Shoulder instability fundamentals
The ball and socket joint of the shoulder is held together by ligaments, muscles and bones. When these structures become over stretched or injured, the shoulder becomes unstable.
The most common cause of shoulder instability is trauma. When a dislocation occurs, the restraining structures of the joint are injured. Contact sports such as football and downhill skiing are common causes of shoulder dislocation, and the condition occurs frequently among young athletes. However, household trauma such as falling down stairs, off a bicycle or while walking along the sidewalk can be damaging enough to dislocate a shoulder. Additionally, some people have a genetic predisposition to shoulder instability. Finally, repetitive activities such as throwing sports and swimming can gradually overstretch the ligaments, resulting in instability and dislocation. Fractures of the shoulder’s ball and socket may occur, which also contribute to shoulder instability.
Athletes can take steps to prevent shoulder instability. Maintaining good rotator cuff and shoulder blade strength is important in decreasing the risk of ligament injury. Learning correct techniques of pitching and throwing is also important.
What are the symptoms?
The most characteristic symptom of shoulder instability is a sense that the shoulder is about to come out of place or that the shoulder has jumped back into its socket. This sensation may or may not be accompanied by pain, but it is typically uncomfortable. Occasionally, a person may feel numbness or a tingling down the arm.
In addition, the patient may experience clicking, catching or looseness of the shoulder with daily activities and particularly with sports that require overhead throwing or swimming.
Sometimes, the ball of the joint will separate completely from socket, and the ball will not spontaneously fall back into place. Severe pain, deformity of the shoulder and a sense of paralysis of the arm may occur as a result. Manipulating the arm into place may require physician assistance.
How is it treated?
The shoulder joint should be put back into place promptly. Immediately after the injury, ice and a sling make the patient more comfortable. In a young and athletic person the chance of redislocation is usually high. This risk decreases with age.
Often, shoulder instability is subtle and repeated examinations are necessary to establish and confirm the diagnosis. It is particularly important for the physician to examine the uninvolved shoulder and to compare the patient’s normal ligament status to the symptomatic shoulder when coming to a decision regarding treatment.
Immediately after injury, the patient should ice and rest the shoulder in a sling. X-rays will help to determine whether any bone injury has occurred as a result of the dislocation. Following a period of a few days’ rest, the patient should begin an exercise program to strengthen the shoulder muscles.
Most patients wear the sling for one to two weeks to decrease acute shoulder pain. After the sling is removed, the patient should avoid extremes of motion over the next four weeks. After this period of time, a progressive rehabilitation program can begin.
If there are continuing symptoms that interfere with sleeping, daily activities, work, or sports participation, surgical stabilization may be required.
The goal of shoulder surgery involves reattaching torn ligament tissue to shorten or tighten the stretched ligament tissue. The surgeries performed can be done by either arthroscopic or open methods, but the goal of the surgery is the same.
After surgery, the arm is kept in a sling for four to six weeks. You are encouraged to keep the elbow/wrist and hand mobile during this time while the tissues in the shoulder heal into place. Physical therapy to gradually regain range of motion and strength is commenced after surgery.
What are the risks of surgery?
The risks include bleeding, would healing problems, infection and nerve and vessel injury. It is also possible for the shoulder to redislocate, as the healing process may not have been complete. Even after complete healing, the shoulder may dislocate if a reinjury occurs.
How do I prepare for surgery?
- Complete any pre-operative tests or lab work prescribed by your doctor.
- Arrange to have someone drive you home from the hospital.
- Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs) one week prior to surgery.
- Call the appropriate surgery center to verify your appointment time. If your surgery is being done at Cleveland Clinic, call:
- Main Campus: 216.444.HAND (4263)
- Lutheran Hospital: 216.363.2311
- Refrain from eating or drinking anything after midnight the night before surgery.
What do I need to do the day of surgery?
- If you currently take any medications, take them the day of your surgery with just a sip of water.
- Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
- Leave valuables and money at home.
- Wear loose-fitting, comfortable clothing.
What happens after surgery?
You will be kept comfortable and be given pain relief initially through an I.V. Later, you will need only tablets for pain relief. Your doctor will discuss the findings at surgery and the details of the surgery if you wish. You will also be told about the appropriate activity restrictions and the period of time that the sling will be required. You will receive details of physical therapy, home exercises and your follow-up appointments.
How long is the recovery period after surgery?
The phases of recovery include the initial postoperative period, through recovery of flexibility and strength and ultimate return to work and sports. Recovery often takes between one and four weeks for mild shoulder instability. For complete dislocation, the patient may wait six weeks before a rehabilitation program can begin and an additional 10 weeks before a return to competitive sports.
Return to contact sports may not be until the six-month mark and will be somewhat dependent on the individual case.
What is the rehab after surgery?
Your physical therapist will assist you with your rehab. Strengthening exercises include using lightweights and bands in shorts arcs with the arm by the side. As the shoulder improves in range of motion and strength, shoulder level and above exercises are begun along with exercises to strengthen the shoulder blade muscles. After three to 10 weeks, a more aggressive strengthening program can begin. It may take up to six to eight months to return to intense sporting activity.
How can I manage at home during recovery after surgery?
When you go home you may need some initial assistance with dressing, showering and eating. Most people become independent in these activities after a few days. If the wound dressing becomes wet, you should replace it. It is safe to get the wound wet after a few days.
How frequently should I schedule follow up appointments with my doctor following shoulder surgery?
Your doctor will give you these instructions and will check your progress periodically until you are able to return to your desired level of activity.
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