Change of lifestyle
For some people, just knowing what the problem is, and what activities to avoid, is enough. You may avoid reaching into positions that make your shoulder feel unstable, or change your sporting activities.
Shoulder Instability
The shoulder is a ‘ball-and-socket’ joint, as shown in the video above. Some people liken it to a golf ball sitting on a tee. Usually, the ball sits in the centre of the socket. Shoulder dislocations occur when the shoulder comes out of joint (i.e. falls off the tee). This is sometimes referred to as shoulder instability.
Traumatic Instability
Shoulder dislocations often happen after a significant injury to the shoulder, such as a fall with your arm above your head. They can also happen as a result of epileptic seizures. Often, this sort of dislocation results in damage to the ligaments around your shoulder, referred to as a labral tear.
Atraumatic Instability
Some people may also dislocate their shoulder without a major injury, such as when reaching out, or even in their sleep in bed. We call this atraumatic instability. Often these people have very stretchy ligaments that don’t stop the shoulder from dislocating. We call this condition ligamentous laxity. Other people have problems with how their muscles work around their shoulder which makes them prone to dislocation.
The shoulder usually dislocates in a forward direction. This is often referred to as an anterior dislocation. Less commonly, the dislocation happens in a backward direction, which is a posterior dislocation. People with laxity can even dislocate their shoulders in both directions, also known as multidirectional instability.
Recurrent Instability
After the first dislocation, you may suffer some damage to the ligaments or tendons around your shoulder. If the damage does not heal, there is a chance you could dislocate your shoulder again, but with a much lesser injury than your first time. For example, if you dislocated your shoulder in a football tackle, you may always notice a weakness in your shoulder or a feeling that it is loose or wanting to pop out. You may even avoid certain positions such as reaching up high because it feels as if it will dislocate again. Some people at this stage wake up from sleep with a dislocation.
Your chance of dislocating your shoulder again depends largely on how old you are when you first dislocate your shoulder. Under 20’s have up to 90% chance of further dislocations, whereas over 40s have around 10% chance.
Who gets shoulder instability?
Anyone can dislocate their shoulder. It is most common in people in younger age groups (under 40) and often a result of contact sports or skiing. People with known laxity (stretchy joints) are also at higher risk of dislocating their shoulders.
Symptoms
01
Shoulder comes out of joint (dislocation), often after a fall with the arm above the head or as a result of contact sports, skiing or epileptic seizures
02
Feeling of weakness, looseness or that the shoulder is wanting to pop out, especially after a first dislocation
03
Avoidance of certain arm positions, such as reaching up high, because it feels as if the shoulder will dislocate again
04
Waking up from sleep with a dislocation (in some people)
05
Dislocation without a major injury, such as when reaching out (in atraumatic instability or people with ligamentous laxity)
How is a shoulder instability diagnosed?
This starts with a conversation with your doctor to describe the problems you are experiencing with your shoulder. You may be able to describe what you were doing when your shoulder dislocated, and what position your arm was in at the time. You will then be examined, with some specialised tests that test for shoulder dislocations, the strength of the rotator cuff muscles and your general flexibility. Quite often, you will already have X-rays if you came to A&E with a dislocated shoulder.
When you first dislocate your shoulder, you can tear some of the ligaments which may not heal properly. This might make you more likely to dislocate your shoulder again. To check whether you have a labral tear, your doctor may arrange an MR arthrogram. This is an MRI scan with dye injected into your shoulder.
People in order age groups, such as over-50s may instead tear their rotator cuff tendons. Your doctor may arrange an ultrasound scan to look at your rotator cuff in more detail.
Treatment options
Physiotherapy
A course of physiotherapy aims to improve the strength and gain better control of the muscles around your shoulder to prevent it from dislocating again. For many people, this is all that is needed after the first dislocation. Indeed, this is usually all that is needed for people who have no damage to their shoulder seen on the scan, those who have ligamentous laxity or problems with their muscle control (also known as muscle patterning problem). It can take several months to get the full benefit of physiotherapy, so it is important to work hard early on, even if you do not feel an immediate benefit.
Keyhole surgery
If physiotherapy fails, or if you are at very high risk for further dislocations, you may be offered keyhole surgery. This is usually called an anterior stabilisation which aims to reattach the ligaments and labrum to the bone. This is successful for approximately 90% of people, depending on the amount of damage to your shoulder before surgery.
Sometimes, if you are found to have a rotator cuff tear, you will instead be offered a rotator cuff repair.
Open surgery
Sometimes there are reasons why keyhole surgery cannot be performed. It might be that keyhole surgery was not successful and you had another dislocation. Alternatively, your scan might show that you have some extra damage to your bone, so a different operation is more likely to be successful. This is usually called a Latarjet procedure which attaches some nearby bone and tendons to the front of your shoulder to prevent future dislocations.