| Shoulder Dislocation is extremely common - roughly | | | | about shoulder dislocation has also resulted in a |
| half of all major joint dislocations seen in the | | | | significant improvement in outcomes with modern |
| Emergency Department are shoulder dislocations. An | | | | arthroscopic techniques in experienced hands. |
| unstable shoulder can result from a shoulder dislocation | | | | Case #2: |
| or a shoulder subluxation, when the ball almost slides | | | | Maya, a 17 year old gymnast from Chicago, initially |
| out of the socket. So an unstable shoulder is a more | | | | dislocated her shoulder doing a back flip on the |
| broad term including both shoulder dislocation and | | | | balance beam 3 years ago. Since then she has had |
| shoulder subluxation. Here is more information about | | | | multiple episodes of subluxation and dislocation, the |
| unstable shoulder. Recommending the best treatment | | | | most recent one before evaluation at our shoulder |
| for an unstable shoulder or a shoulder dislocation really | | | | clinic while throwing a ball. She has had multiple |
| depends on many factors. To help start the | | | | evaluations and extensive physical therapy over the |
| conversation about shoulder dislocation, we present | | | | past 3 years, but her symptoms are worsening and |
| several patient case histories (real patients in my | | | | she has had to stop gymnastics because of the |
| practice with all identifying information changed to | | | | shoulder. Our examination reveals that Maya is |
| ensure their privacy is fully respected. | | | | extremely flexible both generally (double-jointed) and |
| Case #1: | | | | with examination of her other unaffected shoulder and |
| Logan, an avid power lifter, injured his shoulder 5 years | | | | does not have any evidence of nerve injury |
| ago at age 25. He was performing a heavy bench | | | | (sometimes seen with shoulder dislocation). MRI |
| press when he felt like his shoulder "slipped." He had | | | | arthrogram confirms evidence of generalized shoulder |
| extreme difficulty performing the bench press and | | | | laxity and anterior inferior labrum tear. We again |
| military press after the injury and gradually started to | | | | reviewed our protocol for unstable shoulder and global |
| have difficulty with other activities. He was initially | | | | arthroscopic repair and she and her parents wanted to |
| evaluated by an orthopedic surgeon and an MRI was | | | | proceed with an arthroscopic repair. Maya was noted |
| ordered, but he was told "there is nothing wrong." He | | | | to have a "global" labrum tear at surgery, meaning that |
| gradually stopped lifting weights and reduced his | | | | over time she had torn the labrum completely around |
| activities, but when the pain and discomfort persisted | | | | the entire glenoid (socket). She also had created a |
| he sought a second opinion from another orthopedic | | | | chondral defect (gouge or trough) in the humeral head |
| surgeon and a diagnosis of impingement was made | | | | (ball) during one of her previous episodes of shoulder |
| with a recommendation to "shave down a spur that is | | | | dislocation. A successful repair for Maya included not |
| cutting into your rotator cuff." Confused, Logan did | | | | only repairing the torn labrum (cartilage) globally, but |
| some research and took a friend's advice and | | | | also tightening up her capsule and ligaments globally to |
| scheduled an evaluation at our shoulder clinic. His | | | | rebalance the shoulder in all directions. This would have |
| history and examination were both highly consistent | | | | been impossible to do with a traditional open (incision) |
| with chronic posterior instability and we recommended | | | | surgery. Modern arthroscopic techniques allow us to |
| an MRI arthrogram to confirm the diagnosis. The MRI | | | | evaluate and treat the entire spectrum of pathology |
| arthrogram confirmed extensive posterior labrum | | | | involving the entire shoulder joint. |
| tearing that now also extended at least half way | | | | Just as with ACL injuries in the knee, the risk of |
| around the glenoid (socket). We reviewed our | | | | cartilage damage and further damage to the shoulder |
| arthroscopic surgical protocol for unstable shoulder and | | | | joint increases as the number of episodes of shoulder |
| he was extremely relieved to finally have a diagnosis | | | | dislocation and subluxation increase. According to one |
| and wanted to proceed with arthroscopic repair. An | | | | study, "Patients with a history of previous shoulder |
| arthroscopic global capsular shift with labrum repair | | | | dislocation were found to have a 19 times greater risk |
| was performed and although his primary direction of | | | | of developing severe shoulder arthrosis than patients |
| injury was posterior he required a labrum repair both in | | | | who did not have such a history." Another article by |
| the front and the back of the shoulder. | | | | Brems notes that inappropriate diagnosis of the |
| According to one study on posterior shoulder | | | | direction and degree of instability can lead to a surgical |
| dislocation, "more than 60% of posterior dislocations | | | | procedure that may not be ideal for a given patient's |
| are misdiagnosed initially by the treating orthopedic | | | | (true) pathology. Not all instabilities are necessarily |
| surgeon, and the correct diagnosis is often delayed for | | | | anterior or unidirectional. Even with the correct |
| months or years." The other major point to observe is | | | | diagnosis, selection of a less optimal procedure |
| that because the shoulder is a "circle" labels such as | | | | perhaps due to surgeon preference, what Brems |
| anterior and posterior instability are not as valid or | | | | terms ''The Standard Procedure for All,'' may factor in |
| helpful today because with the ability to evaluate and | | | | the subsequent development of arthrosis. Performing |
| treat the entire joint using advanced arthroscopic | | | | the procedure on the wrong side of the joint |
| techniques, we are learning that many different types | | | | predisposes to excessive tightness and ultimately |
| of injuries (labrum, cartilage, capsule, ligament, nerve, | | | | arthritis. |
| and rotator cuff) can be part of the injury spectrum | | | | Although shoulder dislocation and unstable shoulder are |
| regardless of the primary direction of the shoulder | | | | extremely common problems, establishing the correct |
| dislocation. So it is vital to have a surgical technique | | | | or true diagnosis can often be difficult. It also follows |
| that allows us to evaluate and treat the entire "circle" | | | | that the recommended treatments are often highly |
| and not just a limited area of focus. This shift in thinking | | | | debated and controversial. |