Shoulder Instability

Shoulder instability is a condition characterized by a loose, or unstable shoulder joint caused by weakened and stretched surrounding ligaments. This may become a chronic condition after a shoulder dislocation, which occurs when the ball of the upper arm bone comes out of the socket. Chronic instability may produce frequent slipping, or partial dislocation, known as subluxation.

A shoulder dislocation may occur after an acute traumatic injury to the shoulder. This usually occurs during a contact sport such as football, or hockey, but can also occur from a fall onto an outstretched arm.

An unstable shoulder may also be the result of repetitive overuse in an overhead athlete, such as tennis, volleyball, and swimming.

The shoulder is more susceptible to this type of condition than other joints because it provides the arm with a tremendous range of motion. If a dislocation takes place, the muscles, tendons and ligaments of the shoulder may tear or loosen, resulting in the persistent slippage associated with instability.

Symptoms of Shoulder Instability

People with unstable shoulders may experience pain and limited motion in the joint and additional symptoms may include:

Soreness
Weakness
Numbness in the arm

Symptoms of shoulder instability may discourage participation in sports that require stretching the arm overhead.

Diagnosis of Shoulder Instability

Shoulder instability can be diagnosed after a medical history has been taken and a physical examination performed. The exam may include certain tests of movement in order to evaluate potential shoulder instability. Additionally, imaging tests such as X-rays or MRI scans may be necessary to provide clear visualization of the bones and tissues around the shoulder.

Treatment of Shoulder Instability

Treatment for shoulder instability usually begins with conservative measures including resting the affected arm, physical therapy and use of non-steroidal anti-inflammatory medications. However, for some people these approaches may fail to provide relief. At that point, surgical treatment may be recommended. Instability surgery varies depending on the cause of the condition, but usually aims to tighten the loose ligaments of the shoulder. The two most common types of instability surgery include Bankart repair and capsular shift procedures, which may be performed in combination.

Bankart Repair

Bankart repair is an arthroscopic surgery procedure, where the surgeon places a small camera into the shoulder through a portal. Other portals are used to place small anchors in the socket with strong sutures attached. These sutures are then passed around the torn labrum and ligament to repair the tear and restore stability to the shoulder joint.

Capsular Shift

Capsular shift is used to decrease and tighten the joint capsule, which is the lining of the joint, when it is too large. This is accomplished by folding the affected ligaments over on themselves and suturing them in this more layered position.

Both of these outpatient surgeries can often be performed through arthroscopy, which allows for minimally invasive procedures with smaller incisions and shorter recovery times.

Risks of Shoulder Instability Surgery

As with any type of surgery, shoulder repair surgery may pose a risk of complications. Although uncommon, risks may include:

Bleeding
Infection
Blood clot
Shoulder stiffness
Shoulder weakness
Nerve or blood vessel damage

In some cases, the shoulder may fail to heal after surgery.

Recovery from Shoulder Instability Surgery

Patients are required to wear a sling or another immobilization device for 5 days after surgery until their first postoperative visit. Depending upon the procedure performed and the severity of the tear, physical therapy will usually begin 5 days after surgery. Sling use will be gradually weaned as function improves to reduce the risk of postoperative stiffness. Pain medication and applications of ice may be necessary for at least a few days following the procedure. Physical therapy can be very effective in restoring the flexibility and strength to the shoulder. Recovery periods vary depending on the extent of the shoulder damage, but full recovery typically takes several months.

Rotator Cuff Injuries

Four muscles in the shoulder that when injured or damaged can lead to sleepless nights, pain, and weakness.

The most common ways of injury to the rotator cuff are trauma, such as a fall on the outstretched hand, repetitive overload to the tendon by activity, or bone spurs cutting into the tendon.

Symptoms commonly begin with pain over the upper arm that is worse with reaching overhead, lying on your side, reaching behind your back, and weakness.

The rotator cuff has a very limited capacity to heal on its own and therefore treatment is often required to improve symptoms. This usually begins with a short period of rest, followed by a rehabilitation program focused on mobility, and strength to improve function. Steroid injection can be used if significant inflammation is present and interferes with the ability to engage in the exercise program. Two thirds of patients will improve with these modalities alone, and thus this is the first phase of treatment.

If symptoms persist, MRI is utilized to evaluate the rotator cuff for tears. Most commonly injured is the supraspinatus tendon. This is the muscle that allows you to put on a jacket, reach into the kitchen cabinet and get out the dishes, put a gallon of milk in the refrigerator, or pour a pot of coffee. Because the tendon is spring loaded, full tears commonly separate or retract. The more the retraction, the more serious the tear. If these tears are not addressed, atrophy will ensue and the tears will frequently get larger over time.

Surgical repair is performed arthroscopically and consists of stretching the tendon back out to it’s attachment point and repairing it back to the humerus greater tuberosity that it pulled off from. Traditionally, the shoulder was immobilized in a sling for up to 6 weeks before starting physical therapy to protect the repair. The downside of this approach was a high rate of postop stiffness, called frozen shoulder. We pioneered an accelerated rehab program for rotator cuff 25 years ago that reduced this immobilization down to just 5 days and actually lowered to postop stiffness rate.

Quality of the rotator cuff tissue has been a major determinant of success of the surgery, as well as the recurrent tear rate. The larger the tear and degree of separation, the higher the recurrent tear rate – that can approach 50 percent!

Innovation in rotator cuff surgery revolves around the use of biologics to reduce the risk of recurrent tears. CuffMend is an acellular, dermal allograft that is placed upon the repair to effectively double the thickness of an atrophic tendon and reduce the risk of recurrent tears. We have been effectively utilizing this technology over the past 2 years with great success to enhance patient outcomes for the most serious tears.

We remain committed to utilizing the best technology to remain innovators in rotator cuff surgery.