Shoulder Instability: Treatment Options

Shoulder Instability: Treatment Options

Shoulder instability usually begins after a single traumatic event that results in an anterior shoulder dislocation where the ball completely loses contact with the socket out the front of the shoulder. Research has shown that approximately 50% of patients who sustained one dislocation experienced at least two more redislocations, and approximately 25% required surgical intervention. A dislocation event may also lead to a patient developing shoulder arthritis later in life.

Nonoperative treatment for shoulder instability may be considered for older, less active patients and may include activity modification, formal physical therapy, over-the-counter medications, and therapeutic injections. However, younger active patients, including those participating in contact sports, will most likely benefit from surgical treatment of their shoulder instability to help prevent additional dislocation events and further damage to the shoulder joints.

For operative treatment, a doctor may perform a traditional open procedure with an incision or an arthroscopic procedure where a small camera and instruments are used to work inside the shoulder via mini incisions. The decision to perform an arthroscopic procedure versus an open procedure will depend on several factors. Particularly after a dislocation out the front, the glenoid labrum might tear at the front and bottom portions of the glenoid termed a Bankart tear. A Bankart repair is most often performed via an arthroscopic surgery, although an open approach is sometimes required.

Sometimes, after patients have multiple dislocations, there is bone loss on the front of the socket. This may require an open procedure where the surgeon will use bone from another part of the shoulder or donor tissue, referred to as an allograft, to restore the shape of the socket.

We will focus on what arthroscopic treatment of shoulder instability might look like. On the day of surgery, the patient will be positioned one of two different ways, depending on the surgeon's preference. One position is referred to as the beach chair position, where the patient is seated upright with the upper body reclined back slightly. The other position is referred to as the lateral decubitus position, where the patient will be lying on their side with the affected shoulder facing up. Both positions allow for the surgeon to visualize the inside of the shoulder joint using an arm positioning device.

To repair a Bankart tear, typically, 2 to 3 small incisions referred to as portals around the shoulder will be used. The doctor will place a camera, referred to as an arthroscope, through the incision at the back of the shoulder and evaluate the inside of the shoulder joint. Here, they will look for any damage to the glenoid labrum and glenohumeral ligaments, in addition to other pathology that may also be associated with shoulder instability.

After the surgery is complete, recovery begins. At first, a patient will wear a sling to protect and support their shoulder. They will perform gentle motion exercises of the hand, wrist, and elbow to prevent stiffness of these joints while in the sling. Then, slowly, with guidance from physical therapy, they will start regaining their shoulder motion. Strengthening is gradually incorporated and tailored to the patient's goals for return to sport or work.