What is shoulder instability?

Shoulder instability is very common. Shoulders have a broad range of normal joint flexibility. Most of us have known someone who is “loose jointed”. Those patients have a natural instability in many of their joints. Many gymnasts and cheerleaders have naturally unstable joints.

A shoulder can also become unstable as a result of an injury. A forceful injury that overloads the ligaments in the shoulder may cause it to become unstable. Many unstable shoulders do not hurt at all.

When to See a Specialist

An unstable shoulder warrants an evaluation by a shoulder specialist if the shoulder is unacceptably painful or its function is unacceptable. The evaluation of an unstable shoulder will include a history, a careful physical examination, and will sometimes involve imaging studies such as plain x-rays or MRI scanning.

Shoulder instability that is causing pain or dysfunction and is not the result of an injury can usually be successfully treated with nonoperative treatments, such as:

Physical therapy

Physical therapy is very effective in lessening the symptoms of a painful unstable shoulder. Physical therapy recommendations generally center around an effort to strengthen and coordinate the muscles of the shoulder that properly align the shoulder during vigorous activities.

Medication

In some cases, medication taken by mouth or by injection into the shoulder joint may be appropriate.

Surgery

Shoulder surgery is sometimes suggested for an unstable painful shoulder. If surgery is done on a naturally loose shoulder, it often affords temporary relief of symptoms. It rarely affords long-term relief. An unstable shoulder that is made more stable by surgery will usually become unstable again.

If the shoulder has become unstable because of any injury, the treatment is often different than that provided for a naturally unstable shoulder. MRI scanning is commonly utilized in the evaluation of instability that is the result of injury. MRI scanning has the ability to identify an injury to the labrum and the ligaments of the shoulder. Certain injuries to those structures will do better on a long-term basis if the patient has surgery.

Once your specialist has diagnosed the exact nature of your injury, explore the common disorders pages to find treatment FAQs.

What is a shoulder dislocation?

Shoulder dislocation is usually a result of severe trauma applied to the shoulder. If enough force is applied to the shoulder the ligaments can stretch or tear and allow the humeral head (the ball of the shoulder) to come out of the glenoid (the shoulder socket).

Shoulder dislocations sometimes occur without any history of injury in a person who is “loose jointed”. This type of shoulder dislocation has a different treatment than traumatic shoulder dislocation.

What are the symptoms of a dislocated shoulder?

When one sustains a shoulder dislocation as a result of trauma they sufferer intense pain. Often a sense of numbness affects the entire arm. Fingers may feel tingly. Rare cases of shoulder dislocation will result in substantial nerve injury.

What causes a shoulder dislocation?

Most cases are caused by an accident that applies extreme forces to the shoulder. The forces stretch, tear, or detach ligaments about the shoulder.

How is a shoulder dislocation diagnosed?

Traumatic shoulder dislocation is usually very obvious to the patient and the physician treating him. A physical exam reveals gross distortion of the normal alignment of the shoulder. Patients generally hold their arm in a particular position that is characteristic of shoulder dislocation. Physical examination along with plain x-rays are usually sufficient to make a diagnosis of shoulder dislocation.

How is traumatic shoulder dislocation treated?

The patients who sustains a shoulder dislocation as result of trauma usually have no question about their need to seek immediate care. The pain is intense. It is unbearable even when muted by the effects of drugs or alcohol. Patients will usually seek immediate medical attention for traumatic shoulder dislocation. I recommend that one go to an urgent care facility that is capable of intravenous sedation. The treatment of a dislocated shoulder often requires sedation for the physician to put the shoulder back into proper position.

Most traumatic shoulder dislocations can be successfully treated without surgery. Treatment recommendations will vary depending on the presence or absence of associated bone injury, nerve injury, and presence or absence of injuries to other parts of the shoulder. First time dislocations generally have a different treatment recommendation than recurrent dislocations of the shoulder.

Initial treatment usually consist of putting the dislocated shoulder back in place and applying a sling to the patient’s arm. Follow-up with a shoulder doctor usually occurs within the first several days.

The initial evaluation of the dislocated shoulder by a shoulder specialist will usually consist of a careful history, a thorough physical exam, review of imaging studies, and formulation of a treatment plan specifically tailored for that person’s unique injury. At the time the shoulders put back in place plain x-rays are usually sufficient to judge a satisfactory replacement of the ball in the socket. In the days to weeks following the dislocation it may be appropriate to obtain additional imaging studies of the shoulder such as an MRI scan.

Physical therapy is usually begun very early in the course of treatment. Therapy will consist of home exercises and sometimes supervised physical therapy.

Some shoulder dislocations will be best treated by surgery. When surgery is indicated it is usually not an urgent matter.

Pain relieving medications are usually prescribed as part of the treatment of the dislocated shoulder.

What are the long term results of a treated dislocated shoulder?

Results vary widely. Older patients who sustain an isolated shoulder dislocation without other injury usually return to full activity without restriction. They usually do not require surgery.

Some patients will have a recurring sense of looseness, discomfort, and apprehension on a permanent basis. Sometimes the symptoms warrant later reconstructive surgery.

A very small number of patients will need surgery fairly early on in the course of their treatment.

Special considerations

It is safe to travel if one has sustained an isolated shoulder dislocation. It is not infrequent that a shoulder dislocation injury occurs when a patient is far away from their home. Ski trips, hiking, body surfing in large waves at the beach, are all mechanism of injury that I have seen. It is reasonable for a person to have their initial treatment provided locally and then return to their home for long-term treatment of their shoulder dislocation.

Most patients are quite mobile after the initial treatment of shoulder dislocation. They will need to wear a sling. They’re usually able to walk unassisted and used their other arm for most tasks that require use of the hand or arm. My experience is that airlines place no restrictions on a person traveling with a recent shoulder dislocation.

If you sustain a treatment far away and desire treatment with me it would be a good idea to call our office as soon as you know about your injury. Even if it’s on a weekend or holiday it will be helpful in planning your treatment to go ahead and give a call as soon as you know of the need.

Bankart Repair FAQs

What surgery are you suggesting?

I am suggesting that we operate on your shoulder to repair and reconstruct a ligament complex that helps properly center the ball in the socket.

Is it done in an operating room?

Yes.

Will I be anesthetized?

One can have this surgery under a general anesthetic. The surgery can also be done with the shoulder anesthetized. That method involves numbing nerves to the shoulder. It is called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure.

Do I have to stay in the hospital?

No. This procedure is done on an outpatient basis most of the time.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. If you find that your pain and function are acceptable, it is reasonable to decline surgery. There is no clear evidence that ignoring a loose shoulder will do damage to the shoulder over the long run. There is some evidence to show that over very long time frames, perhaps two decades or so, a loose shoulder will wear out sooner than one that is not loose.

Will my shoulder get stiff?

Almost all patients will lose some flexibility in the arc of external rotation.

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I usually perform operations on the shoulder at a rate in excess of 250 per year. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very rare, but they do exist.

How often does infection occur?

Approximately 1% of shoulder surgeries become infected soon after surgery.

What happens if there is an infection?

Infection will sometimes require that another operation be done on the shoulder. During that surgery the infection is washed out and intravenous antibiotics are often begun. Intravenous antibiotics may be necessary for 6 weeks, and sometimes oral antibiotics are needed for long-term use.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from Bankart repair is profoundly low. I would estimate that it is less than 1 in 10,000. Other major events such as heart attack or stroke are extremely rare following this type of surgery.

Will I need a blood transfusion?

Almost certainly, no.

Will it relieve my pain satisfactorily?

I find that about 90% of patients are very happy with the result after they have completely recovered from this type of surgery. Of the remaining 10%, most are improved, but some have reservations such as some mild pain or mild symptoms of instability. About 1 in 20 patients feel like the surgery was not worth doing.

Will I have limitation on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

A Common Sequence of Recovery

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least 8 hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix or Coumadin, be sure to mention that to me. It may be important that those drugs be stopped well in advance of surgery.  If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive about two hours prior to your surgery time.

After surgery is over, you will need to remain at the facility for at least one hour. It is okay to eat or drink as soon as you feel like it. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. I will probably recommend that exercises to your shoulder begin about two weeks after the operation.

What about the overall recovery from this operation? How long does it take to completely recover?

Approximately 12 months is common.

Will I be hurting that long?

No. Generally, within a week or two a person notices a significant diminution in their pain. They continue to improve after that.

How long will I need prescription pain medication?

Most patients will use it regularly in the first week and periodically until about three weeks following surgery. Often by week three, it is only used at night.

When will the sutures or staples be removed?

Usually after two weeks following surgery.

When can I get it wet?

The surgical glue is waterproof, so it is okay to take a bath or a shower from the very first day.

Will I have to wear a sling?

Yes. A sling is provided at the time of surgery, and the patient is instructed to use it for the first six weeks following surgery. It can be removed in certain environments such as the safety of your home when you are confident that no one will bump into you and that you will not trip. When the sling is off, it is important not to move the shoulder beyond the safe arc of motion.

Is any special wound care required?

You will have a prettier scar if you protect it from sunlight for one year. That is easily done with a sunscreen applied along the scar. It is also okay to rub Vitamin E into the scar. The contents of a Vitamin E gel capsule can be expressed onto one’s fingertip, rubbed into the wound twice a day, and continued for about 2 months.