Shoulder Instability

Shoulder Instability Treatment in Indianapolis, IN and Mooresville, IN

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Shoulder Instability Information

Traumatic Shoulder Instability Surgery

SLAP Injury

SLAP Tear Surgical Treatment

Multi-Directional Instability

Shoulder Instability

The shoulder joint is made up of the humeral head (ball) and glenoid (socket). Even though it is referred to as a ball and socket joint, the anatomy of the joint is more like a golf ball on a golf tee. This shape allows the shoulder to move through a large arc of motion. To deepen the socket and prevent the shoulder from shifting, there is a structure called the labrum which surrounds the socket.

Shoulder instability describes a “loose” joint. The shoulder may have significant instability where the shoulder completely dislocates, or mild instability, where the shoulder is not firmly seated in the socket. There are two main types of instability – traumatic and atraumatic. Traumatic instability occurs after an injury or direct blow where the shoulder either completely dislocates and comes out of the joint, or nearly dislocates, also known as subluxation. The second type of instability is atraumatic. These patients suffer dislocations without any type of injury, and usually are born with loose joints. Generally, traumatic and atraumatic shoulder instability are treated differently.

When the shoulder dislocates, the labrum and other supporting structures can stretch or tear. Afterwards, the shoulder becomes less stable and can dislocate more easily. In a teenager with a first-time dislocation, there is about a 70% chance of a second dislocation. However, in a patient over age 40 with a first time dislocation, the risk of a second dislocation is less than 10%. The younger and more active the patient is with the initial injury, the more likely a second dislocation will occur. Therefore, these patients are more frequently treated with surgery to repair the torn labrum. Atraumatic shoulder instability occurs often in teenage females. These patients are frequently treated with extensive physical therapy to strengthen the shoulder muscles and increase stability. Treatment strategies should be designed to suit each patient’s instability type (traumatic vs atraumatic), age and lifestyle.

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Traumatic Shoulder Instability

The most common dislocation that leads to traumatic instability is in the anterior (forward) and inferior (downward) direction. A fall on an outstretched arm, a direct blow on the shoulder, or a forced movement of the arm away from the body are frequent causes of this type of dislocation. Much less common is a posterior (backward) dislocation, which is usually related to a seizure disorder or electrocution. When the shoulder dislocates, it oftentimes causes a tear of the labrum (gasket) either in the front or back, depending on which direction the shoulder dislocates. There is also commonly an injury to the humeral head (ball) called a Hill-Sachs deformity. When the humeral head dislocates, it gets forced against the corner of the glenoid (socket) and makes a dent in the bone. A combination of labral tearing and Hill-Sachs deformity can lead to recurrent (repeat) dislocations in the future, depending on the severity of each.

Non-Operative Treatment: Initial treatment for instability of the shoulder centers on physical therapy. Strengthening the rotator cuff muscles and periscapular muscles (those around the scapula) gives stability to the joint. The goal of physical therapy is to help the muscles provide stability to the shoulder that the torn ligaments can no longer supply. The therapy for recurrent instability should be carefully designed for each patient since this condition often causes fear with certain arm positions or exercise moves. Very often, physical therapy can help regain lost motion, reduce apprehension, and restore shoulder function.

Operative Treatment: Surgery is usually recommended if recurrent instability cannot be controlled with physical therapy and activity modification. The goal of surgery is to return stability to the shoulder with the least loss of motion. All shoulder procedures designed to stabilize the shoulder involve some loss of motion. The current procedures for anterior shoulder instability attempt to restore the normal anatomy without over tightening the ligaments. In certain instances, such as in young persons who have a higher risk of re-dislocation and in contact athletes who plan on continuing to participate in sports that put their shoulders at risk, surgery may be performed after the first dislocation.

Surgery to repair the labrum is performed arthroscopically (minimally-invasive approach) with 3-4 small incisions in the skin. The torn labrum is fixed with anchors that go into the bone and have stitches that pull the labrum (bumper) back to the glenoid (socket). This is an outpatient procedure under general anesthesia. A pre-operative nerve block is given to help with pain after surgery.

In certain instances where the Hill-Sachs deformity (bone dent) is large enough, a procedure called Remplissage may be performed along with the labral repair. This procedure uses anchors that go into the humeral head (ball) and fill the dent in the bone with muscle and tissue from the shoulder. This can sometimes lead to a slight decrease in overall shoulder range of motion.

In the most severe of shoulder instability cases, where there is significant bone injury to both the humeral head (ball) and glenoid face (socket), a Latarjet procedure may be performed. This is a surgical procedure done through a larger single open incision where a bone of the shoulder called the coracoid is cut and transferred to the front of the socket. This bone transfer prevents further shoulder dislocations through several different mechanical ways.

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Labrum and Biceps-Anchor Complex Injury (SLAP tear)

The labrum is a “bumper” of tissue that surrounds the glenoid (socket) side of the shoulder joint. The labrum helps stabilize the joint and acts as a bumper to limit excessive motion of the humerus (ball) side of the shoulder joint. More importantly, it holds the humerus securely to the glenoid, like a suction cup. Although the glenoid itself is a relatively flat surface, the labrum gives the glenoid depth and a more concave (cupped) shape. The secure but flexible fit of the humerus within the glenoid permits the great range motion of the shoulder.

Tears of the labrum can be the result of:

A direct fall or blow to the arm resulting in abnormal or extreme motion of the humerus
A forceful lifting maneuver
Repetitive pinching of the humerus and attached rotator cuff on the posterior (back) labrum with the arm in an overhead and extended position. This injury is termed internal impingement (pinching of the soft tissues) and is most commonly seen in baseball and tennis athletes whose arms are frequently in overhead positions

A SLAP tear (“SLAP” is an acronym for superior labral anterior to posterior tear) is a very common labral injury that occurs on the top of the labrum, extending from the front to the back. This injury affects the attachment of the biceps tendon to the glenoid. An injury in this area can be extremely painful, as the biceps can repeatedly pull on the tear.

Physical therapy is helpful for many types of labral tears. Therapy usually includes modifying throwing technique, strengthening muscles that externally rotate the shoulder, thereby avoiding the impingement position, and stretching of the posterior capsule.

Tears that need treatment are usually seen when healing has not occurred. Tears involving the biceps tendon have more difficulty healing because the biceps constantly pulls on the labrum. Chronic tears may require surgery if patients are unwilling or unable to modify their activities sufficiently to allow for healing. Surgery should be considered if pain is unresponsive to: anti-inflammatory medications such as ibuprofen, rest, activity modification, physical therapy or if the labrum has not healed after an acute injury.

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SLAP Tear Surgical Treatment

What Happens During Shoulder Ligament Reconstruction?
Shoulder ligament reconstruction surgery involves the repair of torn or stretched ligaments so that they are better able to hold the shoulder and collarbone in place. The surgery is performed as an open surgical procedure which involves one incision over the shoulder. This is an outpatient procedure done under general anesthesia. Most patients receive a pre-operative nerve block to help with pain after surgery.

Certain painful and unstable SLAP tears, in which the biceps is detached (separated from the glenoid/socket), need to be reattached to the bone. The surgeon uses anchors in the bone with stitches that fix the torn labrum back to the bone. This type of surgery is reserved for younger and highly active patients. Newer studies are showing that repair, as seen in the picture on the right, in older patients may limit motion too much and can hurt overall shoulder function.

It is often safer for older individuals to have a debridement (clean-up) of the labrum and a biceps tenodesis. A tenodesis is a procedure in which the biceps is repaired away from the labral tear to relieve pain, yet maintain strength and function. This procedure can be a good choice for older patients because the blood supply to the labrum diminishes with age, making the healing process more difficult. The decision to perform a tenodesis should be made by the doctor and patient together, after a thorough discussion of the surgical options and the healing process. The biceps tenodesis can be done either arthroscopically (several small poke-hole incisions) or with an open incision near the arm pit. In the vast majority of patients, there is minimal to no loss in muscle strength. Some patients may notice the biceps muscle sink down slightly (Popeye deformity) due to the movement of the tendon. This change in position of the muscle rarely causes any weakness. This surgery is an outpatient procedure under general anesthesia. A pre-operative nerve block is given to help with pain after surgery.

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Shoulder Multi-Directional Instability (MDI)

The shoulder is a ball and socket joint. Multi-directional instability (MDI) happens when the ball is not seated firmly in its socket, and shifts both forwards and backwards (see image below). Because the shoulder allows the most motion of any joint in the body, it is also most prone to instability. MDI patients have increased laxity (looseness) of the supporting ligaments that surround the shoulder joint. The laxity can be present at birth or due to a condition that develops over time. Many patients with MDI are active in overhead sports (such as gymnastics, swimming, or throwing) that repetitively stretch the shoulder to extreme ranges of motion. The increased motion of the joint can lead to repetitive microtrauma (small injuries), producing tears of the labrum, capsule and/or rotator cuff, all of which are important stabilizing structures. With these loose ligaments, the shoulder may sublux (partially dislocate) or dislocate.

MDI patients often have increased ligament laxity in many joints. Hyperflexible knees, elbows, wrists, fingers and a self-described history of being “double-jointed” are common. These patients often have laxity in both shoulders. Because many athletes with MDI are quite successful in their sports, there is a debate about whether this type of laxity is harmful or can be helpful.

Most patients with MDI can be treated non-operatively with a physical therapy program that emphasizes muscular rehabilitation. There is a focus on strengthening the rotator cuff muscles and periscapular muscles (those around the scapula/shoulder blade). Building up these muscles provides improved stability to the joint. The vast majority of patients (about 90%) who follow a rehabilitation program diligently for at least six months will achieve stability and pain relief. Those who continue with a routine exercise program as outlined by the doctor are most likely to have a successful recovery. Athletes may also benefit from sport-specific rehabilitation that includes technique evaluation and modification. Often this type of program can help eliminate faulty practices that may have led to the instability, particularly with throwing athletes. The most challenging patient to treat surgically is the athlete whose symptoms continue following a rehabilitation program. Many athletes are successful in their sport because of increased laxity (movement) in the shoulder joint. Surgical intervention should only be considered when the patient has a thorough understanding of MDI, and is aware that stability with surgical correction is achieved at the expense of motion. Patients who have significant laxity, and can voluntarily dislocate their shoulder, tend to be poor surgical candidates. Surgery is rarely successful for them.

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Helpful, kind and made it as easy as possible!

“Dr. Calloway did my surgery. He's personable, up front about what your problem is and how to solve it, and open to any questions with a great bedside manner. The surgery went perfectly to the point where I was basically a little weirded out about how well it went. I had a similar surgery on my left shoulder as I did in my right shoulder, a few differences, and this particular shoulder surgery with Dr. Calloway went smooth as butter. His office staff is very nice and personable as well. No one there makes you feel like a dollar sign. When the surgery time came Dr. Calloway came to my room and pre-op to explain what was going to happen and try to call my nerves, as I have an extreme fear of going under anesthesia. He and the surgery staff were helpful and kind and made a difficult experience is easiest possible.”

Excellent Surgeon!

“Excellent surgeon! He's friendly, personable, knowledgeable and does a great job of explaining what he's going to do and what he did do after surgery.”

I have no pain, no popping, my mobility is great!

“Dr. Calloway was great to work with. After dislocating my shoulder multiple times he suggested latarjet procedure. I am now 9 months post surgery and my shoulder feels great, my incision healed very well. I have no pain, no popping, my mobility is great and my shoulder feels secure again witch I am very thankful as I do tree work and need to use my shoulders a lot. Dr. Calloway patiently answered every question I had thoroughly and I believe he set me up for the best recovery possible.”

The surgery results were great!

“I had no problems getting scheduled for appointments or for surgery. He was very friendly and courteous and gave realistic expectations about my rotator cuff surgery. He took the time to explain exactly what procedures were to be used. He answered all my questions. The surgery results were great. He was very much engaged in getting me back on the golf course with his recommendations for physical therapy and encouragement. I would definitely recommend him to others and if I need surgery on my other shoulder he will be my first choice.”

This is the first I've been painfree!

“I was referred to Dr. Calloway as a last resort. He was honest up front and told me he couldn't guarantee that he could be any help. I underwent arthroscopic surgery to have scar tissue cleaned up and he performed a tendon release on my hip. One week after surgery I am having no pain and much more mobility. This is the first I've been painfree in more than 6 years.”