Chronic shoulder instability and dislocation

Marc Darrow MD,JD

Many people call or email me with problems of chronic shoulder dislocation or subluxation. The main reason for their call or email is to see if our stem cell therapy or Platelet Rich Plasma therapy treatments may provide a realistic option to the shoulder surgery they are deciding on or are waiting for. Patients are typically not surprised when I tell them I am the usually the last call before surgery, the “hail Mary,” a final attempt to find something to help them that does not require surgery.

If you have received the surgical recommendation for chronic shoulder dislocations you have already been advised of the possibility of a 6 month post-surgical recovery, and, on top of that is the waiting time to get the surgery. You may also have been told that you should have a realistic expectation that a second surgery may be needed. This is based on how successful or not the first surgery was. You may not even know how successful the first surgery was until the limitations that may hinder you with your work or job performance can be truly determined post-op.

The initial dislocation and the damage it did to your shoulder makes you prone to future dislocations

When you initially dislocated your shoulder, you knew it. In addition to the pain, you saw when you looked down at your shoulder, your shoulder looked funny. Things were not where they were suppose to be. At this first event you may have been rushed to the emergency room or urgent care center and there your shoulder was put back where it belong. You may have even been given instructions on how to do it yourself next time to save yourself the trip to the emergency room or urgent care. However, if the initial shoulder dislocation was considered severe enough, doctors will debate whether or not to perform a surgery to prevent recurrence. If the patient in under 30 years of age, shoulder surgery is typically recommended because younger athletes and patients are much more prone to repeated dislocations than older athletes and patients.

So what if you chronically dislocate your shoulder and you chronically pop it back in? You will wear out the shoulder.

Many athletes or people who have physically demanding lines of work are either very eager to get surgery, because they are in off season, or they are reluctant to get a surgery because they are in season and the rehab maybe be extensive. For people who work year round at physically challenging work, they may not have the time for surgery, or even the ability to get one in a realistic timeframe. So these people wind up popping their shoulders back in, when they would pop out. The problem of course is too many times in and out, you will wear out the joint.

A study published in November 2020 (1) examined the problem of a collapsing humeral head (the ball of the shoulder joint) in younger patients with chronic neglected shoulder dislocation. The study’s main points are discussed below.

In this study, the patients had chronic subluxations and dislocations enough to warrant a surgery because the humeral head was collapsing from all the in/out wear and tear.Once the surgeons put the shoulder back in place. They then decided on how to keep the shoulder in place. Examined in this study were the five most popular surgical procedures:

Coracoid transfer or Latarjet procedure (bone from your shoulder blade is fused into the front of the shoulder joint socket to keep the ball in).
Capsulolabral reconstruction or Bankart repair. (Ligament reconstruction).
Arthroscopic Remplissage to repair Hill-Sachs (fracture, cracks and/or depression in the humeral head).
Putti-Platt procedure. Here surgeons will cut the tendon of the subscapularis muscle and reattached it to the humeral head. This, they hope, will help prevent future dislocations.
Acromio-humeral K-wire fixation. (Wire is wrapped around the bone to hold it together)

The doctors noted that the choice of open reduction (surgery to place your shoulder correctly in anatomical alignment) and stabilization technique for chronic anterior dislocation was highly variable between the different studies. (None of the surgical procedures showed itself any better than the others). This lead to a wide variation in the reported outcomes with high number of complications such as resubluxation and early arthrosis (developing a bone on bone shoulder). The conservative treatment of chronic anterior dislocation led to poor functional results. Let’s point out conservative care is rest, anti-inflammatories, pain medications and exercise or physical therapy.

Surgery success and failure of chronic shoulder dislocation

Surgery for shoulder separations can be effective for some but as always, surgery should be considered a last option because of issues of complications, down time (immobilization), and for the “weekend warrior,” or professional athlete, a weakening of the shoulder through the removal of and damaging of other connective tissue in the surgical process.

A study published in December 2020 (2) suggested that: “The rate of recurrence of anterior unidirectional instability is lower after coracoid bone-block than with other techniques, even if failures still occur with this difficult procedure. Failure may consist in recurrent instability (dislocation, subluxation, unstable painful shoulder) or despite absence of obvious clinical signs, in radiologic failure (non-union, fracture), biologic failure (osteolysis-weakened bone) or infection, all of which may require revision surgery or lead to late instability or subclinical chronic apprehension.

Clinical, X-ray and CT assessment identifies the type of failure and may lead to a second surgery being discussed with the patient according to functional demand. Technical error is often implicated and is generally due to deficient coracoid preparation, insufficient conjoint and coracoid tendon release or problems of positioning and fixing the bone-block on the glenoid. Although less effective, anterior capsule repair can also stabilize the shoulder when associated to posterior Hill-Sachs lesion remplissage by infraspinatus tenodesis. Osteoarthritis of the shoulder may set in after any surgical revision and impair the result.”

Treating chronic shoulder dislocations

The shoulder is made of a complex matrix of bone and soft tissue that allows it an extreme range of motion. But there is a price the shoulder pays for that range of motion. Greater risk for chronic injury. The shoulder is held together by soft tissue stabilizers lead by the ligaments that connect bone to bone. Over the course of time, especially in sports that involve heavy shoulder to shoulder contact such as hockey, lacrosse, football, wrestling and basketball, the ligaments stretch out and become “lax.” When the ligaments become lax, the risk for dislocation and separation becomes greater.

Shoulder dislocation alternative treatments. Addressing the ligaments.

The key to avoiding shoulder surgery or devastating shoulder separation requiring surgery is to strengthen the shoulder capsule. This can be accomplished by working the strong shoulder muscle group and/or by treating the weakened shoulder capsule Platelet Rich Plasma therapy or stem cell therapy.

To understand the importance of the need of strong ligaments to hold the shoulder together, the patient needs to understand that the severity of shoulder separation injury is measured by the degree of injury to the ligaments.

The acromioclavicular (AC) and the coracoclavicular (CC) ligaments hold the shoulder together at the point where the collarbone (clavicle) and the end (acromion) of the shoulder blade (scapula) meet.

In type I level separation the AC is partially torn, the CC is not.
In type II separation the AC is completely torn, the CC is partially or not torn
In type III separation both ligaments are completely torn.

Obviously the more significant the tearing, the longer the athlete or worker is out of their sport or off from work.

Stem cell treatments be an option?

I see people who have had a shoulder surgery, they rehab for a year, the shoulder still hurts, it still pops out. They have another shoulder surgery, they rehab for one year and the results remain limited. If this person has a lot of inflammation, cortisone injections will be given to see if a third surgery can be avoided.

Can stem cells fix a bad shoulder?

The Darrow Stem Cell Institute has published research on the treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow derived stem cells. The research appears in the peer-reviewed journal Cogent Medicine. The study can be found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date.

An extended summary can be found here on our website: Treatment of shoulder osteoarthritis and rotator cuff tears.

The learning points of this research are as follows:

Patients who received either one and two treatments of bone marrow derived stem cells reported significant improvements in resting pain, active pain, and functionality score when compared to baseline.
These groups also experienced a 42.25% (one treatment) and 50.17% (two treatments) overall improvement respectively.
The group that received two treatments experienced statistically significant improvements in active pain when compared to the group that received one injection.
There were no significant outcome differences between rotator cuff tear and osteoarthritis patients.

Conclusions: Our study demonstrated that patients diagnosed with shoulder osteoarthritis or rotator cuff tears experienced symptomatic improvements in pain and functionality when injected with bone marrow concentrate (BMC) or whole bone marrow (WBM) . Further randomized control studies are needed to validate these findings.

More information on these treatments can be found in my articles:

References:
1 Sahu D, Rathod V, Phadnis A, Shyam A. Results and complications of head preserving techniques in chronic neglected shoulder dislocation: a systematic review. Journal of Shoulder and Elbow Surgery. 2020 Nov 14.
2 Métais P. Failure of coracoid bone-block. Orthopaedics & Traumatology, Surgery & Research: OTSR. 2020 Dec 12:102782-.

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