Treating Shoulder Dislocation / Subluxation (Instability) and Associated Pain with Minimally Invasive Arthroscopy
Last updated Thursday, May 29, 2008
Figure 1 - Dislocated shoulder Figure 2 - Reduced shoulder Figure 3 - Normal labrum and biceps tendon (under probe) Figure 4 - Damaged cartilage (SLAP tear) at the top of the shoulder joint. Figure 5 - Damaged cartilage and torn ligament in the front, towards the bottom of the shoulder joint. Figure 6 - MRI showing an anterior soft tissue Bankart (labral) tear and a loose body Figure 7 - Loose body in front of shoulder joint Figure 8 - Loose body removed Figure 9 - Robust labral repair with sturdy bumper in the front Figure 10 - Bankart (labral repair) seen from the front. Note the large restored bumper resisting excessive motion. Review of the conditionCharacteristics of cartilage and ligament tears in the shoulder Individuals with cartilage or
ligament tears will have pain deep in the shoulder, especially with certain
positions and with overhead activities, (e.g., throwing/hitting sports like
softball, volleyball, and tennis; kayaking, surfing, weightlifting, climbing,
painting, racquet sports, etc). They may experience a popping or clicking sound
in the shoulder with motion that may or may not be painful. In some cases the popping seems to lessen the
pain. Not uncommonly, the pain is mild during exercise, but becomes worse later
that evening or the next day. Pain can emerge with specific actions such as
cocking the arm to throw, or when the racquet meets the ball. The pain may
lessen with rest, but recurs when the shoulder is put back in action.
A shoulder slipping in and out of the socket
suggests a more severe ligament tear. Partial slipping is called subluxation,
while complete disassociation of the shoulder joint is called dislocation (Figure 1). Dislocations may require an
individual to have assistance to relocate, or reduce, the shoulder joint (Figure 2). Some people who have had
many dislocations become adept at relocating their shoulders without assistance
by gently manipulating it. However, the “Martin Riggs” (Mel Gibson in the
“Lethal Weapon” movies) method of reduction –violently slamming it into place –
is not recommended as it can actually worsen the injury. Others have been told,
erroneously, that they will have to live with their “trick shoulder” or undergo
a major operation, so they elect to live with the condition.Types Cartilage tears have many names
based on their location in the shoulder joint. Most involve the labrum, an “O
ring”-like structure that runs along the circumference of the shoulder socket (glenoid).
The labrum effectively deepens the glenoid and serves as a point of attachment
for ligaments of the shoulder and the biceps tendon (Figure 3). Tears on the upper half of the labrum are commonly
called SLAP – Superior Labrum Anterior (front) to Posterior (back) – tears. These
tears (Figure 4) can present with
popping or catching sensations within the shoulder. Sometimes by moving the
shoulder a certain way, an individual can make the shoulder feel as the tear
temporarily falls back in place. Unfortunately, these tears do not heal on
their own.
Tears in the lower half of the labrum usually
involve the ligaments in the front or back of the shoulder (Figure 5). This allows the ball (humeral head) to move too far from
the glenoid in one or both directions, and creates instability.Similar conditions Tears
of the shoulder’s labrum and capsule might be confused with – and must be
distinguished from – rotator cuff tears,
“frozen shoulder” (adhesive capsulitis) and shoulder or neck arthritis – each
of which may produce somewhat similar symptoms. Rotator cuff tears usually
cause pain and weakness. Frozen shoulder is characterized by shoulder
stiffness, but X-rays usually are normal. Shoulder arthritis is most often
associated with some stiffness and popping. Neck arthritis may cause shoulder
pain and weakness that can be worse when the head is held in certain positions.
An experienced shoulder surgeon can discern what is causing the patient’s pain
or shoulder instability with a careful history and physical exam.Incidence and risk factors
Tears of the labrum and shoulder capsule
are very common in active people who engage in vocational or recreational
activities that demand upper body use.
Tears can occur when the arm is forcefully moved into an abnormal
position, placing excess stress on the shoulder. People who participate in
sports such as tennis, swimming, rowing, volleyball and baseball, in which the
shoulder is used repetitively, are more at risk. Action-sports athletes
(snowboarders, skiers, skateboarders, surfers and motor-sports enthusiasts) are
also at risk for these injuries. People
whose jobs require frequent overhead lifting or movement are at increased risk.
An external trauma, such as a fall onto an outstretched arm or onto the
shoulder, is another way in which these structures are injured among the
general population. Diagnosis When a patient presents with a
shoulder problem, a doctor’s initial diagnostic technique includes the patient’s
oral history and physical examination. Specific questions about a patient’s
mechanism of injury or background of activity will lend clues. Specific
physical tests are performed to pinpoint the cause of the problem.
X-rays of the shoulder are often typical.
In some cases a magnetic resonance image (MRI) will be ordered, often requiring
an injection of dye into the shoulder joint. This can highlight injuries to
cartilage and ligaments.
However, MRIs can be read as “normal” in some
cases when a subtle abnormality exists.
Alternatively, an unusual cartilage appearance called a tear by a
radiologist might be a normal variant or an incidental finding, when something
else is causing the patient’s pain. In these cases, the history and physical
exam in the hands of an experienced clinician are crucial to determining the
cause of the pain/disability (Figure 6).Medications Anti-inflammatory
or analgesic medications may be helpful in managing the pain that accompanies
torn cartilage or ligaments. However, they but do not change the course of the
condition.
It is
important that the patient be aware of the possible side effects of these
medications, including stomach irritation, kidney problems and bleeding. Injections
of steroids (cortisone) into the shoulder have not been demonstrated to have
lasting benefit and carry some risk of infection.
For each medication, patients should learn the
risks, possible interactions with other drugs, the recommended dosage, and the
cost.Exercises No exercises are known to repair torn structures inside the
shoulder. However, if exercises and stretching are not painful, they may be
helpful in maintaining the flexibility and strength of joints with cartilage or
ligament tears. In most cases, these exercises can be done in the patient's
home with minimal equipment. Shoulder exercises are best performed several
times a day on an ongoing basis with gradual increases in resistance. Any
exercise that is painful should be avoided, as “no pain, no gain” does not
apply in a rehabilitation setting.
Often the exercises will help
during the earlier phases of the condition, reducing discomfort, occasionally
to the point that no further treatment is needed.
Other therapies may be recommended by homeopathic
and chiropractic practitioners. Patients should learn the anticipated
effectiveness of those approaches, as well as the costs and possible risks.Possible benefits of arthroscopic labral repair/capsulorraphy Repairing the torn cartilage of the
labrum can increase the smoothness of the joint surfaces. Surgery can eliminate
or greatly reduce the clicking and popping sensations that some patients
experience. Loose pieces of cartilage or bone can also be identified and
removed arthroscopically (Figures 7, 8).
Repairing the torn labrum recreates
the “bumper” at the edge of the socket, and decreases the ability of the
humeral head to slide out of the joint (Figures
9, 10). Tightening of the ligaments
in the capsule would diminish excessive motion of the shoulder joint,
eliminating or reducing the likelihood of subluxation or dislocation. Overall
this would increase the shoulder's stability. Surgery for Cartilage and ligament tears in the shoulder at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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