Dr. Miller: Shoulder instability - how do you get that, and what can you do about it? We're going to talk about that next on Scope Radio.
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Dr. Miller: Hi, I'm here with Dr. Pat Greis. Pat's a professor of orthopedic surgery in the Department of Orthopedics here at the University of Utah. Pat, what the heck is shoulder instability and how does somebody get that?
Dr. Greis: Well, shoulder instability is when the shoulder actually comes out of the joint. And often when it does that, it stays there.
Dr. Miller: Is that another fancy name for dislocated shoulder?
Dr. Greis: That is what it's called. Dislocated shoulder, often see it in our skiers and our football players and others.
Dr. Miller: Skiing, that's right, I've had it myself from a good fall on hard snow. Do you see it mostly in sports-related injuries?
Dr. Greis: Yeah, it's a common injury for athletes, and then other people who are just unlucky, falling off ladders, other injuries. Certainly does happen that way too.
Dr. Miller: Tell me a little bit about . . . are there degrees of shoulder instability, and how do you know if you have shoulder instability? Is it just pain?
Dr. Greis: Shoulder instability, the classic would be the dislocation, where the shoulder actually comes all the way out of the joint. There are some who injure their shoulder and then have subluxations, where the shoulder just slides a little bit but doesn't come all the way out. So you can have either. Obviously, both can cause symptoms that people find difficult to live with.
Dr. Miller: Primarily pain or function?
Dr. Greis: It's a little bit of both. Obviously function, when the shoulder comes out, that's usually the end of the day for whatever athletic event you're participating in. Like in our football players, they dislocate their shoulder . . .
Dr. Miller: That's game over.
Dr. Greis: That's game over for them. So it's either the docs or the trainers have to pop it back in, and then pretty sore shoulder for the next couple weeks.
Dr. Miller: Well now, if you have a state where the shoulder's out or dislocated and doesn't come back in, you treat that acutely, right? So they can . . . I guess maybe on the sidelines, or do you have to go to an ED to have the shoulder put back in? I know everybody talks about using a towel in the locker room, a lot of screaming, and is that true, or?
Dr. Greis: You can watch movies and see Mel Gibson hit his shoulder against the wall, but that's not recommended. Clearly if the shoulder's out and stays out, that usually results in a trip to the emergency room. There are some techniques that don't require sedation, where people can get their shoulder slid back in. But often in the emergency room with some pain medication, the medical maneuvers of the shoulder, they can get the shoulder to be popped back in, at which point we then have to decide what to do over the next couple weeks.
Dr. Miller: And what generally do you do?
Dr. Greis: For the first time dislocator, it's common that we treat them non-surgically. You do a period of immobility while they're real sore, do a rehabilitation program.
Dr. Miller: You put them in a sling?
Dr. Greis: Sling for a while, realizing that after the first dislocation there's a chance that it'll happen again. And it's a bit of an odds game depending on age and activity, whether or not that risk is high or low.
Dr. Miller: So I suspect that physical therapy probably comes into the treatment.
Dr. Greis: It does, unfortunately a therapy program probably doesn't eliminate the chance that it's going to redislocate. In a young, active, athletic individual, there's still a pretty high chance that if they return to those activities, they can redislocate their shoulder down the road.
Dr. Miller: So this brings to mind a question: if you have a shoulder dislocation, let's say it's treated in the emergency department acutely and the pain goes away and you are an athlete, you're a student athlete or even a professional athlete. Should you seek treatment from someone like yourself, or evaluation from an orthopedic surgeon or a sports medicine physician because of this potential for recurrent injury?
Dr. Greis: I think that's important. I think the discussion on options is a very reasonable thing. We treat many people non-operatively, but on occasion we will treat an athlete or certain individuals after their first time dislocation. And that can be to prevent recurrence, perhaps during the next season, which is coming up in six or nine months, so treating it now decreases the odds they would have a problem down the road. And there's times where with the dislocation there may be a fracture of the front of the socket, that fixing it early would be advantageous.
Dr. Miller: What would you say the percent of time this requires surgery, dislocation or instability requires surgery?
Dr. Greis: That's a tough question because it really does depend on the patient's age and activity. A young individual, 16 to 18-years-old who's very active might have a 70, 80% chance that they'll have a recurrent dislocation. So we can be very aggressive with those folks. Someone in their 40s who dislocates and doesn't have any other major damage to the rotator cuff may only have a 10% chance. And so, you know, same injury doesn't always get the same treatment, it depends on the person, their desires, their activities. So there's a lot of factors that play a role.
Dr. Miller: How do you advise an athlete on what to do after a shoulder injury if they are prone to recurrence, separation or instability? And you mentioned a minute ago that you're sort of counseling them on the fact that this can happen again. I mean, are you also telling them to avoid certain things that they're doing as an athlete? Or just tell them, "Look, this may happen again, so beware."
Dr. Greis: Yeah, I think I try to educate them, counsel them, you know, it's not realistic to think that an 18-year-old's going to modify their life. I just think that's something that's not going to happen.
Dr. Miller: I'd agree with that.
Dr. Greis: Right. So you have to educate them. If we were to say an 18-year-old football player has an 80% chance that over the next 2 years they'll redislocate, and they're nine months away from their football season, well you might say, "Surgery now might make that risk only 5 or 10% down the road." So an acute surgery might be in the cards for that kid. In-season, it's another issue. If it's the start of the football season and they want to play, then we have to talk about how do we manage potential shoulder instability during the football season to try to get them through, realizing that if they have recurrences we may have to pull the plug and have them miss the rest of the season.
Dr. Miller: So in summary, student athletes, athletes, professional athletes tend to have, especially in contact sports, run a higher risk of developing acute shoulder instability to the point that it's painful and not functional, might need to be manipulated back into place. But also I think you mentioned that there's an important piece in that athlete being seen by a professional who deals with sports problems in terms of anticipating what might happen in the future.
Dr. Greis: Yeah, I think that's the important thing, is educating them, trying to give them the options, because at the end of the day it really is about what their wishes are. There's pluses and minuses of being more or less aggressive with this type of an injury. And jumping in early might be right for one but might not be right for everybody.
Dr. Miller: Individualized care. That's what we do.
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