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The shoulder is like a ball and socket connection. When the arm bone's ball part (humerus) is pushed out of the shoulder's socket (glenoid), it's called shoulder instability or dislocation. This often happens from injury, but it can also be caused by doing the same movements too much in sports like baseball or swimming. When the shoulder gets partly or fully dislocated, it can hurt and limit how well it works. This leads us to the question: what causes shoulder instability, and can surgery fix shoulder instability?
While the shoulder has an impressive range of motion, it can still lose its stability. The following are types of shoulder instability:
With significant trauma to a previously normal joint, the humeral head can be forcefully subluxated or dislocated. A shoulder subluxation happens when the humerus partially slides in and out of place quickly. Shoulder dislocations occur when the humerus comes out of the glenoid. It may fall back into place after time or may need to be put back into place with medical assistance.
During shoulder subluxation and dislocation, the capsule, ligaments, or labrum can be stretched, torn, or detached from the bone. Once the humeral head is back in place, these structures can heal in a loose or stretched position that may increase the risk of future episodes of subluxation or dislocation. With each additional episode, more tissue damage can occur, increasing the tendency toward future instability.
Shoulder instability can occur when the labrum is torn or peeled off the glenoid. This can occur after a shoulder dislocation, trauma, or repetitive motion (like throwing a baseball).
Some individuals are born with somewhat loose shoulder ligaments (they have a loose or spacious capsule). For these people, instability can occur without trauma or following relatively minor injury. Some patients may also have a genetic condition that causes looseness in the joints and predisposes them to develop shoulder instability or weakness.
People with the instability of the shoulder joint can often feel the ball of the shoulder come out of its socket or "give way." It's commonly associated with pain. Typically, the episodes of giving way happen with specific activities or positions of the arm, like throwing a ball or reaching behind the body.
More symptoms can include a decreased range of arm/shoulder motion, swelling, and bruising.
An orthopedic doctor should do a complete history and physical examination. The examination includes palpation for checking points of tenderness and determining range of motion and strength. Specific tests can also assess the laxity of the shoulder joint or the degree of shoulder looseness during the examination. X-rays are usually done to determine the possible causes of the instability and rule out other causes of shoulder pain, like a fracture.
Additional tests, like a magnetic resonance imaging (MRI) scan or a dye test (arthrogram) with or without a computed tomography (CT) scan, are occasionally done further to evaluate the bones and tissues of the shoulder joint. However, these scans are not required in all patients with instability.
After a shoulder has dislocated or subluxed, it's important to rest it and avoid aggravating activities for a few days. If the shoulder pain is significant, like following a traumatic dislocation, a sling is usually used to provide temporary immobilization — shoulder bracing may also be an option for some patients. Range of motion exercises are started once the pain and swelling have subsided. Strengthening exercises can begin as motion improves. The exercise program is typically done with a trained physical therapist.
Cold packs or ice bags on your shoulder before and after working out can help lessen pain and swelling. Medications called NSAIDs, which include aspirin, ibuprofen (found in brands like Motrin, Advil, and Nuprin), or similar drugs like Aleve, can also help decrease pain and swelling. You should check with your physician with any questions, as several different kinds of drugs are available, and they may have different side effects.
Therapy helps get your shoulder moving again and makes the muscles around it stronger. These muscles, especially the ones in the rotator cuff, must be strong to keep your shoulder from dislocating or partially coming out of place. When your shoulder is working well, you can start doing your usual activities bit by bit.
Yes, it can! Nonetheless, the procedure(s) that orthopedic surgeons will advise to treat shoulder instability depends on factors like:
When a shoulder moves out of place towards the front of the body, it can tear the cartilage ring (called the labrum) surrounding the socket.
This is known as a Bankart lesion. A Bankart repair aims to fix the tear in the labrum and attach it back to the socket. This repair can be done through traditional open surgery or a less invasive arthroscopic method.
Especially after multiple dislocations, the ligaments holding the shoulder joint in place can become stretched and lax. A capsular shift makes the ligaments tighter by making flaps in the tissue, moving them, and sewing them again to remove any looseness.
The Latarjet procedure (otherwise known as Bristow or Bristow-Latarjet procedure) can be utilized when a bone on the edge of the socket gets damaged during a dislocation. In this treatment, bone is moved from the coracoid process (a part of the shoulder blade) along with the attached conjoint tendon to the front edge of the socket. The Latarjet procedure can be performed through open surgery or arthroscopy.
The remplissage procedure can be performed along with the Latarjet procedure. It might be suggested if the ball of the shoulder, also called the humeral head, is seriously compromised due to dislocation, which results in a problem called Hill-Sachs lesion. This procedure includes repairing the head's surface and filling the gap by attaching it to a section of the rotator cuff.
The ball in the shoulder might need to be replaced (hemiarthroplasty), or both the ball and socket might need to be replaced (total shoulder arthroplasty) to fix shoulder problems. Sometimes, if the ball side has big bone defects that can't be fixed with a bone graft, hemiarthroplasty is needed to rebuild it.
Older patients might have shoulder issues when their shoulder becomes unstable. Sometimes, big tears in the shoulder's rotator cuff can't be fixed. For these cases, a reverse shoulder replacement could be the best option. This involves putting a ball in the socket and attaching a plastic socket to the ball using a stem in the arm bone.
Even after physical therapy to regain full shoulder movement and strength, the shoulder might feel unsafe or unstable. So, there are two main choices for treatment: 1) changing how you do things and 2) having an operation. Changing how you do things is mostly for people who feel their shoulder isn't steady, only when they do specific activities like playing basketball or sports with overhead racquets.
In these patients, avoiding the activity can eliminate their episodes of subluxation or dislocation.
Some patients might need surgery if they don't want to quit activities or sports that set off their issues. Surgery is also an option for those whose routine tasks like dressing or sleeping become tough due to instability.
The surgery includes an examination of the shoulder under anesthesia to fully assess the extent and direction of the instability while the muscles surrounding the shoulder are completely relaxed. An arthroscope is frequently used to inspect the inside of the shoulder joint to evaluate the joint and its cartilage. The arthroscope allows direct assessment of the condition of the labrum and rotator cuff tendons. In a limited number of select patients with relatively mild looseness or laxity, it may be possible to stabilize the shoulder by arthroscopic techniques.
To correct severe instability, open surgery is often necessary. An incision is made over the shoulder, and the muscles are moved to gain access to the joint capsule, ligaments, and labrum.
Depending on the tissue injury identified at surgery, these structures are either repaired, reattached, or tightened. The repair can be done with simple sutures attached to metal or secured to plastic or absorbable tacks or anchors. These anchors are inserted into the bone and hold the sutures used to reattach or tighten the ligaments. These anchors stay in the bone permanently.
The course of recovery following surgery depends upon the type of procedure the surgeon performs. Usually, the hand, wrist, and elbow range of motion begins the day after surgery. Most patients can write and use their arms to eat within three to seven days after surgery. A supervised physical therapy program is initiated one to four weeks after the operation. A full range of motion usually returns after six to eight weeks. Strength usually returns in three months.
Driving sometimes takes several weeks. Return to work or sporting activities depends on the specific nature and demands of that activity but can take up to one year or more for heavy laborers or high-level athletes. With surgery, the chance of recurrence of the instability is low (3 percent to 5 percent), and most patients can go back to their previous activities.
Many of us only notice our shoulder joints' importance when they get hurt. Then, we feel pain and other problems that disrupt what we usually do. To prevent long-lasting pain and keep our shoulder joints healthy, it's best to check shoulder pain early when simple treatments work well. If your shoulder hurts, don't wait. Contact us at Sunnyvale Sports Medicine and Orthopedic Center!