What is it?
shoulder joint is stabilized in part by the shoulder capsule, a series of
ligaments that connects
the humerus to the glenoid. When the ligaments weaken or tear, the shoulder has a
greater tendency to dislocate. This is known as instability, which can lead to
greater and more painful shoulder conditions, especially dislocation and subluxation.
Dislocation and subluxation
are the telltale signs of instability. If either happens frequently, instability
is usually to blame. Usually, a substantial blow to the shoulder can be
identified as the start of the condition. Also, if the patient feels the
shoulder suddenly give way or describes it as "unreliable," this may mark
|Normal shoulder joint.
|Dislocation of shoulder joint. Head of humerus dislocates from glenoid.
Shoulder instability means your shoulder can dislocate or subluxate
repeatedly during active movement or exercise. Subluxate means the
joint moves more than it should do in normal circumstances but doesn't
actually come out of joint. There can be a number of reasons for this
and this will determine the type of treatment you will receive.
Shoulder instability is divided into three main categories and this
is largely decided on the first episode of dislocation.
This when the shoulder has undergone an injury with enough force to
pull the shoulder out of joint such as being tackled in a rugby game,
a road traffic accident etc. Usually this is the first episode and it
would need reducing in A&E. You would be put into a sling for a period
of time and then in some cases would undergo a course of
Due to the amount of force that is associated with such an injury part
of the joint called the labrum can be torn from the bone and this
result in an unstable shoulder which may lead to further episodes of
dislocation. This would be an indication for a surgical procedure
called an Anterior Stabilisation where the torn part of the labrum is
repaired, following this a course of physiotherapy is needed to regain
range of movement and strength.
This occurs when the shoulder dislocates with minimal force such as
reaching up for an object or turning over in bed. Usually it will
'pop' back in itself or with a little help. Normally this type of
dislocation does not need reducing in A&E. It can occur regularly
throughout the day and will be associated with certain positions the
arm is placed into. This type of dislocation is associated with people
that have 'lax' joints, for example people who hyper-extend their
knees and elbows and can get the palms of both hands onto the floor
with ease. This joint laxity is normal for these people and the onset
of dislocation can be associated with a change in how the muscles
around the shoulder are interacting with each other or a change in
posture/ position of the arm. This can produce an imbalance in the
control of the joint. Referral for appropriate physiotherapy is the
initial form of management. The physiotherapist should look at the way
in which the muscles and shoulder joint is moving and posture aiming
to restore the balance. Treatment can 'cure' the problem as long as
the exercises and advice is continued, but in some cases there is only
minimal or nil benefit. At this point surgical intervention is
This group of people can dislocate their shoulders without any form or
history of trauma. Some may have started out dislocating their
shoulder as a party trick; others may have always had shoulders that
just 'fall' out of joint. This type of dislocation is usually painless
and can be put back in easily. Both shoulders are typically involved.
The cause of this type of dislocation is usually a result of what we
call 'abnormal muscle patterning' which means the strong muscles
around the shoulder joint are not working in the correct order causing
them to pull the shoulder out of joint with active movement in the
particular direction such as lifting the arm forward above the head or
out to the side and above the head. The only treatment for this is
physiotherapy that looks at re-sequencing the muscles in order to
prevent further dislocations.
Causes and Risk Factors
Often an initial
subluxation or dislocation forces the ligaments of the shoulder capsule to
be torn away from the bone (glenoid). If the initial condition does not heal properly, instability will
result and worsen over time.
Risk Factors: Overhead and contact sports
pose a greater risk of instability. Additionally, those with above-average joint
laxity, or looseness of the ligaments, stand at great risk of shoulder
Possible Causes: Injury and Trauma
Physiotherapy - to train
the shoulder muscles to control the shoulder correctly and prevent further
Painkillers and anti-inflammatories
- when pain occurs
Surgery - A number of procedures are available to remedy chronic
instability, depending on the causes and findings on investigations.
Procedures - through keyhole surgery.
Procedures - depending on the problems found.
shoulder muscles remain the best defence against shoulder dislocation,
subluxation, and, thus, instability. Exercises that build up these muscles
around the shoulder should be done. Adequate warm-up before activity and
avoidance of high-contact sports will help prevent of an instability-causing
This is carried out under a
general anaesthetic. It involves repairing the over stretched or torn ligaments
deep around the shoulder joint. The surgeon may perform the surgery
arthroscopically (keyhole), or as an open procedure. The doctors will discuss
your individual surgery with you before the operation.
The operation involves
reattachment and tightening of the torn labrum (blue) and ligaments (green) of
the shoulder (see picture below). This usually done using sutures and small bone
|View of the glenoid from the inside of the glenohumeral joint with the
humerus removed. The blue area is the labrum.
|A Bankart lesion is a tear of the labrum
off the glenoid bone (red)
For more details of the surgery and videos:
For Interactive Animations see
Interactive Surgery - go to [Shoulder] then [Instability &
Labrum Problems] and [Bankart Repair].
Some people who have dislocations due to loose shoulder joints (MDI) and no torn
labrum may require a Capsular
You must not eat or drink anything after
midnight the day before your surgery. When you wake up following the procedure
you will be wearing a sling with a body belt (see picture). The sling should be
worn under the clothes for 3 weeks. The body belt can be removed at 3 weeks
and you can begin wearing the sling outside your clothing, but the remaining
sling is to be continued for a further 3 weeks. For more details on
Living with a Shoulder Sling CLICK HERE
You will probably be in hospital
overnight after your operation. A physiotherapist will see you in hospital to
teach you the appropriate exercises. You may also see an occupational therapist
to give you advice regarding the use of your arm.
A nerve block
is usually used during the surgery. This means that immediately after the
operation the shoulder and arm often feel completely numb. This may last for a
few hours. After this the shoulder may well be sore and you will be given
painkillers to help this whilst in hospital. These can be continued after you
are discharged home. Ice packs may also help reduce pain. Wrap crushed ice or
frozen peas in a damp, cold cloth and place on the shoulder for up to 15
minutes. Ensuring you cover the wound site with a piece of cling film to keep
the area dry.
repair: There is an incision at the front of the armpit within the
natural skin crease. The stitch is dissolvable but is usually removed at 3
weeks. Keep the wound dry until it is well healed. This usually takes 3 weeks.
Arthroscopic (keyhole) repair: This keyhole operation is usually done
through two or three 5mm puncture wounds. There will be no stitches only small
sticking plaster strips over the wounds. These should be kept dry until healed.
This usually takes 5 to 7 days.
For the first six weeks your
sling must be worn in bed.
Sleeping can be uncomfortable if you try and lie on the operated arm. We
recommend that you lie on your back or on the opposite side, as you prefer.
Ordinary pillows can be used to give you comfort and support. If you are lying
on your side one pillow slightly folded under your neck gives enough support for
most people. A pillow folded in half supports the arm in front and a pillow
tucked along your back helps to prevent you rolling onto the operated shoulder
during the night. If you are lying on your back, tie a pillow tightly in the
middle (a "butterfly pillow") or use a folded pillow to support your neck. Place
a folded pillow under the elbow of the operated arm to support that.
FOLLOW UP APPOINTMENTS
An appointment will be made for
you to see a physiotherapist after your discharge and you will be seen by the
Shoulder Team 3 weeks post-operatively.
For the first six weeks all activities
of daily living for example feeding, dressing, cooking etc must be carried out
using your un-operated arm. If appropriate an occupational therapist will be
available to give you advice on how to do this.
Your physiotherapist and surgeon will advise
you when it is safe to resume your leisure activities.
This will vary according to your sport and
level, as well as the period required to retrain your shoulder muscles with
Below is a rough guide:
Includes rugby, horse riding, football, martial arts, racquet sports, and rock
You will not
be able to drive for a minimum of 8 weeks. Your surgeon will confirm when you
RETURNING TO WORK
depend upon the size of your tear and your occupation. You will need to discuss
this with a member of the Shoulder Team