Shoulder Instability

Background

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. The unstable shoulder may slip completely out of the socket and become dislocated. Over many years instability can lead to arthritis of the shoulder joint.

Anatomy

The main part of the shoulder consists of the ball at the top of the arm (humerus) which sits in a shallow socket (glenoid) connected to the shoulder blade (scapula). The socket has a ring of cartilage (labrum) around its edge which deepens it and helps keep the ball in it. Surrounding the shoulder joint is a watertight sac called the joint capsule. The joint capsule holds in fluids that lubricate the joint. The walls of this capsule are made up of ligaments. These ligaments loosely connect the ball to the socket and attach to the ring of cartilage (labrum) at its edge. They become tight if the shoulder rotates too far in any direction and prevent the ball slipping out of the socket (a dislocation). One of the biceps tendons enters the shoulder and attaches to the ring of cartilage near the top of the socket.

Structural damage

Instability most commonly occurs due to separation of the ring of cartilage (the labrum) plus the capsule and shoulder ligaments attached to it from the bone of the shoulder socket (referred to as a Bankart injury or tear):

Usually this is created by a complete dislocation of the shoulder. It may, however, result from an injury where the shoulder is stretched or wrenched in an abnormal direction but without actually dislocating.

Sometimes the capsule and ligaments alone become stretched without separation of the cartilage. This most commonly occurs in people who have loose ligaments around the body (“double-jointed”).

SLAP (Superior Labrum (tear) from Anterior to Posterior) tears occur either alongside the Bankart injury described above when a shoulder is dislocated, or may occur alone. This is a cartilage separation also, but in a certain part of the socket where a tendon (one of the two biceps tendons) attaches to the bone.

Consequences

The Bankart injury results in instability of the shoulder which can lead to:

• Repeated dislocations of the shoulder – the younger the age at first dislocation, the greater the chance of experiencing another
• Feelings of looseness in the shoulder with the arm in certain positions or with certain activities
• Lack of strength or confidence in the arm
• Pain or clicking with the shoulder in certain positions (SLAP tear)
• Arthritis of the shoulder if present for many years.

Treatment

Non-operative treatment of shoulder instability involves physiotherapy and avoidance of the activities which lead to the feelings of looseness or which cause repeated dislocations. Despite this the chance of a repeat dislocation or of having a shoulder which feels loose and doesn’t perform well with this type of treatment remains high in young active people.

Research indicates that early surgical repair following a dislocation of the shoulder will result in less chance of dislocation later, as well as less looseness and more confidence in the arm. It is for this reason that surgical repair is now offered as a treatment option for a first dislocation in young people and professional athletes. The success of the surgery performed at this stage is higher than that following many months or years of shoulder instability and often numerous dislocations.

There is some evidence to show that the duration of instability and the number of dislocations relates to the long-term prognosis of the shoulder, particularly with respect to the development of arthritis.

In older people and those who are recreational athletes, a non-operative approach to treating a first dislocation of the shoulder is preferred.
This treatment revolves around intensive physiotherapy and home exercise to strengthen the muscles around the shoulder and improve the co-ordination of their actions to keep the ball of the shoulder centered in its socket. Permanent modification of sports, work or other lifestyle goals is often required to prevent repeated dislocation.

Surgery is reserved for failure of this treatment, however, if necessary should be performed without excessive delay for the reasons mentioned above.

The surgery

Stabilisation surgery (shoulder ‘reconstruction’) is performed under general anaesthetic and usually via a keyhole (arthroscopic) technique.

2 or 3 small incisions ( 1 cm each) are made around the shoulder through which the camera (arthroscope) and plastic instrument tubes are inserted.

Bankart tear

Bankart tear - repair

The cartilage is repaired and the ligaments in front of the shoulder tightened with small stitches inserted through these holes. Pictures or video of the operation can be taken during the procedure.

At the end the wounds are closed with an external stitch and then covered with a waterproof dressing.
The keyhole technique has some advantages compared with traditional methods of ‘open’ surgery using larger incisions:

• Less pain
• Shorter hospital stay (day case or overnight only)
• Faster rehabilitation
• Less stiffness (restriction of movement) following the surgery
• Better ability to identify and treat other areas of damage

In some cases, an open incision is preferred to the keyhole technique. This is used when adequate tightening of the ligaments at the front of the shoulder cannot be achieved arthroscopically, or when a large bone fracture at the front of the socket requires repair. Occasionally a bone block connected to a tendon is transferred from one part of the shoulder to the front of the socket. This type of reconstruction may apply to shoulders which are very loose, or which have been damaged through loss of bone after repeated dislocations.

What to expect after the surgery

You will wake up in the recovery area of the operating suite with a bulky dressing over the shoulder and a sling and swathe applied.

Pain will be present however not extreme. By evening it should be well controlled with tablets given on the ward. Occasionally a small dose of a strong pain killer given via injection is needed.

The shoulder will be swollen for approximately 24 hours due to collection of sterile fluid used during the operation to enable vision inside the joint.

Discharge from hospital is usual the following morning but may be in the same evening following a morning operation. The bulky dressing is taken down and the small waterproof dressings replaced if soiled. These should be left in place until the time of review which is generally 10 to 14 days following surgery (the date of this will be given to you at the time the surgery is booked). You may shower but try not to directly soak the dressings each day. The wounds should be kept dry until the dressings (and stitches if present) are removed.

A physiotherapist will see you prior to discharge and instruct on simple exercises to do and how to manage the sling. In general it should be used all of the time except for brief periods when doing specific exercises. At these times the elbow should be stretched out and the underarm can be cleaned. It should be used over night also unless otherwise instructed.

You will receive a short (usually 5 day) supply of pain killing tablets to use at your discretion. Reaction to the tablets may occur and can include a rash, nausea, stomach pain, dizziness and light-headedness. Stop them and see your local doctor for alternatives if needed.

The small wounds usually heal well with only a faint scar ultimately visible.
In the short term, the size of the muscle surrounding the shoulder will decrease due to lack of use. This will return following rehabilitation and is expected to take many months.

Rehabilitation

The first 6 weeks after the surgery is critical for healing and to the overall success of the procedure.

• Strict use of sling and swathe including at night. No elevation of the arm above shoulder height or rotation outwards is permitted. On occasions e.g. when a SLAP repair was required also, straining the biceps muscle will not be permitted during this time.
• Pain will be minimal or non-existent – avoid the temptation to do too much too soon. The aim is to prevent excessive movement or loading of the shoulder while it heals.
• Running should be avoided in this time. An exercise bike can be used.
• Most general duties of daily living should be performed with the other hand.
• Driving is not permitted while a sling is being used.

Three Phases of Rehabilitation

• Phase 1 rehab – regain motion
  It is normal to have a degree of stiffness in the shoulder following surgery and the subsequent immobilization in a sling outlined above which needs to be overcome
  
  • Physiotherapy plus home exercises
    To commence from 6 weeks post surgery.
    The sling is discarded at the 6 week mark.
    Full or near full movement achieved by 3 months.

• Phase 2 rehab – regain strength
  • Physiotherapy plus graduated weights program in some cases.
    Resistance work with therabands and progressing to a graduated gym programme will start once adequate range of movement is achieved – usually from 6 to 8 weeks post surgery. It will overlap with regaining motion.
    Swimming (breaststroke) permitted from 10 weeks

• Phase 3 rehab – Return to work or sport
  • Sport / activity specific physiotherapy plus ongoing strengthening work
    
    This phase will aim to restore muscle balance, co-ordination and full strength in the shoulder. It may take up to 1 year.
  • Timing to full recovery and return to sport or work is variable and depends greatly on individual demands.
  • Freestyle swimming is permitted from 3 months.
  • Throwing or overhead sports may resume from 3 months, avoiding maximal force until 6 months.
  • Contact sports should be avoided for 6 months or until full strength and adequate co-ordination is achieved.
  • Non-physical work duties are appropriate from the time of removal of the sling, or before this as comfort allows in some situations.
  • Return to physical work with the involved arm will require 3 to 6 months depending on demands.

Possible complications

Complications are rare from this type of surgery. The procedure generally takes an hour to perform and there is no blood loss.
Some of the more common or important potential complications or consequences are outlined below.

1. Some complications which are related more directly to the shoulder:

• Bleeding under the skin related to the arthroscopy entry holes leading to local bruising. This bruising may run down the arm and across to the chest area. It is common, goes away in a couple of weeks, and does not require treatment.
• Infection may occur and may be suspected by an increase in pain, fever, nausea and generally feeling unwell. The surgical wounds may be surrounded by reddening of the skin and may discharge fluid, blood or pus. There may be a foul odour. Infection around the small wounds only will settle without consequence after treatment to the area such as removing the stitch, local dressings and possibly antibiotic tablets. Infection deep within the shoulder is very rare however more serious when it occurs, and may require surgical washout of the shoulder along with prolonged courses of antibiotics. This type of infection may lead to permanent damage to the cartilage within the shoulder joint.
• Stiffness (restricted movement) may occur despite appropriate rehabilitation with exercise and physiotherapy. It is uncommon. On occasions a brief procedure under anaesthetic may be required to free up the shoulder.
• Failure of the procedure will result in re-dislocation of the shoulder, a return of a feeling of looseness, or persistent pain. This may happen due to the ligaments stretching out again or the cartilage (labrum) not adhering well to the bone. Failure usually occurs following another injury to the shoulder but may occur with only minimal trauma to the shoulder. Failure rates vary from 3% to 15% depending on individual circumstances, and this should be discussed specifically. Repeat surgery is often, but not always, required in the case of failure of the initial preocedure.
• Nerve injury resulting in weakness of the muscles around the shoulder or of the arm or hand, and / or loss of feeling in the skin in the same areas, have been reported following this type of surgery. It may result from stretching of the nerves during grasping and positioning of the arm during the surgery, or direct damage to the nerve from the arthroscope or arthroscopic instruments used. Nerve injury is usually temporary but rarely may be permanent. Permanent nerve injury may require grafting or other corrective surgery.
• Injury to the major blood vessels passing by the shoulder is possible however extremely rare. If this happens, surgery to reconstruct the artery or vein could be needed. Permanent loss of muscle function in the arm or hand may occur.

2. Some complications of a more general nature:

• The surgery is carried out under general anaesthetic which is very safe, however on very rare instances a problem relating to the airway, lungs or heart and circulation may occur.
• An intravenous line is always required, and usually an additional line into a small artery near the wrist to monitor blood pressure. Its use may result in pain or bruising at the point of entry, and rarely an infection or thrombosis of the vein or artery.
• Blood clots in the veins of the calf and / or leg (Deep Venous Thrombosis) may occur despite the surgery not involving these areas. It is very rare but when large can pose the threat of movement of the clots within the veins to the lungs (Pulmonary Embolus) and this can be serious or even fatal.
• Your anaesthetist will discuss the use of an injection above the shoulder near the neck (Nerve Block) to help ‘deaden’ the shoulder and arm for approximately 24 hours to help control pain. There are complications reported relating to this including bruising and nerve damage. A nerve block is not often used with this particular type of keyhole surgery.
• Allergy to the antibiotic which is routinely used immediately prior to the surgery can occur. This most often causes a rash. Very rarely when serious an allergy can cause obstruction to the airway or reduced blood pressure.

In case of problems:

1. Pain control – contact local GP initially
2. Signs of infection (persistent increase in pain, wound discharge beyond 2 days following surgery, foul odour, fevers) – contact Mr. Dallalana via the rooms or through the hospital where you had your surgery if out of business hours. GP may be contacted for review concomitantly.
3. Tingling in the arm or hand or calf pain – contact Mr. Dallalana via the rooms or GP if convenient. Contact the hospital where you had your operation if out of hours.
4. Numbness or persistent coolness in the hand or fingers – attend nearest emergency department
5. Shortness of breath, severe lack of energy or sudden high fevers with chills or shakes – attend nearest emergency department.

Non-urgent matters should be listed for discussion at the next review with Mr. Dallalana or alternatively queries can be directed via e-mail at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or by calling the rooms.

Certificates can be obtained at review or by your GP at other times.

• Please contact Mr Dallalana's rooms if you require further information.