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Caitlin Whyte: Hello and welcome to Check-Up Chat with EvergreenHealth. We have Dr. John Manning, an orthopedic surgeon with us here today to talk about shoulder instability, an often painful condition involving the strange sensation of the shoulder giving way. Dr. Manning, welcome and thank you so much for joining us on Check-Up Chat. To start, can you tell us a little bit about yourself?

John Manning M.D.: I'm an orthopedic sports surgeon, and what that means is that I take care of a lot of athletic injuries, things that people sustain playing sports or being active, living an active lifestyle. Injuries often come up and that's what I treat as far as my profession. I'm active myself. I have a couple young kids that keep me outside and moving outdoors, and I also have an active outdoor lifestyle, a lot of hobbies and sports that I enjoy.

Caitlin Whyte: So, Dr. Manning, most folks at home likely hear about a condition like shoulder instability and think it doesn't sound terribly serious. So, what is shoulder instability?

John Manning M.D.: Yeah. So, shoulder instability actually in a lot of ways can be better summed up by just saying shoulder dislocation. At least, that's one subtype of shoulder instability that we see more commonly from a sporting injury. So, anytime an athlete or someone you know sustains a shoulder dislocation that can become recurrent where it happens again and again. And that's the term we use to describe that shoulder instability.

Now, there's also a sort of a lesser traumatic version of shoulder instability that's maybe not a true frank dislocation of the shoulder, but where the shoulder can feel loose due to some sort of overuse and injury to a structure we call the labrum that can happen with certain types of exercise and work types.

Caitlin Whyte: Now, because it often involves the ligaments being stretched or torn, are there certain things that are more likely to cause shoulder instability, like certain activities or exercises?

John Manning M.D.: Yeah. You know, the most common type of exercise or sports that cause shoulder dislocations or shoulder instability are contact sports. So, this is something we see in the younger athletic population playing football, soccer, basketball, wrestling, lacrosse, rugby, those sorts of sports are higher risk because there's a lot of collision and high speed energy being transmitted through the arm and the shoulder. And those are usually what cause those types of dislocations.

And as far as ligaments being torn, so typically what is actually torn is a structure called the labrum. And it's a soft tissue structure around the shoulder joint that helps stabilize the shoulder and keep the shoulder in place. And once that's disrupted, that can sometimes require being treated specifically to stabilize the shoulder once again to prevent future dislocations.

Caitlin Whyte: Well, let's talk about patients who are at risk. Is age a factor and what are some ways that you've seen the condition impact your patients?

John Manning M.D.: Age is certainly a factor. It's one of the major risk factors. When a very young athlete sustains a shoulder dislocation, their likelihood of recurrence is much higher than someone in their third, fourth or fifth decade of life. And that's because of anatomic factors. The younger population probably has a little bit more laxity in their joints to begin with, and so the risk of recurrence is higher there. But the main reason is that younger people participate in higher risk activities, so they're playing some level of competitive sports. And going back to that level of sports can be a risk in itself. The high risk sports are the ones that have a lot of collision activity. And then, there are other factors regarding the patient that contribute as well, such as laxity in their soft tissue. So, people that are really stretchy, just by the way they're built can be at risk and their age, as you mentioned, younger is a higher risk factor.

Caitlin Whyte: Now, are there any preventative steps that folks can take? Is there a way we can lower our risk of tearing the ligaments without altering, you know, all our everyday activities?

John Manning M.D.: Sure. The strength of the shoulder or the dynamic stability of the shoulder is incredibly important in preventing recurrence of dislocation and even initial dislocation. So having, you know, a strong shoulder girdle, so the rotator cuff muscles, the deloid muscles, all the muscles around the shoulder blade or the scapula, they all factor into the way the shoulder is mechanically used. And if those muscles and their tendon units are all strong due to, you know, strengthening and stabilizing exercises, that can help prevent the shoulder from dislocating or having instability.

Caitlin Whyte: So, doctor, would you say shoulder instability is difficult to diagnose? Is there a risk that a patient may think they've simply dislocated their shoulder without realizing that ligaments are torn?

John Manning M.D.: It's usually fairly easily diagnosed, particularly in the setting of a true dislocation. That patient usually presents to an emergency department in order for some, you know, provider or emergency personnel to actually put that shoulder back in place, a procedure called a reduction.

In the absence of a shoulder being stuck out, so a patient who might feel like they dislocated and maybe it popped back in on its own, it's maybe a little bit harder to diagnose. However, I can usually determine that on a quick physical exam and with use of some basic x-rays, some instances of the sort of pseudoinstability in the shoulder where they aren't frank dislocations, but the shoulder is moving excessively, that can sometimes require a little bit more sleuthing and physical exam, combination with x-rays and possibly an MRI arthrogram in which we take a close look at those structures inside the shoulder, such as the labrum and the glenohumeral joint ligaments to see if they've been injured.

Caitlin Whyte: Well, in terms of treatment, what kind of options are there for someone with shoulder instability? And at what point would you move from those non-surgical options to surgery?

John Manning M.D.: Yeah, so the treatment for shoulder instability varies depending on the patient's risk factors for recurrence typically and their age, the type of sports they play. Initially, after a first time dislocation, many patients are potential candidates for non-surgical treatment with physical therapy and strengthening up the muscles around the shoulder to help the shoulder heal and to be firm, and it's basically tightening things up in a way that will allow them to get back to their lifestyle without dislocating the shoulder again.

However, there are patients that have recurrence of this, and that's the problem we try to avoid. But once recurrence has happened, especially in a patient that's trying to play sports or any sort of high risk activity for further dislocations, the treatment actually has progressively become more and more surgical. And we've found that with every dislocation, there's increased risk of more dislocation and potentially further damage to important structures in the shoulder and the shoulder's long-term health down the road. So, in that patient that's going to have high risk of recurrence, we really do err on the side of surgical treatment and that decision is made based on their age, their sports, the imaging findings, and there are various surgical procedures that we use to restabilize the shoulder.

Caitlin Whyte: Well, then what does recovery look like following the operation? Is there any chance of the condition coming back?

John Manning M.D.: So, recovery after a simple arthroscopic labral repair, which is kind of the standard treatment for a dislocation that doesn't have any major bony injury with their dislocations, would be something along the lines of maybe five, six months before they're getting back into a competitive sport or a contact sport.

Now, they're getting back to their normal daily life in, you know, a month or two where they're going about day-to-day, you know, activities and not wearing a sling and doing simple things, but actually getting back to the level of athletics they previously did will require further strengthening, getting all their range of motion back, and that can take quite some time.

Now, with some of the more involved surgeries where we have to restore some bony anatomy, the recovery can be a bit longer just because the shoulder could be a bit stiffer initially and require a longer period of time to get back on the field and rehabed.

Caitlin Whyte: Well, wrapping up Dr. Manning, if left untreated, are there serious more long-term effects of letting the condition continue?

John Manning M.D.: That's the main reason for the treatment really, is the longevity of the shoulder and the long-term consequences of potentially having recurrence. As I mentioned before, every dislocation or every incidence of partial instability can cause the shoulder to be, one, at risk of more instability and more dislocations and, two, damage to the particular cartilage, which is that smooth gliding surface in the shoulder that allows you to use the shoulder. And when that gets injured or worn away, that predisposes people to getting arthritis in the shoulder.

And in neglected cases where patients don't get surgically stabilized and can have many, many dislocations, they can start having shoulder arthritis at very young ages, which is a very challenging condition to treat, and a very challenging condition to deal with as a patient. So it's an important thing to be seen and evaluated for really after even just that first dislocation, just to get an understanding of what has been injured and what are the chances of recurrence and, you know, what can we do to mitigate this or treat this.

Caitlin Whyte: Well, Dr. Manning, thank you so much for being with us today and for sharing all this great information. You can call 425-899-4810 to schedule an appointment with the Collaborative Arm and Shoulder Care Team at EvergreenHealth, where you'll find advanced care that fits your needs. This has been Check-Up Chat with EvergreenHealth. I'm Caitlin Whyte. Stay well.