Chronic shoulder dislocation, subluxation and shoulder instability
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
Chronic shoulder dislocation, subluxation, and shoulder instability
If you are reading this article, you are probably wrestling with a decision to have shoulder surgery and getting on the waiting list. While the surgical option is something that may not be the first choice in your mind, you may be thinking anything has got to be better than my shoulder popping out all the time.
So you went to the surgeon’s office. There you may have been told that the conservative care, non-surgical option of exercise and physical therapy has at best a 50% chance of helping you and this is a long-term treatment set. If you are active in sports or do physically demanding work, long-term PT may not be the best option for you. On the other hand, surgery may not be the answer for you either. Six months of surgical recovery time, the possibility of the need for revision or secondary surgery, muscle atrophy on the surgical site, all have their concerns to you. If you are self-employed, keeping your arm in a sling 4 – 8 weeks is not going to be realistic for you, nor is three month wait before you can swing a hammer. But anything has to be better than a chronically dislocating shoulder, even surgery. There may be an option for you.
In this article, we will explore non-surgical tissue building injections in the form of Prolotherapy combined with Platelet Rich Plasma Therapy as well as exploring different treatment options. In discussing the surgical options, we will rely on the surgeons to explain procedures and success rates.
If your shoulder popping out of place is happening so often that you do not go to the doctors unless the pain is very severe and you have more numbness than usual, you may also be ignoring the “my shoulder is out of place protocol of treatments,” because they are not helpful either.
If you look at your guidelines sheet that you may have been given at your orthopedist center or physical therapists’ office of how to manage your shoulder after it fell out of the socket, you start to understand that nothing in the guidelines suggests any long-term resolution of your problem. With the possible exception of how to prevent this from happening again.
Is this the information you are reading or getting? Does it make sense to you?
If your shoulder popping out of place is happening so often that you do not go to the doctors unless the pain is very severe and you have more numbness than usual, you may also be ignoring the “my shoulder is out of place protocol of treatments,” because they are not helpful either.
- ICE – carefully, so you do not give yourself ICE BURNS, apply ice for 20 minutes at a time for every 3 to 4 hours until the pain goes away.
- Ibuprofen – take anti-inflammatory medicine, as directed. We have written extensively on the problems of taking Nonsteroidal anti-inflammatory medicines (NSAIDs) may cause. For many patients, prolonged use of NSAIDs can make your problem worse.
- Avoid activities that cause pain – If it hurts to move your shoulder a certain way don’t move your shoulder that way – avoid activities that cause pain.
Once you are through the immediate reaction to your shoulder popping out of place, then the long-term answers are suggested:
- The best treatment for the loose, wobbly, unstable shoulder prone to subluxation and dislocation is shoulder strengthening exercises. If exercises do not work, then surgery may be needed.
At the orthopedist or the physical therapists, there is a brief talk about repairing the shoulder ligaments that cause this problem in your shoulder. Yet they will acknowledge that the ligaments are the big problem. Unfortunately, surgery or physical therapy does not have a good remedy for this problem. We believe we do, Prolotherapy injections.
In this video Ross Hauser, MD and one of our patients, William, discuss his chronically dislocating shoulder.
- William tells us that about 13 years ago he suffered from chronic shoulder problems where his shoulder would pop out “sometimes ten times a day.” He says he “would pop in by myself and I got pretty good at that.” But sometimes it would be really difficult to get it back in place.”
- He decided to give Prolotherapy injections a chance before he would decide to go to surgery. Thirteen years ago he had one Prolotherapy treatment and noticed a big difference, dislocations were much less frequent. Two months later he returned for a second Prolotherapy treatment. William reported that treatment resulted in his shoulder being tight, dislocations were not occurring.
- “I have about 90 percent of the use of my arm which is more than I ever expected . . . I am still as active as ever, I swim a lot, I bike, I do everything I use to do.”
- William’s results may not be typical results for everyone, but they are his results.
Let’s get to the research and clinical observations on treatments
The main cause of chronic shoulder dislocations are chronic shoulder dislocations. This is not a play on words, repeated chronic shoulder dislocation weakens already significantly damaged connective tissue in the shoulder. The more shoulder dislocation you have, the weaker your shoulder gets, the more chronic shoulder dislocations you will have.
These are questions we may ask new patients about their previous visits to the orthopedist to help us and them understand what is going on in his/her shoulder:
Was your past dislocation(s) a shoulder subluxation?
In a shoulder dislocation, the ball of the shoulder pops completely out of the shoulder socket. In a shoulder subluxation, the ball of the shoulder does not come completely out of the shoulder joint capsule. It can be also called a partial shoulder dislocation.
Are your dislocations the result of a traumatic injury?
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. This is because the shoulder ligaments, tendons, and cartilage are usually significantly damaged in traumatic shoulder dislocation.
Are your dislocations the result of overuse, repetitive strain injuries?
For some people, chronic shoulder dislocation and subluxation just happen without there being an initial traumatic injury. These are typical laborers with physically demanding jobs like landscapers, machinery operators, firefighters, and construction workers to name but a few. It can also happen in musicians, especially drummers. Many of the patients we see are athletes or people who work out a lot. Shoulder wear and tear instability that can lead to chronic dislocations are typically seen in volleyball players, tennis players, swimmers, workout enthusiasts, and weight trainers.
Are your dislocations the result of past arthroscopic surgeries to fix your shoulder?
For someone who has not had surgery for their shoulder instability, this last question will certainly cause concern? How does the surgery that was supposed to fix the problem, make the problem worse?
Chronic shoulder instability caused by anterior shoulder dislocation treatment
This is how the treatment of dislocations can cause future dislocations. Many readers will probably recognize their own story here:
Initial traumatic shoulder dislocation is almost always seen in an emergency room because of the almost immediate recognition by sight of some type of clear and gross anatomical defect. This portion of our article focuses on the aftermath and treatment recommendations for someone treated in the emergency room or urgent care center after they had their first dislocation.
Anterior simply means the front. An anterior shoulder dislocation occurs in approximately 95 percent of all shoulder dislocation cases. In this dislocation, the anterior static shoulder stabilizers the soft tissue and muscles of the shoulder are injured and sometimes torn away from the bone. Your doctor may have talked to you about these structures.
They are the:
- inferior glenohumeral ligament process, three ligaments whose main job is to prevent Anterior shoulder dislocation
- The shoulder or glenoid labrum
- The shoulder or glenohumeral capsular (inside the joint) ligaments
- The rotator cuff complex holds the scapular muscles.
- In some cases, a chip of bone or a gouge of the posterolateral (the back and side) of the humeral head (ball) occurs as the soft head of the shoulder crashes into the shoulder socket.
- This impact may also cause a Bankart lesion. This is damage to the shoulder labrum which causing problems of future dislocations.
- 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 published in The Journal of bone and joint surgery, (1) 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. 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. Please see Doctors question the effectiveness of glenoid labrum surgery look for alternatives to surgery.
The research we just cited was from 1987, thirty-four years ago. That 1987 research was not only relevant for us to use in this article it was also cited by published research:
“shoulder laxity and instability.” The correct approach to the management of failed stabilization procedures (surgery) has not been yet defined.
Doctors at the Department of Orthopaedics, Catholic University, Division of Orthopaedic Surgery, A. Gemelli University Hospital, in Rome, wrote in the medical journal Joints (2) the following observations about shoulder laxity and instability:
Generalized joint laxity (looseness) and shoulder instability are common conditions that exhibit a wide spectrum of different clinical forms and may coexist in the same patient.
Laxity is a physiological condition (a disruption in the regular movement of the shoulder) that may predispose to the development of shoulder instability.
A high prevalence of generalized joint laxity has been identified in patients with multidirectional instability of the shoulder. Multidirectional instability is defined as symptomatic instability in two or more directions.
The diagnosis and treatment of this condition are still challenging because of complexities in its classification and etiology.
These complexities are compounded when multidirectional instability and laxity exist in the same patient. With an improved understanding of the clinical symptoms and physical examination findings, a successful strategy for conservative and/or surgical treatments can be developed.
Conservative treatment is the first-line option. If it fails, different surgical options are available.
The correct approach to the management of failed stabilization procedures has not been yet defined.
A 2019 study (3) was launched by a research team to further these 1987 findings and look at immobilization following shoulder dislocation: Here is a brief summary of this research:
“The treatment of shoulder dislocation can be divided into operation and conservative therapy. Surgical treatment is used only for complex dislocation or failure of conservative reduction. Therefore, conservative treatment is the main measure. Conservative treatment is usually followed by internal or external rotation fixation after reduction. (Immobi9lzation after your shoulder is popped back in). Some studies have shown that internal rotation fixation can reduce the recurrence rate compared with external rotation fixation,while others have the opposite results.. Consequently, it is necessary to conduct a systematic review of immobilization in external rotation vs internal rotation on shoulder dislocation with the increasing of related studies in recent years.”
This study is asking the same question more than 30 years later. Is immobilization good or bad?
The surgery controversy again
Let’s explore a paper from April 2019 published by a combined research team from the Mayo Clinic and The Ohio State University. It was published in the Journal of clinical orthopaedics and trauma.(4)
Here is what the researchers published: “Optimal management of primary anterior instability of the shoulder remains a controversial topic. Traditionally, nonoperative management has been the treatment of choice, as a subset of patients with isolated anterior instability will not have any further instability episodes. Operating on all first-time instability episodes would, therefore, induce operations on a number of patients who may have been asymptomatic without surgery.
In certain segments of the population, however, the risk of recurrent dislocation is at or above 80% (young, male, overhead/collision athletes). Furthermore, recurrent instability may increase the degree of labral injury, cartilage injury, and bone loss, eventually compromising the outcome of the stabilization procedure. This has pushed a subset of surgeons to discuss the outcomes of primary stabilization of the shoulder in young patients at high risk for recurrence.
The goal of this study was to assess the outcomes of surgical shoulder stabilization completed acutely, after a single instability episode, in comparison to those stabilized after recurrent instability. (The) primary outcome measure was recurrence of instability (as measured by recurrent dislocations or subluxations). Secondary outcomes that were analyzed included revision surgery, complications, and functional outcome measures.”
In brief, surgeons started debating whether it was advisable to send patients to surgery after their first shoulder dislocation. Those in favor cited that if you did not repair the shoulder instability, this would lead to recurrent and chronic dislocation as well as the continued destruction of the shoulder joint to the point of advanced osteoarthritis. The researchers of this study thenexplored whether surgery after a primary dislocation gave the patients better instability and delayed or prevented subsequent shoulder damage. The result?
“This systematic review failed to demonstrate a statistically significant difference in recurrence rates in patients with surgical stabilization after their primary instability episode compared to patients after multiple instability episodes, although a small benefit was shown. No conclusion could be made on the rate of complications, or functional outcomes with either approach or further shoulder injury with recurrent instability. Further high quality trials to evaluate the results of primary and delayed stabilization are necessary to help make better treatment decisions for this group of patients and to better inform patients of their risks, complications and expected outcomes post-operatively.”
In brief, the results of this study did not suggest surgery after primary dislocation was any better than surgery after multiple dislocations. As other research points out, the surgery itself, at any point is inconclusive.
A 2021 study from the European Clinic of Sports Traumatology and Orthopedics (5) however does suggest when certain conservative treatments fail, certain surgeries would be advisable. Some people do have very successful shoulder instability surgeries. These are not the people we see at our center. We see the people with a long history of subluxation, sometimes surgery, all the time instability. The focused keywords of this research was Bankart surgery, Latarjet and arthrolatarjet; glenoid deficiency; shoulder arthroscopy; shoulder instability.
As you are reading this article you may already be aware of what a Bankart procedure, surgery or sometimes called Bankart shoulder repair procedure. The concept being that the ligaments of the shoulder are re-attached or shortened to tighten their group on the shoulder bones.
The Latarjet and arthrolatarjet procedure may have been recommended to you if you had many dislocations and the constant popping our and popping back in of your shoulder has worn away the bone of the shoulder socket. To keep the shoulder in place, bone or more precisely the coracoid structure on the shoulder blade is removed and reattached at the shoulder socket to hold the ball of the joint in place.
Again, for many people these procedures are very successful. These are not the people we see in our center. We see the people who tell stories of initial shoulder dislocation and subsequent and constant subluxation and dislocation even after surgery. So much so, that they were told to stop all activities that may dislocate their shoulder until a more permanent answer could be arrived at.
Chronic shoulder instability caused by 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, according to a study from researchers in South Korea, the ALPSA group presented a significant postoperative loss of external rotation after capsulolabral repair.(6) 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 conservative injection treatments as an alternative to standard treatment approaches.
Research: Surgical failure related to damage to the subscapularis tendon and ALPSA tears
Medical University researchers in Turkey published a study to help their fellow surgeons predict which patients would have continued shoulder instability and dislocation following surgery. This study was published in the Orthopaedic Journal of Sports Medicine (7). How would the researchers predict which patients would have poorer outcomes after surgery? They would look for damage to the subscapularis tendon.
The subscapularis tendon attaches the subscapularis muscle of the rotator cuff to the humerus, the long bone that connects the shoulder to the elbow. When this tendon is damaged, the shoulder loses strength in the subscapularis muscle. This will cause shoulder weakness, shoulder instability, and degenerative damage to the shoulder.
These surgeons had the idea that multiple subscapularis tendon sign (tests to determine tendon damage) could identify a possible risk factor for the recurrence of shoulder instability after anterior stabilization.
This is what they said:
“A thin, weak, or lax anterior shoulder joint capsule may be associated with anterior shoulder instability. In this case, the multiple subscapularis tendon sign may have some role in anterior shoulder instability or some potential negative effect on recurrence after shoulder instability surgery. It is either an anatomic variation or a pathological condition that cannot be fixed with plication (surgical folding over of the tendon attachment), which is performed for capsular abnormalities. It is our opinion that the multiple subscapularis tendon sign is a demonstration of the insufficiency of the anterior joint capsule.”
This is what patient examination revealed:
- A total of 87 patients underwent arthroscopic stabilization for anterior shoulder instability.
- Nine (10.3%) patients experienced recurrent instability.
- The presence of the multiple subscapularis tendon sign, existence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, and history of overhead or contact sports participation were significant risk factors for recurrence.
- The recurrence rates were as follows: 30.7% with the multiple subscapularis tendon sign;
- 40% with the multiple subscapularis tendon sign and an ALPSA lesion; and
- 75% with the multiple subscapularis tendon sign, an ALPSA lesion, and a history of overhead or contact sports participation.
CONCLUSION: “Considering the low success rates of anterior capsulolabral repair in patients participating in overhead or contact sports, especially when an ALPSA lesion is present, encountering the multiple subscapularis tendon sign (damage) during surgery in this at-risk group may be an indicator for the surgeon to choose the surgical procedure more carefully.
Option: Prolotherapy injections
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 the 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 a non-surgical treatment that is designed to help repair the painful area. Prolotherapy is an injection technique utilizing simple sugar or dextrose. 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.
In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- Initially, a Prolotherapy solution is injected into the posterior structures of the shoulder. The Posterior Shoulder Capsule and the attachments of the rotator cuff.
- Treatment moves on the address problems of the Acromioclavicular joint and the insertions on the superior shoulder.
- Prolotherapy is a lot of injections into the shoulder tissue. It is a very comprehensive treatment.
- Prolotherapy is effective for rotator cuff tears, labral tears and biceps tendonitis, various tendonitis as well as shoulder instability.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient in particular comes to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrate cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments in this case it was in his anterior shoulder attachments to address the chronic dislocations.
Chronic shoulder instability caused by Acromioclavicular joint instability, osteoarthritis, and chronic dislocation
Acromioclavicular joint osteoarthritis is a degenerative disease where the articular cartilage lining of the Acromioclavicular joint bones wears out over time. In this condition, there is shoulder instability causing grinding and pain.
The shoulder joint is a juncture of three bones, the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The scapula and the clavicle meet to form the top or roof of the shoulder and is called the acromion. The joint where the acromion and the clavicle join is the Acromioclavicular joint or AC joint. Acromioclavicular (AC) joint osteoarthritis can develop as a result of chronic shoulder dislocation or normal wear and tear in the aging patient with heavy shoulder rotational loads in sports or work.
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.
- The sternoclavicular joint is a very difficult joint to dislocate, however, it can play a role in chronic shoulder dislocations.
- One of the unrecognized problems of shoulder dislocation is that its causes can be widespread. A weakened sternoclavicular joint can create instability problems that extended throughout the chest and into the shoulder.
During the early stages, AC joint arthrosis usually manifests itself with tenderness and pain in the front of the shoulder around the joint. The pain gets worse when the arm is extended across the chest as this motion compresses the joint, or when lifting. A vague pain may be felt in the shoulder, the neck, and the front of the chest. The affected joint may also be disproportionate to the uninjured joint and may snap or click when used.
Typically, surgery is not required in acromioclavicular joint dislocation, however, there is a debate as to the best method of treatment.
Doctors at the University of Michigan describe the problem in their review published in Current reviews in musculoskeletal medicine:
“In high-grade injuries, acromioclavicular joint reconstruction procedures may be indicated for functional improvement. There is currently no gold standard for the surgical management of these injuries.
Multiple reconstructive options exist, including coracoclavicular screws, hook plates, endobutton coracoclavicular fixation, and anatomic ligament reconstruction with tendon grafts”(8)
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.
Chronic shoulder instability caused by 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 success. Furthermore, the surgery following the failed conservative treatment fairs no better. This is pointed out by Finnish researchers in the journal Springerplus.
- “Conservative treatment of acromioclavicular joint dislocation is not always successful. A consequence of persistent acromioclavicular joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant acromioclavicular joint instability and impaired shoulder function.”(9)
- In this cited research from doctors at the University of Rome examined 39 patients who underwent coracoclavicular (CC) ligament reconstruction. After surgery, almost half of 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.(10)
- In a seeming contradiction, a study from the University of Missouri says the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency.(11)
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.(12)
Conservative management and surgery for acromioclavicular joint osteoarthritis
- The usual treatment for this injury is a figure-eight splint to keep the joint immobile while the healing process occurs. While the initial immobilization may relieve pain, the weakening of the ligaments will occur if the immobilization continues indefinitely.
- Physical therapy and an exercise program may restore strength and function to the shoulder, but the injured ligaments may continue to grind, pop, click and cause pain, especially with overhead activities and when reaching across the chest.
Because these activities put a strain on the ligaments, the surrounding muscles may go into spasm and become chronically painful, inhibiting the ability of the patient, often an athlete, from using the shoulder normally.
Another standard practice is to inject steroids into the shoulder or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.
This is often the case in patients who have had numerous cortisone shots and are eventually recommended to shoulder replacement surgery. However, in our experience, this type of surgery is avoidable. For patients who have already been through any type of shoulder surgery and still having pain or instability symptoms, a consultation outside of a surgeon’s office needs to be considered, particularly with a Prolotherapy specialist to determine instability from ligament failure or laxity.
Doctors need to pay attention to the shoulder ligaments
Doctors at the Autonomous University of Barcelona writing in the Journal of Orthopaedics and Traumatology examined the use of surgery for acromioclavicular joint instability. What they found was a very strong need to pay attention to the shoulder ligaments.
“Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts, (for ligament reconstruction).
Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential.”(13)
In March 2020, (14) research lead by the Steadman Philippon Research Institute and published in the journal Orthopedic research and reviews also suggested that the shoulder ligaments play an important role in future dislocations
“Whereas the majority of acromioclavicular joint dislocations can be treated nonoperatively with a trial of immobilization, pain medication, cryotherapy, and physiotherapy, there are patients that do not respond well to conservative management and may require surgical treatment. Identifying and treating these patients according to the type and chronicity of AC joint dislocation is paramount. To date, a myriad of surgical techniques have been proposed to address unstable AC joint dislocations and are indicative of the uncertainty that exists in optimal management of these injuries. Historically research has focused on the restoration of the coracoclavicular ligament complex. However, recently the importance of the acromioclavicular capsule and ligaments has been emphasized.“
This paper concentrated on ligament reconstruction as a vital part of shoulder surgery: In this regard, the researchers noted: “Treating acute and chronic acromioclavicular joint injuries is still a challenging task for orthopedic surgeons. Considering these injuries mostly affect younger patients, long-term consequences involving cosmesis and shoulder dysfunction are not yet well understood, and therefore must be anticipated. The myriad of existing (surgical) techniques is indicative of the uncertainty regarding this topic and a gold standard has not yet been determined. However, when diagnosed correctly and treated accordingly, the results are overall satisfactory.”
Over 160 different surgical techniques described in the literature for acromioclavicular joint injury. Do any of them work? Ask the surgeons.
In the May 2019 edition of the medical journal Arthroscopy (15) researchers from the University Hospital Regensburg and Technical University of Munich in Germany made these observations regarding the confusion that surgery brings to acute acromioclavicular joint injury and the importance of treating and repairing ligaments.
“Over the past decade, the interest in acromioclavicular (AC) joint research has experienced a revolutionary increase. Biomechanical and anatomic studies have been carried out to investigate and obtain a better understanding of the function of this joint. The reason for this huge investigational effort is the fact that we do not have any gold standard for the treatment, diagnosis, or follow-up of patients with acute or chronic AC joint injuries.
“This is reflected by the huge number of over 160 different surgical techniques described in the literature. . . Because of this wide variety, it is hard and nearly impossible to compare clinical data.
Within the past 5 years, we have focused not only on the vertical instability but also, more and more, on the horizontal instability and tried to understand the rotational component of this joint with the importance of scapulothoracic motion (very simply the ability to raise your shoulders as in shrugging your shoulders or the ability to reach out with your arm and pull something back or away from you).”
The researchers of this editorial concluded that: “We have changed our practice in the past few years in line with the newly derived data, by addressing the coracoclavicular ligaments as well as the AC capsule to restore horizontal and vertical stability but also allow for physiological rotation and movement.”
Simply, whatever repair you decide on, it is best to try to achieve nature’s original design. Something that many surgeries cannot do.
In this video, Danielle R. Steilen-Matias, MMS, PA-C discusses treating nerve pain following shoulder surgery.
It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues. Other times we will see patients after shoulder surgery who have continued pain. It may be the same pain that they had before surgery or it may be a different type of pain. What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve release injection therapy or more commonly hydrodissection.
Prolotherapy treatment focuses on shoulder ligaments to restore shoulder stability
Comprehensive H3 Prolotherapy and a rehabilitation program can strengthen the ligaments and dynamic shoulder stabilizers (rotator cuff muscles). Chronic pain is most commonly due to tendon and ligament weakness or cartilage deterioration, as is the case in acromioclavicular joint syndrome.
Prolotherapy is a regenerative injection treatment, which is what degenerated structures need. In our office, the shoulder is one of the most common areas we treat.
In addition, we have published scientific articles and studies on our results, this includes shoulder pain, glenoid labrum tears, arthritis and more.
RESEARCH: A Journal of Ultrasound in Medicine (16)
The aim of this study was to evaluate the therapeutic efficacy of ultrasound-guided prolotherapy in the treatment of acromial (inflammation of the enthesis) enthesopathy and acromioclavicular joint degeneration.
- Thirty-one patients with chronic moderate-to-severe shoulder pain
- Ultrasound-guided prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule.
- Prolotherapy was given in 2 sessions separated by a 1-month interval.
- Average follow up 62 days
- Conclusion: Ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint damage.
Comparisons in shoulder instability treatment: Physical therapy and surgery
Research hospital doctors in Spain publishing in The Open Orthopaedics Journal, write of the complexities in treating a patient who has multidirectional instability of the shoulder. (15)
Complexities include hyperlaxity (very to extremely loose shoulder), anatomical problems, muscle imbalance and possible traumatic incidents in each patient.
First treatment: Physical therapy
- “Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder.” However, they go on, “significant traumatic incident (an injury), anatomic alterations (degenerative – osteoarthritic or genetic problems), and psychological problems (depression and anxiety, et al), are widely considered to be poor prognostic factors for conservative treatment.”
Next treatment after three months: Surgery
- Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.
- When conservative treatment fails, surgical intervention is warranted.
- Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes.
A discussion of the surgeries are included here in the second paper we are looking at:
In the August 2017 edition of The Open Orthopaedics Journal, (176) researchers from Spain published these observations:
- Due to the complex anatomy of the shoulder and the large range of movement of this joint, a wide variety of anatomic injuries and conditions can lead to shoulder instability, especially present in the young population.
- Recognizing and treating all of them including Bankart repair (see below) and capsule-labral plicatures (this is a condition where the soft tissue that lines and holds the shoulder in place becomes excessively loose).
- SLAP repair, circumferential approach to pan-labral lesions (a 360-degree tear), rotator interval closure (in simple terms, suturing to hold the rotator cuff together), rotator cuff injuries and HAGL lesion repair (humeral avulsion of the glenohumeral ligament tears) is crucial to achieve the goal of a stable, full range of movement and not painful joint. (If they work)
While looking at all these possible candidates for shoulder instability, the Spanish team wrote of the difficulties in making these surgeries work.
- The glenohumeral joint is a ball-and-socket joint that is inherently unstable and thus, susceptible to dislocation. The traditional and most common anatomic finding is the Bankart lesion (anterior-inferior capsule labral complex avulsion), but there is a wide variety of anatomic alterations that can cause shoulder instability or may be present as a concomitant injury or in combination, including bone loss (glenoid or humeral head), complex capsule-labral tears, rotator cuff tears, Kim´s lesions (injuries to the posterior-inferior labrum) and rotator interval pathology.
Comment: The warning is that all these things may be happening at once. Below the research finishes with the recognition that if you fix one thing, you may make one of the other problems worse.
- In The Open Orthopaedics Journal, (18) surgeons wrote: “Physicians must be familiarized with all the lesions involved in shoulder instability, and should be able to recognize and subsequently treat them to achieve the goal of a stable non-painful shoulder. Unrecognized or not treated lesions may result in recurrence of instability episodes and pain while overuse of some of the techniques previously described can lead to stiffness, thus the importance of an accurate diagnosis and treatment when facing a shoulder instability.”
Caring Medical Research
In published research from Caring Medical doctors, The optimal long-term, symptomatic therapy for chronic shoulder pain has not been established. Accordingly, we investigated the outcomes of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved shoulder pain at a charity clinic in rural Illinois.
- We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy.
- An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation). Prolotherapy, PRP, and Stem Cell Therapy have been used successfully in patients seeking alternatives to rotator cuff surgery. as well as patients with SLAP Lesions and Glenoid Labral Tears.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated May 16, 2021