Physiotherapy in Toronto for Shoulder

Q: I am 33-years-old and retiring from a professional ball throwing career. My pitching arm has become unstable from overuse. The team doc has suggested I have surgery to tighten up the joint so it will stop dislocating. What kind of surgery can they do for something like this?

A: Joint laxity (even hyperlaxity) is a common shoulder problem among overhead pitchers. Hyperlaxity means the soft tissues around the joint that usually hold it in place are extra long and very elastic.

Some people are born with joint hyperlaxity. Their joints can slide and glide all over the place. They can move and rotate joints in all directions without dislocation. This condition is called multidirectional hyperlaxity.

Athletes like yourself who use their shoulder(s) over and over cause the soft tissues to stretch out too much. Overuse or overtraining often only affects one direction of shoulder motion making this a problem of unilateral hyperlaxity. Conservative care may be helpful but surgery at the end of a long career is often the best answer.

If you decide to pursue nonoperative care, you will see a physiotherapist who will help you modify your activities. Essentially you'll learn how to do things that don't stress your shoulder.
The physiotherapist can provide a program of exercises to help strengthen the muscles around the joint. Strong muscles help stabilize loose joints. The patient with multidirectional shoulder hyperlaxity must follow the prescribed program for at least a full year with a maintenance program that should be carried out for the rest of life.

If rehab doesn't help and surgery is indeed advised, then the techniques used most often include the capsular shift, capsular plication, and thermal capsulorraphy. The procedures are usually done arthroscopically at a special shoulder unit by a surgeon who has advanced training in this type of treatment.

The capsular shift procedure is a bit like a tummy tuck. Incisions are made so that the excess tissue can be pulled up and tightened. Different types of incisions and incision patterns can be used depending on where the greatest laxity is located.

With the plication procedure, excess capsular material is pinched and tucked to form pleats. It's like taking in the waistband on a pair of pants or a skirt that is just too big. The surgeon attaches the pinched pleat to the stiff labrum (fibrous rim around the shoulder joint). This procedure must be done in such a way that the folds of extra tissue don't get pinched during shoulder motion.

And the last procedure thermal capsulorraphy uses heat to shrink the shoulder capsule. Results from this technique have not been very good, so the method is not recommended much anymore.

You'll need to see an orthopedic surgeon to find out what's the best approach for your problem. Tests for ligamentous laxity, directional instability, and motion will be done. The strength and condition of other joints and soft tissues around the shoulder are also tested. Surgery for patients with structural abnormalities of the shoulder will address those imbalances.

Reference: Simon M. Johnson, BSc, MRCSEd, and C. Michael Robinson, BMedSci, FRSCEd(Orth). Shoulder Instability in Patients with Joint Hyperlaxity. In The Journal of Bone and Joint Surgery. June 2010. Vol. 92-A. No. 6. Pp. 1545-1557.