Because of the complex composition of the shoulder, you can position your arms and hands basically anywhere in space. But, for the very same reason, your shoulder is one of the easiest parts of your body to injure.
One of the most common of these injuries is shoulder instability or “shoulder looseness.” Since the shoulder is a ball and socket joint (where the top of your upper arm is the ball), an area of your body called the shoulder girdle is responsible for keeping the shoulder in place. It does this with the help of a round rim of fibrocartilage called the labrum and several ligaments. The labrum has the same effect on the shoulder as the rounded lip of a golf tee has to a golf ball. That is, the labrum helps the shoulder from slipping out of its joint. The ligaments also aid in keeping the shoulder stable and in joint.
When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. Two common ways this can happen are from sudden dislocation (often from a trauma such as falling on an outstretched arm) and repetitive strain (overuse injuries, etc). Both of these injury types lead to stretching and/or tearing of the labrum, causing joint weakness. This makes the labrum too loose to keep the shoulder in the socket while moving or adjusting into certain positions, creating overall instability of the shoulder. If one or more of the ligaments are torn, this can cause the loose or unstable feeling as well.
The following are frequently asked questions regarding Shoulder Instability:
Q: How will I know if my shoulder is loose?
Depending on the severity of the loose shoulder, you might not even notice it. Sometimes a loose shoulder only feels like a gentle popping when the shoulder is moved in certain ways, others feel their shoulder slide in and out of the joint at times. As looseness persists, you will find that you experience dull to severe pain when you try to move your shoulder. For athletes, particularly those who frequently use an overhead throwing motion (such as baseball pitchers), loose shoulders cause a decrease in power that is immediately noticeable. There is also a genetic condition called Ehler’s Danlos Syndrome that can cause loose or hypermobile joints. This is a connective tissue disorder that gives your joints increased elasticity.
Q: What is a shoulder labral tear?
The labrum is a pear-shaped bumper of cartilage that is attached to the shoulder socket rim, where the ball shaped humerus head fixes into the depression (glenoid) in the shoulder blade. This acts to keep your shoulder joint fixed and stabilized along with several ligaments.
Q: How do Shoulder Labral Tears occur?
The fraying and tearing of your labrum may be due to the wear and tear that comes naturally with age, or it could also result due to injury and/or stress to your shoulder. Other factors that contribute to shoulder labral tears include:
- Car Accidents
- Repetitive Overhead Activity
- Shoulder Dislocation
Labral tears can fall into any of the three following categories, based on the location of the tear. The categories are:
- SLAP Tears: A Superior Labrum from Anterior to Posterior (SLAP) tear is most commonly seen in overhead throwing athletes, and results from damages done to the top of the labrum.
- Bankart Tears: A Bankart tear occurs during a shoulder dislocation—when the shoulder comes out of joint, the labrum is torn, and the shoulder is more susceptible to future dislocations.
- Posterior Labral Tears: Posterior Labral tears occur when the rotator cuff and labrum are pinched together in the back of the shoulder.
Q: What are the symptoms of Labral Tears?
Symptoms of labral tears and shoulder instability include:
- Pain in the shoulder joint
- Unstable feeling during shoulder movement
- Locking and catching sensation in the shoulder joint
- Limited overhead activities
- Loss of shoulder strength and range of motion
- Loss of velocity when throwing
Q: How is a Labral Tear Diagnosed?
The best way to diagnose a labral tear is seeking an evaluation from an Orthopedic Physician. They will perform a clinical exam to evaluate for a tear. In order to do an evaluation, the Physician will perform several common orthopedic special tests that indicate a labral tear could be present. If the physician suspects a labral tear, further imaging is needed to confirm the diagnosis. Further imaging in the form of an MR arthrogram is typically ordered. The MR arthrogram is a little different than a typical MRI because dye is injected into the affected joint. This dye adds to the imaging test because the fluid from the dye can sneak under the tear and make it easier to detect on the images. This is the best way to interpret a labral tear short of having surgery.
Q: How is shoulder instability treated?
Instability can be treated with nonsurgical treatment (conservative) or surgically. Typically a course of conservative treatment will be tried before surgery is recommended. Nonsurgical treatments for shoulder instability can include:
- Lifestyle Changes
- Avoid the aggravation of current symptoms
- Anti-Inflammatory Medicine
- Cortisone Shots
- Physical Therapy
Q: What are some exercises I can do at home to help prevent shoulder instability?
First and foremost, shoulder instability is best prevented with resistance strength training—exercises that will help strengthen the muscles in your shoulder to maintain optimal joint stability. The OrthoInfo website is a good reference for information and exercises regarding instability.
Below are some of the exercises you can do to start improving your overall shoulder stability:
- Standing Rows
- External Rotations
- Internal Rotations
- Bent-Over Rows
Q: When is it Time to Consult an Orthopedic Physician?
If your shoulder pain persists despite at home treatment or conservative treatment from your Primary Care Physician, it is best to consult with an orthopedic surgeon to find out your options. Some of the potential surgical procedures to remedy labral tears are as follows:
- Labral Repair: this is an arthroscopic procedure that is used to either repair or debride the tear. A debridement involves removing frayed edges and any loose parts that get caught when your shoulder is moved—especially in smaller tears of the labrum. When your tear is large enough, suture anchors and heavy sutures are used to reattach the labrum to the socket. Doing this procedure arthroscopically helps minimize the incision size and cause less damage to the normal tissues surrounding the joint—leading to faster healing and recovery.
- Capsular Shift: this arthroscopic procedure is performed to tighten the joint capsule in the shoulder. In this procedure, your physician will tighten the capsule, and the ligaments that stabilize the shoulder together, in order to better stabilize movements in the shoulder joint.
- Latarjet Procedure: this open procedure is done when the shoulder socket experiences bone loss due to repeated dislocations. A small bone graft is taken from another part of the shoulder and placed into the worn away area of the shoulder socket. Once in the appropriate place, the bone graft is affixed to the worn area using screws to secure the graft in place.