineup on Sept. 4 (3+ weeks).
The best news is it's not his throwing shoulder (glove hand left side). So unless the MRI to be done saturday shows something really bad (like a fracture), I'd expect him to be treated with a therapy protocol (as physical therapist, Merigold Bowling has explained here). Timetable for that is 4 weeks.
Finally, I'll add some of the immediacy from yesterday's drama to this writeup by adding key ARam related posts from Rob G's. "Ramirez Gets Hurt...Badly" post. Kudo's to Rob for the great screen captures which show the moment of injury in picture #1. Please note some of the links included as there are a few good anatomy diagrams included and my last post (#53) which shows how fragile any one of us can be (the Scott Rolen scenerio) especially when we talk about quick timetables/estimates to recovery.
Post #5 (Cubster...hey, that's me!):
Official word per Pat/Ron...dislocated Left shoulder
probably needs xrays then manipulation to reduce it. Very painful for a first time dislocation but almost no pain once it's reduced back in place.
Need XRays to make sure no fracture is associated.
Fortunately it's not his throwing arm.
Post #14 (MerigoldBowling):
As a physical therapist, I'm going to say 4 weeks. Just needs to get the pain and inflammation down and hope it doesn't sublux everytime he swings the bat or some other motion.
Post #24 (Ryno): (As panic from seeing one of the key men in blue in severe pain sets in...)
To elaborate, I'd say this injury falls somewhere between Lee's broken wrist and Nomar's groin.
Post #29 (Cubster):
If it's just a dislocated shoulder it's much less severe than either of those injuries. If there is a fracture associated with it...then it's up there.
It's his first dislocation so it's not like he's had stretched tissue making the shoulder less stable as in a recurrent shoulder that dislocates. Therefore there is usually more pain and muscle spasm until the shoulder is reduced back in place. Recurrent shoulder dislocations hurt but usually it's easier to relocate them. The quicker they can get it in place the less sedation/muscle relaxation is needed to overcome muscle spasms.
Again it's not his throwing shoulder so unless the shoulder is really loose/unstable after this injury he can make a recovery probably closer to 4 weeks as MGB has estimated.
Also note the first pic in Robs screen capture and you can see his glove (left) arm hyperextending and being forced farther back with ground impact with it being fully outstretched in an overhand position...fairly classic for the position to create an anterior dislocation. The dislocation event is in the process of happening around this pic. In pictures 2-4 the shoulder is already anteriorly dislocated.
Here's a link with a quote that matches ARam's mechanism of injury: "Most dislocations occur with the arm in a position away from the body, often overhead, and then with the arm rotated backwards."
Post #47 (Paul Noce):
(Tribune says...)
4-6 weeks. And this is the same shoulder Rammy hurt in Pittsburgh in both 98 and 2000. I wouldn't be surprised at all to see him have a major drop in power once he returns. He might not get his full strength back for months, perhaps not until next season. Not good.
I don't like any of the options for that length of time. I don't want to beat the Dero thing into the ground, but man he was a valuable guy.
Whoever plays 3b the majority of time might depend more on who plays 2b the majority. Scales fielding percentage at 3b over his minor league career is under .900. I know minor league fields aren't as well kept as major league fields, but that is a god awful percentage. I doubt he can play there very often and not reveal some major shortcomings. We are probably stuck with a platoon of Fontenot/Freel at 3b, with Miles getting most of the play at 2b. That's going to kill the offense.
I knew there was nothing in the minors to help at 3b, but I took another look. Nobody who is a true 3b at Iowa, just weak hitting middle infielders. West Tenn has 3 third baseman, but the two top guys, Kyle Reynolds and Marquez Smith, aren't hitting even .200, and neither are on the 40 man.
It's still early in the season, but if DLee, Soto, and others don't pick it up, and the bullpen doesn't settle down, they could be looking up the entire year.
Post #49 (MerigoldBowling):
took a course taught by Kevin Wilk last fall (Dr. Andrews's physical therapist). They don't do surgery much anymore for these injuries, unless they are associated with a bony defect. Simply, they don't work. Dr. Andrews doesn't even put them in a sling all of the time. Generally, get the pain down, and get the motion loss back, if there is any. Start strengthening in maybe a week to two, and start taking grounders and BP in two. Back in 4. I've had similar baseball injuries with my patients, including one specifically who dislocated diving for a ball, and these generally do well, especially on the glove hand. I'm going to fool around a little bit later with a swing to see if I would stress the inferior/anterior parts of the shoulder.
Post #51 (Cubster):
So it's more clear that this is a recurrent dislocation although he's probably never had a full dislocation (they called it partial or a subluxation from his earlier injury to this shoulder). The injuries from 98 and 2000 imply he had a pre-existing (Bankart) lesion...
...making it sound like last night's injury just made the previously injured tissue somewhat more extensive. Next step is an MRI but MGB's post #49 is an appropriate scenerio. Once the shoulder is reduced the pain is usually minimal. Thanks MerigoldBowling. Good info.
and from Bruce Levine's blog...
According to Ramirez's agent, Paul Kinzer, the Cubs' third baseman has had two other occasions during his major-league career where he had partial dislocations in his shoulder.and from the Tribune/Sullivan...
Ramirez had suffered a partial dislocation of his left shoulder on Aug. 28, 2000 (with Pittsburgh), Levine reported. He missed the remainder of the season. On August 9, 1998, Ramirez hyperextended his left shoulder. He returned to the lineup on Sept. 4 (3+ weeks).
Ramirez returned to Chicago for an MRI after a Brewers' physician popped his shoulder into place.
Post #53 (Cubster): (once again slipping into the Dark Side)
also by ARam's injury being his (left) front shoulder...I don't think it will have significant impact on his power wrt hitting. Thankfully it wasn't his throwing side or all estimates for recovery would get pushed out longer and it would be a major concern.
but just to put a little more fear of the dark side into everyone that surgery on this is always a cure, I'll bring up Scott Rolen's shoulder problems. Also left side. Also thirdbaseman and power hitter. The following is one reminder as to why MerigoldBowling mentioned that treatment in a non-throwing shoulder just might be getting less surgical.
Here's his major injury (from Wikipedia): Note the ex-cub factor
On Tuesday May 10, 2005, Scott Rolen injured his shoulder in a collision with Dodgers first baseman Hee-Seop Choi and was placed on the disabled list two days later. He was expected to be out 4–6 weeks. On May 13, Scott Rolen underwent shoulder surgery - additional MRI revealed tear in labrum. He eventually opted to have surgery on his shoulder, rather than attempt to let it heal on its own and return for the playoffs. He returned to full-time duties in 2006
So it was surgery on a torn labrum (note the report says it was a small labral tear). Somewhat different than the anatomy in full dislocaton. Surgery in this area continues to improve...but
Things did not go well in 2007 for Rolen. He was placed on the 15-day disabled list on August 31, 2007 because of his recurring left shoulder problems. Then on September 11, Rolen had season-ending shoulder surgery "for the removal of scar tissue and a bursectomy and a manipulation of his left (non-throwing) shoulder", according to a release from the team.
on to Toronto (blame it on a LaRussa conflict):
After coming off another stint in the DL in late August, this time for his shoulder, he modified his batting stance by lowering his shoulders and arms by six inches, enabling him to reestablish his offensive power for the season's final month and hitting a couple of home runs at the comfort of less strain on the shoulder, in which he had 3 prior surgeries to correct.
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