A 37-year-old ex-professional player presented with a six-month history of increasing pain in his dominant right shoulder. He described a deep ache felt within the deltoid region that was exacerbated by movement, especially end-range movements. On examination he had a mild global restriction of shoulder movements with pain towards the extremes of range. Rotation movements were especially provocative. He had a history of previous surgery to address instability. He describes having experienced about a total of five shoulder dislocations. The surgery had been done about ten years prior to this visit.
There is the impression of four metallic bone suture anchors in the inferior aspect of the glenoid with overlying bony irregularity consistent with previous anteroinferior labral repair. There is cartilage space narrowing in the inferior aspect of the glenohumeral joint with a prominent inferior humeral head osteophyte consistent with post traumatic degenerative change.
This player had been using oral NSAIDs for pain relief and had been working on a shoulder strengthening programme prior to presenting for review. After a discussion of the treatment options he elevated to try an intra-articular steroid injection. This was primarily to try to get better control of his pain and to help progress his rehabilitation. There was a clear discussion that this may only provide short term improvements. After the injection there was a dramatic improvement in his pain and function. This has now persisted for seven months following the injection.
During a player’s career recurrence is the most common consequence of shoulder instability. Recurrent instability after the first episode is common and multiple dislocations are the rule. For this reason, many player’s elect to have a shoulder stabilisation procedure. While these procedures have been clearly demonstrated to reduce the risk of further instability their impact on longer-term joint health is less well known.
Post-traumatic arthritis (also known as ‘arthritis of dislocation’) is frequently seen in patients who have a history of shoulder instability. While shoulder instability itself has been identified as a risk factor for post-traumatic osteoarthritis (OA), it is possible that choosing surgical treatment may further increase the risk of developing OA. Data suggests that a larger number of patients who develop arthritis of dislocation have had prior instability surgery. It is likely that there are multiple causative factors including direct trauma to the articular surfaces of the joint, abnormal loading of the joint surfaces (following injury) as well as possible “overtightening” of the joint with instability operations. It is known that several historical operations have been shown to have high rates of arthritis in long-term studies. More modern techniques, including arthroscopic and open Bankart repairs, appear to have lower rates of arthritis. This may be because there is less alteration of anatomy than with older surgical treatments. A recent case series showed that eight years after arthroscopic Bankart repair, 41 % of shoulders displayed some evidence of radiological arthropathy.
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