Denver, Colorado Writes: I have shoulder instability, what treatment options exist?

Dr. Peter J. Millett, orthopedic shoulder surgeon in Vail, Colorado and the greater Denver, Colorado area, offers the following discussion regarding shoulder instability, shoulder dislocations and treatment options for an unstable shoulder.

The shoulder is the most mobile joint in the human body. While it offers the largest range of motion of all joints, it also has extraordinary strength that allows one to position the hand in space so that we can accomplish great tasks and movements.

According to Dr. Peter J. Millett, a top orthopedic shoulder surgeon in Vail, Colorado, it is this great strength and range of motion, that often leaves the shoulder joint susceptible to injury.

“Shoulder instability is one of the more common shoulder problems that I see in my patients,” says Dr. Millett. “It is a condition that occurs when the ligaments, muscles and tendons within the shoulder no longer work together in a unified fashion to hold the ball into the socket. When this occurs, the ball (humeral head) literally comes out of the socket (glenoid) and the feeling of shoulder instability is the result.”

Types of Shoulder Instability

When shoulder instability occurs, the bones of the shoulder move beyond what Mother Nature intended such that the ball slips or ‘pops’ out of place.” There are two, sometimes overlapping, degrees of shoulder instability – one is a shoulder dislocation where the ball comes completely out of the socket and the other is a shoulder subluxation, where the ball comes out partially and then pops back in place. When the shoulder is locked out with a complete dislocation, the shoulder is usually painful and difficult to move. When the joint completely slides out of place (dislocation), it may reduce (go back in) spontaneously or it may require a trip to the local ER so that the joint can be properly put back into place by a medical professional.

With a shoulder subluxation, there is usually a transient sense that the joint is out or that it has slipped, but with a subluxation it invariably reduces spontaneously. Most individuals who subluxate their shoulder are able to move their shoulder joint back into a reduced position and are able to treat the pain with mild pain relievers.

Patients can have shoulder instability in different directions – anterior (front of the shoulder) is most common. Posterior (back of the shoulder) and multi-directional shoulder instability are other variants.

Causes

Collision sports athletes are at highest risk to suffer shoulder instability. Athletes who engage in contact and collision sports, such as football, hockey and lacrosse, are at the higher risk for complete shoulder dislocations, and furthermore they are also at greatest risk for recurrence of the instability once the first dislocation has occurred.

When an athlete suffers a traumatic blow or hit directly to the shoulder area, damage can occur within the shoulder joint. If the trauma is severe enough, ligaments and a cartilage known as the labrum may be disrupted. Without proper treatment, an individual may continue to experience recurrent symptoms of shoulder instability, pain, and weakness for months or years following the injury. Additional episodes of instability can cause additional damage to the cartilage, ligaments, and bone. Thus, it is important to get this evaluated and treated early so as not to create additional damage to the shoulder joint. There can be secondary consequences of the damage such as arthritis if it is not treated properly and the shoulder continues to come out.

Some people who have shoulder instability, may in fact, never have a complete dislocation but only recurrent subluxation events. Often these individuals simply have looser ligaments (hyperlaxity). Overuse and activities that involve repetitive motion can stretch the capsule and ligaments that stabilize the shoulder, resulting in symptoms of shoulder instability. Athletes who participate in repetitive overhead movements, such as throwing a baseball, swimming, or serving a tennis ball are at particular risk for developing this type of shoulder instability pattern.

Finally, some patients are simply more genetically inclined to develop shoulder instability and shoulder dislocations because they are born with loose ligaments, colloquially known as double-jointed, due to stretchy collagen or other types of connective tissue disorders.

Treatment

Dr. Millett explains that some individuals can sustain an injury and live with the instability, while others may need surgery after only a single dislocation. It depends on the age of the patient, the sports in which they participate, and the pattern of injury “It is common for some patients to suffer a traumatic injury that causes recurrent shoulder subluxations, and yet they live with the annoying symptoms for years, because it is either not that severe or the diagnosis is not made. These individuals often rely on over the counter pain medication to relieve the soreness in their shoulder. In some instances, a secondary injury can lead to a shoulder that is highly unstable and needs surgery to stabilize it.”

Ty Lenard, a patient of Dr. Millett’s, knows this story too well. A basketball player for years, he injured his shoulder during the 8th grade while playing in a basketball tournament. The injury left his shoulder weak and vulnerable for months. By high school, he was playing football for his high school team and began to experience dislocations on a regular basis. One final, hard hit, sent him straight to the ER and eventually into the hands of Dr. Millett.

“Ty had some serious damage to his right shoulder from years of traumatic injuries and subsequent dislocations. His CT scan showed an anteroinferior glenoid fracture, which essentially is a bone defect in the socket that made the shoulder highly unstable. The fracture made the ball unable to stay in the socket, similar to a golf ball sitting on a broken tee. The only way he would be able to resume playing football, was with surgery to rebuild the deficient socket.”

There are new surgical options available today for patients with mild and/or severe shoulder instability. Arthroscopic surgery is one of the most current and effective treatment options. Small holes are made through the skin and tiny instruments are used to repair the shoulder joint.

The most common procedure is called an arthroscopic Bankart repair, where the torn labrum is repaired and the ligaments are re-tensioned. Sometimes there is more damage and an arthroscopic capsular shift is performed. This is used for injuries exhibiting a more intricate and complicated instability. It is also performed arthroscopically and involves a reattachment of loose or torn ligaments to the joint with the use of special implants called suture anchors. These anchors are used to relocate, hold in place and tighten injured joints. In some cases this is done posteriorly (in the back); this is called a posterior capsular shift. In other cases where the shoulder dislocates in multiple directions (multi-directional instability) the capsule is tightened in the front, back, and bottom, a procedure sometimes known as a pancapsular shift.

For some cases, like Ty’s where there is bone loss on the glenoid, the socket will need to be rebuilt. A technique that has been used in France for years, known as the Latarjet procedure, can be used in cases such as this. Dr. Millett has used this technique for many years now and performed a Latarjet procedure on Ty to rebuild the bone that had been damaged from years of instability. At the same time he also performed an arthroscopic procedure to remove some loose debris from the shoulder joint and to smooth out his Hill-Sachs defect (a common injury to upper end of the humerus). After a strict rehab protocol, Ty has gotten back on the football field and is playing in college on a scholarship with 100% return of normal function of his arm and shoulder.

There are a number of different types of shoulder instability and procedures to treat them. Dr. Millett has ongoing laboratory and clinical research projects on these surgical techniques for shoulder instability to allow for faster and better recoveries.

Shoulder instability is a very common condition that can be treated reliably with predictably in the vast majority of patients and athletes. Proper diagnosis and appropriate surgery are however essential for an optimal result. Once surgery has been performed and the shoulder rehabilitated, most individuals can return to their normal activities without the fear or anxiety of instability or a dislocation. Recovery typically takes between 4 and 6 months.

Talk to your orthopedic doctor if you are experiencing shoulder instability so that a proper course of treatment can be prescribed and you can resume a normal, active lifestyle.

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