 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.
|
