Anterior Shoulder Instability

Randale Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV remote. Today we’ll be speaking again with Dr. William Seeds. Dr. Seeds is an orthopedic surgeon who practices in Ashtabula, Ohio. Good afternoon Dr. Seeds.

William Seeds: Good afternoon Randy. Thanks for having me on today.

Randale Sechrest: Well, Dr. Seeds today I thought what we would discuss is a fairly common problem amongst athletes especially and that is anterior shoulder instability. So lets go through how you evaluate anterior shoulder instability, a little bit about how you might consider treating anterior shoulder instability? And let’s start by just defining, what is anterior shoulder instability?

William Seeds: Sure Randy, the anterior shoulder instability that I typically see is usually in our younger athletes that have had some traumatic injury to the shoulder. So typically the type of instability I see is in anterior instability caused by a trauma to the shoulder in a particular sport or sometimes an accident. The presentation is usually they presented to the emergency room where they had an actual dislocation and the shoulder was relocated in the emergency room or the other presentation maybe where they've had an event of where they felt the shoulder kind of moved and then went back into place and that’s usually how I get those patients as far as referred to me for that type of an injury.

Randal Sechrest: Let’s talk a little bit about the anatomy of the shoulder and how an anterior shoulder dislocation or anterior shoulder instability comes about. You know, what we are really talking about is the upper arm bone, the humerus, actually dislocating or moving out of the socket, called the glenoid. And for patients that don’t understand the term anterior shoulder dislocation, then what we are really talking about is a situation where the shoulder would dislocate with the upper arm bone coming into the front of the body in to the anterior portion of the shoulder and the body. You know, it’s by far [0:02:25.9] the most common dislocation. Clearly the shoulder can dislocate in the posterior aspect, which means it goes out the back, and sometimes we can even see it come out inferiorly, or below the shoulder. But as I recall about 97% of the shoulder dislocations come out the front and there is a very small number of folks that actually go out the back or down the front, is that your understanding as well?

William Seeds: Yes, that’s correct Randy and I would tell you that the observation on the acute phase or the early phase of the dislocation is a pretty obvious picture of a patient that is usually kind of bent over and they are holding, they are listing their shoulder down because it’s the most comfortable position and they are hunched with the arm in front of them and that seems to be the best place for that patient to help with the pain control. And that’s a pretty arm and a sign of a dislocation of a shoulder.

Randale Sechrest: Right, you know, when you see this patient let’s take the person who actually has dislocated their shoulder and if you are called into the emergency room as an orthopedic surgeon, what are you going to do with that patient, that you walk into the emergency and you see in front of you, a clear example of an anterior shoulder dislocation, where the upper arm bone is completely dislocated out of the socket, what are you going to do at that point?

William Seeds: Well, typically if I am in a setting of an acute care facility that has the ability to take an X-ray, I always like to have an X-ray present to see if there is any associated fracture of the glenoid or of the -- one of the tuberosities the bone of the shoulder itself. I like to get a neurological assessment right away just to kind of complete the picture and then from there what I’ll try to do is, it’s very helpful if you can get to these initially and I’ll try to relocate the shoulder without any anesthesia, by kind of doing what I call, it’s called the modified Kocher maneuver where I try to use the muscles in the scapular plane to assist in reducing the shoulder and most of the time I’d say probably 95% of the time I can get that done without any anesthetic and you know get the patient to control their breathing and relax their muscles and we’ll get the shoulder back in that way. And that’s what we do on the field and it seems to work every time if you get to a shoulder that’s dislocated within the first 20 minutes or so. It’s a pretty easy maneuver to get the shoulder back in place.

Randale Sechrest: So as a sports medicine physician this is something that you would do on the sidelines of a football game or perhaps a soccer game, if you see what you think is an anterior shoulder dislocation, you would go ahead and try to relocate that shoulder as soon as – as you see the patient, whether you have an X-ray or not?

William Seeds: Absolutely, immediately I’d get it back in the place.

Randale Sechrest: And what’s the advantages of getting it back in place sooner rather than later or is there damage that goes on over time or is it just that, it’s easier to relocate, why would you do that?

William Seeds: A couple of reasons, I mean, number one, any - just from the neurovascular status of a patient you want to be able to relocate that joint as soon as possible because you are, you know, the longer a joint is out of place, there are some obvious potential problems with blood flow and nerve injury that can follow something like this. And the most obvious thing though, I think for all of this is the fact that if you get to this acutely you can really get a shoulder back into place with minimal trauma and I think we could all attest to the fact that the longer shoulder is been out, the more difficult they are to get in, because of the muscle changes and the rigidity and spasming that occurs. And we all know that some damage can occur in getting the shoulder back in place. And so you want to make that the smoothest transition you can without doing anymore damage than has already been done.

Randale Sechrest: Now, what about paramedical personnel, such as trainers or emergency room or emergency medical technicians or even sometimes coaches perhaps, do you -- in your environment train these paramedical people to actually relocate shoulders, do you think they ought to be doing it at the sidelines?

William Seeds: Yeah, Randy, I can tell you that I haven’t been able to find any of those people really that have been comfortable enough to take that step and who really feel confident that they understand that the real anatomy of, you know, has it -- is it an anterior dislocation, is this the right thing I am doing, it’s seems to be an arena that I don’t feel comfortable, you know, entering in trying to train people to do that. I think that still needs to be in the professional realm of the physician.

Randale Sechrest: Now, let’s talk a little bit about what’s happened with the shoulder dislocation in terms of what’s been damaged in the shoulder? I think you mentioned you get an X-ray to one, look at where the bones are, but also to rule out any fractures of the upper arm bone or the proximal humerus. What else do you think is injured during an anterior shoulder dislocation? What structures in the shoulder are we taking about being damaged?

William Seeds: Well, I usually when I discuss with a family what’s happened and the patient, what’s happen to the shoulder, I like to explain it as far as usually a couple of things have to occur in the shoulder for the shoulder to come out of place. Number one, I try to explain to the family to think of the shoulder with a balloon, basically a balloon around the shoulder joint itself and that is the capsule of the shoulder and that gives some restriction to movement. And in order for that shoulder to come out of place, usually that capsule has to stretch a little bit, it’s kind of like a rubber band if you stretch it enough it may not go back to that original length. And that capsule stretches out. And then also what we call the shock absorber in the shoulder, the labrum, that helps give stability to the shoulder. Sometimes the labrum and the capsule can be injured in that transition of the shoulder coming out of joint. And those are the two basic things that two of the early things that will look at besides any bony injury and I’m jumping ahead, but we’ll look at those on exam and then also I follow all of these injuries with an MRI to verify the specific injury in the shoulder joint itself.

Randale Sechrest: So if you treat a patient let’s say in the emergency room for a shoulder dislocation, you get the shoulder relocated, the X-rays look, okay. You are going to send that person or schedule that person for an MRI scan at some later date before you see them back. Is that accurate?

William Seeds: Absolutely, yes, I will MR every patient that’s had a subluxing event or a partial, you know, instability episode, or a full dislocation on the shoulder if I suspect it.

Randale Sechrest: You know, I think we ought to get clarify these terms for patients. We are really talking about a full dislocation, where the ball of the shoulder joint or the upper humerus comes completely out of the socket. You referred to subluxation, can you describe the difference between subluxation and full dislocation?

William Seeds: Sure, you can imagine that this is the cup of the shoulder and if this is the ball, you know, in a full dislocation the head or ball of the humerus will come out of place, completely out of place of the cup. In a subluxation, there is just a transient motion that may rest on the ridge, on the front of the shoulder and then comes back in; it doesn’t completely come out of joint. And usually those patients are people that we can examine and almost reproduce that instability on exam, as supposed to somebody who has just come out of place completely there a little tougher to show that exam because they are guarding specifically because of the injury. It’s just a little bit easier on exam to demonstrate the subluxation of the shoulder.

Randale Sechrest: Let’s move on and talk a little about how you treat the total dislocation. When you see this patient you get the shoulder relocated. How do you like to treat those patients? Are you a proponent of surgery in these cases right away? Do you try to treat these patients with conservative treatment? And if you do what type of conservative treatment do you like to use for these patients?

William Seeds: Well, I think that the, my best information is information for that family in giving them the statistics of, the age group, and the potential of the second event occurring, particularly if they continue their sport, or you know what usually the statistics will show as we know for younger patients that recurrence rate can be higher. Based on that and informing the family and then the MRI findings I use to help correlate how unstable I feel that shoulder is, I usually - with all of that data - I still take the next step of telling the family what I like to do is mobilize the shoulder in a sling, a sling and a swath where we bring the shoulder in and also wrap it to the chest.

And I like to take a conservative approach for first time subluxators or dislocators, I should preference that more with dislocators I will start demobilization. I’ll do that for about a three to four week time frame and then we’ll go into the physical therapy aspect of it. And I try to give first time dislocators, I give them the benefit of what I believe is the opportunity of trying to heel this without any surgical intervention - even aware of some of the statistics that the recurrence rate could be higher. I’ve had good success with it and with the subluxators I may start them into therapy immediately, I may not even mobilize them or for a short period of time I’ll keep them in the sling, but I’ll start them in therapy. So that’s usually my first attempt at treating these types of patients.

Randale Sechrest: You know, when would you move to surgery in these patients, is that after a second dislocation or a second subluxation event? When would you counsel the patient that is probably better to move on to surgery?

William Seeds: If number one, that the patient has finished the therapeutic part of the rehabilitation and then they’ve had a second event, then I recommend surgical intervention to improve the stability of the shoulder. If they’ve had an event that’s occurred during their therapy where there is been just some evidence of gross instability and we are not really making any progress and we are making things worse. I’ll intervene also in the therapeutic route where we’ll take that step towards surgery.

And also if they’ve had a second event, typically we may see some MRI findings that may even show some change that – that show that labral tear maybe a little bit bigger or worse or there maybe other aspects that definitely push you toward that surgical side.

Randale Sechrest: Now, you mentioned physical therapy and I think that we sort of just assume that the physical therapist knows what to do with the shoulder dislocation. But I guess for the viewers what do you expect in the therapist to work on and why do you have patients go through physical therapy? What are you trying to accomplish?

1. William Seeds: Well, I think a number of things and I think you hit on a very good, an important point that I work very closely with the therapist so that they understand exactly what we are trying to achieve through this process. And number one, we are first working for range of motion, in just getting the mechanics back as far as motion because, you know, when these patients come out of place they are painful, the first few weeks are -- can be a little difficult if we’ve had them wrapped in a sling and swathe for a few weeks getting things started can be a little hard. So you know, the first things we start a range of motion and also explaining to the patient that we are going to be working on muscles that they can’t see around the shoulder. And I think it’s really important for them to understand these are muscles that they are not aware of, they are not what they could see and we don’t have to be doing extreme workouts to work on these, basically these rotator cuff muscles that are going to help strengthen the shoulder. And that’s really where we start. We start early with some resistance-type of strengthening and actually working on stabilization exercises around the shoulder - also paying attention to the scapula and the scapular mechanics, because we believe the scapula and the muscles around, surrounding it are just as important as we progress with the shoulder rehab.

Randale Sechrest: Well, let’s move on and talk a little bit about surgical invention, when you decide to sit down with a patient and discuss the different ways that the shoulder can be restabilized, what are your trying to convey to the patient? What are you trying to tell them and what type of techniques do you recommend for surgical stabilization of the unstable shoulder?

William Seeds: Well, I think that what I try to convey to the patient is number one, their expectations of what we are trying to achieve. And even from the youngest athlete up to the 40 year, 45 year old worker who requires overhead use of the shoulder and so forth, is number one I am trying to recreate an environment, number one, that’s pain free and number two, that is realistic as far as in the initial stages of trying to strengthen that shoulder and keep them away from a recurrent event. After I feel that we have worked through those aspects then my goal is what I try to tell them is, I am looking at as far as stabilization in the shoulder I make some of those decisions intraoperatively when I am in the shoulder and I will tell you that I’ve pretty much gone from an open procedure to a arthroscopic procedure where I’ll stabilize the shoulder.

And in my hands I feel a lot more comfortable arthroscopically stabilizing the shoulder, because I feel that I am addressing a lot, a lot more of the anatomy than I typically was with the open procedure, though I feel it in any surgeon’s hands either approach is a good approach. With the arthroscopic approach, what I’ll typically be addressing is the labrum in the front of the shoulder and also the capsule, because from my experience I have seen a redundancy in the capsule where I talked about before, you get the stretching of the capsule and it just doesn’t go back to that, that confined capsule it was originally. So I’ll incorporate some of the capsule sometimes in to the repair of labrum or I’ll repair the labrum and then I’ll do what’s called a capsular plication where you can kind of dial in the tightness of the capsule in the front of the capsule then the superior part of the capsule, it just depends on where you feel the most instability is. So I like those approaches of being able to kind of adjust to what you see intraoperatively and I have had good success with that.

Randale Sechrest: Well we probably explain a few of the terms that we’re using. One is the labrum, can you explain what the labrum of the shoulder really is anatomically?

William Seeds: Yeah, the labrum is a soft cushion that is basically like the shock absorber in the capsule. And it helps for what we call static stability and dynamic stability, but it’s more of a static stabilizer of the shoulder and it’s kind of like the meniscus in knee. It helps protect the cartilage on the humeral head and it helps us in stabilizing the shoulder. And that cushion when the shoulder comes out of place in the front of the shoulder, if the cushion is in the front, it’s pretty much circumferential around the cup, but when the shoulder comes out, it rubs against that cushion and it can tear it. And it can tear with the bone or it can tear it off the bone or it can peal it back. And so we’ll address that and trying to repair that because for stability and when I say static that means when there is no motion in the shoulder, that is, that’s a stabilizer of the joint.

Randale Sechrest: And the capsule plication that you are talking about, you are really talking about talking a capsule that’s been stretched and it’s just too much tissue and sort of pulling it together with sutures or some sort of a connector. So that ligament of the capsule or that tightness of the capsule becomes more back to normal, is that accurate?

William Seeds: That’s absolutely right. It’s, you can imagine it as a, you are just bringing up, it’s you are bringing tissue together to close it up and you are suturing that tissue at certain levels and you can like I said you can kind of dial it in as to how much tension you need on that capsule and you can immediately see arthroscopically and observe you know how much tension you are putting on the capsule and I think it’s a, it’s in my hands it’s absolutely the way I can get what I feel is that the appropriate stability for this patient at that time.

Randale Sechrest: Yeah, I think probably the patients that don’t understand what we were talking about, if you think about, you know, loosing weight and having your pants taken up at the waist, it’s the same process, you are just simply taking up some of the slack so that, like in your pants, when the waist band fits tighter, the same thing happens in the capsule. It fits tighter around the structures of the shoulder and actually, creates some restraint to dislocation. You know, one thing we’re probably ought to point out to patients as we move through this is, you know, people will say, well okay, so I have dislocated my shoulder five times, you know, I can get it back in place it doesn’t bother me, why should I have it surgically fixed? So I guess we probably should explain a little bit about what we are concerned with the surgeons with that shoulder that’s unstable and what that means long-term for patients. So can you talk a little about the natural history of untreated shoulder instability?

William Seeds: Yes, Randy, I believe that’s a real important point that you really trying to express to the patients family, especially in the younger population and your athletes were where, you want to make them aware of the fact that instability has some consequences to that shoulder as the age. And specifically we are trying to help the patient in controlling the potential cartilage injuries that will and can occur over time to the joint. If we are able to stabilize the shoulder then the mechanics of the shoulder will be reproduced more likely towards the original anatomy of that patient. Where if the shoulder is not flowing congruently in that joint, then there are different stress points to the cartilage that you typically, that patient typically wouldn’t have, and you can potentially see increased wear of the cartilage and a progression of over time some real degenerative arthritic changes that can occur later on in life.

On top of the that, the mechanical changes can lead to impingement problems where the patient can complain of bursa problems where the shoulder just isn’t riding correctly in the shoulder. You can have rotator cuff problems over time, we can have biceps problems. So there’s a whole host of mechanics that can change in the shoulder over time, of where that patient is adjusting to the changes of the shoulder. And this can go even further with problems in the neck, neck complaints and even nerve complaints in the arm. So it can really potentially over time cascade into multiple problems with that patient.

Randale Sechrest: Yeah, you know, I think that’s an important point because I think a lot of patients come in and say, well, you know, what you are telling me is that I can take my chances of having another dislocation or not and they sort of say, well, I would rather do that than have surgery. I think a lot of them don’t understand that the unstable shoulder whether ever dislocates again or not is still setting you up for problems with wear and tear on that shoulder that as you pointed out can become quite significant as we age. So I think there’s more to within just having a trick shoulders so to speak that can dislocate. It can definitely cause some problems later on in life and you need to take care of those before they become a life long problem. So thanks for clarifying that. Let’s talk a little bit about the procedure itself, you have mentioned that you do this arthroscopically, is this something you now do as an out patient? Do the patients need to stay in the hospital after this type of surgery? How do you deal with that?

William Seeds: Randy, these are out patient surgeries and I think with changes in anesthesia and the techniques now that we were able to utilize, you can get a patient home the same day. And definitely, significantly comfortable as far as, you know, the post operative pain that these patients might experience we can do very well with.

Randale Sechrest: And what about the open procedure in patients, who had an open procedure, do they go home as well or does that require to stay in the hospital?

William Seeds: I would tell you that again, that depends on the anesthesia approach, but even the patients with the open procedures can still get home now, they can be same day procedures. And I think that’s changed more from the anesthesia approach of where we’ll use blocks for the shoulder and those blocks can last anywhere from 12 up to 24 hours. And if we felt good about the education of the patient in understanding what that problems to look for over those first 24 hours you can get that patient home also.

Randale Sechrest: You know, I think a lot of patients are going to -- want to know what to expect after surgery and sort of the prognosis of how long they are going to be in rehab, when they are going to start a physical therapy? And probably, most importantly for the athletes, when they can return to relatively normal activity and pursue their sport? So give us some idea of how you deal with the post operative care of the shoulder stabilization procedure and sort of what you tell patients to expect?

William Seeds: Well, Randy, I use kind of a standard before the actual surgery of telling the patients and giving them the expectation of okay, here is the process, probably the first three weeks you are going to be locked up in a sling and swathe, we may show you some pendulum-type exercises or you may work with a therapist, once a week or twice a week where we’ll work a little bit on some early motion activities. But really no specific intense therapy. And at that three week mark then we’ll start you into the therapy of achieving, first getting the range of motion back.

And at the six week mark, typically where we expect the tissue and the repair to be healed, we’ll progress into the active range of motion and progress into the strengthening phase. I’ll tell patients that at about the three month mark or twelve weeks, is usually when we can be more aggressive with the strengthening aspects of the shoulder where they are feeling pretty good about starting to really progress with more of a weighted-type of program with the cuff muscles and then starting to really work the deltoids, around the shoulder and the scap, more of the scapular muscles. And I will usually tell them it’s about between the four to five month mark before we’ll let them get back into their sport. These things can change depending on what I find intraoperatively, if I feel that we’ve got a great repair the stability is better than I anticipated. The tear is smaller, I may start some of those patients of with range of motion immediately and not lock them up initially for that first three weeks, but I try to give them those realistic expectation at the beginning, so that they already have a set in stone. And I think you’ll find that the surgeons, you know, we have a, we do vary in when we start these therapeutic realms either post operatively, right away or we wait three weeks or we wait two weeks or we wait four weeks. But I think all of us follow that mode of okay, we know at the six week mark we can feel pretty comfortable that the repair, that the tissues have healed and we can really start moving at that point.

Randale Sechrest: Well, let’s talk a little bit about the potential complications of this procedure and not only the procedure but the potential complications of the dislocation itself. We’ve talked a little bit about the long-term problems with instability in the shoulder, but let’s start with the dislocation itself. What are you looking at in terms of injury that maybe you don’t always expect, but you would consider a complication of a dislocation? What are you looking for?

William Seeds: Well, I think from the standpoint of complications of a dislocation, the initial things that we want to assess and make sure that aren’t progressing are any injuries to the nerve or the artery or vein of the shoulder. So we are going to assess the blood flow to that extremity, we are going to assess the nerves to that extremity and how they are functioning, and take that step as far as the initial evaluation. The other complications are things that can happen within a dislocation that maybe settle changes or things that we will pick up on the MRI, such as bone bruising, where I feel that’s important to understand and to let the patients understand that a bruise on the bone and cartilages is something that we need to take a good look at because that may change the rehab process or they need to know that boy they’ve had a significant injury to that cartilage so we have to be careful how we move them ahead.

So it’s all of those of kind of things together that will assess in the complication from the original dislocation. And also I think its just as important that you have to inform that patient if you’ve gotten a good, if you have a good exam neurovascularly before you are able to put that shoulder back in, the patient needs to know that some things can occur in relocating that shoulder, that you can injure the nerve more or so what we call that axillary nerve, anterior axillary nerve, there can be injury to the nerve in putting the shoulder back in to place. And I think it’s very important to let the family and the patient understand that, that’s sometimes that can be out of your control in putting the shoulder back into place.

Randale Sechrest: Now, what about the surgical procedure itself, when you go in and do a stabilization procedure, what complications are you worried about in that case?

William Seeds: As far as the complications in the surgical aspects of the repair of the shoulder, the first and foremost things I am worried about are any type of infection that can occur through the portal sites, things that are some of the obvious things that you want to keep on top of early, the complication of if the patient is doing too much too soon, where they can - I tell them that look we put things back in to place, but your body is actually what’s going to heal this. If I am using some fixation devices like tacks or sutures to hold things in place that’s - they are just holding it in place, they are not there long-term to keep things in place.

So you’ve got to give those patients that expectation of understanding, because a lot of these arthroscopic procedures, the patients feel pretty good and they think that they can move along a lot faster. And I think that’s the biggest complication that a lot of us see as is patients not following the protocols that you set forward. And they try to do too much too soon and then they can definitely pull apart or they can stretch out that capsular repair. Some of the other things we look for postoperatively are potential blood clots that can occur in the shoulder even arthroscopically, they can occur where you get unwanted swelling in the extremity, or some times some, a little bit of a nerve sensation that they feel has changed because of that swelling. And those are thing initially that you want to keep aware of. And those are the big things that I look for.

Randale Sechrest: Dr. Seeds, you know, one of the things that we as surgeons worry about is what’s commonly called the frozen shoulder, sometimes it’s referred to as adhesive capsulitis. You know, I think that we all are concerned that an increasingly stiff shoulder after surgery maybe a problem for some patients, what’s your experience been with this complication?

William Seeds: Randy, you bring up a very good point, that should be addressed, and the patient should have an awareness that, unfortunately with some of our surgically techniques with the specific patient, sometimes what we do in the shoulder can aggravate that shoulder and accelerate their healing process. And it can lead to scar tissue development and adhesions in the shoulder postoperatively. And those are some issues that even though they are rare, they are things that we have to be aware of when they are in their therapy process, because if we are seeing that early enough in to the postoperative, you know, post surgical follow up there are things we can do to keep that patient, you know, to make sure that they don’t scar down too much and we can help them get through that process, but I thinks it’s a very important that patients understand, it’s a potential possibility, and it can be a complication of the surgery itself.

Randale Sechrest: Well, you know, I think this has been a comprehensive discussion of the treatment of anterior shoulder instability. Is there anything in this discussion that we have not covered, that you feel patient should know about this condition?

William Seeds: Yeah, I think, I still believe in even in this, in our era right now of medical care, I believe we still see that issue of where these patients may get to an emergency room, their shoulders put back in place and they are given that advices of okay, you need to stay in that sling, if, as things progress, you know, you can go see your primary doctor. We are still not seeing all those referrals immediately, where I believe that is, that’s the most important time to get to these patients as is initially with this type of treatment. And I mean I still can't tell you how many people I’ll see that have had, already had one dislocation, were seen in the emergency room, but never followed up with an orthopedic physician. And I just think that the more awareness people have of this injury, I think in education, then we’ll end up getting to these patients earlier.

Randale Sechrest: So your advice to patients is that if you’ve suffered a subluxation event or a full dislocation, that rather than just taking that advice of just letting it heal and go back to your business, you feel that all of these patients should be seen by an orthopedic surgeon and evaluated. And I think you have also stated that you would go ahead and do an MRI scan, so I am assuming that your recommendation would be that any patient that’s had one of these events, needs to have an MRI scan as well, is that accurate?

William Seeds: Absolutely Randy, absolutely. And that’s you know, that is I think the perfect formula for preventing and improving, preventing problems and improving the outcomes of that patient, in every patient that we see initially.

Randale Sechrest: Well thank you very much for joining us today `and giving us this information, I think there has been a wonderful discussion about anterior shoulder dislocation. So thank you very much and thanks again for joining us.

William Seeds: Thanks Randy. I appreciate it.