Ask a Vail Sports Doc column: Assessing and correction shoulder instability
Shoulder instability can be a frustrating and painful issue to deal with for athletes of all kinds. Often, younger athletes, especially males ages 18 to 25, or those participating in high-risk activities, are the most susceptible to shoulder subluxations or dislocations. Most commonly, athletes report to us that they fell forcefully on an outstretched hand and this caused their shoulder to dislocate.
We treat most patients who have suffered a shoulder dislocation for the first time non-surgically. We prescribe physical therapy and recommend a sling for comfort. However, in young, active patients, it is not uncommon to have further episodes of shoulder instability in which the shoulder dislocates or subluxates (meaning the ball comes partially out of the socket) again and again.
Anterior shoulder dislocations, in which the ball, or humeral head, comes out the front of the shoulder, are the most common direction of shoulder dislocations, comprising more than 85 percent of all dislocations.
When a shoulder dislocates, the labrum usually tears away from the socket. The labrum is a fibrocartilage ring attached to the edge of the entire socket that helps keep the ball in the socket. In some cases, there is not tearing of the labrum but, rather, a fracture of the edge of the socket, or a so-called bony Bankart lesion. We liken the shoulder to a golf ball sitting on a golf tee. In a bony Bankart fracture, there is a resultant chip fracture of the edge of the golf tee or socket, which makes the shoulder joint very unstable.
X-rays and a physical exam are the first steps for evaluating shoulder instability. Often, a bony Bankart fracture can be seen on an X-ray alone. However, we typically order an MRI and CT so associated bone and soft-tissue injuries can be better visualized. This also helps with pre-surgical planning.
After diagnosing a bony Bankart fracture, we usually recommend early surgical intervention, as these fractures do not heal in the proper place without surgery. Moreover, patients who have these fractures are very unstable and are often even unable to take their shirt off, for example.
The main goal of a bony Bankart repair is to reattach the fracture fragments and labrum back to the edge of the socket, and this is done using small suture anchors and suture.
In our practice, we are able to actually fix these fracture fragments back to the socket arthroscopically, whereas most surgeons make a big incision to fix these. We make three small incisions, and with small instruments and a telescope-like camera in the shoulder, the surgery can be performed. Doing it arthroscopically leads to less disruption of normal muscles and tendons around the shoulder, there is less pain and the recovery is faster.
With good physical therapy, most patients do very well and do not have further episodes of shoulder instability in the future.
Following an arthroscopic repair, patients are able to go home the same day. Patients are confined to a sling for four weeks, but easy range-of-motion exercises are started right away. Most patients are back to pain-free daily activities, normal strength and most sports within four months. Throwing athletes may need six months until they are cleared to resume their sport.
Unfortunately, shoulder instability is quite common. We have noticed that bony Bankart fractures of the shoulder are more common as sports become more extreme. Fortunately, these injuries can be repaired arthroscopically, the shoulder can be effectively stabilized and athletes can once again resume their active lifestyle.
Dr. Richard Cunningham is a board-certified, fellowship-trained orthopedic surgeon and knee and shoulder specialist with Vail-Summit Orthopaedics. Gretchen Meador, P.A.-C., is a physician assistant to Cunningham. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.