Overview

Shoulder instability is a condition in which one of the bones in the shoulder joint slides partially or completely out of place.

Normally, the head of the humerus, the upper arm bone, moves within the confines of the shoulder socket. Instability occurs when the head of the humerus slips outside its normal position. The head of the humerus may move in one or more directions. The disorder is classified by how much this bone moves and by the direction it moves:

• subluxation
  When the humeral head moves part way out of the shoulder socket.
• dislocation
  When the humeral head moves completely out of the socket.
• anterior
  When the humeral head moves toward the front. This is the most common form. It typically occurs in young men. Athletes with great shoulder flexibility are more prone to the disorder. Reinjury is more common in teens and young adults, because they have more elasticity in their shoulder capsule and ligaments. This can lead to later chronic instability.
• posterior
  When the humeral head moves toward the back. This is often caused by a severe muscle spasm during an electric shock or seizure. It less commonly happens as a consequence of direct trauma, which can lead to later chronic instability.
• multidirectional
  This usually occurs in athletes born with very loose joints. Certain sports that require great shoulder range of motion such as swimming may lead to multidirectional instability. In some instances, patients purposely contract or relax muscles to create an instability episode. This is sometimes associated with psychological problems.

Shoulder instability often results from an initial acute injury producing a dislocation that, even with healing, leads to stretching of the shoulder capsule and ligaments. Such an injury could be due to falls or direct hits to the area. More rarely, shoulder instability develops slowly without any history of previous injury. In some cases, the shoulder may slip out of place at predictable times, such as when lifting a suitcase or even when shaving.

Risk factors for shoulder instability include:

• athletic activity, especially:
  • baseball — pitching
  • football — blocking
  • gymnastics
  • weight lifting
  • tennis
  • any contact sport
  • volleyball
  • swimming, especially backstroke or butterfly
• congenital collagen disorders, such as:
  • Marfan syndrome — a connective tissue condition
  • Ehlers-Danlos syndrome — a condition in which patients have loose joints
• family members with shoulder instability

Diagnosis

Symptoms may come on suddenly or develop over time. Symptoms of shoulder instability may include:

• pain in the shoulder area
• shoulder or arm weakness
• shoulder may feel loose
• shoulder may slip out of place
• numb feeling down the arm

The doctor will ask about your symptoms and medical history, and perform a physical exam. Special attention will be given to your shoulders. Your doctor will determine your range of motion and try to move the humeral head within the socket. Tests may include:

• x-rays — a test that uses radiation to take a picture of structures inside the body, especially bones.
• magnetic resonance imaging (MRI) scan — a test that uses magnetic waves to make pictures of the inside of the body. The capsule and ligaments of the shoulder can be seen with this study.

Treatment Options

Therapy will depend on the extent of the injury, the cause, and other factors. Treatment may include:

• rest
  Avoid activities that produce pain or stress the joint.
• ice
  Ice will help control pain, especially after exercise.
• medication

  Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to manage pain. These include:

  • aspirin
  • ibuprofen (Motrin, Advil)
• rehabilitation

  This can last several months and may include:

  • physical therapy to strengthen the muscles that control the shoulder joint
  • specific exercises for certain sports or job activities
  • learning how to modify activities to prevent re-injury
• surgery
  Many different procedures may be used to correct shoulder instability. The goal is to fix the cause. The doctor may use an arthroscopic or an open technique. After surgery, the arm is kept from moving for 3-6 weeks, depending upon the procedure.
• Prevention

  Guidelines to help protect the shoulder from injury include:

  • do regular exercise to strengthen the supporting muscles
  • use proper athletic training methods
  • do not increase exercise duration or intensity more than 10% per week
  • modify activities to prevent external rotation and overhead motions of the shoulder

Types of shoulder separations

As with many injuries, shoulder separations are classified according to the severity of the injury. They are as follows:

• Type I
  A sprain (without a complete tear) of either of the ligaments holding the joint together.
• Type II
  A tear of the acromioclavicular ligament.
• Type III
  A tear of the acromioclavicular and coracoclavicular ligaments.
• Type IV
  Both ligaments are torn, and the clavicle is pushed forward and sideways into soft tissue.

How can I prevent a separated shoulder?

Since a shoulder separation is nearly always the result of a fall or blow, there is not much that can be done to prevent it. However, use of proper protective equipment, such as shoulder pads, is preventive.

Education may also play a role. Athletes can be taught to avoid extending the arm when falling forward or to the side, but whether such teaching is effective when the incident spontaneously occurs is highly questionable.

Shoulder separations subsequent to the first one may be prevented by assuring that rehabilitation has resulted in full recovery before returning to the activity.

Improving sports performance

The key to improving sports performance after recovering from a shoulder separation is a proper rehabilitation program, and adhering to some of those same principles after the injury is gone.

Keep in mind that a shoulder separation is most often the result of a fall or blow, and you can better prepare yourself for these incidences by paying close attention to the rehabilitation exercises listed above. These will not only keep you in the game, but will also help you perform better and with more confidence.

Shoulder separation rehabilitation

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important. Rehabilitation for a separated shoulder often includes the following:

• reduce activity during the acute phase
• ice injury multiple times per day
• compression of the injured shoulder with a secure wrap or ACE bandage
• elevation of the injured shoulder above heart level
• use anti-inflammatory medications such as ibuprofen to reduce inflammation and speed up recovery

The major objectives of rehabilitation from a separated shoulder are to increase flexibility, obtain pain-free range of motion, and strengthen the shoulder, wrist, forearm and elbow joint. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Keep in mind that rehabilitation of a separated shoulder is different when the shoulder requires surgery (or reconstruction). In these cases, your doctor will prescribe physical therapy.

Rehabilitation exercises

General shoulder rehabilitation strengthening exercises include:

• Overhead stretch
  Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.
• Cross-body reach
  Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.
• Towel stretch
  Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.
• Shrugs
  Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.
• Saws
  Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least three times daily.
• Pendulum swings
  Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least three times daily.
• Shoulder rotation
  Stand in a doorway with affected side arm bent at the elbow and the palm of the hand against the doorframe. Turn the body away from the injured side hand until a stretching sensation is experience in the injured shoulder. Hold this position for 10 seconds. Return to the starting position. Relax for 10 seconds. Repeat this sequence 10 times at least three times a day.
• Shoulder flexion
  Stand erect close to a wall. With the palm of the injured side arm turned so as to face you, slowly slide the forearm and then the upper arm up the wall by moving closer to the wall. Slide the arm upward to the point of initial significant pain. Hold this position for 10 seconds. Return to the starting position and relax for 10 seconds. Repeat this sequence 10 times, at least three times daily.
• Flexed elbow pull
  Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least three times daily.

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• stationary bicycle - add resistance gradually from one session to the next, as pain allows
• walking
• jogging or running
• swimming - if pain permits

Rehabilitation after surgery

When surgery is necessary to repair a shoulder separation, you will need to wear a sling or figure-of-eight strap while you heal.

When your doctor decides you are ready, you may start range-of-motion and strengthening exercises. You may be referred to a physical therapist to assist you with these exercises, and under no circumstance should you return to sports activity until your shoulder is fully healed.

A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates power, aerobic and muscular endurance, flexibility, and coordination drills.

How long will the effects of the injury last?

With proper treatment of a Type I separation, you'll probably have pain-free, full range of motion in about two or three weeks. Type II separations may take three to five weeks to reach this stage of recovery.

In Type III separations where surgery is not necessary, it may take six weeks to two months before complete recovery of the injured joint. Should a Type III acromioclavicular separation need surgery, full recovery may take three to five months.

Invariably, Type IV separations are surgically treated. Even with proper rehabilitation, full recovery may not be achieved for six months, and recurrences are common if you're not careful.

When can I return to my sport or activity?

For most Type I and Type II acromioclavicular separations, activity poses no threat to aggravating the condition, and return to activity depends on your level of pain. An athlete can usually do what he or she wants to do, as long as the pain can be tolerated. Those with a Type I condition may return to activity with little discomfort within three weeks. Those suffering Type II separations can expect to return to activity within three to five weeks.

Surgically treated Type III shoulder separations are often not fully restored to normal function for 10 to 12 months, and sometimes even longer.

Restoration of a surgically treated Type IV acromioclavicular separation to full function can take 12 to 18 months.

Remember: the goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your shoulder separation recovers, not by how many days or weeks it has been since your injury occurred