Treating Patients with Multidirectional Shoulder Joint LaxityHave you ever wondered how some people can put their leg behind their head or use their clasped hands together like a jump rope? How can anyone move like that without dislocating a joint? Most likely those individuals have something they are born with called joint hyperlaxity. The condition is considered congenital because it is present from birth throughout life.
Joint hyperlaxity means the soft tissues around the joint that usually hold it in place are extra long and very elastic. Without those restraints, the joint can slide and glide all over the place. The end result is the ability to move and rotate joints in all directions without dislocation.
Can those joints be dislocated? Yes they can but it doesn't happen very often. Shoulder instability in people with joint hyperlaxity is the subject of this report. Surgeons from the Shoulder Injury Clinic from England review the latest ideas about shoulder joint hyperlaxity.
They discuss what can happen to cause a hyperlax joint to become unstable, how surgeons can assess patients with this type of problem, and treatment for shoulder hyperlaxity with instability. Both nonoperative and surgical procedures are presented.
Shoulder hyperlaxity with instability is different from chronic shoulder instability from a traumatic dislocation. Usually, a shoulder that has dislocated does so in one direction (forward most often). This is called a unidirectional laxity. That's the direction it will tend to dislocate again. Hyperlax joints have multidirectional laxity (excess motion in all directions not just one direction).
That is one major difference between traumatic versus hyperlax instability. Another is the fact that with a traumatic injury, there's often damage to other soft tissue structures that help support the shoulder. With congenital hyperlaxity, there's nothing wrong with the supporting soft tissue structures or the underlying bone.
There is actually a third group of people who fall into shoulder problems from hyperlaxity. That group is made up of athletes who use their shoulder(s) over and over and over causing the soft tissues to stretch out too much. Overuse or overtraining often only affects one direction of shoulder motion making this a problem of unilateral hyperlaxity.
What can be done about shoulder instability associated with joint hyperlaxity? Sometimes nothing needs to be done. The patient modifies or changes his or her activities to avoid problem motions or activities and all is well.
In other cases, it's necessary to modify activities and see a physical therapist. The therapist can provide a program of exercises to help strengthen the muscles around the joint. Strong muscles help stabilize loose joints. The patient with multidirectional shoulder hyperlaxity must follow the prescribed program for at least one year with a maintenance program that should be carried out for the rest of life.
When a long period of time passes and conservative care doesn't help, then surgery may be needed. Before surgery is done, the surgeon does a thorough examination. The patient history is taken. This includes things like what's wrong, how did it happen, what makes it better/worse, what other health problems are present? Symptoms are reported and recorded.
Various tests are conducted to get a complete picture of what's going on. Where are the areas of weakness and imbalance? Any abnormal patterns muscle activation or movement are identified.
Tests for ligamentous laxity, directional instability, and motion are conducted. The strength and condition of other joints and soft tissues around the shoulder are also tested. Surgery for patients with structural abnormalities of the shoulder will address those imbalances.
There are several different ways to surgically treat multidirectional instability and hyperlaxity. Capsular shift, capsular plication, and thermal capsulorraphy are the techniques used most often. The procedures are usually done arthroscopically at a special shoulder unit by a surgeon who has advanced training in this type of treatment.
The capsular shift procedure is a bit like a tummy tuck. Incisions are made so that the excess tissue can be pulled up and tightened. Different types of incisions and incision patterns can be used depending on where the greatest laxity is located.
With the plication procedure, excess capsular material is pinched and tucked to form pleats. It's like taking in the waistband on a pair of pants or a skirt that is just too big. The surgeon attaches the pinched pleat to the stiff labrum (fibrous rim around the shoulder joint). This procedure must be done in such a way that the folds of extra tissue don't get pinched during shoulder motion.
And the last procedure thermal capsulorraphy uses heat to shrink the shoulder capsule. Results from this technique have not been very good, so the method is not recommended much anymore.
The authors conclude that it can be a challenge finding a balance between stability (keeping the shoulder in the socket) and mobility (having the motion needed for everyday activities and sports) for patients with multidirectional shoulder instability from joint hyperlaxity. But there is treatment for those who need it.
When surgery is part of the plan of care, patients who have gotten used to the extra motion must be counseled to prepare for a change in how the arm moves. This is especially true for athletes who have come to depend on that extra motion.
For those individuals who gain attention by showing how they can dislocate their shoulder or by moving in unusual ways, removing that ability may have some psychologic effects. Surgeons treating these patients are advised to carry out honest presurgical counseling about what to expect and how to adjust to the changes.
Simon M. Johnson, BSc, MRCSEd, and C. Michael Robinson, BMedSci, FRSCEd(Orth). Shoulder Instability in Patients with Joint Hyperlaxity. In The Journal of Bone and Joint Surgery. June 2010. Vol. 92-A. No. 6. Pp. 1545-1557.
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