Shoulder Instability

Introduction

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. In some cases, the unstable shoulder actually slips out of the socket. If the shoulder slips completely out of the socket, it has become dislocated. If not treated, instability can lead to progressive injuries, incapacitating pain and arthritis of the shoulder joint.

Anatomy

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone,) and the clavicle (collarbone). The rotator cuff connects the humerus to the scapula. The rotator cuff is actually made up of the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move bones by pulling on tendons. The muscles of the rotator cuff also keep the humerus tightly in the socket. A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat.

Surrounding the shoulder joint is a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are soft connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion. If the shoulder moves too far, the ligaments become tight and stop any further motion, something like a dog coming to the end of its leash.

Dislocations happen when a force overcomes the strength of the rotator cuff muscles and the ligaments of the shoulder. Ninety-seven percent of dislocations are anterior dislocations, meaning that the humerus slips out of the front of the glenoid. Only three percent of dislocations are posterior dislocations, or out the back.

 
Shoulder X-ray showing a dislocation.  The humeral head is beneath and in front of  the glenoid.

Sometimes the shoulder does not come completely out of the socket. It slips only partially out and then returns to its normal position. This is called subluxation.

Causes

What causes a  shoulder to become unstable?

Shoulder instability often follows an injury that caused the shoulder to dislocate. This initial injury is usually fairly significant, and the shoulder must be reduced. To reduce a shoulder means to have a doctor manually put it back into the socket. The shoulder may seem to return to normal, but the joint often remains unstable. The ligaments that hold the shoulder in the socket may not heal properly, or they may have gotten stretched out. This makes them too loose to keep the shoulder in the socket when it moves in certain positions. An unstable shoulder can result in repeated episodes of dislocation, even during normal activities. Instability can also follow less severe shoulder injuries.

In some cases, shoulder instability can happen without a previous dislocation. People who do repeated shoulder motions may gradually stretch out the joint capsule. This is especially common in athletes such as baseball pitchers, volleyball players, and swimmers. If the joint capsule gets stretched out and the shoulder muscles become weak, the ball of the humerus begins to slip around too much within the shoulder. Eventually this can cause irritation and pain in the shoulder.

In some cases, a genetic problem with the connective tissues of the body can lead to ligaments that are too elastic. When ligaments stretch too easily, they may not be able to hold the joints in place. All the joints of the body may be too loose. Some joints, such as the shoulder, may be easily dislocated. People with this condition are sometimes referred to as "double-jointed."

Symptoms

What problems does an unstable shoulder cause?

Chronic instability causes several symptoms. Frequent subluxation is one. In subluxation, the shoulder may slip (sublux) in certain positions, and the shoulder may actually feel loose. This commonly happens when the hand is raised above the head while throwing. Subluxation of the shoulder usually causes a quick feeling of pain, like something is slipping or pinching in the shoulder. Over time, you may stop using the shoulder in ways that cause subluxation.

The shoulder may become so loose that it starts to dislocate frequently. This can be a real problem--especially if you can't get it back in the socket and must go to the emergency room every time. A shoulder dislocation is usually very obvious. The injury is very painful, and the shoulder looks abnormal. Any attempted shoulder movements cause extreme pain. A dislocated shoulder can damage the nerves around the shoulder joint.

If the nerves have been stretched, a numb spot may develop on the outside of the arm, just below the top point of the shoulder. Several of the shoulder muscles may become slightly weak until the nerve recovers. But the weakness is usually temporary. 

Diagnosis

What tests will my doctor run?

Your doctor will diagnose shoulder instability primarily through your medical history and physical exam. The medical history will include many questions about past shoulder injuries, your pain, and the ways your symptoms are affecting your activities.

In the physical exam, your doctor will feel and move your shoulder, checking it for strength and mobility. Your doctor will stress the shoulder to test the ligaments. When the shoulder is stretched in certain directions, you may get the feeling that the shoulder is going to dislocate. This is a very important sign of instability. It is called an apprehension sign. (Don't worry--unless your shoulder is extremely loose, it will not dislocate.)

Your doctor may order an X-ray. X-rays can help confirm that your shoulder was dislocated or injured in the past.

If your doctor is unsure about the diagnosis, you may need to undergo further tests. Your doctor may want to examine your shoulder while you are under general anesthesia, using an arthroscope. An arthroscope is a tiny TV camera inserted into the shoulder through a small incision. This allows a good look at the muscles and ligaments of the shoulder. When you are awake, it is hard to test the ligaments because you automatically tighten the muscles during the exam.

When you go to the doctor with a dislocated shoulder, X-rays are necessary to rule out a fracture. X-rays are usually done after the shoulder is put back into joint. This allows your doctor to make sure the joint is back in place. 

Treatment

How can I get the stability back in my shoulder? 

Conservative Treatment:

Your doctor's first goal will be to control your pain and inflammation. Initial treatment is likely to be rest and anti-inflammatory medication, such as aspirin or ibuprofen. The anti-inflammatory medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, patients are shown ways to avoid positions and activities that put the shoulder at further risk of injury or dislocation. Overhand athletes may be issued a special shoulder strap or sleeve to stop the shoulder from moving in ways that strain it.

Your therapist may use heat or ice treatments to ease pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and nearby joints and muscles. Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This will improve the stability of the shoulder and help your shoulder joint move smoothly.

You may need therapy treatments for six to eight weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgical Treatment

If your therapy program doesn't stabilize your shoulder after a period of time, you may need surgery. There are many different types of shoulder operations to stabilize the shoulder. Almost all of these operations attempt to tighten the ligaments that are loose. The loose ligaments are usually along the front or bottom part of the shoulder capsule.

The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. The Bankart repair involves sewing or stapling ligaments on the front side of the joint back into their original position. First, the doctor clears away any frayed or torn edges. Holes for the sutures are drilled into the scapula bone. The capsular ligaments are then attached with sutures to the bone.

The ligaments heal, and scar tissue eventually anchors the ends to the bone. With the ligaments back in place, the joint is much more stable.

Typically the Bankart repair is done through an incision on the front of the shoulder. Some doctors prefer to perform a similar operation using an arthroscope. This new technique is not yet widely practiced. Arthroscopes require smaller incisions, which means less time in the hospital and less time to heal.

Another surgery to tighten a loose shoulder joint is with a procedure called a capsular shift. In this procedure, an incision is made on the front of the joint capsule to create a flap. The surgeon pulls the flap of tissue over the front of the capsule and sews it together. This is similar to when a tailor "tucks" loose fabric by overlapping and sewing the two parts together.

Some surgeons are using an even newer procedure called thermal capsular shrinkage. Using an arthroscope, the surgeon slides an electrode probe inside the unstable shoulder. The electrode is heated up, and the surgeon moves the probe over the injured ligament. The heat causes the capsule to shrink and tighten. One of the risks with this type of surgery is that the capsule may get too tight, leading to restricted shoulder motion.

Rehabilitation

When will I be able to use my shoulder normally again?

Even conservative treatment for shoulder instability requires a rehabilitation program. The goal of therapy will be to strengthen the rotator cuff and shoulder blade muscles to make the shoulder more stable. At first you will do exercises with the therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

Rehabilitation after surgery is more complex. You may need to wear a sling to support and protect the shoulder for one to four weeks. A physical or occupational therapist will probably direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for two to four months. You should expect full recovery to take up to six months.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy after Bankart surgery proceeds slowly. Range-of-motion exercises begin soon after surgery, but therapists are cautious about doing stretches on the front part of the capsule for the first six to eight weeks. The program gradually works into active stretching and strengthening.

Therapy goes even slower after surgeries where the front shoulder muscles have been cut. Exercises begin with passive movements. In passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts three to four weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

By about the tenth week, you will start more active strengthening. These exercises focus on improving strength and control of the rotator cuff muscles. Strong rotator cuff muscles help hold the ball of the humerus tightly in the glenoid to improve shoulder stability.

Overhand athletes start gradually in their sport activity about three months after surgery. They can usually return to competition within four to six months.

Some of the exercises you'll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problem