As I have discussed in the main shoulder page, shoulder instability is common as a result of the rather shallow socket and the wide range of movement which nature has given us. There is a wide variation in a degree of laxity of the shoulder joint from one individual and another and some people are able to nearly dislocate their joints normally as a party trick and have absolutely no symptoms. Typically shoulders are supple in teenage girls and gets stiffer as you get older. For once getting older is sometimes of benefit!
The symptoms of instability are of apprehension when the arm is away from the side. It is almost invariably the ball coming out of the front of the socket and the apprehension that “something horrible is going to happen” occurs with the arm away from the side and the arm rotated outwards as in the cocking phase of throwing a ball or before hitting the ball in a tennis serve. Patients will often say they feel something horrible is going to happen and occasionally that the arm goes completely dead for a moment.
Born Loose or Torn Loose?
We usually divide shoulder instability up into “loosey goosey” shoulders which will slip out forwards, backwards and downwards in any direction you try and push them, and the other extreme which is “torn loose” as opposed to “born loose”. The caricature of a “torn loose” shoulder is an 18 stone rugby forward who has a previously normal (not loose) shoulder, but sustains an injury where he tears it out of joint in a badly-timed tackle and has to go to hospital to have it put back.
These are extremes of the spectrum. The “born loose” shoulder very commonly responds to retraining of the muscles around the shoulder to re-co-ordinate the dynamic restraints governing the movement of both the shoulder blade and the shoulder itself. This is quite a prolonged rehabilitation programme and involves concentrated work not just strengthening, but on balancing the muscles around the shoulder to hold the ball in the depths of the socket. The rugby player who dislocates his shoulder will very commonly require surgery since he will have torn all the ligaments at the front and torn the washer off that forms the seal around the edge of the socket.
My recommendation would certainly be to any sportsman under the age of about 25 who sustains a traumatic dislocation to a previously normal shoulder that they should have it fixed primarily. This is based on evidence that there is probably around an 80% chance of further trouble in the shoulder without an operation, with probably a 10% chance of further trouble in the shoulder with one. Whilst it does mean that some people will have an operation that they would not need, it can now be done through the key hole using special gadgets to stitch the ligaments back into place. The reason for suggesting surgery straight away is that the results of surgery after one dislocation are much better than after ligaments have all been stretched out and re-injured on numerous occasions. It used to be a very big and painful operation with a big scar across the front of the shoulder and leading to quite a lot of stiffness and impairment of function, but increasingly we are trying simply to put back what nature gave you and retension the ligaments to exactly how they were before the injury. We can now do this through usually three little key holes incisions less than a centimetre in length and with a very high success rate. It is usually just a procedure requiring one night in hospital, but again quite a lot of physiotherapy to get over. Return to contact sport should not be less than three months after the operation.
The “born loose” shoulder also just occasionally requires surgery which again can sometimes be done arthroscopically – either with a radiofrequency tightening or arthroscopically-tied sutures, but it is much more difficult to judge since the shoulder can be dislocated in any direct it is easy to tighten the shoulder up too much in one direction and exacerbate a problem in another. Again this can often be done through the key hole, although more frequently requires an open operation to retension the ligaments.