Shoulder Instability

with R. Sean Churchill, M.D., Orthopaedic Surgery, Advanced Healthcare

Posted: April 1, 2004

A weekend athlete, while skiing, grabs a tree to slow down and dislocates his or her shoulder. After a trip to the emergency room and follow-up visits to the orthopaedist, the initial pain and trauma pass. But for patients who end up with traumatic instability, the shoulder continues to dislocate, possibly requiring surgery. It’s an age-related situation; the older you are, the less of a chance you have of developing traumatic instability following a dislocation.

“If you have traumatic instability and you’re under 20, you’re probably going to continue to dislocate unless it’s fixed surgically,” said Dr. R. Sean Churchill, an orthopaedic surgeon with Advanced Healthcare who specializes in treating shoulders. “If you’re 30, there’s a 50-50 chance you can rehabilitate it with physical therapy and do well, and if you’re over 30 the chances that you’ll require surgery are much lower.”

R. Sean Churchill, M.D., Orthopaedic Surgery, Advanced Healthcare "If you have a traumatic dislocation and you're under 20, you're probably going to continue to dislocate unless it's fixed surgically. If you're 30, there's a 50-50 chance you can rehabilitate it with physical therapy and do well, and if you're over 30 the chances that you'll require surgery are much lower."

This is the rare case in which age actually works in someone’s favor. Chances of developing traumatic shoulder instability reduce as people get older. Shoulder instability not caused by trauma, or atraumatic instability, also tend to stabilize with age.

“People in that group can pop their shoulder in and out at will,” Dr. Churchill said. “Most of it is hereditary; there are swimmers, divers and gymnasts who have very lax joints.”

Dr. Churchill cited Mark Spitz, who won seven gold medals at the Munich Olympics in 1972. “He was seen by a number of physicians throughout his college and Olympic career,” he said, “and they said they needed to tighten his shoulders surgically, but it helped him excel. People excel at these sports because they can get their arms in positions that the ordinary person can’t.”

But, he cautioned, being able to grab all the attention at a party by pulling your shoulder out of its socket at will doesn’t mean it’s a good idea. Even the most flexible teens are setting themselves up for problems down the line if they continue to pop their shoulders out of joint.

“Every time that ball slides out it causes a little more damage,” he said. “It takes a little more cartilage and tears the soft tissue a little more. It’s just not good to have a joint out of place.”

Treatment
The ideal treatment for atraumatic instability, Dr. Churchill said, can be summed up in one word, “Therapy, therapy, therapy.”

Non-surgical treatment for atraumatic shoulder instability is similar to that for a traumatic injury. Patients work with rubber band tubing to strengthen the rotator cuff, a flat group of tendons that are fused together and that surround the shoulder joint. Each one is attached to muscles originating from the scapula which pull on the rotator cuff tendon and cause the shoulder to rotate upward, inward and outward.

Atraumatic shoulder instability generally isn’t a problem after age 25, Dr. Churchill said, for the same reason that surgery for traumatic shoulder instability isn’t as common in older people.

“As we age, we all get stiffer and tighter just because of the nature of aging,” Dr. Churchill said. “Kids are so loose that if the force of the injury is strong enough to cause a big dislocation, they tear the labrum (a rim of cartilage on the shoulder capsule) and can rip a chunk of the socket off, and also can cause a hole in the back part of the ball.”

Or put another way, Dr. Churchill said, a dislocation in a younger, more flexible person can cause the back part of the ball (part of the ball and socket joint of the shoulder) to become dented inward; and the socket to chip. When someone in this situation raises an arm upward to throw a ball or to wave, he or she ends up in a position where the dented ball lines up with the chipped socket, and the shoulder dislocates.

In the rarer cases of older people dislocating their shoulders, chances are much greater that they will also end up with a torn rotator cuff. As we age, the rotator cuff weakens, and greater force is required to pull the ball out of the socket.

Surgery
In both cases – repeated injuries in younger people and the rare older person who dislocates his or her shoulder – Dr. Churchill will perform surgery after a complete evaluation and a trial of physical therapy.

“If you had a normal shoulder before you were injured, the first thing I do is evaluate you and get an MRI or ultrasound,” he said.

Surgery is sometimes open, and sometimes arthroscopic.

“I perform the right operation for the right situation,” he said, “and I’m going to do whatever will leave your shoulder the strongest after surgery and recovery.”

Surgery for an unstable shoulder involves repairing, reattaching or tightening the structures in the shoulder, depending on the degree and nature of the damage Dr. Churchill encounters.

For the first two weeks after surgery, movement is kept to a minimum, with patients keeping to a regimen of controlled and limited motion. For the four weeks, Dr. Churchill works with patients to help them return to more normal motion, and at six weeks starts some strengthening work. At three months post-op, patients involved in sports are able to resume normal activities.

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