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Shoulder Instability

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Introduction

Instability of the shoulder means an inability to keep the humeral head (ball of the joint) in glenoid fossa (socket of the joint). You may feel that the ball of the joint is slipping, catching or even coming out of the socket. The ligaments and muscles around the shoulder joint create a balanced environment to make the shoulder most mobile joint in your body.

 

There are 2 different types of instabilities that cause disruption to this balanced environment. The instability can occur anterior (towards the front of the shoulder), posterior (backwards), inferior (downwards to your armpit) or a combination of these three.

Signs & Symptoms

Anterior Instability

  • Constant clicking or clunking of the joint.
  • Pain – this is not as consistent as other symptoms.
  • Keep having a ‘dead arm feeling’ especially with overhead work or after overhead forceful throwing action.
  • Pain behind the shoulder joint.
  • Pain when you lift the arm forwards with a rotation movement of the shoulder joint.
  • A feeling ‘apprehension’ about moving the arm in certain directions such as away from the body.
  • Your Physiotherapist may discover increased movement of your ball area of the joint, when moved forwards in the socket.

 

Posterior Instability

  • Inability or apprehension when reaching hand behind the back.
  • Pain – again it is not as consistent as other symptoms.
  • Clicking or clunking of the joint when trying to move the arm.
  • Your Physiotherapist may find increased translation of the ball within the socket.

 

Multi-directional Instability

  • General shoulder pain with no specific pattern.
  • Sulcus sign – your Physiotherapist may notice that the ball of the joint has dropped from socket on your affected side.
  • You may feel apprehensive with certain movements associated with shoulder joint.
  • Your Physiotherapist may experience increased mobility of your ball within the socket.

Causes

Traumatic Instability

As the name implies there must be a traumatic incident to your first dislocation. Most commonly happens in contact sport. Out of all types of instability, anterior instability following a trauma is the most common one comprises more than 90%!

 

Usually the ball is forced forwards and downwards. Commonly the ligament in the front of your shoulder is over-stretched and can pull part of the rim of cartilage off the socket. If the cartilage is detached in this way it is called a ‘Bankart lesion’ (click here to see more information). It is sometimes detectable with an MRI (Magnetic Resonance Image) scan but may only be visible when the surgeon looks in your shoulder joint at surgery. Surgery is indicated when it become unstable with lightest of the movements. Sometimes you can have a dent in the back of the ball of the joint which is formed as the ball is forced out of the socket. This is known as a ‘Hill-Sachs lesion’ this will mostly picked up on an X-ray.

 

Atraumatic Instability

It is a sub classification of glenohumeral joint (ball and socket -shoulder joint) instability, a clinician may put you under this category if there is no history of a trauma to cause the dislocation.

 

Atraumatic is again sub-divided into two main types:

  • Congenital instability (born with laxity of structures around the shoulder).
  • Chronic recurrent instability.

 

May be seen after surgery for shoulder dislocation, due to glenoid rim lesions. Over time, microtrauma can lead to instability of the glenohumeral joint. This type is common in people/athletes who perform repetitive overhead movements.

Assessment & Diagnosis

Your Physiotherapist at Pure or your GP will be able to tell you if your shoulder joint is unstable by doing some simple clinical tests and taking accurate history of symptoms from you. However, sometimes an X-ray will be done and very occasionally an MRI scan will be ordered, to see if there is any damage to the rim of cartilage and/or bone. With a definitive diagnosis in place, an effective, personalised treatment plan can be formed based on your individual goals. We provide regular re-assessment to measure progress and ensure that your treatment remains optimal throughout and beyond your recovery.

Self-Management

It is also important that you have some education on condition which your Physiotherapist will provide. They will discuss activities or movements that should be avoided or carried out with caution. We provide ongoing support and advice so that you feel confident and well equipped in managing independently and helping to prevent further complications going forward.

Physiotherapy

There is strong evidence to suggest progressive strengthening of the shoulder can be helpful in both traumatic and atraumatic instability. Your Physiotherapist at Pure can help you with this and will design an individualised rehabilitation programme which will be modified as your make progress.

Escalation of Treatment

If the movement is good and muscles are working well, but the joint is dislocating or slipping regularly and stopping you doing what you want to do, your Doctor or Physiotherapist may refer you to a Specialist Orthopaedic Surgeon for consideration.

 

There are several types of shoulder operations that stabilize the shoulder.

 

  • Capsular shift – this procedure is performed to tighten the joint capsule. A capsular shift is commonly performed using an arthroscope (keyhole). In this procedure, your surgeon tightens the capsule, including the ligaments that stabilize the shoulder.
  • Labral repair (Bankart repair) – this procedure is performed to repair a tear to the labrum (bankarts lesion refer to traumatic instability) and is also commonly done using the arthroscope.
  • Latarjet procedure – this procedure is done when there is bone loss from the socket due to repeated dislocations. It is done as an open procedure.

 

Please note that you may have to undergo a progressive long term rehabilitation with a Physiotherapist, under surgeon’s protocol.

References

Barrett, C. (2015). The clinical physiotherapy assessment of non-traumatic shoulder instability. Shoulder & elbow, 7(1), 60-71.

 

Cuéllar, R., Ruiz-Ibán, M. A., & Cuéllar, A. (2017). Suppl-6, M10: Anatomy and Biomechanics of the Unstable Shoulder. The open orthopaedics journal, 11, 919.

 

Tzannes, A., & Murrell, G. A. (2002). Clinical examination of the unstable shoulder. Sports Medicine, 32(7), 447-457.

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