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Shoulder Instability Symptoms and Evaluation

Shoulder instability is usually the result of an injury when the bony ball of the shoulder joint is driven or pulled out of the socket, also known as a glenohumeral dislocation.  The ball will either pop back into place on its own, or you might have to have a doctor or friend help put it back in place.  Instability is the ongoing sensation of the shoulder continuing to slip out of socket after that initial injury.  Each time it slips out of place, it takes less and less force to drive it out.  Eventually, many people with shoulder instability will feel their shoulder fall out with their daily activities.  Alternatively, some people will only feel that uneasiness in certain positions, like with their arm overhead to throw a ball; and they will avoid that position to avoid the feeling that their shoulder will dislocate.

Initial emergency treatment for a shoulder dislocation is to reduce the dislocation, popping it back into place.  Following a brief period of rest in a sling, you can resume your normal activities as you progress with a therapy program which emphasizes strengthening the muscles around your shoulder blade and your rotator cuff muscles. 

This is one of the times it is better to be older than younger with an injury.  People over 30 years old will likely not have any further dislocations.  People under 30 years old are very likely to go on to have recurrent, repeated dislocations.  The younger you are, the even greater the likelihood.  Despite the low chance of developing instability after the initial dislocation for older people, this same group, unfortunately, will commonly tear their rotator cuff at the same time they dislocate their shoulder.  That rotator cuff tear may require treatment as described in the arthroscopic rotator cuff repair page.

Despite appropriate rehabilitation and therapy, many people will continue to be bothered by their unstable shoulders.  They may have pain, uneasiness in certain positions, weakness, or persistent clicking or popping within their shoulder.  When the shoulder came out of place the first time, it ripped a rim of cartilage off of the socket and tore the ligaments in the front of the shoulder off of the bony socket.  This is known as a Bankart lesion or Bankart tear.  That injury doesn’t heal in its normal location with rehab.  That rim of cartilage is known as the glenoid labrum, and along with the ligaments that attach to it, function to keep the ball of the shoulder joint centered within the socket, just as bumpers would keep a bowling ball in the center of the lane.  Without surgical repair, the labrum and ligaments heal in a lower position than normal, resulting in laxity or instability of the joint.  Surgical repair of the labrum, known as arthroscopic Bankart repair, places tension back on the glenohumeral ligaments and stabilizes the shoulder.

Normal labrum marked
Normal labrum

Bankart tear marked
Bankart tear

Therapy may get you to a point where you can get by with that persistent injury.  Unfortunately, each time your shoulder slips out of place, a little more damage is done to the inside of your shoulder, sometimes tearing the cartilage more or other times knocking pieces of bone off of the back of your humeral head, the ball of the shoulder joint.  This is known as a Hill-Sachs lesion. 

Bankart hill sachs marked
Hill-Sachs Lesion

If you continue to have problems, your doctor can discuss your specific problems and limitations from your persistent instability.  A detailed physical exam can usually reproduce your symptoms and help your doctor to understand the extent of your injury.  Frequently, a MRI with contrast material injected into your shoulder, known as an MRI arthrogram, can help to finalize the diagnosis.

Arthroscopic Bankart Repair or Arthroscopic Shoulder Stabilization

Arthroscopic Bankart Repair Video

 

Arthroscopic Bankart Labral Repair Slideshow

If you are a young athlete or if you are unable to return to all your activities after a trial of rehabilitation, your doctor may offer you an arthroscopic Bankart repair or arthroscopic shoulder stabilization.  This is an outpatient surgery, or you may spend one night in the hospital.  You will have general anesthesia as well as an injection in your shoulder known as an interscalene block so that you have very little discomfort following the surgery.  Your arm with be immobilized in a pillow and sling immediately following the surgery.  You will return within the first week of surgery to have your skin sutures removed.  Following this, you can begin to bathe normally.  You will start your own rehabilitation early, with your first goal being to regain your motion.  You will stretch your shoulder, but no one else will be allowed to stretch your shoulder for the first several months to avoid stretching your repair.  You can anticipate getting back to contact athletics when you have full motion of the shoulder and normal strength of your rotator cuff, usually 4 to 6 months after surgery.

The primary goal of the surgery is to regain stability to your shoulder.  The plan during the surgery is to use bone anchors and semi-permanent stitches to sew the torn cartilage, capsule, and ligaments back down to the bony socket of your shoulder.  All of this work is done through two or three ¼ inch incisions around your shoulder and viewed through a pencil sized arthroscopic digital camera.  This same operation used to be done through a three inch long incision on the front of your shoulder, but with new arthroscopic tools, the same or better success rates can be accomplished without having to open your shoulder.

Bankart tear marked
Bankart tear

bankart repair
Bankart repair