Oskars Bartulis suffered a shoulder injury in last Tuesday’s overtime loss to the Phoenix Coyotes after a late hit when, then Coyotes forward, Scottie Upshall sent Bartulis head and shoulder first into the boards. Bartulis left the game and did not return. The next injury update on Bartulis left many fans scratching their heads when they heard that he was out indefinitely with left shoulder “instability” and would likely need surgery. What’s up with that, you ask?
The shoulder is an awesome joint. It is blessed with incredible range of motion to allow you to raise it above your head, reach behind you or in front of your body and rotate. People will often refer to the shoulder joint as a “ball and socket” joint. The extensive range of motion of the shoulder makes it especially prone to dislocation and subluxation. A dislocation usually occurs as a result of trauma to the joint and should not be confused with a separated shoulder, which I wrote about previously.
The ball of this ball-and-socket joint is the head of the humerus (upper arm bone) and the shoulder blade creates the shallow socket. Because the socket is fairly shallow, the socket is lined with cartilage, called the labrum (just like the hip); to deepen the socket and the ball is held into place by strong, fibrous tissue that surrounds the joint, called the joint capsule. Think of the joint capsule as a kind of ligament system that attaches the humerus to the shoulder blade. The joint capsule is reinforced by the strong tendons and muscles that also surround the joint.
Shoulder instability is usually the result of one of three things: traumatic dislocation, repetitive strain and multidirectional instability. I am not going to discuss repetitive strain and multidirectional instability.
An injury or trauma is often the cause of an initial shoulder dislocation. The most common type of dislocation is an anterior dislocation. Posterior dislocations, or dislocation towards the back, only comprise a small percentage of all shoulder dislocations. During an anterior dislocation, the ball slips completely out of the socket to the front. Anterior shoulder dislocations commonly cause damage by stretching or tearing the joint capsule and the tendons or muscles. A partial or incomplete dislocation is called a subluxation. The damage to the labrum or cartilage in an anterior shoulder dislocation is called a Bankart tear and will usually happen in a first time dislocation in people younger than 30. The portion of the labrum that is damaged is often referred t as the glenohumeral ligament. Dislocations that result in a Bankart tear cause significant pain, swelling, and subsequent shoulder dislocations or subluxation as well as the shoulder “giving out” or a feeling of instability in the shoulder.
Many times dislocations will have to be reduced or put back into place and there are a few methods used for this. If you are thinking Mel Gibson’s character in Lethal Weapon, think again. There is almost always a risk of nerve damage with traumatic shoulder dislocation and many people can experience a “dead arm” sensation or they may have numbness and weakness of some of the surrounding skin and muscle. Because of the possibility of significant damage to the nerve, reducing a dislocated shoulder may require sedatives to relax the athlete or patient and the muscles to allow the head of the humerus to slip back into place.
After a dislocation athletes may complain of an uncomfortable sensation that their shoulder may be about to slide out of place–this is what physicians call apprehension. Someone who has suffered a shoulder dislocation will usually object to putting their arm and shoulder in certain positions because they feel that it will pop out of place again. After a physical assessment, x-rays or MRI may be done if there is a suspicion of a Bankart tear. An x-ray will sometimes show evidence of an injury to the bone when there is a Bankart tear present and sometimes a piece of bone is pulled away with the ligament. An MRI to evaluate the possibility of a Bankart tear usually requires an injection of contrast into the joint.
Athletes under the age of 25 are most likely to sustain a Bankart injury if their shoulder dislocates and are likely to have a repeat dislocation. Repeat dislocation rates in these younger athletes range from 75-90% chance. In a Bankart repair, any frayed or torn edges are usually trimmed. Holes for sutures are drilled into the scapula bone and sutures then secure the labrum back to the bone. The ligaments heal, and scar tissue eventually anchors the ends to the bone to restore stability. An open Bankart repair is done through an incision on the front of the shoulder. Some surgeons prefer using an arthroscope.
Surgery may be delayed for around 2 weeks to give the swelling a chance to go down as well as allowing any bleeding in the joint to resolve. The time leading up to surgery is utilized to reduce pain and swelling. If you are thinking Rest-Ice-Compression, pat yourself on the back! Bankart repairs require a lengthy recovery time because rehabilitation usually progresses slowly. Recovery and rehabilitation of this injury and surgery is not easy and usually takes 6 months or more for even high level athletes to return to their prior form. The day after surgical repair, the athlete usually begins range of motion exercises in the hand wrist and elbow and they can usually use the effected arm to write and eat within a week. Physical therapy starts 1-4 weeks after surgery and full range of motion usually is achieved in 6-8 weeks. Strength is built over a period of about 3 months and then rehabilitation focuses on sports specific training. After surgery, the recurrence of instability, dislocation and subluxation, is very low.
Sometimes instability occurs in the absence of a Bankart tear. In this case, the capsule is usually loose and does not hold the head of the humerus securely in place. In these cases, the capsule may simply be tightened up to stabilize the shoulder. Recovery is usually much easier than that of a Bankart repair.
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