SHOULDER INSTABILITY – TREATING THE TRAUMATIC SHOULDER DISLOCATION
One general category of shoulder instability typically involves a traumatic event in an individual with normal tissue elasticity, resulting in a single-direction dislocation and tearing of soft tissue structures. This is particularly common in younger patients and is often treated with surgery. For example, in the most common scenario, the ball dislocates in an anteroinferior direction, resulting in tearing of the anteroinferior portion of the labrum, referred to as a Bankart lesion.
Treatment of a first-time shoulder dislocation is dependent on a number of factors, including a patient’s age, desired activity level, the nature and extent of the injuries, pertinent findings on physical exam, and one’s underlying genetics. Of these factors, the risk of a recurrent shoulder dislocation with non-operative treatment is most dependent on a patient’s age. Patients under the age of 20 have a 72–100% risk of another dislocation, whereas those between ages 20-30 have a 70–82% risk, and patients over the age of 50 carry a 14–22% risk of recurrent instability.1
With surgery, that rate of recurrent instability is significantly improved down to a range between 3-7%2-4 in adults and 24-25%5-6 in teenagers.
For this reason, surgery is a reasonable option in young patients who wish to participate in high demand activities, or who wish to avoid experiencing another dislocation.
However, some patients do very well with a conservative approach, consisting of approximately four weeks of immobilization, followed by several months of comprehensive shoulder and periscapular rehabilitation. If after returning to the patient’s preferred activities, the shoulder remains in the socket, then no further treatment is required. If subsequent instability episodes do occur, then a stabilization surgery would be recommended in an effort to prevent further joint damage that may ultimately result in arthritis, as well as further risk of nerve damage. Although it is usually minor and transient, at least some degree of injury does occur to the axillary nerve, the major nerve of the shoulder, in up to 42% of dislocations.7
Some athletes who are in the middle of a sports season occasionally pursue conservative treatment after a shoulder dislocation with special restrictive braces that stabilize the shoulder and allow them to return to play several weeks later. This is particularly risky and has been shown to result in a 64% chance of having another instability episode during that same season.8
Patients with a higher risk of recurrent instability or those who have not improved with rehabilitation may elect to proceed with surgery. After obtaining the appropriate imaging studies, a surgical plan is developed. In the majority of cases, surgery is performed arthroscopically through several small 1cm incisions and involves a repair of the torn labrum and capsular structures using suture anchors. In higher risk scenarios, additional stabilizing procedures (e.g. arthroscopic remplissage, Latarjet, etc.) may be necessary. Surgery is typically an outpatient “same-day” procedure after which patients are immobilized in a sling for 4-6 weeks. Rehabilitation begins several weeks after surgery and continues for 4-6 months. Patients may return to high demand activities/sports at six months following surgery.
Surgery, however, is not without it’s risks. These risks, but are not limited to, neurological injury to the extremity, infection, deep venous thrombosis, the possibility of continued pain, and the possibility of re-operation if the labral tear doesn’t heal, if the tear recurs, or if the anchors used in the repair become prominent or loose within the joint. Lastly, although a patient may have a more stable shoulder, they may feel stiff and notice a loss of motion. If the shoulder becomes excessively stiff after surgery and does not improve with therapy, then a second procedure is sometimes required to loosen the capsular ligaments. On rare occasions, if the stiffness persists chronically, the patient may go on to develop damage to the articular cartilage, ultimately resulting in arthritis.
1. Polyzois I et al. Traumatic First Time Shoulder Dislocation: Surgery vs Non-Operative Treatment. Arch Bone Jt Surg. 2016 Apr; 4(2): 104–108.
2. Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up. Arthroscopy. 2007 Feb; 23(2):118-23.
3. Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc. 2010 Dec; 18(12):1742-7.
4. Chahal J, Marks PH, Macdonald PB, Shah PS, Theodoropoulos J, Ravi B, Whelan DB. Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation. Arthroscopy. 2012 Apr; 28(4):565-75.
5. Jonathan Kramer, Gio Gajudo, Nirav K. Pandya. Risk of Recurrent Instability After Arthroscopic Stabilization for Shoulder Instability in Adolescent Patients. Orthop J Sports Med. 2019 Sep; 7(9): 2325967119868995. Published online 2019 Sep 17.
6. Shanmugaraj A, Chai D, Sarraj M, Gohal C, Horner NS, Simunovic N, Athwal GS, Ayeni OR. Surgical stabilization of pediatric anterior shoulder instability yields high recurrence rates: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2020 Feb 28; Epub 2020 Feb 28.
7. Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br. 1999 Jul; 81(4):679-85.
8. Dickens JF, et al. Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study. Am J Sports Med. 2014 Dec;42(12):2842-50.
Nels Sampatacos, MD
Orthopedic Surgeon and Sports Medicine Specialist
