Shoulder instability – Arthroscopic/open stabilisation

Regaining stability in your shoulder

The shoulder is one of the most mobile joints in your body, it is a complex structure and prone to injury for a number of reasons. What would you do if your shoulder is dislocated or subluxed in an accident? Chronic or recurrent instability can also be an issue.

At Schoen Clinic London you will find experts who specialise in the prevention, diagnosis, treatment and rehabilitation of all aspects of shoulder conditions and injuries.

Understanding your shoulder anatomy

Made up of three bones: the shoulder consists of the humerus (the upper arm bone), the clavicle (the collar bone) and the scapula (the shoulder blade). Holding these bones together are a number of structures, including tendons, ligaments and cartilage (labrum). These structures work together to provide your shoulder with mobility, function and stability.

What is shoulder instability?
Several ligaments are attached to the labrum and these, together with muscles surrounding the joint, enhance shoulder stability. When the shoulder dislocates, damage can occur to numerous structures within the shoulder. The ligaments or the labrum can be torn or stretched and in many cases need to be repaired. If the structures do not work in the way they are supposed to due to injury, the shoulder becomes unstable.

Symptoms of shoulder instability

  • Traumatic shoulder dislocation
Shoulder dislocation can be very painful. The affected arm will be almost unable to move, and nerve stretching or crushing can lead to sensory disturbances in the affected arm or fingers. A shoulder dislocation must be treated and reset immediately. In the event of this injury, you will need to go straight to an emergency outpatient clinic.

Shoulder instability can occur after a shoulder dislocation. The most common complaint is of pain and a feeling of “instability” with overhead movements. The fear of dislocating the shoulder again can also be very stressful. Contact sports or sports with a risk of falling increase the chances of another shoulder dislocation. In the case of pronounced forms of shoulder instability, a simple rotational movement is all it takes.

  • Congenital shoulder instability
Congenital shoulder instability does not occur from a traumatic injury, it is present from birth. Affected persons can sometimes dislocate their shoulder at random. In these cases, there is usually a functional problem, a form of misdirectional instability. The ligaments and tendons of those affected usually show no injuries.

People suffering with congenital shoulder instability are often restricted in their everyday lives. They feel insecure and describe avoidance behaviour. Sport or certain everyday movements are no longer possible.

The causes of shoulder instability

There are three main causes of shoulder instability:
  • Post-traumatic tear: of the labrum and the ligaments that occurs more often during an injury with the arm far from the body and in external rotation.
  • Atraumatic instability: this is often a combination of hypermobility of the tissues of the body that can be associated with an abnormal pattern of movement of the shoulder girdle.
  • Overuse syndrome, or repetitive strain: this is a condition often associated with overhead sports, or work where the ligamentous structures are overstretched and overused for years. This can generate a micro instability of the joint. In turn, this results in symptoms of mechanical conflict of the soft tissues around the shoulder, and the bony surfaces that surround it.

Diagnosis: How shoulder instability is determined

The diagnosis is made from your medical history and findings obtained during a thorough physical examination. The patient can present with pain or mechanical symptoms in the joint like recurrent dislocations. Special imaging studies such as an MR-Arthrogram assist in confirming the diagnosis. An MR-Arthrogram combines fluoroscopy with magnetic resonance imaging (MRI) to reveal injuries which may not be visible on MRI scans alone. X-rays can be beneficial in determining any damage to the bones that form the shoulder. In the absence of findings on examination or MR, a diagnostic arthroscopy may sometimes be performed.

Restoring shoulder mobility

Whether you undergo surgical or conservative treatment, our role is to advise on the best course of action, providing you with the means to make an informed decision on how to proceed. Following an accurate diagnosis, we work together with you to clarify the best treatment for your shoulder instability in a detailed discussion.

Conservative therapy

The mainstay of treatment for shoulder instability is appropriately guided physical therapy. This is essential to maintain good scapular position and posture for the shoulder which is the foundation of shoulder movement. By recruiting and strengthening the muscles appropriately around the shoulder, this will help aid centre the humeral head in the glenoid cup, thus improving overall shoulder stability throughout a range of motion.
At Schoen Clinic London, your specialist works as part of a multidisciplinary team to formulate a treatment plan to relieve your symptoms. Conservative treatments focus on a combination of pain management and physical therapy. Part of your rehabilitation will involve modifications to your lifestyle, avoiding activities that are likely to aggravate your condition.

Depending on your individual diagnosis, your specialist will detail different medications and non-surgical options to help resolve your shoulder instability symptoms.

Arthroscopic shoulder stabilisation

Sometimes however when there is a structural lesion in the shoulder, such as a tear or damage to the labral bumper (Bankart lesion) or the shoulder ligaments an operation is required to gain lasting shoulder stability.

The operation is done by arthroscopic, or “keyhole” surgery and usually through two or three 5mm incisions. The minimally invasive procedure involves repairing the over-stretched or torn ligaments deep around the shoulder joint. During arthroscopic procedures, the surgeon creates small incisions and uses an arthroscope (tiny camera) to see the inside of the joint on a video monitor. Using special surgical instruments, the repair involves stitching the torn or stretched ligaments back onto the attachment, to the socket of the shoulder blade (glenoid). This is done using tiny anchors with sutures attached to them. The repair should be protected until healing takes place (four weeks for initial healing).

Sometimes, repair of the soft tissue structures alone is not possible to achieve lasting stability of the shoulder. In these instances, often where there is also significant damage to the bone of the socket or the humeral head, a bone transfer procedure (with or without a tendon attachment) may be required. This is a very robust way of achieving shoulder stability but is often performed as an open procedure rather than a keyhole procedure. During an open procedure the surgeon creates a larger incision at the shoulder, which allows for direct visualisation of the joint.

As with all surgery there is a risk of complications. These are rare, but you should be aware of them before your operation. They include:

  • Complications relating to the anaesthetic
  • Infection
  • Failure to achieve a successful result with further dislocation of the shoulder
  • A need to redo the surgery
  • Injury to the nerves or blood vessels around the shoulder
  • Fracture
  • Prolonged stiffness and or pain
  • Implant failure

Aftercare

The procedure often can be performed as a day-case procedure. The operation is often performed under general anaesthetic with the benefit of regional anaesthesia to ensure that you are very comfortable immediately following the procedure. Simple oral pain killers are often all that is needed for a few days following this.

As part of your treatment you will need to engage in a structured programme of rehabilitation supervised by a physical therapist. The inpatient physio team will instruct you initially, but this care will continue as an outpatient by your physio team. The aim is to gradually regain a full range of motion and then regain strength and control with time. You will be advised regarding return to driving and contact sporting activities.

Shoulder instability: Our specialists

Our shoulder surgeons at Schoen Clinic London have many years of experience in treating shoulder instability. Your shoulders are in the best hands with us.

Shoulder instability: Our specialised hospital

Schoen Clinic Orthopaedic and Spinal Hospital is located in the heart of London’s Harley Street area. With experts in the prevention, diagnosis and treatment of all aspects of shoulder conditions, a diagnostics and imaging suite, surgical theatres and rehabilitation facilities at the same location, your return to stability is in safe hands.