Ocean County Sports Medicine Dr Joe Tauro

How is a dislocation and traumatic shoulder instability treated?

The initial reduction of a dislocation can be quite difficult. Contractions of the shoulder muscles can trap the humeral head against the glenoid. Gentle traction, and at times, medication may be needed to accomplish the reduction. Once the shoulder is reduced, a sling is used for a few days to protect it, and relieve discomfort. Physical therapy may help the patient regain motion in the joint.

Non-Operative Treatment

Initial treatment for recurrent instability of the shoulder centers on physical therapy. Strengthening the rotator cuff muscles and periscapular muscles (those around the scapula) gives stability to the joint. The goal of physical therapy is to help the muscles provide stability to the shoulder that the torn ligaments can no longer supply. The therapy for recurrent instability should be carefully designed for each patient since this condition often causes apprehension about certain arm positions or exercise maneuvers. Very often, physical therapy can help regain lost motion, reduce apprehension, and restore shoulder function. In patients over 30 years old, physical therapy is usually successful and therefore is always recommended before consideration for surgery. In patients under 20 years old, recurrent instability is likely even with physical therapy. Dr. Tauro will discuss with patients and parents the option of early arthroscopic ligament repair to prevent the discomfort and possibility of further damage from recurrent dislocations. Patients between 20 and 30 years old are in a "gray zone" and treatment recommendations are individualized.

External Rotation

Pendulums

Standing parallel to an elastic resistance cord, the elbow should be bent 90 degrees at the side. The hand should slowly rotate away from the body, using the elbow as a hinge. Rotation should continue until the arm is in a neutral position.

While bending at the waist the affected arm should hang relaxed.
The arm should be moved in all directions using momentum.

Operative Treatment

Surgery is usually recommended if recurrent instability cannot be controlled with physical therapy and activity modification. The goal of surgery is to return stability to the shoulder with the least loss of motion. All shoulder procedures designed to stabilize the shoulder involve some loss of motion. All shoulder procedures designed to stabilize the shoulder may involve some loss of motion, although the loss of motion is typically minimal with arthroscopic repair. The current procedures for anterior shoulder instability attempt to restore the normal anatomy without over tightening the ligaments. In certain instances, such as in young persons who have a higher risk of re-dislocation and in contact athletes who plan on continuing to participate in sports that put their shoulders at risk, surgery may be performed after the first dislocation.

Use the bottons above to see the different steps.

Open Labral Repair

This procedure is performed through a two to three inch incision on the front of the shoulder. The torn labrum is repaired and the stretched-out anterior shoulder capsule is imbricated (overlapped) to make it smaller. Open repairs are more painful and cause more loss of motion than arthroscopic repairs but may be stronger and appropriate for athletes involves in high level contact sports. Dr. Tauro rarely finds it necessary to perform open labral repair.

Arthroscopic Techniques
Dr. Tauro is a regonized national expert and lecturer on the techniques of arthroscopic instability repair. His published results on arthroscopic shoulder instability repairs have demonstrated very good results with long term recurrence rates under 10%. Recent advances in the techniques of repair, including stronger sutures and anchors, have reduced short term recurrence rates to under 5%. These procedures are performed with visualization through a small fiberoptic scope. Instruments are inserted into the joint through two or three small incisions to repair the labrum. The internal surgical repair is similar to the one used in an open repair. Procedures using thermal energy to shrink the loose capsule have been developed, but Dr. Tauro and other shoulder experts around the country have found that this technique has an unacceptably high recurrence and complication rate and, therefore, do not use it.

What types of complications may occur?

The major complications of anterior stabilization techniques are recurrent instability and/or loss of motion. The rate of recurrent instability depends partially on the technique used for the repair, the activity level of the patient after repair and also on other anatomical problems such as boney damage to the glenoid or humeral head or severe ligament tissue damage or deficiency The loss of motion can be significant with open repair but is minimal with an arthroscopic repair. Other small risks (less than 1%) include infection, nerve damage, or blood vessel injury.