Caitlin Whyte (Host): This is Wake Med Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm your host, Kaitlyn White. Joining me once again is Dr. Ryan Lee, an orthopedic sports medicine surgeon at Wake Orthopedics. Doctor, thank you so much for joining us again today. We are talking about shoulder instability.

Please tell us what that means.

Dr. Ryan Li: Yeah, so the shoulder is probably the most flexible joint in the body. unlike the, the hip or the knee or other joints in the body, the shoulder is really meant to move. so the structure of the shoulder really makes it, it, it's kind of like a double-edged sword. Everybody says the shoulder is like a ball and socket joint, and I can tell you that.

From a structural standpoint, it's really not. What I normally tell people is that the shoulder, imagine it much more like a golf ball on a golf tee, okay? And so it's quite a bit less stable than a true ball and socket joint like the hip. So that has both advantages and disadvantages.

So if you're listening at home, I want you to try and move your arm. Both up and down And then backwards forwards. What you'll quickly notice is that you can move your shoulder way more than you can move any other joint. Like there's no way that you're gonna be able to move your hip or your elbow nearly as much as you can move your shoulder.

And for that reason, allows us to put our arm in space and allows us to do a lot of different things with it. But the drawback for it is that we do get shoulder instability more often because of the inherent. anatomy of the shoulder joint, so shoulder instability. comes from, a couple of different mechanisms.

I think the most common thing that you'll hear from, with regards to shoulder instability is the story of like either an athlete, a collision athlete or like a football player, for example, who's been hit and his shoulder basically pops out of place, because he either lands on it wrong or he was hit wrong.

alternatively. You know, for, There are people who are just very, very flexible, who like, you know, try and catch themselves and they kind of land the wrong way And the shoulder pops out of place. And so it's often more common than you would think. at the time that it happens.

it is extremely painful and, sometimes, people are able to get that shoulder back into place by themselves. But oftentimes it requires a trip to the emergency department where somebody actually has to physically. put it back in place.

Caitlin Whyte (Host): Well, who do you usually see this condition in? How common is it?

Dr. Ryan Li: we see this condition oftentimes in athletes. I think there's two different types of instability. that we can talk about. So the first type is something called traumatic unilateral instability. that's when the shoulder just pops out of place. That's the classic, football player, soccer player, somebody who basically gets hit.

Or lands on it wrong And the shoulder just pops out of place And then somebody has to pop it back into place. That's overwhelmingly the most common type, of shoulder instability. Alternatively, there is something called multi-directional instability, and This is something that happens more insidiously. This is more something that occurs to somebody who's hyperflexible.

in this scenario, the shoulder's just very loose in all directions, and it doesn't present with a shoulder dislocation so much as general pain because the shoulder wants to move more than normal. with regards to a standard shoulder dislocation, it happens more frequently in the younger population. So I would say it happens in about 2%.

or it's got a 2% annual rate in the general population. but probably about. 80 to 90% of these, injuries happen in teenagers. In fact, being, a teenager under 20 years old is actually a major risk factor for one shoulder instability happening and two for it happening again or repeatedly after the initial incidents of of shoulder dislocation.

It occurs more commonly in military patient's And in contact or collision sports athletes.

Caitlin Whyte (Host): So, is there any chance that this could just happen in everyday life, or does it really have to be sparked by an injury of some sort?

Dr. Ryan Li: You know, I think that, This is typically brought about by an injury. I think if you're, you know, just walking down the street or doing day-to-day activities, things like that. And an overwhelming of, majority of cases, your shoulder is not going to pop out of place. Now that being said, once a shoulder does pop out of place and it goes back in your risk of re dislocating, it becomes higher.

So, the reason for That is we talked about earlier how the shoulder joint is a lot like a golf ball and a golf tee. So I want to imagine like a guardrail that surrounds the golf tee. And so most of the time that guardrail is what's keeping the ball in place, or it's keeping that golf ball on the golf tee, when a shoulder pops out of place.

A lot of times what can happen is when the ball pops out of place, it can peel off part of that guardrail. And so even if that ball goes back into where it belongs, what'll happen is that the guardrail is either off the shoulder socket or it's kind of stretched out.

So it's not really doing the job that it's supposed to. And so a lot of times in those circumstances, what we see is that, you know, once you've dislocated the shoulder once. It's not uncommon to re dislocate in the future.

Caitlin Whyte (Host): Well, what are some signs to look out for if someone thinks their shoulder may be unstable?

Dr. Ryan Li: a lot of times, what you'll find is that the shoulder will feel like it wants to slip. the tough part about shoulder instability, I think, is that the vast majority of the time, even if you have an unstable shoulder, your rotator cuff muscles And the muscles around the shoulder.

Are very good at keeping the ball the shoulder in place. So I would say like 95% of the time you're gonna be just fine if you're, working at the desk or like, watching TV on your computer doing day-to-day activities. The only problem with shoulder instability is that especially for someone with an unstable shoulder, you don't know when it's going to come out of place and there's certain activities or moves that makes your shoulder more unstable.

For example, sudden movements where your shoulder muscles don't really have time to accommodate that new change of the ball of the shoulder. we've had patient's who came in. Who basically, had chronically unstable shoulders who said that they were just reaching up all of a sudden and they felt their shoulders flat out of place.

Alternatively, patient's who sometimes, are doing things without even thinking, so I had one patient who came in who basically try to shut a heavy door behind her or was reaching behind her car seat to get something when she felt her shoulders slide out of place. that's not something that's very typical, I would say, but something like that can happen.

A lot of times though, what you'll feel is this really, really, I guess disconcerting sensation where it almost feels like your shoulder wants to slide out of place, but your body's actively keeping it from sliding out of place.

Caitlin Whyte (Host): mm. Well, if someone's feeling those things, what kind of doctors should they see first?

Dr. Ryan Li: shoulder instability is diagnosed, a couple of different ways. So, if you are feeling something like this, definitely see, either a sports medicine physician or an orthopedic provider, just to, get your shoulder evaluated. I think that something like This is, Diagnosed with a combination of just physical exam, x-ray and MRI.

I'll often get an MRI for something like this just because what we'll often see is that we can actually see that bumper or the guardrail from the shoulder socket. That has peeled off the golf tee. And whenever we see that, we know This is probably going to be an unstable shoulder, especially with a history of prior shoulder dislocations or instability events.

Sometimes in cases where, people have dislocated their shoulder 6, 7, 8, 9, 10 times. in the past, you know, year or two, and did not seek any, medical advice for that. What we'll also see is, that the shape of that golf tee has actually changed. So if you think again about, we'll go back to the example of the, golf ball on a golf tee.

When the ball basically starts to come off the socket repeatedly, what can happen is that it can start to wear away at the front of that golf tee. So rather than being. A circle, the golf tee becomes maybe, three quarters of the circle, or in rare cases, half a circle.

And you can imagine the more of that in the face of that golf tee gets worn away, the easier it is for that ball to slip off of the tee, especially when the guardrail isn't there anymore. And so that's why we typically, would request that people come in and have these shoulders evaluated, just because, if they.

Aren't addressed in a timely manner, then it just becomes progressively harder to kind of keep that ball in place.

Caitlin Whyte (Host): So when can physical therapy fix the problem and when do you know that surgery might be needed?

Dr. Ryan Li: I think over the years we've identified, a lot of different factors that predispose someone to, re dislocation, some of those factors. So if you are under the age of 20, and specifically under the age of 17. You're at way higher risk of re dislocating if you are some kind of a collision sport athlete.

Any football, rugby, martial arts, soccer, basketball, you are at a much higher risk for re dislocating if you have, you know, significant looseness of your joints overall. If you feel like you're a very flexible person, that's gonna cause. a significantly higher risk of instability of the shoulder. I would say if you're someone who has had a first-time dislocation, but who doesn't really demonstrate any of those risk factors, if you're a normal mom or dad in your thirties or forties after first-time dislocation, you should still be evaluated anyway.

but if. you know, the rest of your history doesn't have any of the risk factors, then I think physical therapy is a pretty reasonable first step. So, physical therapy, what that does is it strengthens your rotator cuff muscles. So if you imagine the, golf ball on a golf tee again, so imagine that.

Your rotator cuff muscles are wrapped around that ball, right? And it's pushing the ball against the golf tee. So physical therapy, what that does is that it pushes that golf ball a little bit harder against the golf tee to keep it in place. That's not gonna do anything if, for example, your golf tee is missing half of its surface area.

Or if, for example, the entire guardrail of your shoulder has peeled off. So that's not going to structurally change a deficient stabilizer in your shoulder. But in the absence of any of those risk factors, I think that physical therapy is a really good first step in terms of helping your shoulder become more stable.

Caitlin Whyte (Host): can you walk us through what that surgery for shoulder instability looks like, And then what recovery typically looks like?

Dr. Ryan Li: Yeah, so shoulder instability, I think that surgery for. It seeks to, address the structural issues at play. And I think the first question that needs to be answered when I see someone with chronic shoulder instability is, what are number one, what are this patient's risk factors, and how likely are they to redislocate in spite of a basic instability procedure?

And two, how much of that. golf tee surface area is still there. So for the majority of cases we see, the golf tee is intact, so there's no bone missing. the primary issue is that the guardrail has peeled off or it's really, really stretched out and it's not doing its job.

those scenarios, what we do is this would be arthroscopic surgery, so through keyhole incisions, in the shoulder, And we would go in with a camera, And what we would do is put a couple of, I mean, I guess the best way to explain it is they're like drywall anchors almost.

And we put those into the bone. And so those anchors are connected to sutures, which we then use to pass around that guardrail. And so we are basically tying that guardrail, using the drywall anchors to tie that guardrail back to the shoulder socket and allowing that guardrail to heal in place.

So that basically rebuilds that bumper or that guardrail to keep the ball of the shoulder in place. alternatively in. More severe cases. What we'll see is that part of the golf tee has either worn down or broken off. And if that bone piece is not able to be addressed or if we're not able to build that bone back up, That bone stock has to come from somewhere.

So oftentimes what we will do is use a piece of either donor bone or a piece of bone from either the patient's collarbone or their scapula and use that to rebuild the surface area of that golf tee. So instead of having half a golf tee, we would basically rebuild that bone to give them complete golf tee again, And then we would repair that guardrail back to the bone that we put on.

recovery for something like this, I think really depends on the surgery. So, in most cases, surgery is outpatient, so it's same-day surgery and you would go home that same-day. for something that's purely arthroscopic, where we do it through keyhole incisions, most people are in a sling for about four weeks.

They start physical therapy right away and they're usually feeling pretty good by about two months. where they regain. Almost all, if not all, of their range of motion. We typically allow them to return back to collision sports between four and six months after surgery. if we had to rebuild the bone, that recovery is a little bit longer, so they would be in a sling for about six weeks at that point.

But recovery is still relatively the same in terms of return to sport. We'd still let them, return in about four to six months.

Caitlin Whyte (Host): And are there any exercises or routines that people can do to prevent shoulder problems from happening in the first place?

Dr. Ryan Li: I think a lot of that relies on strengthening of the rotator cuff. there are exercises that you can do. They take anywhere from like 10 to 20 minutes every day. In terms of doing lightweight work or doing band work And what that does is it basically strengthens the, the rotator cuff of the shoulder, And that allows it to keep that ball of the shoulder riding on the, golf tee, more successfully.

Caitlin Whyte (Host): Do you have any stories about the most unusual or surprising shoulder injury that you've seen in your practice?

Dr. Ryan Li: I Think it was a, a high schooler who came in to see me and he said that like, over the past 10 years or so, his shoulder just kept dislocating in and out of place and you could actually see, like he could make. His shoulder dislocate in and out of place.

And so, you know, this, this was pretty unusual to me. I mean, we see it sometimes, but you know, it's not something that we typically see. And so we dove into his history a little bit And what he told me was that maybe about seven years ago he had sustained like an injury, I think when he was doing like martial arts or something like that where, I mean, he, I think he like flipped over and his shoulder never dislocated, but like.

At that exact time when he said his shoulder issues started. so when we got an MRI of his shoulder, what had ended up actually happening was I think that. When he injured it years and years ago, his shoulder head basically popped out of place And then came back in so that he didn't realize it.

But what had happened was that a piece of that golf tee that we were talking about basically broke off and it healed. In a position where it wasn't really doing anything anymore, So where, along the neck of that golf tee so that the actual surface area of the golf tee was probably only about 60, 65%.

Of what it was normally. And so, he didn't think anything of it because he never truly dislocated his shoulder. But he developed symptoms where his shoulder could basically just sub blocks in and out of place because he was so deficient with regards to his bone, I, I don't think he realized that until, you know, he, he just asked me to check it out one day and he was like, is this something that, you see sometimes?

And, and you know, I assured him that no, This is not something that's normal. so his problem was his bumper or his, guardrail had peeled off and he was missing a decent amount of his bone, but he wasn't like a collision sport athlete or anything like that. So I didn't think that he needed like a big open surgery to rebuild his bone stock.

So what we did was we actually harvested a small piece of his collarbone And we used that. To basically screw into the front of his shoulder we were able to use that to build the golf tee from Two-thirds of a golf tee into a full surface area golf tee.

And this was all through arthroscopic incisions. so that, you know, I think his biggest incision was probably about like maybe an inch or two. And so after that, we were able to repair that bumper back. Where we were able to repair that guardrail back to the golf tee and So, It was actually a fairly immediate difference that he noticed.

Like he came in two weeks in and he was really not able to push his shoulder out of place anymore. So that was just a, a really interesting case of, a shoulder instability. Case where it was basically unrecognized for 6, 7, 8 years. it really shows like what can happen when these types of injuries don't get recognized.

Caitlin Whyte (Host): Well, doctor, once someone has had had shoulder instability, maybe a more standard version than the story you just told, how likely is it to happen again?

Dr. Ryan Li: that's probably one of the most important questions that we're trying to answer. in orthopedic sports medicine right now. And actually we, we did a fair amount of work, on this topic, training as a fellow about seven years ago, and, over the years since, and I think that, You know, re dislocation after just a purely an arthroscopic repair really depends on a lot of risk factors.

we've actually developed a, a score that predicts, your risk of re dislocation after just a repair alone. And it can range from low risk individuals who are, over 25 non-contact athletes. With minimal bone loss, where their risk of re dislocation is only about 2%. And that can range all the way up to very, very high-risk individuals.

So, like individuals who are under 17, who are collision sport athletes who have significant bone loss, who have, hypermobility of their shoulders where they're, Ligaments and joints are just loose at baseline. And for those individuals we see upwards of, almost 50% in terms of their risk of re dislocation.

So that's one of the things that we've been trying to figure out. when is it appropriate to only do a soft tissue only procedure where we're just repairing the guardrail? And when is it, do we have to add in other procedures, like for example. Augmenting the bone, or like building up the bone stock of the golf tee sewing the rotator cuff into a bony defect to give it more stability.

And so I think we've come up with pretty good prediction tools in terms of like knowing when to do an arthroscopic procedure alone and when more is necessary. But I think the risk of re dislocation after a Shoulder stabilization surgery is highly variable. but the goal is to always get it to under 10% if possible.

Caitlin Whyte (Host): And for those dealing with this right now, doctor, what's the one piece of advice that you would give them?

Dr. Ryan Li: I would say seek medical advice sooner rather than later. dealing with shoulder instability is always tough because a lot of times it doesn't affect your day-to-day activities. Like I said, most people who've dislocated their shoulder either once or multiple times. They're doing day-to-day activities just fine. They're on their computer, you know, they're cooking, they're cleaning, they're going to school.

And the vast majority of times it's not a big deal for most people. their shoulders in place. The problem with shoulder instability is you don't know when it's going to happen, And the other issue is that if you don't seek medical attention for something like this, And we don't get a handle on, hey, is this something that either needs surgery or needs physical therapy, then neglecting this And then dislocating it repeatedly is going to increase the risk of failure of future surgery.

So, it's always better to address something like this to at least speak to, either a sports medicine provider or a shoulder surgeon to see whether surgery is something that's right for you or whether this can be managed non-operatively. And it's always better to, have that conversation early rather than later when things become a lot more difficult.

Caitlin Whyte (Host): Thank you again, doctor, for being back on the show. That was Dr. Ryan Lee. To learn more about shoulder instability, please visit wake ortho.com. And if you enjoyed this podcast, Please share it on your social channels and check out the entire podcast library. I'm Kaitlyn White with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.

Thanks for listening.