The shoulder is the most mobile joint in the human body with a complex arrangement of structures working together to provide the necessary movement. The shoulder is a ball-and-socket joint that is made up of the humerus (the ball) and the glenoid (the socket). A strong network of soft tissues and bones work cohesively to provide movement and stability to the shoulder. The head of the humerus fits into a shallow socket, called the glenoid, in the scapula while the shoulder capsule, a strong connective tissue containing the ligaments, surrounds the shoulder joint. Synovial fluid lubricates the joint and the shoulder capsule to ease the movement of the shoulder.
Atraumatic shoulder instability, also called multidirectional instability is often described as general laxity, or looseness of the shoulder's glenohumeral joint in multiple directions which causes symptoms. Ligaments, which are tough bands of tissues within the capsule that hold bones together, provide support and stability to the bones by restricting excessive motion. However, some individuals have increased looseness in the ligaments surrounding the glenohumeral joint. This laxity can be a natural condition that is present since birth or be a condition that has developed over time.
Individuals who have atraumatic shoulder instability may often show little or no symptoms. The first sign of symptoms might be an episode of the shoulder partially dislocating (subluxing). Some other symptoms may be:
- Feeling of extreme looseness of the shoulder joint
- Felling of something slipping or pinching in the shoulder joint
- Shoulder pain or dull ache either during or following activities requiring use of the shoulder
- Fully dislocating the shoulder
If the subluxing or dislocating increases and is causing pain or discomfort, it is highly recommended to visit a physician to avoid further dislocation of the glenohumeral joint.
Multidirectional shoulder instability can be diagnosed with the help of a thorough physical examination. The physician will examine the shoulder to test the range of motion of the shoulder joint as well as the strength of the shoulder. The physician will then order X-rays to rule out arthritis or the involvement of other structures. In some cases, the physician may order an MRI scan to look for tears in the labrum or inflammation of the tissues and to help determine the characteristic of the tear and to determine the appropriate treatment method, whether this be conservative or surgical. In most cases, the MRI involves an injection of dye into the shoulder prior to having the MRI.
Most individuals with multidirectional shoulder instability can be treated with conservative, non-operative treatment methods, specifically physical therapy. The vast majority of patients that follow a strict rehabilitation program achieve pain relief and increased stability. In some cases, conservative treatment fails to reduce pain and other symptoms so the physician my recommend operative treatment.
Physical Therapy - Physical Therapists will often prescribe specific strengthening and range of motion exercises that promote healing, improve shoulder strength and mechanics, and muscle coordination. It is crucial that these exercises be done accurately and routinely to optimize recovery of the mobility of the shoulder joint.
Surgery - If conservative treatments have not helped reduce symptoms, the physician may recommend surgery to reduce pain and restore stability and function of the shoulder. Depending on the severity of the instability, the physician may recommend a minimally-invasive arthroscopic procedure called a capsular shift. Small incisions are made around the joint where surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Due to shoulder instability, the capsule that helps hold the humeral head in the glenoid may have been stretched, so the physician will fold the excess tissue and suture them together in order to tighten the capsule. Sutures will be used to close the incisions and the arm will be placed inside a sling for five to seven days until the incisions have healed. This will be followed by a course of physical therapy.
Regardless of the treatment approach taken, patients go through a rehabilitation program which includes physical therapy exercises that are crucial to restore function. Each patient is unique, so the therapy program will vary based on his/her level of pain, extent of injury, and desired level of activity they would like to return to. Recovery after surgery typically takes at least six months depending on the complexity of the procedure, but the individual's commitment to following their physician's instructions and all the exercises prescribed by the physical therapist is the most important factor in returning to activities.
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