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Shoulder pain can arise from many injuries including dislocation and subluxation.  For patients with Ehler-Danlos Syndrome(EDS), this is especially problematic given their joint laxity.  EDS is a group of inherited disorders that affect and weaken connective tissues such as tendons and ligaments (1).  Joints are typically hypermobile with an excessive range of motion.

What is Hypermobility?

Hypermobility means that the joint is too mobile or sloppy. Ligaments and muscles stabilize joints and keep them moving in set predetermined motions with micro-millimeter precision. When the ligaments are loose. the joint surfaces crash together abnormally, causing more wear and tear on the joint itself, damaging cartilage, tendons, and other structures. This is also called instability.

What is the Difference Between Subluxation and Dislocation?

A dislocation is when there is a displacement of a bone from its natural position in the joint. Dislocations can occur due to trauma such as a fall or if the supporting ligaments in the shoulder are injured, torn, or separated. Dislocation is also referred to as luxation. A subluxation is simply a partial dislocation. Subluxations can occur as a result of trauma, injury to supporting ligaments and tendons or lax ligaments. Patients with EDS (EDS-HT) have known impaired shoulder function (2) which along with ligament laxity puts them at risk for dislocation or subluxation.

What Happens if a Dislocated Shoulder Goes Untreated?

Shoulder dislocation is serious and if left untreated can result in the following:

  • Damage to the muscles and tendons
  • Damage to rotator cuff tendons;
  • Nerve or blood vessel damage
  • Damage to the humeral head which is referred to as a Hill-Sachs lesion (3).  When the humerus displaces anteriorly it causes a depression in the back and outside of the shoulder bone (humerus).

hill sachs lesion 300x164 - EDS Shoulder Pain

  • Damage to the labrum which is referred to as a Bankart lesion (4).  When the humerus displaces towards the front it can also injure the fibrocartilage cup that helps to hold it in place called the labrum.

bankart lesion - EDS Shoulder Pain

  • Damage to the ligaments that stabilize the top of the shoulder (glenohumeral ligaments and coracohumeral ligaments) (5).

shoulder ligaments labled 300x236 - EDS Shoulder Pain

How Do You Fix a Dislocated Shoulder?

If dislocated it is critical that you seek immediate medical attention and get the joint back to its normal position( 6). This may include a forceful maneuver termed closed reduction of the joint. Once the joint is back and properly aligned, working in physical therapy to strengthen the rotator cuff muscles may help prevent future dislocations. This is because they help hold the ball in the socket. In extreme cases, you may be placed in a brace for a few weeks to help the damaged ligaments heal, but this is less common.

What to Make Sure You Rule Out

If your shoulder dislocates, as discussed above you could have injured lots of different structures including tendons, the labrum, the bones, etc… Hence an MRI is critical to make sure nothing got damaged. If something was harmed, then while sometimes surgery is needed, most of the times a precise injection of your own concentrated blood platelets or stem cells may help heal the damage.

Can Injections Help the Dislocations?

Steroid injections are not indicated in patients with shoulder dislocation as the steroid can compromise both the cartilage in the joint and the supporting ligaments. (7). At the Centeno-Schultz Clinic, we have extensive experience with precise ultrasound-guided injections of both PRP and stem cells into shoulder ligaments.  Studies have demonstrated the beneficial effects of PRP on ligament and tendon injuries.(8). The goal is to tighten down the lax ligaments to prevent future dislocations and in our experience, this helps EDS patients live a more normal life.

As you can see, there is hope for EDS patients with chronic shoulder subluxations or dislocations. However, recognizing what’s going on and why is critical. Also making sure nothing was damaged is important. Finally, we’ve seen that newer orthobiologic injection therapies can help EDS patients live a more normal life!


References:

1. Zhou Z, Rewari A, Shanthanna H. Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature. Medicine (Baltimore). 2018;97(45):e13115. doi:10.1097/MD.0000000000013115

2. Johannessen EC, Reiten HS, Løvaas H, Maeland S, Juul-Kristensen B. Shoulder function, pain and health related quality of life in adults with joint hypermobility syndrome/Ehlers-Danlos syndrome-hypermobility type. Disabil Rehabil.2016;38(14):1382-90.DOI: 10.3109/09638288.2015.1102336

3. Horst K, Von Harten R, Weber C, et al. Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study. Br J Radiol. 2014;87(1034):20130673.doi: 10.1259/bjr.20130673

4. Spiegl UJ, Ryf C, Hepp P, Rillmann P. Evaluation of a treatment algorithm for acute traumatic osseous Bankart lesions resulting from first time dislocation of the shoulder with a two year follow-up. BMC Musculoskelet Disord. 2013;14:305. doi: 10.1186/1471-2474-14-305.

5. Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop Relat Res. 2002 Jul;(400):32-9. DOI: 10.1097/00003086-200207000-00005

6. Avila Lafuente JL, Moros Marco S, García Pequerul JM. Controversies in the Management of the First Time Shoulder Dislocation. Open Orthop J. 2017;11:1001-10.DOI: 10.2174/1874325001711011001

7.Laseter JT, Russell JA. Anabolic steroid-induced tendon pathology: a review of the literature. Med Sci Sports Exerc.1991;23(1):1-3. https://www.ncbi.nlm.nih.gov/pubmed/1997802

8. Kia C, Baldino J, Bell R, Ramji A, Uyeki C, Mazzocca A. Platelet-Rich Plasma: Review of Current Literature on its Use for Tendon and Ligament Pathology. Curr Rev Musculoskelet Med. 2018;11(4):566-72. DOI: 10.1007/s12178-018-9515-y