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Shoulder Instability

What Is Shoulder Instability?

The shoulder is a ball and socket joint, it is made up of 3 bones that move together as one; the scapula (socket of the shoulder blade) and the head of the arm bone (ball section) and the collar bone.

The joint is designed to give a large amount of movement. This also means that it has the potential to be too loose. There are various structures that help to keep the joint in position. The most important ones are:

  • Ligaments, which hold the bones together
  • Labrum (A rim of cartilage, which deepens the socket)
  • Muscles, which keep the shoulder blade and ball in the correct position when moving or using the arm.
  • Joint capsule (lining that covers the joint)

Shoulder instability is when the ball is not suitably controlled within the socket. It can develop in two different ways; Traumatic and Atraumatic.

  • Traumatic caused by a sudden injury of dislocation (joint moving fully out of place), or subluxation (joint partially moving out of place).
  • Atraumatic when shoulder instability can occur without an injury, in people who naturally have greater laxity (looseness) in their joint and surrounding tissues.  Additionally, in a very small minority of people shoulder instability can occur due to muscle imbalances i.e some muscles pulling too strongly or not coordinating well enough.

What Are The Symptoms Of Shoulder Instability?

Patients commonly complain of pain, weakness and poor movement and may feel apprehensive about moving their arm in certain ways.  They may feel that their shoulder is slipping, giving way, catching or coming out of joint, which can cause patients to feel less confident about using their arm for general tasks of daily living, at work and during sporting activities.

If the problem develops following a sudden injury, patients may report that their shoulder repeatedly dislocates (comes out of joint) and need to visit the hospital to have it relocated (put back in), whilst other patients may feel as if their shoulder is partly coming out and then moving back in again (subluxing).

How Common Is Shoulder Instability?

The shoulder is a very mobile joint, and therefore dislocation (the joint coming out of place) is more common than in some other joints.

Traumatic shoulder instability accounts for approximately 96% of shoulder dislocations.

The first time of dislocation is an important factor:

  • If you first dislocate your shoulder before you are 30, there is a 70% chance of recurrent instability (the shoulder dislocating again in the future).
  • If you are over 40 years old when the first dislocation happens, there is less than a 10% chance of reoccurrence.

Atraumatic (without injury) The true prevalence is unknown but thought to be approximately 4% of shoulder instabilities. Predominately in the younger age of under 25 years.

What Causes Shoulder Instability?

Shoulder instability develops in two different ways:

  • Traumatic cause: Due to a specific injury or trauma.  This can damage other structures in the shoulder such as ligaments, tendons, labrum (the rim of cartilage) or the bone in the upper arm (humerus).  This can increase the chance of the shoulder coming back out again or inhibit how the shoulder works.
  • Atraumatic cause: the shoulder problem may not be linked to any injury. The person is either born with, develops laxity of their shoulder joint tissues

Shoulder joint laxity can also develop as a result of repetitive minor injuries, such as overhead throwing sports, that cause the shoulder structures to stretch out over time. Patients in this category can lose normal muscle control, causing the shoulder to become unstable whilst doing simple daily tasks and sporting activities.

What Can Help With Shoulder Instability?

Following a first-time dislocation/injury, your arm may be put in a sling. Your doctor or physiotherapist will advise you on when to remove it to exercise.

Making changes to the activities you do does not mean that you have to stop moving or stop using your shoulder altogether.  Try to avoid activities that involve lifting your arm over your head, or contact sports for the first three months after the dislocation.

Your physiotherapist will guide you with an exercise programme to help regain shoulder function.

If you need any help with activities of daily living please follow the links below:

Atraumatic shoulder instability is a complex problem to treat. The shoulder is naturally too mobile, and you can’t control or move it correctly.

Resting the shoulder does not help, keeping your shoulder moving and the muscles strong is beneficial. Learning to recognise the triggers and learning how best to prevent or deal with it is necessary.

In most cases, specialist Physiotherapy input and hard work from you, is the best treatment option to help shoulder instability, whether due to an injury or not.

Physiotherapy helps patients regain their shoulder mobility and targets specific strengthening for the muscles that surround the shoulder to increase the stability. It also helps to retrain the brain, to coordinate and control shoulder movement and restore more normal movement patterns.

Please speak to a healthcare professional for guidance on how to improve your shoulder stability.

Timescales/ Prognosis

Recovery timescales vary depending on the cause of the problem, and whether or not this is your first dislocation.

First-time dislocations with no structural damage can improve within 3-6 months.

Patients will be advised to avoid heavy lifting and sports involving shoulder movements for between 6 weeks and 3 months.

You’ll probably be off work for 2 to 4 weeks, or longer, if you have a physical job. Discuss this with your physiotherapist or care team.

Surgery

There are procedures that can help and these usually work best in people who have had a specific injury and have clear damage to the structures in the shoulder – usually the labrum (the thickened tissue around the socket), or a specific ligament, or a certain type of damage to the bone in the shoulder.  Further imaging of your shoulder in this case would then be done to tell us what exact damage is there to repair.

Surgery can consist of key hole surgery or open surgery depending on the damage in your shoulder.

Surgery for instability isn’t perfect and carries risks. There is a chance your shoulder will dislocate again or continue to cause problems, including weakness, stiffness, giving way and pain. Infection, nerve and blood vessel injury are possible with a surgery, amongst other general risks.

If however after an extended period (minimum of 6 months) of specialist Physiotherapy input there is no improvement, surgery can be discussed to tighten up the joint.  You may require specialist Physiotherapy input post – operatively too.

When to speak to a health professional

Following a first time dislocation you will need to attend ED to have your arm assessed.  Do not try to pop your arm back in yourself – you could damage the tissues, nerves and blood vessels around the shoulder joint.  Following this your Orthopaedic doctor may refer you onto Physiotherapy for rehabilitation and guidance.

In atraumatic cases Physiotherapy is the most effective way to help improve your shoulder pain, movement and function. 

Your GP can refer you to Physiotherapy.  

Help And Support

If after following the above advice, your symptoms have not improved within 6 to 12 weeks, a referral to a physiotherapist may be beneficial.

You can access physiotherapy by any of the following:

Additional information

Acute Injury Management

POLICE is an acronym (Protection, Optimal Loading, Ice, Compression and Elevation) that is used as a management strategy for many injuries and conditions for the first 24 to 72 hours.

  • Protection and relative rest are advised immediately after injury for the first 24 to 72 hours.
  • Optimal Loading refers to having a balanced rehabilitation program which encourages early and gradual activity to improve recovery. How you progress will vary from person to person depending on the injury. It is about finding the injured areas happy place and increasing slowly and gradually.
  • Ice may be used for reducing pain and swelling. There are safety points to follow when you use ice:
    • Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound can increase the risk of infection.
    • Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes is usually adequate.
    • Apply crushed ice/frozen peas wrapped in a damp towel for 10-20 minutes, 2-3 times per day for the first 5-7 days post injury/ flare up of pain.
    • Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.
  • Compression and Elevation are helpful for reducing inflammation. This can be done by keeping your joint raised on a pillow and compressed by wrapping a bandage around it.
    Do not make the bandage too tight and do not wear tubi-grip or any compression bandage in bed at night.
  • Heat: After 2-3 days, you may find that heat is more relaxing.

You could use a heat pad or a hot water bottle with an insulated cover on it. Make sure this is not too hot and is not directly touching your skin.

You should do this for 10 to 15 minutes, 3 to 4 times a day.

What do I do if my symptoms flare up?

Flare ups of pain are common. Some people have recurrent flare ups of pain so it is important to know how best to manage these flare ups. In most cases a pain flare-up will settle within 6 weeks.

Top Tips

  • You will likely find it helpful to rest a bit more but it is still important to keep active. This will help to avoid becoming stiff and your muscles becoming weak.
  • If you aim to get a balance between rest and activity it should help your pain to settle down. You may be sore at first, however, start slowly and gradually increase the amount you do.
  • Reduce movements or tasks that aggravate your symptoms. This can help especially in the early days.
  • Adopting positions or movements that reduce your pain can be useful.

Pain Relief

Analgesia

  • Analgesia also known as pain relief can be an important part in helping you manage your symptoms and allow you to stay active.
  • Taking suitable pain relief regularly allows you to move more normally and continue your usual activities without causing any damage. It is unlikely that medication alone will resolve your pain totally. For this reason we are using the term pain relief (A 30-50% reduction in pain would be deemed to be a good success).

Paracetamol

  • Paracetamol is a good general pain management medication. It is used to help manage lots of different types of pain.
  • Sometimes people believe they need something ‘stronger’ than paracetamol when in fact, taking a regular dose rather than a one-off dose is more effective.
  • Spreading the doses of the paracetamol evenly out over a day will help you control your pain. Visit NHS Inform for more detailed information on paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

  • NSAIDs are medications that can reduce swelling around joints and nerve endings to give pain relief. They are particularly useful
    in treating inflammatory type pain. Two commonly prescribed NSAIDs are ibuprofen and naproxen.
  • Although NSAIDs can be very useful they are not suitable for everyone. Visit NHS inform for further information related to NSAIDs.

There are other forms of pain relievers available. If you feel your current pain relievers are not helping your pain or you are
experiencing any side effects from your medication, please seek advice from your GP or pharmacist.

For general information on medication visit NHS Inform.

Staying in work and returning to work

We know that staying in work or returning to work as soon as possible is good for your mental and physical health.

If you have problems with activities at work, it may be helpful to ask for a workstation/workplace assessment or talk with your manager or Occupational Health Department. This can help with alterations or provision of equipment or altering your working day or tasks.

There are organisations which can support you at work or help you return to work. You can visit Knowledge Scotland for further information.

Weight Management

Weight Reduction – People who are overweight tend to have more prolonged pain and poorer tissue healing due to increased levels of inflammation in the body. Reducing your weight can generally help improve the healing process.

A good indicator of whether you need to lose weight is your body mass index (BMI), which you can calculate with the NHS BMI calculator.

If your BMI states you are overweight or obese it is likely that losing weight will reduce your symptoms. Carrying extra fat also increases your risk of heart disease, stroke, type 2 diabetes, and some cancers. Reducing your portion sizes and eating a balanced diet can be helpful in reducing weight. NHS informs provides a free online 12-week weight management programme to get you started right away.

If you need a little more help and feel that you would benefit from working with others in group sessions NHS Lanarkshire’s Weigh to Go programme, groups in North and South Lanarkshire, will help you become more active, eat well and lead a healthier lifestyle.

Smoking

Smoking can affect how your body recovers from musculoskeletal problems. If you smoke then the good news is that by stopping smoking it can improve your health in many different ways. Giving up smoking is not something you have to do on your own. You’re twice as likely to stop smoking successfully if you get the right support from the NHS. There is a free NHS stop smoking service available in Lanarkshire to help you succeed.

Chronic Pain

Some people will have pain which persists beyond the expected time frame for their condition. For further information on this and how best to manage it please visit our Chronic Pain webpage.

Pain Association Scotland is a national charity that delivers professionally led self-management pain education in the community.

Active Health Programme

South Lanarkshire

Active Health is a programme for residents of South Lanarkshire living with long term conditions. Residents are referred via Acute, Physio & specialist nurses to a 10-week programme and then signposted onto a wide variety of mainstream physical activity, sport & outdoor opportunities.

South Lanarkshire Leisure and Culture have many active community opportunities as well as specialised referral programmes. Full details of the 20 leisure centres can be found on the SLL website. Contact details across South Lanarkshire or call 01698 476262 to find out the number of your local leisure centre.

Please contact your health professional to discuss this referral or contact SLLC on 01698 476262.

Contact details

North Lanarkshire

North Lanarkshire Leisure’s Active Health Programme in partnership with NHS Lanarkshire provides a range of supported programmes to help individuals realise the benefits of becoming more physically active whilst also assisting those who are recovering from minor or even more serious illness.

The Active Health Programme has both a General Programme where individuals can access the mainstream health and fitness programmes running within NL Leisure Venues including swimming, jogging, golf and more!

A Specialised Health Class Programme which requires a referral from a health professional, this option is available to individuals who require additional specialised support in taking part in physical activity and classes include Strength and Balance, Cardio I, Cardio II, Back Care and Macmillan Move More classes.

A health and social care professional can make a referral by using the Active Health referral form found at the bottom of the page in the link below.

Contact Details - Health & Wellbeing Information

Mental Wellbeing

It is very important to look after your own mental wellbeing. This can have an influence on your recovery or management of your Musculoskeletal problem. Visit our mental wellbeing page for more information.

Your Feedback – comments, concerns and complaints

NHS Lanarkshire is committed to improving the service it provides to patients and their families. We therefore want to hear from you about your experience. If you would like to tell us about this please visit our feedback page.

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