What is shoulder instability?
Shoulder instability is a condition characterized by a dislocation of the shoulder joint, when the head of the humerus pops out of the glenoid (socket bone of the shoulder joint). There are different types of shoulder instability. An acute trauma, with the shoulder dislocating in an accident, is a very painful injury. Sometimes, the humeral head does not relocate by itself and gets stuck underneath the glenoid. This condition is referred to as an acute shoulder dislocation or luxation.
Some dancers also experience regular dislocations of the shoulder joint in everyday situations. They are often able to reposition the humeral head themselves without any effort, and luxation may not be very painful. This condition is referred to as chronic shoulder instability.
If the shoulder does not dislocate completely but just quickly pops in and out, this is called a subluxation.
How can it occur?
Severe injury or trauma is often the cause of a first shoulder dislocation. A direct blow to the shoulder, a fall on an outstretched arm, or a severe pull on the arm may trigger dislocation.
When the head of the humerus dislocates, the glenoid and the ligaments in the front of the shoulder are often injured. The labrum, a stabilizing cartilage rim around the edge of the glenoid, may also tear and dislocate. This is commonly called a Bankart lesion. If a fracture of the glenoid goes with it, this is referred to as a bony Bankart lesion. Muscles around the shoulder joint and the fascia are also severely stretched and injured and will get into dysfunction after a shoulder dislocation. This myofascial dysfunction contributes to chronic instability in a way that is often underestimated.
What are the typical symptoms of shoulder instability?
In an acute shoulder dislocation, you will actually feel the humeral head moving out of the glenoid in the moment of luxation. There will be a significant pain that is sometimes felt along the arm past the shoulder. Moving the arm from its current position will be extremely painful. You may also experience a numbness of the arm. Sometimes the shoulder appears unusually square compared to the other side.
Recurrent shoulder dislocations that may happen in everyday situations and are usually not very painful characterize chronic shoulder instability. You may have a persistent sensation of the shoulder feeling loose, slipping in and out of the joint, or having no proper control over it.
How can shoulder instability be diagnosed?
Traumatic shoulder dislocation is an acute injury with severe pain and restricted range of motion. Most often the symptoms are very typical. A fracture of the humerus or glenoid, however, is an important differential diagnosis so that an X-ray of the joint is always necessary.
Chronic instability of the shoulder shows very typical symptoms as well, but demands a more precise evaluation to find out about all the factors that contribute to the instability. Your doctor will examine your shoulder and may find the joint slipping out even upon examination. A series of specific clinical tests exist to determine the type of instability. Most joints dislocate to the front, however, they may also dislocate to the back or show a multidirectional instability with the joint dislocating in several directions. X-rays and MRI-scans are helpful to identify anatomical variations of the joint that contribute to the instability and to find out about any damage to the bones or the soft tissue structures that contribute to joint stability.
A thorough functional muscle evaluation is crucial to find out about the degree of muscle dysfunction of the shoulder girdle. Oftentimes you can easily identify muscle dysfunction just by comparing both shoulders in the mirror. The affected shoulder will appear to be dragged down and to the front and the movement of the two shoulder blades will be asymmetrical if watched from behind.
This overlay of two X-rays illustrates a typical situation after a shoulder luxation. You can see that the humeral head is displaced from its original position in the direction of the white arrow.
What treatment options are there?
Traumatic shoulder dislocation demands prompt medical treatment. A pillow between the arm and torso may provide support and increase comfort as a first aid. Emergency department care is focused on returning the shoulder to its normal position. Usually the joint can be repositioned without any surgery necessary.
After repositioning of the joint, the shoulder will usually be immobilized in a sling or brace. You should avoid any abduction and external rotation of the arm during the first weeks. An intense rehabilitation program has to be started soon after the accident to restore range of motion and normal muscle function to prevent future dislocations.
After treatment and recovery, a previously dislocated shoulder may remain more susceptible to reinjury. Damage of the intraarticular joint stabilizers and persistent muscle dysfunction increase the chance of repeated dislocation.
Muscle dysfunction can seriously affect scapular motion and shoulder function and is thus an important contributing factor to chronic instability of the shoulder. In order to handle chronic instability successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. Chronic shoulder instability demands intense rehabilitation including corrective exercises that address present muscle dysfunction and scapular dyskinesia. Working on false movement patterns of the scapula is often challenging and requires very specific exercises to be performed on a regular basis. Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Manual medicine and especially deep myofascial release treatment is recommended to treat present joint and myofascial dysfunction. Restriction of the fascia plays a key role in chronic shoulder instability and can be addressed effectively with this technique.
A shoulder that remains unstable despite intense rehabilitation may require surgery. There are different surgical methods to address shoulder instability. Your doctor and orthopedic surgeon should help you choose the best option for you.
You had a shoulder dislocation or you have chronic shoulder instability and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Strength training: Core training – resistance band workout
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.