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What is shoulder instability?

Shoulder instability describes the clinical scenario wherein the humeral head (upper arm bone) is able to slide out of the glenoid socket of the scapula (shoulder blade). Shoulder instability can result in a dislocating shoulder or a subluxating shoulder. Shoulder instability is typically described as anterior (front), inferior (bottom) or posterior (rear); the classification of shoulder instability corresponds to the direction of the dislocating humeral head. Shoulder instability can occur following a traumatic dislocation, participation in repetitive throwing sports (i.e. pitching) or in association with a developmental predisposition to having loose ligament surrounding the joints.

What is multidirectional shoulder instability?

The glenohumeral joint of the shoulder, one of the more complex joints within the body, is formed into a ball-and-socket type joint where the head of the humerus (upper arm bone) meets the glenoid cavity of the scapula (shoulder blade). This ball-and-socket joint arrangement enables joint movement in multiple directions. In some cases, the ligaments, tendons, and labrum (fibrous cartilage) of the shoulder do not provide adequate stabilization of the humeral head relative to the glenoid socket.  This loss of soft-tissue restraint can cause the humerus and scapula to partially or completely separate or slide apart. When these soft tissue restraints lose their competency (i.e., stretch out or tear), recurrent joint dislocations can occur. When this instability occurs in two or more directions, the patient is described as having multidirectional shoulder instability.  Sports that require repetitive overhead movement (swimming, volleyball, tennis, baseball) can cause athletes to experience multidirectional shoulder instability because of the cumulative effect or repetitive micro-trauma associated with overhead arm motion.

What is the treatment for multidirectional shoulder instability?

Individuals with multidirectional shoulder instability are typically treated non-operatively.  A combination of rest, ice, and non-steroidal anti-inflammatory medications (NSAIDs) can be used for pain management following an acute dislocation. Physical rehabilitation and shoulder girdle strengthening is the mainstay of treating MDI patients. The muscles of the shoulder girdle are dynamic stabilizers of the shoulder joint. When the shoulder joint muscles are strong, they provide support to the ligaments, tendons, and labrum. Strong rotator cuff and peri-scapular muscles are necessary to hold the shoulder joint in place during high load sporting activities.

Patients with recurrent shoulder instability, and those who fail nonoperative management of their shoulder instability condition are treated surgically. The goal of surgery is to reestablish the competency of the static stabilizers of the gleno-humeral joint. This is achieved by either reattaching a torn labral complex, tightening a loose joint capsule or both.  Tensioning a loose shoulder caspule or ligament is also known as shoulder capsulorraphy.  Shoulder capsulorraphy can be performed using arthroscopy or open surgery.  Understanding the clinical circumstances underlying a patient’s unstable shoulder is critical to determining which approach is best to achieve a successful outcome following surgery. Dr. Riley J. Williams, orthopedic shoulder doctor, treats patients in Manhattan, Brooklyn, New York City, NY and surrounding areas, who have experienced multidirectional shoulder instability and need a surgical repair.

How is a shoulder capsulorrhaphy performed?

Dr. Williams performs both arthroscopic and open shoulder capsulorraphy. Most individuals can be treated using minimally invasive techniques. This minimally invasive procedure involves small incisions to introduce a small camera (arthroscope) for Dr. Williams to methodically examine the muscles, tendons, ligaments, and cartilage of the shoulder joint. Specialized surgical instruments are inserted through another small incision and used to excise and remove the damaged tissues. The remaining healthy tendons, ligaments, and cartilage are wrapped around the shoulder joint to form a capsule. This capsule is subsequently fastened to the glenoid cavity of the scapula with special surgical anchors that are secured within the bone. These surgical anchors tighten the new shoulder capsule and realign the joint back to its correct anatomical position.

Those athletes who participate in contact sports (american football, rugby, lacrosse, wrestling) may be best treated using open shoulder capsulorrhaphy.  The rate of re-dislocation in this group of individuals is lower following open surgery compared to arthroscopic repair techniques. The open surgical approach, known as open shoulder stabilization, requires a slightly larger incision to facilitate surgical access to the unstable ligament of the shoulder joint. Dr. Williams may recommend open surgery over an arthroscopic procedure for patients who have experienced bone loss, chronic multidirectional shoulder instability, or a failed shoulder joint reduction.

What is the recovery period like after a shoulder capsulorrhaphy?

The recovery period after a shoulder capsulorrhaphy is as follows:

• Joint immobilization using a sling for approximately 2 weeks following surgery.
• Pain and inflammation are managed with sling wear, ice, non-steroidal anti-inflammatory medications (NSAIDs), and for a brief period, narcotic pain medications.
• Physical therapy program will focus on strengthening the shoulder joint muscles and starts one week following surgery. Patient should expect to do PT for 2-3 months following the procedure.
• A full recovery is anticipated by 3-4 months. Contact sports are allowed 5+ months following surgery.

For more information on shoulder capsulorrhaphy, or to discuss your multidirectional shoulder instability treatment options, please contact the office of Riley J. Williams, MD, orthopedic shoulder doctor at the Hospital for Special Surgery (HSS), serving Manhattan, Brooklyn, New York City, NY and surrounding areas.