Shoulder Instability: What Does It Mean?
Dr. Hunt: Hi. My name is Dr. Stephen Hunt, and I'm a sports medicine fellowship-trained orthopedic surgeon here at Tri-County Orthopedics. Today, I'd like to take you through one of the common shoulder injuries that I treat in my practice.
The shoulder has a very important role in our body. It is a ball-and-socket joint that is crucial to help position our hand up above over our head as well as away from our body.
Shoulder instability is when the ball will not stay in the socket. It usually occurs after a dislocation event in which the ball shifts away from the socket like this. It is different from a shoulder separation, which is when the collarbone ligaments get injured away from the shoulder blade up in this area here.
Shoulder stability is a complex interplay between bony stabilizers as well as soft tissue stabilizers. The bones, you have very little control over, and the shape of the bones provides some stability to the shoulder. However, soft tissues have both static stabilizers, which are the ligaments in the front, back, top, and bottom of the shoulder joint, as well as dynamic stabilizers, which are the muscles such as the rotator cuff as well as the muscles that move your shoulder blade. It is this complex interplay that keeps the ball from dislocating out of the socket.
When you have a dislocation event, there is an injury to the static stabilizers of the capsule and ligaments in the front part of your shoulder as well as the labrum, which is a fibrocartilage structure on the rim of the socket. This injury is one of the main reasons that we see people continue to have dislocation events. The younger you are when you have a dislocation, the higher your chance of having repeat dislocation events.
Most people who have shoulder instability have had at least one dislocation event. That usually is a very painful trauma that requires manipulation either at an emergency room or by an on-field physician to put the shoulder back into place.
People who have recurrent instability complain of pain. They complain of weakness in the shoulder. They may actually have episodes where the shoulder does pop out of position and then pops back into position. These people often have a lot of apprehension about using their arm because they never know when their arm's going to fall out of position and the ball will dislocate.
Initially, like most injuries, a dislocation can be treated with a short period of a sling as well as some gradual physical therapy. If you are under the age of 20, there is a very high likelihood that you may have a recurrent episode of instability. However, most people can be treated without any type of operation, and they will not have a repeat episode of dislocation. We tend to just send them to a therapist to have them rebuild their dynamic stabilizers such as their muscle strength as well as improve their motion so they do not have another dislocation event.
For the patient that continues to have pain as well as episodes of instability, whether it's just a partial dislocation called a subluxation or a true dislocation, there are surgical options available. Most commonly, what I'm able to do is do a reconstruction of the labrum and tighten up the capsule on the front part of the shoulder to restore the integrity of that static stabilizer. Most times, that is done with an arthroscopic approach, which involves several small incisions and inserting a camera into the shoulder joint to address any other injuries at that time.
Occasionally, people will have significant instability that is associated with a bony fracture or they have had multiple episodes of instability, and therefore, they have worn down some of the bone on the front of the socket. These patients sometimes will require an open surgical procedure to try to restore that bony stability, as well as sometimes we will use a bony block to try to improve the size of the socket so the ball won't slip out the front part of the shoulder.
After surgery, you can expect to be in a sling for three to four weeks. We start therapy right away. The therapy is a gradual progression of certain motions as we walk a tightrope between your shoulder being too stiff and you putting too much stress on the repair that we have just performed to the capsule and labrum and front part of the shoulder.
Ultimately, it will take three to four months till you're cleared to resume most activities, particularly overhead activities, without restriction. However, contact athletes may take as long as four to six months till they will be cleared to go back into their contact sports, such as football, lacrosse, or hockey.