Shoulder Instability
The shoulder is a highly mobile joint. It allows us to raise and rotate our arm and to reach up above our head. This multidirectional range of motion, however, predisposes to instability
Shoulder instability occurs when the head of the head of the humerus is forced out of the glenoid socket. This could happen as a result of a sudden injury,
such as a fall or accident.
Once a shoulder has dislocated, there are high chances of the joint dislocating again.When the shoulder is loose and dislocates repeatedly, it is called shoulder instability.
Description
When the humeral head comes partially out of the glenoid socket, it is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.
the tissues like labrum, ligaments, tendons, and muscles around the shoulder which prevent it from dislocating are torn, dislocations can occur repeatedly. Shoulder instability is the inability of these tissues to keep the arm centered in the glenoid socket.
Causes
Shoulder Injury
Injury, or trauma, is commonly the cause of an initial shoulder dislocation.
Such injuries can happen in gyms or sports and even in Road traffic accidents The labrum (the cartilage rim around the edge of the glenoid )along with the anterior capsule are the major restraints to dislocation. The labrum is commonly torn in many cases . This is commonly called a Bankart lesion. A Bankart lesion is a tear in the labrum — the cartilaginous rim around the edge of the glenoid socket
Hyperlaxity
There is a subset of people who have comparatively more loose ligaments in all their joints vis a vis general human population. They may subluxate or dislocate their joint without any significant injury. These are called hyper lax individuals. The looseness could also be because of repetitive overhead motion. Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments. Such lax ligaments can make it hard to maintain shoulder stability. Strenuous repeated activities can challenge a weakened shoulder. This results in a painful and unstable shoulder. In some patients, the shoulder can become unstable without a history of injury or repetitive strain. In such patients, the shoulder may feel loose or dislocate in multiple directions, meaning the Humeral head may dislocate in any direction. This is called multidirectional instability.(MDI) These patients have naturally loose ligaments throughout the body and may be double-jointed.
Symptoms
- Recurrent shoulder dislocations
- Feeling of Apprehension when the arm is taken in position of throwing
- Posterior instability patients complain of shoulder pain rather than instability
- Feeling of less power or weakness in doing heavy activities
Physical Examination And Patient History
After a detailed questioning of your symptoms and medical history, Dr Ahmed would examine your shoulder. Specific clinical tests like Apprehension test, Shift and Load test, Jobe’s test are performed to assess instability in your shoulder. Clinical assessment of general looseness in your ligaments is also done. For example, you may be asked to try to touch your thumb to the underside of your forearm.
Imaging Tests
Radiological investigations will be advised by Dr Ahmed to confirm the clinical findings and to find any associated pathologies. X-rays. X-rays are done to assess bony defects of the glenoid and Humeral head. Bony Bankart and Hill Sach lesion are well identified on Xray.
Computed Tomography (CT Scan ) is advised in cases of bony injuries to assess bone loss on glenoid side and Humeral side. Magnetic resonance imaging (MRI). MRI is the investigation of choice and most needed to assess, Bankart lesion, capsule tears, labral injuries , HAGL lesion, GAGL lesion, and other soft tissue pathologies
Treatment
There are a few indications for non surgical treatment as given below
Nonsurgical Treatment
Non surgical treatment is advised by Dr Ahmed for those patients who have had only one dislocation and are very old or have a sedentary lifestyle
and low demand.
Activity modification: Like avoid playing sports requiring throwing and overhead abduction.
Non-steroidal anti-inflammatory drugs (NSAIDs): Anti-inflammatory drugs like aspirin, ibuprofen, and naproxen can reduce pain in acute setting
Physiotherapy: Should be Done under the supervision of a shoulder rehab specialist ,Strengthening shoulder girdle muscles and working on kinetic
control of shoulder can increase stability.
Surgical Treatment
Surgery is offered to young , active , high demand patients with repeated dislocations to repair torn or stretched ligaments so the liagments are better able to hold the shoulder joint in place. Bankart lesions can be surgically repaired. Sutures and anchors are used to reattach the ligament to the bone.
Arthroscopy: Arthroscopy is a keyhole procedure used to repair soft tissues in the shoulder. Dr Ahmed will look inside the shoulder with a tiny camera and perform the surgery with special pencil-thin instruments.
Open Surgery: Some patients with more bone loss may need an open surgical procedure. This involves making an incision over the shoulder and performing the repair.
Rehabilitation: For 4 to 6 weeks, depending upon your tissue quality, Dr Ahmed will immobilise your shoulder in a Shoulder arm pouch. This time of rest to shoulder allows healing of the torn tisues. At 4 to 6 weeks gradual exercises under supervision of a shoulder specialist physiotherapist are started. These exercises will improve the range of motion in your shoulder and prevent adhesions as the labrum heals. Your physical therapist will gradually expand your rehabilitation program by adding exercises to strengthen your shoulder. It is important to abide by the protocol advised by Dr Ahmed because every patient is given a customised program on the basis of the condition of tissues repaired and the demands of the patient. Rehabilitation plays an important part in achieving success in such surgeries.
