TREATMENT OF INSTABILITY
Conservative Treatment
This is usually
the first step in restoring shoulder function. Physical
therapy can assist in building up muscle and re-teaching
the muscle the proper sequence to contract to restore
coordinated, strong muscle contractions that are important
for maintaining glenohumeral stability.
The rotator cuff
muscles play an important role in stabilizing the shoulder
joint and optimal control of neuromuscular forces is
required to restore shoulder function. Your physical
therapist will assist you in learning how to isolate
individual muscles of the rotator cuff and strengthen
them. This strengthening is initially performed
within the "stable range" of shoulder function.
In atraumatic instability,
studies have shown an 80% success rate with physical
therapy. Unfortunately on 16% of patients with
traumatic instability improved. Physical therapy
is important even in traumatic instability to improve
the muscle and tissue tone prior to planned surgery. Finally
the old adage of "If it hurts doing that, don't
do it!" is true here. It is important to
avoid activities that stress the capsular and muscular
structures. Certain habits must be broken to
avoid the "unstable" positions. Any
position, action, or sport that promotes shoulder subluxation
or dislocation must be avoided.
Surgery
Tremendous gains
have been made in the past ten years for surgery on
shoulder instability. Most procedures can be
performed through the arthroscope (scope) as "in & out,
same-day" surgery with the use of three 1/2 inch
small incisions. Bone anchors with attached suture
9thread) allow the reattachment of torn tissues. These
are made in absorbable or non-absorbable materials. My
preference is to use absorbable suture anchors in younger
athletes with simple tear patterns. It takes
about 6 weeks for the tissues to heal to bone, so the
anchors are around for plenty of time to allow for
healing. The body reabsorbs the absorbable tack
or suture anchor over 3 months, leaving no trace behind! Lasers
or even more improved thermal controlled radiofrequency
devices are used to shrink the redundant capsular tissues
and stretched capsular ligaments.
In large studies
performed at the U.S. Coast Guard Academy, in addition
to West Point and the Navy Academy, success rates from
these completely arthroscopic procedures approached
the rates of older open surgical techniques at about
80% to 97% when defined by redislocation or recurrent
instability after surgery. The morbidity as defined
by hospitals stay, patient pain levels and return to
sport was far superior in the arthroscopic group. Open
techniques are still utilized for revisions, or complicated
cases.
Rehabilitation
After surgery it
is very important to get into a regularly scheduled
physical therapy rehabilitation program. Usually
the arm will be in a sling post-op with a special formfitting
ice pack in foam on the shoulder. ice can be
discontinued after 2 or 3 days when comfortable. Studies
have shown a 50% reduction in narcotic pain medications
post-operatively with the use of ice therapy. Simple
pendulum exercises can be performed at home three times
a day for the first two weeks. Then, depending
on the repair, when you return to have the single stitches
closing each wound removed you'll be enrolled in a
formal P.T. programs.
The shoulder is
kept "protected" for 6 weeks while soft tissue
healing occurs. Then active range of motion and
strengthening are begun. The goal is to have
the patient return to activities of daily living by
12 weeks post-op. A more conservative 14-18 weeks
is used to return the athlete back to his sport.
Frequently Asked Questions
Does
it hurt?
The pain is substantially less with the arthroscopic
techniques today then with older open techniques. Patients
usually say it hurts for 2-3 days then relents to a
dull tooth-ache like pain for 3-6 weeks. As healing
occurs the pain is intermittent and often associated
with the physical therapy sessions. You'll go
home with strong and mild painkillers to assist you
in dealing with the discomfort. Cryotherapy or
the use of ice sleeves has substantially reduced the
amount of pain perceived.
Will
I be able to return to my sport?
The aim for these advanced arthroscopic techniques
in sports medicine is to return athletes to their previous
level of functioning in as rapidly amount of time that
is safe for the individual. There have been football
players, baseball pitchers, wrestlers, crew team, lacrosse
players, swimmers, and basketball players that have returned
to their sport at NCAA division-III levels. Over
90 Coast Guard Cadets have been commissioned into the
U.S. Coast Guard after undergoing shoulder stabilization
procedures.
I
have one dislocation, and now my shoulder is
just a little loose...should I be worried?
The answer to this one varies with each individual. A
comparison to the opposite non-involved extremity will
usually exhibit significant more shoulder laxity then
was appreciated. An early evaluation by an Orthopedic
Surgeon can help advise you on the proper course of treatment
prior to a re-dislocation occurring.
I
think I've got instability. What do I do
now?
In these days of Managed Care and Health plans,
most insurance plans demand that you get referred to
an Orthopedic Surgeon through your Primary Care Physician,
tell him your symptoms, and request a referral to an
orthopedic surgeon.
|
