Services & Specialties
Take a minute and think of all the things we do with our arm. Whether it’s putting on a belt or a jacket. Reaching above to grab something from the top shelf. Or reaching across to hit a backhand down the line. None of these things would be possible were it not for the amazing flexibility of the shoulder joint. But this freedom of motion comes at a price…INSTABILITY.
SHOULDER INSTABILITY can result from trauma, sports related injury, overuse or be related to genetic factors. The vast majority of cases occur as a result of a sports related injury, and shoulder dislocations are frequent occurrences in contact and collision sports such as football, rugby, hockey and basketball.
In the most basic sense, the shoulder can be thought of as a simple ball and socket joint. It has often been likened to a golf ball resting on a tee. To be completely accurate, the tee must be turned 90 degrees, to horizontal. Certainly, doing this would cause the BALL TO FALL FROM THE TEE. This analogy helps to highlight the inherent instability of the shoulder joint.
So what is it that provides stability to the system?
The shoulder is supported by a complex arrangement of muscles, ligaments and
capsule. To put it simple, the MUSCLES
PULL, the LIGAMENTS RESTRAIN and the CAPSULE KEEPS IT ALL CONTAINED.
Shoulder instability occurs when one or a combination of these structures is injured
When evaluating patients with shoulder instability we consider several factors:
Shoulder dislocations occur much more commonly in younger patients. In fact, nearly half of shoulder dislocations occur in patients between the ages of 15-29. Also, approximately 70% of dislocations occur in males, though this tide is moving as girls continue to become more active in contact sports.
Some studies have shown that nearly 100% of patients who are younger than 20 at the time of the initial dislocation will continue to experience shoulder instability. This can be in the form of continued shoulder pain or frank dislocations. THEREFORE, WHEN TREATING YOUNGER PATIENTS, WE GENERALLY TAKE A MORE AGGRESSIVE APPROACH as to minimize risk of complications associated with recurrent injury.
Most commonly, shoulder dislocations result from trauma. In fact,
nearly 50% OF ALL DISLOCATIONS OCCUR DURING SPORTS OR
RECREATION. Shoulder dislocations also often occur in the
home environment. These injuries generally are associated with falls, and occur in relatively older patients. Though recurrent instability is less of a concern for the older patients, the risk of additional injuries, including rotator cuff tears, is much higher.
History or Recurrence
All patients who sustain a shoulder dislocation will be at some increased risk of recurrence. Younger patient certainly have a much higher risk. Additionally, patients who sustain injury to the bone about the shoulder are at an increased risk. Think back to the golf ball and tee analogy. Anyone who has tried to use an OLD BROKEN TEE can attest to the fact that it is generally much more difficult or impossible to keep the ball on the tee.
Degree of Injury
Utilizing thorough clinical evaluation, radiographs and advance diagnostic imaging, we are able to determine the extent of injury. This information is critical when treating patients with instability. Whereas, some injury patterns may be treated with physical therapy alone, other more complex injuries may require early surgery.
Level of Activity
Once the shoulder has been injured, we consider the patient’s level of activity and the pattern of instability when determining the most appropriate treatment plan. Some patient’s may only experience shoulder symptoms with certain activities. If possible, in addition to supervised physical therapy, we recommend modifying activities to limit instability symptoms.
Some patients will develop instability symptoms with non-athletic activities. It is not uncommon to experience shoulder dislocations during daily activity as well as while turning over in bed.
In situations where the patient determines that they cannot modify their activities to accommodate the shoulder instability, or the instability occurs during regular daily activities, further treatment is recommended. Generally, in these scenarios we will recommend surgical treatment for the injury.
Treatment for shoulder instability can be divided into two main categories: Non-operative and Operative. Based on the factors previously discussed, we determine the most appropriate treatment plan for each patient.
Historically, non-operative treatment for shoulder instability was considered the gold standard. Through activity modifications, physical therapy and possible bracing, many patients are able to resolve their shoulder instability symptoms.
PHYSICAL THERAPY FOCUSES ON STRENGTHENING THE MUSCLES ABOUT THE SHOULDER, which become vitally important in the unstable shoulder. The rotator cuff muscles, as well as the muscles that stabilize the shoulder blade, are the focus of this treatment.
Recently there has been significant interest in alternative options, including kinesiology tape (KT TAPE). Despite the enthusiasm, there is little scientific evidence to support the use of these products.
In patients who continue to experience shoulder instability despite prior treatment, surgery may be necessary. The goal of surgery is to restore the normal anatomy of the shoulder. The essential injury encountered in most patterns of instability is to the GLENOID LABRUM and CAPSULE. The labrum is a cartilage structure that serves to “Keep the Ball on the Tee”. It is wedge shaped and can be likened to a WHEEL CHOCK. The wedge shape of the labrum has significant mechanical advantages. Just as the wheel chock can prevent a large plane from moving on the tarmac, a normal labrum is important for shoulder stability.
SURGICAL TREATMENT FOR SHOULDER INSTABILITY FOCUSES ON REPAIRING THE INJURED CAPSULE AND THE LABRUM. Historically, this required a large incision on the shoulder and an open procedure. These procedures often resulted in shoulder weakness and loss of motion. Additionally, the open techniques have been associated with increased risk of shoulder arthritis over time. This was mostly due to non-anatomic repair of the injured structures associated with the open procedures. Furthermore, the normal structures about the shoulder were often damaged by these procedures.
Modern surgical treatment involves minimally invasive techniques performed using ARTHROSCOPY, or small camera and specialized instruments. The goal is similar to the old open procedures, but the injured structures are repaired in an anatomic fashion. Additionally, the arthroscopic procedures avoid injury to the normal shoulder anatomy.Because the normal shoulder anatomy is restored, and other structures are not injured in the process, recovery is generally shortened after arthroscopic shoulder stabilization. Furthermore, as the arthroscopic techniques and instruments have improved, the risk of recurrence after arthroscopic procedures has also improved, and now is considered at the very least comparable to the open surgeries. THE RISK OF RECURRENCE AFTER SURGICAL TREATMENT FOR SHOULDER INSTABILITY IS APPROXIMATELY 10%.
Most patients are able to resume daily activities within 4-6 weeks. Patients are able to resume non-collision sports in 3-6 months and collisions sports in 6-9 months. Full recovery after shoulder stabilization may take up to one year and there can be some loss of motion.
To maximize outcomes, patients must work closely with a skilled physical therapist. Additionally, frequent physician follow-up is important to ensure an optimal outcome.