The Burden of Shoulders

The Burden of Shoulders

a Carolina Paddler Article

Text and Photography by Alton Chewning

-We count on our shoulders to carry the burden of paddling. They enable us to throw strokes, to brace, to execute a roll. They aren’t the only joints we use but they are critical to boating. The most common injury to befall paddlers is a shoulder dislocation.

Fingers, elbows, knees and hips can also dislocate but shoulders carry the vast load of injuries. Shoulders can pop out from behind us (posterior dislocation) or even downwards, but frontal (anterior) dislocations are far more common.

What’s wrong with our shoulders? Were they not designed well? The shoulder is an unstable joint. The glenoidpocket of the shoulder cups the rounded humeral head at the top of the arm bone However, the humerus is only lightly sheltered in the glenoid. Fortunately, fibrous tissues like tendons and muscles help stabilize and strengthen the shoulder but these too can be damaged by trauma or gradual wear.

Sometime a humerus bone merely slips out of the glenoid socket. These subluxations are partial dislocations where the humerus will often slide back into place on its own. More severe dislocations can involve tearing or separations of muscles and tendons from the bones and require medical attention.

The human body is a wonder of contrast and balance. Joints provide marvelous suppleness and articulation in the body. The combination of flexibility and stability allow our bones, tendons, and muscles to have a vast range of expression. A few people have an unusual degree of flexibility, hypermobility, a genetically acquired condition medically known as the Ehlers-Danlos Syndromes (EDS). It is sometimes called the Cirque de Soleil disease because people with this extraordinary flexibility often work as performers: dancers, gymnasts or contortionists. The downside of hypermobility is the tendency to lose stability. Joints are more prone to dislocations and various other painful conditions.

We live in a time of miraculous medical treatments. Our access to care and an abundance of information gives us an added resources in the treatment of shoulder problems and the knowledge of how to avoid them.

Dave Johnson

In an earlier Carolina Paddler article we discussed shoulder injuries suffered by Dave Johnson and Steve Johnson. Dave dislocated his right shoulder while kayaking on the Ocoee in late October of 2023.  The top tendon/muscle combination on the shoulder, the supraspinatus, was torn. The labrum was also torn. The labrum is the cartilage “pad” that lines and reinforces the ball-and-socket joint of the shoulder.

Several years before this, Dave dislocated his left shoulder while executing a roll. With both injuries, he went through various treatments and a long rehabilitation before paddling again. After the Ocoee dislocation, his orthopedic doctor said the labrum would never fully heal, however the supraspinatus tendon in the rotator cuff could recover with rest and physical therapy. The alternative was surgery.  Dave decided to forego surgery.

Dave went through several months of physical therapy and other exercises to improve his overall fitness.  He started yoga to add flexibility and rotation.  By March he was back to paddling. He first paddled the local rivers, then moved to the Pigeon and French Broad.  Soon, he was doing all his regular runs, trying to improve his skills and conditioning.

A goal in 2023 had been to try the Upper Gauley, a benchmark Class IV-V run for many advanced paddlers. The UG only releases in early fall and Dave couldn’t manage the schedule in 2023. In mid-2024, Dave felt he now had the skills and fitness. He decided to give the Upper Gauley a go.

The New Injury

In September, Dave was having a good day on the Upper Gauley. He had made his first descent on the UG a week earlier. He was feeling more comfortable on big water. On this day, Dave had already hit much of the big stuff: Insignificant, Pillow, Lost Paddle.  Dave describes what happened next:

“I was running the final drop of a rapid called Lost Paddle. The line I was on required a must-make ferry from river left to right, to avoid a sieve and several holes, and then another ferry from right to left, which ends in a boof into “Tumblehome”. I made the first ferry, and while transitioning to the second ferry I threw a low brace (which is usually very shoulder-safe). My left shoulder came out. Then I swam the last part of Tumblehome — not a place you want to swim! Here is a video (not mine), of Tumblehome rapid. The boater starts the left to right ferry around the 01:00 minute mark and ends at about 1:20. That’s approximately where I got hurt.”

With the help of his friends and some kind rafters, Dave was able to get off the water and to reduce the injured shoulder. To reduce a shoulder is to put the humerus back into place. This doesn’t solve all the problem, but it does significantly lessen the immediate pain.

The Big Decision

On the long drive home Dave was able to ponder his next move. He had already determined to have surgery if any other shoulder injury occurred. It was time to set the plan in action. He had a relationship with an orthopedist since his last injuries. Now it was a matter of piecing together the puzzle of MRI’s, CT scans, second opinions and other appointments. Through good planning and a bit of luck, the first surgery was scheduled for roughly a month after the injury.

At this point Dave had dislocated his left shoulder twice and his right shoulder once. He decided to have both shoulders repaired. The left shoulder (the one recently damaged) would be the first procedure, in early November. He could use his right arm for eating, cleaning, dressing, etc. Surgery on the right arm would be done in early December.

No special regimen was observed before the procedures. On the advice of a friend, Dan Gosner, Dave purchased a recliner to help with getting comfortable sleep. It was indispensable.

Why did Dave go this surgical route?  Dave shared, “The idea is that my shoulders will regain the stability and strength they had prior to being damaged.” Dave is still eager to paddle at an advanced level but was troubled by chronic pain from the other dislocations and the uncertainty of whether his shoulders could withstand the stress of whitewater paddling. With successful surgeries, his shoulders would be returned to a “pristine” condition.

The Procedures

Dave would have the same procedures on both arms. The left arm also had a bone fragment that needed to be reattached. A capsulorrhaphy would tighten the shoulder capsule while repairing the torn labrum. This would be done arthroscopically, which allows a quicker recovery than open surgery.  The other procedure is called remplissage (a French term meaning, “to fill in”). This addressed damage (an indentation) to the ball of the humerus, by altering some of the rotator cuff to fill in the lesion (or dent) caused by the shoulder dislocation. This provides better long-term stability to the shoulder.

The Day of the Surgery

The process was similar as in other surgical procedures: arrive with an empty stomach, sterile bathing , verify ID and the target shoulder, have a nerve block and sedation.  After the procedure, Dave woke up in the recovery room wearing a sling. He was connected to an ice-water recirculating machine that fed a compression pouch wrapped on his shoulder. This ice machine would be his constant companion in the weeks to come. His affected arm was numb.  Anna, a close friend, gave Dave rides to and from the hospital.

Afterwards

Dave describes the difficulties of the first week home, “You’re on heavy medication. You’re lugging around this ice machine. There is some pain. You just kind of survive and try not to think too much about it. You sleep in a recliner because you can’t sleep flat.”

The left arm was in a sling for a month, except for dressing or bathing. Even those basic tasks were challenging. After the month the arm was still weak, “Lifting a coffee cup was tough at first!” Dave couldn’t drive but he was lucky since he works from home, mostly behind a computer. He was fortunate in other ways, having minimal pain and the assistance of Anna.

After a month of recovery, Dave had one week without the sling. Then, in early December he had surgery on the right shoulder. Afterwards the routine repeated. Light exercise was encouraged so he walked, did leg mobility exercises and other prescribed physical therapy.

By January, Dave was out of the sling. Soon he was back to driving, jogging, sleeping in bed. By March he hopes to start aggressively rebuilding strength and range of motion.  As for paddling, he plans to attend roll sessions in March and get on easy whitewater in April or May. Dave explains, “While I’m super excited to get out on the water, I’m not in a rush either. I’ll take the time it takes to build up my fitness properly. We’re very fortunate to have modern medicine. Day-to-day activities like running, walking, etc., feel better than they have in a long time.”

Outcome of the Surgeries

The doctor reported the surgeries were successful. What does this mean? For Dave, it means he should have as much stability and strength as ever. However, it is unlikely he will regain full range of motion.

Most likely, Dave will have less of the range for shoulder flexion, extension and external rotation. Some flexibility was sacrificed to build stability. His doctor observed Dave previously had an extremely flexible upper body, particularly for his age, and will still have very good flexibility.

Assessing His Experiences

Many boaters suffering a shoulder dislocation describe the emptiness of the recovery period. the lack of contact with the sport and the community paddlers love. This time around, Dave had a different mindset. He knew surgery was coming in the event of another injury. He knew what to expect.

Dave explains, “To me it was worth the discomfort and inconvenience, because if I want to keep kayaking, I must have safe and healthy shoulders. And, even if the surgery is not a complete success, or if I decide down the road to no longer kayak, I’ll still have better shoulders that I otherwise would!”

Dave learned a lot from his experiences the last couple of years.  He offers a few guidelines.

1. Stay in good physical shape. “Many of us have sedentary lifestyles outside of the activities we love to do, which leaves us unprepared to engage in something as demanding as whitewater kayaking.”
2. Practice and maintain good paddling technique. “Sit up straight and stay in the paddlers box.”
3. Don’t Put Off Surgery. “Good fitness and correct paddling technique help to prevent injury in the first place. Once you had a dislocation, you are anatomically compromised. If your doctor recommends surgery, just do it already! I put surgery off for a while, and I wish I hadn’t, since it only gets harder to handle the logistics and healing as time goes by.”

“I wish I had pursued surgery sooner.”

REFERENCES

-an overview of shoulder injuries   -medicalnewstoday.com

-A discussion of shoulder mobility and exercises.  www.acefitness.org

-A video taken by a Gauley River National Park Service ranger/paddler of a Upper Gauley run.

-Shoulder diagram by Robert O’Conor

-“So-called Cirque du Soleil disease afflicts the extremely flexible”  Ottawacitizen.com

Other Carolina Paddler articles involving shoulder and arm injuries:

The Art and Agony of a Stone Mason by Alton Chewning

Part One: The Agony – A beautiful weekend, a good group, a proven paddler, yet life can spiral in unexpected ways.

The Art and Agony of a Stone Mason by Alton Chewning

Part Two: The Art – You may know Brooks Burleson’s skill with a C-1 but did you know about his work as a stone mason? 

Dreaming of Paddling, Stuck in PT by Angela Wiseman

Angela shares her experience with tendonitis recovery and the loss of river time with friends.

What’s Hurting Our Johnsons? By Alton Chewning

We look at shoulder injuries suffered by two CCC members.