How does a Shoulder Dislocation happen?
Shoulder Dislocations occur typically as a traumatic event, frequently as the result of an injury during sports or an awkward fall. The most common mechanism is a stretching of the arm behind the shoulder with the palm facing forward–such as a linebacker’s arm when the running back runs through his arm tackle. The ball typically moves forward on the socket and gets caught in the front of the socket. In a small percentage of patients, the ball actually moves behind the socket and this type of injury is best recognized by an experienced shoulder physician. Note a dislocation is different from a separation which involves a different area of the shoulder.
In patients with more chronic instability, the shoulder can start to slip out with low-energy activities such as reaching up or even during sleep. Proper treatment of this degree of instability is imperative to allow normal, everyday function.
What are the symptoms?
Shoulder Dislocations are immensely painful and any movement of the arm hurts. The arm may feel “dead” and any attempt to bring the arm across the body makes the pain worse. There may also be a deformity or fullness in the front of the shoulder. Suspected shoulder dislocations require emergent “reduction” or a setting of the ball back onto the socket, usually with sedating medication in the Emergency Room. There are injuries that are slightly lesser (subluxation) in which the ball is partially out of the socket and these sometimes “pop” back in place prior to receiving medical attention.
What type of damage occurs in my shoulder?
Shoulder Dislocations result in significant damage to the labrum and ligaments that maintain stability of the shoulder joint. Occasionally minor fractures involving either the ball or socket can occur, rarely a major fracture can occur–xrays are necessary to assess for this type of damage.
What is the treatment for a Shoulder Dislocation?
While this can be treated with a period of rest and physical therapy, recent studies have shown earlier surgical restoration of the labrum can lead to better long-term results in higher level athletes. The decision between surgical repair and rest/therapy is a shared process and based largely on your desired level of activity going forward—our goal is always to restore you to the highest level of activity you desire. In some patients with lower overall demands on their shoulders, nonsurgical management can provide a successful return to all desired activities. For higher level athletes, particularly collision athletes, surgical repair may provide a more predictable path back to high level participation.
While we know that ligaments and labrum are always going to sustain some degree of damage in a dislocation, the degree of collateral damage plays a significant role in determining proper treatment. X-rays and MRI are frequently necessary to determine the extent of the structural injury. With certain types of ligament tears, surgery may be more likely to help and rehabilitation more appropriate for other types of tears. Likewise, the socket or the ball can also be damaged by a dislocation and depending on the severity of such damage, surgery may be more or less likely to be recommended.
What type of surgery is done for this problem?
Arthroscopic repair will be recommended for typical patients with dislocations requiring surgery. This is an outpatient procedure to repair of the damaged labrum and the ligaments which typically are stretched from the shoulder dislocating. This is a relatively minor and outpatient surgery but return to sport may take 4-6 months depending on the demands your particular activities place on your shoulder. Several months of therapy are also necessary for a full recovery. However, some patients have more complex patterns of instability that may require more than a routine arthroscopic repair.
Several variants of shoulder damage can occur and these subtleties are of paramount importance to recognize as the recovery and treatment can vary significantly. Bony damage to the humeral head is called a Hill-Sachs lesion and can require a specialized arthroscopic repair or bone graft to treat successfully. If there is bony damage to the glenoid, a Latarjet procedure can become necessary. We are one of the few centers in the country performing arthroscopic Latarjet repairs. This involves the transplant of bone from one part of the shoulder to the damaged area. This is an uncommon procedure but highly successful for athletes with more severe collateral damage to their shoulders.
Even more uncommon is a HAGL lesion in which the labrum does not tear, rather the ligaments tear from the ball instead; with more advanced types of tearing of the shoulder ligaments, a standard shoulder stabilization operation will likely fail. Indeed, the most common cause of failed instability surgery is using a one-size-fits-all basic repair technique in someone who has a complex injury pattern that was unrecognized either preoperatively or intraoperatively. A HAGL injury should be recognized on the MRI and is certainly evident during arthroscopy for those experienced in its diagnosis and surgical repair.
While many surgeons are trained in basic instability repair, Drs. Bak, Frush and Silas are trained and experienced in all techniques of shoulder stabilization and will perform the operation best suited to your specific pattern of instability. We frequently get these types of patients referred to us due to our ability to transition to different repair techniques, even intraoperatively.
I have never had a dislocation but my shoulder pops and feels unstable. What could be going on?
Some athletes have a condition in which the ball repeatedly comes close to dislocating but does not quite come completely out and lock in front of the socket. This is known as a subluxation. While less dramatic than a dislocation, these can negatively affect confidence and ultimately, performance in an athlete. Additionally, the cumulative damage of this lesser injury can, over time, approach the amount of anatomic damage that can be done with a single dislocation event. When shoulder subluxations are treated early and appropriately, frequently a full recovery can be made without surgery. If this becomes a more chronic condition, surgical repair via outpatient arthroscopy could become necessary.
When can I go back to sports or work?
This depends highly on the physical demands of your job or sport. For general, everyday activity, most people feel relatively normal within 6 weeks. For overhead athletes/throwers, it takes generally 6-9 months until a return to full, high-level throwing. Our collision athletes are able to return to sports approximately 4-5 months after surgery. For athletes in predominantly lower-extremity sports (soccer, skiing, snowboarding, etc), 3-4 months is a safe timeframe for return. Depending on your unique circumstances, we will get you back to your activities at the soonest but safest time.