Chronic Shoulder Dislocation and Instability
In this article, Tim Speciale, DO discusses chronic shoulder dislocation and regenerative medicine techniques that can rebuild the soft tissue of the shoulder capsule.
The main cause of chronic shoulder dislocations are chronic shoulder dislocations. This is not a play on words, treat and cure the chronic shoulder dislocation and you prevent future dislocations.
Patients need to be made aware that in first time dislocations there is usually enough trauma and significant soft tissue damage that future and chronic instability and dislocations and a long medical history of shoulder problems will occur.
Anterior shoulder dislocation
Anterior shoulder dislocation occurs in approximately 95 percent of all shoulder dislocation cases. In this dislocation, the anterior static shoulder stabilizers, including the anterior capsule and the inferior glenohumeral ligament, are torn away from the bone.
In some cases a chip of bone from the posterolateral aspect (Hill-Sachs lesion) of the humeral head (ball) or a torn rim (Bankart lesion) of the glenoid (socket) may occur.
Exercise and rehabilitation usually follow a period of immobilization after an anterior dislocation and, if this fails to restore strength and stability to the shoulder, surgery is usually recommended. In one definitive 10-year prospective study it was found that half of those treated with immobilization had recurrent dislocations and, of these, half had surgical treatment. This study included 247 patients with first-time dislocations.1
It demonstrates an alarming number of athletes who are unable to continue their sport without further dislocation or the need for surgery. This also does not address the percentage of athletes who do have surgery and return to their sport.
In our experience, an athlete who undergoes surgery rarely is able to perform as well as before surgery. If an athlete desires to enhance their athletic performance, the best option is Prolotherapy, Platelet Rich Plasma Therapy or Stem Cell Therapy, not surgery. Please see the article Doctors question effectiveness of glenoid labrum surgery look for alternatives to surgery.
ALPSA Lesions- A Type of Anterior Shoulder Dislocation
Recurrent anterior shoulder dislocation and instability is sometimes associated with an ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion or labral tear.
The difference between a Bankart lesion and ALPSA lesion is that both have labrum displacement, in the ALPSA lesion the anterior scapular periosteum (the membrane covering the bones which contain fibroblasts and osteoblasts – healing and building cells of cartilage and bone) tears off as well allowing the labroligamentous (the labrum, ligaments and connective tissue) structures to also be displaced.
People with ALPSA tears tend to have a high number of recurrent dislocations, because of the instability and weakness of the anterior inferior glenohumeral ligament. ALPSA tears are also associated with larger sized Hill-Sachs lesions.
Those with ALPSA tears not only suffer from recurrent dislocations, but high surgical failure rates.
Arthroscopic ALPSA repair failure is quite high compared to repair of Bankart lesions. In a study comparing ALPSA lesions with Bankart lesions and postoperative recurrence rates after arthroscopic capsulolabral repair- the ALPSA group had more than double the recurrence rate. In addition, the ALPSA group presented significant postoperative loss of external rotation after capsulolabral repair.2 The obvious choice for ALPSA lesion treatment and repair of the tears is Prolotherapy rather than surgery.
While surgery can treat the anterior dislocation effectively in certain types of lesions, post-operative pain, lengthy rehabilitation, and a chance of not returning to a previous level of activity, work or sports participation are reasons to consider Prolotherapy as an alternative to standard treatment approaches.
Prolotherapy injections directed at the anterior shoulder capsule and the insertions of the middle and inferior glenohumeral ligaments will increase joint strength and allow pain-free motion through the wide range of movement in overhead throwing sports.
Once pain has been reduced, a gradual return to one’s previous level of activity can be expected. Substantial improvement may be noted in as few as one to two Prolotherapy treatments, and the scar tissue from surgery can be avoided. There are other advantages to Prolotherapy over surgery for shoulder instability.
- Prolotherapy is the only treatment that is designed to help repair the painful area. It involves no cutting, suturing, sewing, or stapling. The patient is also encouraged to exercise while undergoing Prolotherapy, whereas after surgery there are careful limits to activity.
Acromioclavicular joint dislocation
The acromioclavicular joint contribution to your shoulder’s range of motion is to get your arm above your head. It also distributes the weight of the arm to the rest of the body. It is therefore not surprising that weight lifters and wrestlers who frequently lift large amounts of weights have significant incidences of AC joint sprains. Tremendous forces not only injure the AC joint, but are transmitted down the clavicle to the sternoclavicular (SC) joint, which can also be sprained or dislocated. There is a direct correlation between the amount of weight lifted and the weight that is transmitted throughout the AC and SC joints. The greater the weight lifted, the greater the impact throughout the AC joint and, ultimately, the SC joint.
Typically surgery is not required in acromioclavicular joint dislocation, however there is a debate as to the best method of treatment. The acromioclavicular (AC) joint is one of the unsung heroes of the body. It is formed by the distal clavicle and medial facet of the acromion. (The end of the collar bone and that portion of the shoulder blade that meets to form the point of the shoulder). Interposed in the joint is a fibrocartilaginous disc, and the joint is covered by a capsule.
The acromioclavicular joint becomes injured or dislocated when a large force is applied to the acromion when the arm is in an adducted position, for example, during a wrestling takedown or a tackle in football.
The acromioclavicular joint is stabilized by three ligaments:
- Acromioclavicular ligament,
- Inferior Acromioclavicular Ligament
- Superior Acromioclavicular Ligament.
- A fourth ligament – the Coracoacromial Ligament is a strong triangular band which serves to prevent the upward dislocation of the shoulder (glenohumeral) joint.
Acromioclavicular joint dislocation treatments
Treating the patient with chronic shoulder dislocation with the “gold” standard of treatments, physical therapy, activity modification, anti-inflammatory medications or cortisone shots has not shown successful. Furthermore, the surgery following the failed conservative treatments fairs no better.
- “Conservative treatment of acromioclavicular joint dislocation is not always successful. A consequence of persistent cromioclavicular joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant cromioclavicular joint instability and impaired shoulder function.”3
In this cited research, doctors examined 39 patients who underwent coracoclavicular (CC) ligament reconstruction. After surgery, almost half the AC joints failed to stabilize. In chronic and acute cases of shoulder dislocation management remains controversial, and the debate about whether patients should be conservatively or surgically treated continues.4 In a seeming contradiction, another study says the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency.5
Lastly, the more surgery – the more bone loss
- The more shoulder dislocations you have, the more bone breakdown and the more difficult the surgery, because now bone repair is involved.6
1. Hovelius, L. Anterior dislocations of the shoulder in teen-agers and young adults. Journal of Bone and Joint SurgeryùAmerican. 1987; 69 (3):393-9)
2.Lee BG, Cho NS, Rhee YG. Anterior labroligamentous periosteal sleeve avulsion lesion in arthroscopic capsulolabral repair for anterior shoulder instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2011; 19(9): 1563-1569.
3. Virtanen KJ, Savolainen V, Tulikoura I, et al. Surgical treatment of chronic acromioclavicular joint dislocation with autogenous tendon grafts. Springerplus. 2014 Aug 10;3:420. doi: 10.1186/2193-1801-3-420. eCollection 2014.
4. De Carli A, Lanzetti R, Ciompi A, Lupariello D, Rota P, Ferretti A. Acromioclavicular third degree dislocation: surgical treatment in acute cases. J Orthop Surg Res. 2015 Jan 28;10(1):13. [Epub ahead of print]
5. Ma R, Smith PA, Smith MJ, Sherman SL, Flood D, Li X. Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction. Curr Rev Musculoskelet Med. 2015 Feb 8. [Epub ahead of print]
6. Denard PJ, Dai X, Burkhart SS. Increasing preoperative dislocations and total time of dislocation affect surgical management of anterior shoulder instability. Int J Shoulder Surg. 2015 Jan-Mar;9(1):1-5. doi: 10.4103/0973-6042.150215.