Shoulder Instability 

The shoulder is a special joint because it has more motion than any joint in the human body! The shoulder joint is a ball and socket joint where the humeral head is the ball and the glenoid is the socket. The bony restraints of this joint are minimal and depend heavily upon the surrounding soft tissues (muscles, ligaments and cartilage) to stay in place. Sometimes, laxity (looseness) of these soft tissues can cause the humeral head (the ball) to slide partially out of the socket, a condition called subluxation. Other times, a large force can cause the humeral head to “pop out” or dislocate from the joint.  

Although in many situations after a dislocation, the shoulder “pops” back in, your child should see an orthopedic surgeon for evaluation if they have dislocated or there is a strong suspicion that a dislocation has occurred. Some growing athletes have very naturally loose or “lax” ligaments and soft tissues which can be a risk factor predisposing them to instability episodes of their shoulders. Shoulder instability can also develop in young athletes involved in overhead sports such as baseball, volleyball, gymnastics and swimming. Repetitive motions can stretch out some of the surrounding soft tissues of the shoulder. 

Anatomy of the shoulder: 

The shoulder capsule has three main ligaments that attach from the glenoid (socket) to the humeral head (ball) and are important in holding the ball in the socket during shoulder range of motion. Each different ligament secures the shoulder at different arm positions. When a dislocation occurs, the capsule and the ligaments get stretched and torn. 

Depending on the severity of the dislocation, parts of bone from the socket or the ball may be injured as well. 

What are some of the signs and symptoms of shoulder instability? 

• Pain in the shoulder/upper arm 
• Difficulty in moving the shoulder 
• A bump causing deformity of the shoulder 
• Restricted motion 
• Weakness of the arm 

What are some of the risk factors for recurrent traumatic instability? 

• Young age - usually younger than 15 
• Male sex 
• Number of previous dislocations 
• Overall Body laxity/ looseness 

What does a visit with the doctor look like?

The doctor will perform a thorough history and physical examination. Imaging including x-rays and MRI will also be an essential part of the initial evaluation after first time traumatic shoulder dislocation. If there is concern for bone loss with the dislocation, a CT scan may also be ordered to provide additional information. 

What are the treatment options: 

• Initial Treatment recommendations after re-location 
• Rest with sling immobilization 
• Ice and pain medication 
• Physical therapy and rehabilitation to regain strength and motion. There will be sport specific instructions at the end of the rehab protocol. This can last up to 2 months in some situations.  

Will my growing athlete be okay? 

There can be a high rate of recurrence with traumatic dislocation of the shoulder in adolescent athletes. Males and those that participate in collision/contact sports are at increased risk of having multiple episodes of recurrence that may necessitate surgical treatment. 

When is surgery required for this instability? 

Surgery may be required initially if the shoulder is unable to be successfully put back in the proper position. Surgery may also be required if the dislocation has dislodged a large piece of bone from the socket (glenoid) or ball (humeral head). Also, because adolescent athletes are at high risk for recurrence, in certain situations surgery may be recommended initially if they are trying to return to a high level contact or collision sport. Surgery will also be considered if physical therapy and strengthening of the shoulder fail to improve symptoms. 

If required, what does surgery entail? 

The goal of the surgery is to repair or fix the stretched out ligaments and torn cartilage. This is usually done with a small arthroscopic camera, which allows the doctor to see inside the shoulder. In certain cases, a larger open incision in the front of the shoulder may be required. Success with surgery typically runs around 90 percent. Your child will be in a sling for 4 to 6 weeks. Physical therapy will start after the first post-operative visit and will be an important part of the recovery and a good way to prevent a recurrence.  Most athletes are able to return to sport around 4-5 months after a repair. 

Maintaining good shoulder and core strength will be helpful in minimizing recurrence. The shoulder is the most frequent dislocated joint accounting for up to 50% of presentations to the Emergency Room. Traumatic shoulder instability is a common problem seen by orthopedic surgeons with an incidence close to 2% in the population. In the growing athlete, recurrence rates after first time dislocations can be extremely high (greater than 80-90% in some studies)