What Is Shoulder Instability?
In shoulder instability the shoulder joint feels loose as though the ball is falling out of the socket in extreme cases the shoulder dislocates repeatedly and has to be reduced back into normal position. It may occur following an injury such as a fall or commonly in contact sports such as rugby where the shoulder dislocates damaging the tissues. It may also occur spontaneously due to general laxity of the joint.
Why does the shoulder become unstable? The shoulder is the most mobile joint in the body. It is a ball and socket joint. A number of structures are required to keep the shoulder joint stable. These include:
- The shape of the bones i.e. the head of the humerus which forms the ball and glenoid of the scapula bone that makes up the socket.
- The glenoid labrum which is made from fibrocartilage that deepens the socket.
- Ligaments and capsule surrounding the joint.
Any disturbance to the normal anatomy of these structures of these structures may result in shoulder instability.
In a shoulder dislocation the glenoid labrum commonly detaches from the bone making the shoulder more susceptible to further dislocations.
What Is The Treatment?
A number of treatment options are available: Physiotherapy may help to strengthen the muscles surrounding the joint.
If the glenoid labrum has been torn, then surgery may need to be performed to reattach the torn glenoid labrum to the bone. This restores normal anatomy and reduces the likelihood of further dislocations. This can be done either by an open operation or through arthroscopic or keyhole surgery.
If there is a large capsule this may be tightened, again by either open surgery, or through keyhole surgery using radiofrequency to shrink the tissues.
Do I Need Surgery?
This is a decision that should be made in consultation with your surgeon. It depends on the lifestyle you lead, the number of dislocations you have had and the interference with normal daily living.
Studies have shown that if you are young (under 30), actively involved in sports and have had a shoulder dislocations, then there is a 50% chance of having a further dislocation in the future.
Open Shoulder Stabilisation – Laterjet Bone Transport Procedure
In certain circumstances, arthroscopic stabilisation of an unstable shoulder is not possible. For example, when in addition to torn labrum, a piece of bon has detached from the socket (glenoid) of the shoulder. Arthroscopic intervention may also not be appropriate if there is a large divot of bone taken from the back of the ball (humeral head – Hill Sachs lesion) of the shoulder joint, when the shoulder dislocates.
In these cases, open surgery is necessary to compensate for the bone injuries. The procedure involves the transfer of part of the coracoid bone to the front of the glenoid, thereby replacing missing bone or deepening the socket, such that there is increased contact between the ball and the socket. In addition muscle attachments to the coracoid are transferred adding to the stability by acting like a sling in front of the shoulder.
In order to perform the surgery, the patient will usually have a regional anaesthesia involving a nerve block to the arm, supplemented with general anaesthetic. The operation is generally performed as 1 – 2 night stay dependent on pain.
A wound is made over the front of the shoulder usually 8 – 10 cm in length. The coracoid is divided and transferred to the front of the glenoid, where it is held with a screw.
In order for the bone to heal, the arm will be immobilised in a sling for approximately 4 – 6 weeks, before shoulder range of movement is re-established. During the initial period many patients experience significant sleep disturbance and regular analgesia is likely to be required. It is not possible to drive whilst the arm is in the sling.
A strengthening programme is subsequently employed usually light weights 6 – 8 weeks post surgery. Non contact sport is usually recommended 3 months following the surgery, with contact activity initiated between 4 – 6 months dependent on progress. Rehabilitation may continue for 9 months following the procedure. Commitment to the physiotherapy programme is fundamental to the success of the surgery.
Arthroscopic Shoulder Stabilisation
The aim of this procedure is to repair the torn labrum and ligaments in the shoulder following a dislocation. This returns tissues to the normal position and thereby tightens the shoulder preventing further dislocation.
In order to perform the surgery, the patient will usually have a regional anaesthesia involving a nerve block to the arm, supplemented with either sedation or a general anaesthetic. In some instances,The patient my watch the operation on the monitor in theatre. The operation is generally performed as a day case or overnight stay if performed later in the day.
Usually 3 small (0.5 cm) wounds are made around the shoulder in order to allow the passage of the arthroscope (camera) and the instruments into the shoulder. Most commonly there is one wound at the back of the shoulder and two wounds at the front.
Bioabsorbable, or occasionally metal, anchors are inserted into the socket (glenoid) of the shoulder joint, after small holes ( 2.8 mm ) have been drilled. Sutures attached to the anchors are then passed through the torn labrum, called the Bankart lesion, and are then tied such that the labrum is repaired back to the bone.
In order for the labrum to heal, the arm will be immobilised in a sling for approximately 3 weeks, before shoulder range of movement is re-established. During the initial period many patients experience significant sleep disturbance and regular analgesia is likely to be required. It is not possible to drive whilst the arm is in the sling.
A strengthening programme is subsequently employed usually allowing light weights 6 – 8 weeks post surgery, with contact activity initiated between 3 – 5 months dependent on progress. Rehabilitation my continue for 6 months following the procedure. Commitment to the physiotherapy programme is fundamental to the success of the surgery.
Following arthroscopic stabilisation surgery, the risk of redislocation is 5% provided certain preoperative parameters are met, and confidence to participate in normal activities should be restored.
SLAP Lesion Repair
SLAP lesions are often repaired by an arthroscopic operation. The basic principle is to repair the torn labrum and hence the attachment of the long head of biceps tendon, which has become detached from the shoulder socket (glenoid). This is achieved using sutures and bone anchors, which are usually bioabsorbable.
In order to perform the surgery, the patient will usually have a regional anaesthesia involving a nerve block to the arm, supplemented with either sedation or a general anaesthetic. The operation is generally performed as a day case or over night stay if performed later in the day.
Approximately 3 small (0.5cm) wounds will be made about the shoulder in order to allow the arthroscope (camera) and other instruments into the shoulder.
In order to place the anchors, small holes will be drilled into the bone (2.8 cm). The sutures are then passed through the torn labrum and then tied down, stabilising the tissue back to the bone.
In order for the labrum to heal, the arm will be immobilised in a sling for 2 – 3 weeks before shoulder range of movement is re-established. During the initial period many patients experience significant sleep disturbance and regular analgesia is likely to be required. It is not possible to drive during this phase.
A strengthening programme is subsequently employed usually allowing light weights 3 – 6 weeks post surgery, depending on the magnitude of injury. Non contact sports are normally able to resume 6 – 8 weeks post surgery, with contact sports at 3 months post operation.
Mr Philip Ahrens On Shoulder Instability
One of our leading Consultants Mr Philip Ahrens shares his thoughts on Shoulder Instability, including diagnosis and treatment options based on his years of experience. In particular Mr Ahrens specialises in treating sports related injuries and has treated numerous athletes back to full recovery.
To ask a question about a shoulder instability or to book an appointment, contact our specialist team available Monday – Friday 8am – 6pm. Our shoulder team have a dedicated and caring approach and will seek to find you the earliest appointment possible with the correct specialist for your needs.
If you are self-paying you don’t need a referral from your GP. You can simply refer yourself and book an appointment. If you have medical insurance (e.g. Bupa, Axa PPP, Aviva), you will need to contact your insurer for authorisation for any treatment and, in most cases, you will require a referral letter from your GP.
If you do not have a GP, then we have an in-house private GP practice that you can use. Alternatively we can suggest the most appropriate course of action for you to take, given your location and individual circumstance.