Doctors at the Department of Orthopaedics, Catholic University, Division of Orthopaedic Surgery, A. Gemelli University Hospital, in Rome, wrote in the medical journal Joints the following observations about shoulder laxity and instability:
Generalized joint laxity (looseness) and shoulder instability are common conditions that exhibit a wide spectrum of different clinical forms and may coexist in the same patient.
Laxity is a physiological condition (a disruption in the regular movement of the shoulder) that may predispose to the development of shoulder instability.
A high prevalence of generalized joint laxity has been identified in patients with multidirectional instability of the shoulder. Multidirectional instability is defined as symptomatic instability in two or more directions.
The diagnosis and treatment of this condition are still challenging because of complexities in its classification and etiology.
These complexities are compounded when multidirectional instability and laxity exist in the same patient. With an improved understanding of the clinical symptoms and physical examination findings, a successful strategy for conservative and/or surgical treatments can be developed.
Conservative treatment is the first-line option. If it fails, different surgical options are available.
The correct approach to the management of failed stabilization procedures has not been yet defined.1
In this article we will discuss non-surgical and surgical treatments for various shoulder injuries.
Shoulder pain is one of the most common reasons patients give for a physician visit, third only to headache and back pain. The incidence of shoulder pain is escalating, especially among office workers with intensive computer use.
The shoulder was uniquely designed by God to have tremendous mobility. The shoulder enables a person to scratch the head, between the shoulder blades, and even the back without pivoting anything but the shoulder. The lack of big ligamentous structures supporting this joint allow its mobility. The shoulder, when abducted and externally rotated, is more vulnerable to injury due to a lack of bony and ligamentous stability in this position. The primary support for the shoulder involves the rotator cuff muscles, which also move the shoulder. People who frequently abduct and externally rotate their shoulders, especially athletes such as pitchers, gymnasts, tennis players, quarterbacks, swimmers, and volleyball players, are prone to chronic shoulder problems. Any activity done with the hand away from the body involves some sort of shoulder abduction and external rotation.
A shoulder that crunches and “pops out of joint” is unstable, and is always a sign of weakness in the joint. People who suffer from this condition will feel their shoulders coming out of the sockets when they abduct and externally rotate them, because the ligamentous and bony support of the joints is minimal in this position. When this occurs, a person is said to have shoulder subluxation or instability. This diagnosis can be confirmed by abducting and externally rotating the shoulder and pushing the arm forward from the back. In the case of anterior shoulder instability, a positive “frighten sign” will be displayed on the patient’s face; the patient is afraid his or her shoulder is going to dislocate.
Traditional treatment for shoulder instability is rotator cuff strengthening exercises, specifically of the supraspinatus muscle, the primary muscle responsible for the external rotation of the shoulder. The rotator cuff is a group of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. The rotator cuff muscles help stabilize the shoulder and assist with movement. Rotator cuff strengthening exercises help strengthen shoulder muscles but often do not cure the underlying problem of shoulder instability: joint laxity.
To cure shoulder joint instability, the ligamentous and shoulder capsular structures must be strengthened. The main capsular structure involved in the stability of the shoulder is the glenoid labrum, which holds the humerus bone to the glenoid cavity of the scapula. A shoulder is usually unstable because the structures are torn or stretched. Once these structures are stretched or loosened, no amount of exercise will strengthen the shoulder joint enough to permanently hold it in place.
LESIONS OF GLENOID LABRUM TREATED WITH PROLOTHERAPY
The advantages of using Prolotherapy versus surgery for labral tears:
- Prolotherapy requires no general anesthesia.
- Prolotherapy does not involve big scopes in the joint.
- Prolotherapy does not typically require time out of work.
- Prolotherapy accelerates the return to athletics.
- Prolotherapy is a fraction of the cost of surgery.
- Prolotherapy risks are minimal.
- Prolotherapy can treat all the injured structures.
- Our glenoid labrum lesion study did show that Comprehensive Prolotherapy eliminated 69% of the symptoms in patients with lesions, primarily tears of the glenoid labrum.5 The patient-reported assessments were taken 16 months after their last Prolotherapy session. Treated patients reported highly significant improvements with respect to pain, stiffness, range of motion, crunching, exercise and need for medication. Only 1 out of the 33 shoulders treated experienced a worsening of symptoms. P r o l o t h e r a p y should be the treatment of choice for labral tears. Surgery is needed on rare occasions, and should be a last resort.
1 Saccomanno MF, Fodale M, Capasso L, Cazzato G, Milano G. Generalized joint laxity and multidirectional instability of the shoulder. Joints. 2013 Oct;1(4):171. [Google Scholar]