Shoulder Instability & Dislocation treatment in San Antonio
What is Shoulder Instability?
Shoulder instability occurs when an athlete's shoulder joint feels loose or unstable. Dislocation happens when the ball of the upper arm bone (humerus) pops out of its socket in the shoulder blade (scapula). Shoulder instability and dislocation can be concerning for young athletes and parents. Dr. Rush, a leading pediatric sports surgeon, has extensive experience treating these conditions in young athletes.
Understanding the Shoulder Joint
The shoulder joint is a ball-and-socket joint, offering a wide range of motion for everyday activities like throwing and reaching overhead. This joint relies on a delicate balance between flexibility and stability. Key structures include:
Humerus: The upper arm bone, with a round head that fits into the socket.
Glenoid cavity: The shallow socket in the shoulder blade that cradles the humeral head.
Ligaments: Strong bands of tissue that connect bones and stabilize the joint.
Labrum: A ring-shaped cartilage that deepens the glenoid cavity for better stability.
Learn Why Early diagnosis of shoulder dislocation is crucial for young athletes
If your athlete experiences any of these symptoms, it's crucial to seek medical attention:
Feeling of the shoulder "giving way," often accompanied by pain.
Feeling of looseness or instability in the joint.
Difficulty raising the arm overhead.
Popping or grinding sensation in the shoulder.
Visible deformity in the shoulder (in case of dislocation).
Symptoms of Shoulder Instability
Causes of Shoulder Instability
Several factors can contribute to shoulder instability:
Traumatic Injuries
Falls on outstretched arms: A common cause, especially during activities like gymnastics or playing on playgrounds.
Direct hits to the arm during sports: Contact sports like football or baseball can put stress on the shoulder joint, leading to dislocation.
Insufficient Stabilization
Weak ligaments or rotator cuff muscles can make the shoulder joint unstable. Dr. Rush emphasizes the importance of these structures in maintaining shoulder stability.
Age and Ligament Laxity
Younger children: Their tissues are still developing, making them more prone to repeat dislocations after an initial injury.
Looser ligaments: Some children are born with naturally looser ligaments, increasing their risk of instability even with minor injuries.
Multidirectional Instability
In some cases, the shoulder joint can become unstable in more than one direction, such as forward (anterior), backward (posterior), or downward (inferior).
Treatment Options for Shoulder Instability
Rest and immobilization: A sling might be used for short-term support to allow the joint to heal.
Physical therapy: Physical therapy is crucial to regain range of motion and strengthen the rotator cuff muscles for improved stability.
Activity modification: Avoiding activities that aggravate the shoulder joint is essential during recovery.
However, in some cases, surgery might be necessary. Dr. Rush may recommend surgery for:
Persistent instability: If a child continues to experience symptoms of looseness or repeated dislocations despite following non-operative treatment.
Young athletes: Research suggests surgery after a first-time dislocation could benefit young athletes (under 25) to prevent future problems and maintain function.
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FAQs on Shoulder Dislocations & Instability
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The shoulder is a ball and socket type of joint that permits a wide range of movement. Its bony structures include the upper arm bone (the humerus) and the shallow cavity (the glenoid) of the shoulder blade. While it is called a ball and socket joint, the shoulder looks more like a golf ball on a golf tee - a ball on a shallow dish like surface. The ball of the humerus (humeral head) is meant to stay close to the socket. The humeral head is held into the socket by the lining of the joint (the capsule), thickenings of the capsule called ligaments, and a cartilage rim (the labrum).
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While the shoulder has tremendous range of motion, it can lose its stability and the humeral head can sometimes move out of the socket of the joint. This can happen due to a traumatic injury such as a fall or a direct hit to the arm while playing sports. It can also occur due to insufficient stabilization from the capsule and rotator cuff muscles. The humeral head (ball) can move either partially (sublux) or completely (dislocate) out of the socket. The humeral head can dislocate or sublux forward (anterior), backward (posterior), or out the bottom of the joint (inferior). The most typical pattern seen after injuries is anterior, though posterior dislocations can occur. If the shoulder is unstable in more than one direction it is called multidirectional instability.
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With significant trauma to a previously normal joint, the humeral head can dislocate. The capsule, ligaments, or labrum can be stretched, torn, or detached from the bone. When athletes have multiple dislocations, further tissue damage can occur increasing the risk of more dislocations. The chance of repeat dislocations often depends on the age of first dislocation. Younger patients are much more likely to dislocate their shoulder again. Alternatively, some people are born with somewhat loose shoulder ligaments and capsule. In these patients, instability can occur without any trauma or following relatively minor injury.
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People with shoulder instability can sometimes feel the ball of the shoulder come out of its socket. This is commonly associated with pain. Often, the episodes of “giving way” occur with specific activities or positions of the arm, such as with throwing a ball or reaching behind the body.
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A complete history and physical examination is critical. The examination includes palpation to check for points of tenderness as well as a determination of range of motion and strength. The degree of shoulder looseness or laxity of the shoulder joint can also be assessed by specific tests during the examination. X-rays are usually done to obtain information about the possible causes of the instability and to rule out other causes of shoulder pain, such as a fracture. An MRI us usually performed to further evaluate the bones and tissues of the shoulder joint, including the labrum.
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After a patient has dislocated their shoulder, it is important to rest the shoulder and avoid aggravating activities for a couple of days. Patients are usually placed in a sling or a shoulder immobilizer for their comfort for the first few weeks. Once the pain and swelling have subsided, physical therapy for range of motion exercises and gentle strengthening are started. Typically, the exercise program is done in conjunction with a physical therapist. Applying cold packs or ice bags to the shoulder before and after exercise can help reduce the pain and swelling. NSAIDS (non-steroidal anti-inflammatory drugs) such as Ibuprofen or Naproxen can be used to reduce pain and swelling. The goal of therapy is to restore shoulder motion and increase the strength of the rotator cuff muscles. By strengthening the rotator cuff, you can stabilize and help prevent the shoulder from further dislocation. Once you have full motion, no pain, and full strength, you will be released to gradually return to activities.
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Surgery may be necessary in patients who have continued symptoms of looseness or instability, or have further dislocation events, despite nonoperative treatment. Additionally, surgery may be indicated in young patients after a first dislocation. Research has shown that in young patients (younger than 25 years of age), especially those paying contact sports, having surgery after a first-time dislocation is more effective and leads to lower recurrence, higher function, and less shoulder arthritis than nonoperative treatment. Furthermore, repeated dislocations can make surgical stabilization more difficult, more invasive, and less successful. The surgical plan should always be individualized based on the individual patient.
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The surgery includes examination of the shoulder under anesthesia to fully assess the extent and direction of the instability while the muscles surrounding the shoulder are completely relaxed. An arthroscope is used to inspect the inside of the shoulder joint and to evaluate the joint and its cartilage. The arthroscope allows direct assessment of the condition of the labrum and rotator cuff tendons. In a majority of patients, it is possible to stabilize the shoulder by arthroscopic techniques. The repair can be done with sutures or stitches that are attached to plastic or absorbable anchors. These anchors are inserted into the bone and hold the sutures that are used to reattach or tighten the ligaments. These anchors stay in the bone permanently.
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The course of recovery following surgery can depend on multiple factors. Patients will attend formal supervised physical therapy. Typically, after an arthroscopic surgery, you will be in a sling full-time for 6-weeks following the surgery. Usually, range of motion of the hand, wrist and elbow begin the day after surgery. Most patients can move their wrist and hand and use the arm to eat, get dressed and even type on a computer within three to seven days after surgery. The second 6-week block following surgery is focused on restoring range of motion followed by 6 weeks of strengthening. Return to sports can take five to six months. With surgery, the chance of recurrence of the instability is low (3 to 5%), and most patients can return to their previous activities.
Dr. Jeremy K. Rush, MD, FAAP, is San Antonio's only orthopedic surgeon who is Dual-Fellowship Trained in pediatric orthopedic surgery and sports medicine. He specializes in arthroscopic surgery of the knee, shoulder, elbow, and ankle, as well as the treatment of fractures and other injuries in young athletes.
