Shoulder instability is a fairly common condition that is characterized by weakening of the connective tissue (ligaments and joint capsule) surrounding the shoulder joint and, therefore, the bones that form the joint have an excessive range of motion.
The shoulder joint has a ball joint structure. The glenoid fossa of the scapula forms the rosette of the joint, and the head of the humerus forms a spherical support. The head of the humerus and the glenoid cavity are surrounded by dense connective tissue called the joint capsule and its associated ligaments. Additionally, a group of muscles called the rotator cuff covers the shoulder joint and helps hold the joint in place and increases joint stability.
When performing certain arm movements (such as throwing or falling on an outstretched arm), tensile forces are applied to the joint capsule or ligaments. When these forces are excessive or repeated frequently, stretching or tearing of the connective tissue can occur. As a result of this damage, the connective tissue loses its strength and the function of supporting the shoulder joint is reduced, which in turn leads to an excessive increase in the range of motion in the shoulder joint (shoulder instability). Instability of the joint can lead to the head of the humerus slipping out of the glenoid cavity or to dislocations (subluxations and dislocations). Typically, shoulder instability occurs in one shoulder. But sometimes instability can occur in both joints, especially in patients with inherently weak connective tissue or in patients who have performed repetitive, excessive movements of both arms (such as swimmers).
Causes
Shoulder instability most often occurs after a traumatic episode in which partial or complete dislocation of the shoulder occurs (for example, a fall onto the shoulder or an outstretched arm, or due to a direct blow to the shoulder). Quite often such injuries occur in contact sports such as football or rugby. This usually occurs with a combination of shoulder abduction and excessive external rotation. Shoulder instability can also develop gradually over time and is caused by repeated significant loads on the shoulder joint when performing movements that stretch the connective tissue structures of the joint (throwing or swimming). In addition, the development of instability is facilitated by impaired biomechanics of movements, poor technique and is most often found in athletes who need to perform movements with their arms above their heads (baseball players, javelin throwers, cricket players, tennis players). Shoulder instability can also be caused by congenital connective tissue weakness (joint hypermobility).
False joint: treatment
To treat a non-united fracture, an individual method is selected for each patient. However, in all cases, surgical intervention is necessary to eliminate the newly formed connective tissue with subsequent fixation of bone fragments.
At the earliest stage, low-traumatic reduction of fragments with fixation using a properly selected titanium clamp is possible.
If cartilaginous tissue begins to form at the ends of bone fragments, it is removed surgically, and plastic surgery is performed on the ends of parts of one bone to lengthen them and subsequently fuse them together.
Recently, endoprosthetics and intramedullary osteosynthesis are very often used for ununited fractures. This greatly increases the likelihood of bone healing and restoration of limb function.
If you have questions about the treatment of non-united fractures (false arthrosis), you can ask them by phone +7 (905) 640-64-27 or in a message from the Contacts section. I will answer shortly.
Factors contributing to the development of shoulder instability
There are a number of factors that can contribute to the development of shoulder instability and associated symptoms. Studying these factors allows the rehabilitation physician to better carry out treatment and avoid relapses of instability. These are mainly the following factors:
- history of episodes of shoulder dislocation (dislocations or subluxations)
- inadequate rehabilitation after shoulder dislocation
- intense participation in sports activities or excessive stress on the shoulder
- muscle weakness (especially the rotator cuff muscles)
- muscle imbalance
- impaired biomechanics of movements or sports techniques
- rigidity of the thoracic spine
- shoulder hypermobility
- ligamentous weakness
- muscle stiffness due to poor posture
- changes in training
- bad posture
- insufficient warm-up before playing sports
Symptoms
Patients with shoulder instability may have few or no symptoms. With atraumatic shoulder instability, the first symptom may be partial shoulder dislocation or pain in the shoulder during or after performing certain movements. With post-traumatic instability, the patient usually reports the presence of specific painful injuries that caused problems in the joint. Usually we are talking about dislocation (dislocation or subluxation), often this occurs with a combination of abduction and external rotation during injury. After an injury, the patient may experience pain during certain activities and also afterward while resting (especially at night or early in the morning). In addition, the patient experiences sensations in the shoulder that he has not observed before.
Patients with shoulder instability may notice a clicking or other sensation in the shoulder when performing certain movements. The patient may also notice decreased muscle strength in the affected shoulder and a feeling of weakness during certain movements (for example, moving an arm overhead). Patients may also experience tenderness in the anterior and posterior aspect of the shoulder joint and a fear of dislocating the joint when performing throwing movements. Patients may also experience pain and a feeling of joint displacement when sleeping on the affected side. In severe cases of shoulder instability, patients often experience repeated episodes of subluxation or dislocation of the joint. These episodes may be accompanied by pain, sometimes complete numbness of the shoulder, which usually lasts a few minutes. In these cases, or in cases of multivector shoulder instability, patients may self-inflict dislocation. In more severe cases, dislocations can be caused by even minimal movements, such as yawning or turning over in bed.
Fractures of the head and neck of the radius
The main manifestations are swelling and pain in the elbow joint, which intensifies when moving the arm or palpating the injury site. There is no crepitus (characteristic crunching sound). An accurate diagnosis is made after obtaining an x-ray of the elbow joint. In case of a non-displaced fracture, a plaster cast is applied immediately. If the injury is accompanied by displacement of the fragments, the doctor first connects them by closed reposition, after which the patient undergoes repeated X-rays for control. If the results do not satisfy the doctor, he makes a correction and fixes the head with a special knitting needle, and then applies a plaster cast. The pin is removed after about 2–3 weeks, but immobilization of the limb lasts about another month. Surgical treatment is resorted to if, as a result of radiographs, a comminuted fracture is revealed, accompanied by significant destruction of the head of the radial bone. During the operation, excision of the head is performed, followed by endoprosthetics.
Diagnostics
As a rule, to make a diagnosis of instability of the shoulder joint, an examination by a traumatologist with functional tests is sufficient. The traumatologist examines the medical history, palpates and determines pain, determines the range of motion, and evaluates muscle strength. The traumatologist determines the degree of instability by conducting special functional tests.
X-rays are taken to determine if there are changes in bone tissue (for example, fractures). MRI or CT with contrast is necessary when it is necessary to exclude damage to other structures of the shoulder joint (for example, damage to the rotator cuff or labrum).
Fracture of the radius in a typical location
This is an injury to the bone just above the wrist joint. The symptoms of damage are quite clear:
- severe pain with movement or palpation;
- swelling and hematoma;
- crepitus and pathological mobility.
If the fracture is accompanied by displacement of the fragments, deformation of the bone slightly above the joint is clearly visible. The diagnosis is made after obtaining radiographic data. If the fracture is complex, a CT or MRI must be performed before surgery. Treatment is most often conservative. For non-displaced fractures, a plaster cast is applied for 1–1.5 months. If there is displacement of the fragments, a closed reduction is first performed, and then immobilized with plaster. If it is not possible to compare the fragments, they resort to surgical intervention - osteosynthesis of the distal metaepiphysis of the radius. In the postoperative period, the patient may be prescribed pain medication, antibiotics, and UHF procedures.
Treatment
In most cases, shoulder instability can be treated conservatively. Treatment includes exercise therapy, physical therapy, and activity modification. The success of conservative treatment primarily depends on the patient. The patient must not only follow the recommendations of the attending physician and carry out treatment, but also change the nature of physical activity. Physical activity that causes stress on the joint should be minimized (in particular, with atraumatic instability), for example, movements such as throwing, swimming, bench press, etc. You should also avoid activities that cause pain. This change in physical activity prevents further tissue damage and allows the tissue to recover.
But often patients ignore the doctor’s recommendations and, when pain disappears, return to their usual types of physical activity. In such cases, instability becomes chronic and requires much more time to heal.
The basis of conservative treatment for all patients with instability of the shoulder joint is exercise therapy. Physical exercises are primarily aimed at strengthening the muscles of the rotator cuff. The selection of exercises must be carried out with a physical therapy doctor, as improper physical activity can only increase instability.
For athletes, biomechanical correction of movement technique is of great importance, which can significantly reduce injury to the structures that stabilize the shoulder joint (for example, practicing throwing techniques, swimming techniques, etc.). In addition, it is possible to wear orthoses during the rehabilitation period, which eliminates possible shoulder dislocations, this is especially true for athletes of contact sports.
Drug treatment includes the use of NSAIDs, which helps reduce pain and reduce inflammation.
Physiotherapy can improve microcirculation and accelerate regenerative processes, as well as gentle massage techniques.
Unfortunately, in some cases, especially with post-traumatic instability, conservative treatment may not be effective and, in such cases, surgical treatment is required.
Surgical treatment is indicated if conservative treatment is ineffective, with recurrent dislocation, as well as in the presence of damage to the rotator cuff, labrum and other structures of the shoulder joint (cartilage, bones, nerves). Currently, atroscopic methods for treating shoulder instability are used in most cases. But severe instability may require open surgery.
Dislocation
Dislocation is a complete displacement of the articular ends of bones relative to each other. If they stop touching, the dislocation is called complete; if there is partial contact, it is called incomplete or subluxation. A dislocation is usually accompanied by a rupture of the joint capsule and one articular surface protruding through the tear. Dislocation is a pathological condition in which the articular surfaces are displaced relative to each other. The dislocated part of the limb is considered dislocated. The exceptions are clavicle dislocation (the name indicates the dislocated end of the bone) and vertebral dislocation (the overlying vertebra is indicated). Dislocation is a fairly common pathology in traumatology. Traumatic dislocations account for 1.5-3% of the total number of injuries to the musculoskeletal system. Traumatologists and, less commonly, orthopedists treat dislocations.
Considering which bone came out (dislocated), they speak of a dislocation of the shoulder, hip or forearm bones, etc. It is believed that dislocation occurs in the bone whose articular surface is located distal (further) in relation to other bones taking part in the formation of this joint. The exception is the spine; the upper vertebra is displaced in relation to the underlying one.
Highlight:
- congenital dislocations - those that developed during the intrauterine life of the fetus;
- acquired - as a result of injury (traumatic dislocation) or a pathological process in the joint area (pathological dislocation).
- The vast majority of congenital dislocations occur in the hip joint on one or, more often, both sides. As a rule, they are noticed when the child begins to walk. There is lameness, looseness of the joint, pain in it, and shortening of the leg. Bilateral dislocation is characterized by a waddling (“duck”) gait. The diagnosis is confirmed by x-ray.
Acquired (traumatic) dislocations occur in 80-90% of cases and therefore have the greatest practical importance. Some individual anatomical and physiological characteristics of a person (mismatch in the size of the articular surfaces, wide joint capsule, fragility of the ligamentous apparatus, etc.) are predisposing factors. With indirect application of force, dislocations develop more often than from direct impact on the joint.
During traumatic dislocations, its capsule ruptures in the form of a gap or in the form of a significant tissue defect. Dislocations in the trochlear joints (knee, elbow, ankle) are always accompanied by rupture of the ligamentous apparatus. Tendon ruptures at the points of their attachment to the bone, hemorrhages into the surrounding tissues and into the joints may also be observed. Simultaneous fracture of areas of bone close to it, damage to large vessels and nerves complicates the treatment of a dislocation (complicated dislocation).
Symptoms and course:
The circumstances of the injury and the mechanism of injury are clarified by questioning the victim. Typical complaints are pain in the joint and the inability to move in it due to increased pain. Sometimes there is numbness of the limb, which is associated with compression of the nerve trunks and fixation of the dislocated fragment with spastically contracted muscles. There is a forced incorrect position of the limb and deformation of the joint area. For example, with a dislocation in the shoulder joint, the shoulder is abducted 15-30. and gives the impression of being elongated, there is a depression in the area of the deltoid muscle.
The displaced articular end of a bone can often be identified by palpation in an unusual place. So, when a shoulder is dislocated, it can be felt in the armpit or under the pectoralis major muscle. Attempts to determine the possibility of passive movements in the joint give a feeling of spring fixation: a dislocated bone, when forcibly displaced, returns to its previous position again, which is explained by the action of spastically contracted muscles, strained ligaments and capsule. This symptom is characteristic of dislocations.
Recognition:
The diagnosis of dislocation is confirmed by x-ray examination, which also confirms or excludes concomitant bone fractures near the joints, which is of great importance for the choice of treatment method.
Treatment:
The patient should be immediately sent to a medical facility. The wound is covered with an aseptic bandage. Reduction of a dislocation is easier and better in the first hours of the injury. Dislocations of two five days ago are very difficult to reduce, and after 3-4 weeks surgical intervention is often required, which gives much worse results.
A necessary condition for successful reduction is complete muscle relaxation, which is achieved by good pain relief. The use of brute physical force is unacceptable, because this leads to additional damage to the joint capsule, bone and subsequent relapses - the so-called. “habitual dislocations”, they most often occur in the shoulder and mandibular joints.
Reduction methods are based on stretching the muscles of the joint area using a series of manipulations that seem to repeat in reverse the movements that caused the dislocation. Therefore, it is very important to imagine the mechanism of development and the sequence of movements that led to the dislocation.
After the reduction, a control x-ray is taken to confirm that it was performed correctly. The limb is fixed for 6-10 days in a functionally advantageous position with a bandage or traction. In the future, a set of physical therapy exercises is regularly carried out.
A patient with suspected traumatic dislocation must be taken to a specialized medical center as quickly as possible. institution (the best option is within the first 2-3 hours), since subsequently increasing swelling and reflex muscle tension can make reduction difficult. The limb should be immobilized using a splint or bandage, the patient should be given pain relief and cold applied to the area of injury. Patients with dislocations of the lower extremities are transported in a lying position, patients with dislocations of the upper extremities - in a sitting position.
The diagnosis of dislocation is made based on the clinical picture and X-ray data. In some cases (usually with complicated dislocations), an MRI or CT scan of the joint is prescribed. If compression or damage to blood vessels and nerves is suspected, the patient is referred for consultation to a vascular surgeon and neurosurgeon. Treatment is carried out in an emergency room or trauma department. The need for hospitalization is determined by the location of the dislocation, the absence or presence of complications.
Uncomplicated dislocations are subject to closed reduction. Fresh uncomplicated dislocations of small and medium joints are usually reduced under local anesthesia, dislocations of large joints and stale dislocations are usually reduced under anesthesia. In young children, reduction in all cases is carried out under general anesthesia. For open, complicated and chronic dislocations, open reduction is performed. Subsequently, rest is prescribed and an immobilization bandage is applied. The duration of immobilization is determined by the characteristics and location of the dislocation. Premature removal of the bandage and early start of movements in the joint are under no circumstances allowed, as this can lead to the development of habitual dislocation. During the rehabilitation period, exercise therapy, physiotherapy and massage are prescribed. The prognosis is favorable.