 Like the other major joints of the body, the shoulder is built to perform some rather incredible movements. And it's built to withstand some rather violent insults. But of course the shoulder isn't always capable of doing what it's asked to. Sometimes instead it dislocates or subluxates. This may result from trauma or from some violent normal activity. After the initial insult, shoulder instability will occur with increasingly less severe activities. Sometimes reaching the point of interfering with routine daily actions. The question is, what can you do for a patient who complains of a shoulder pain? How do you diagnose subluxation? And how should this condition be treated? For dislocation, the answers are familiar. We'll focus our attention instead on subluxation. What is your problem? Sir, I have a shoulder injury. How did you injure your shoulder? It happened in a boxing class and it's been giving me quite a bit of trouble throughout the summer. And what kind of activities give you problems? That's a key question. It's important for you to determine whether the activity causing pain is avoidable or not. Some examples of avoidable activities. In contrast, a lot of everyday activities are not avoidable. There are as well some in-between situations. A patient may experience pain when playing tennis. But if tennis is his only form of exercise, he may not consider it avoidable. Some other activities that patients may report include hammering a nail overhead, putting a book on a high shelf, and sleeping with arm under the pillow. Could you describe for me your initial injury, please? So that happened in the boxing ring and I was throwing a right hook at the time. And when I threw it, he blocked it with his forearm while I was coming down with it. In taking the history, you also want to determine whether the first episode of suspected subluxation occurred after an injury. Whenever I came and recovered from the punch, it was just like my arm was hanging there. It really hurt pretty bad then. Could you demonstrate for me right now with your arm the position that gives you trouble? Yes, sir. It's back here, right here. Of special importance, what was the position of the arm? Subluxation of the shoulder always occurs with the shoulder in abduction and external rotation. Insidious origin is rare. In the examination, there are two items of particular significance. Most important, is there pain with forward displacement of the humeral head on the glenoid? And secondly, is there instability compared with the normal side? Relax all this muscle. Stay relaxed. Good. Now try to keep that relaxed throughout the examination. That's fairly important to me. Relaxation is absolutely essential. Feel the deltoid muscle to be sure it is relaxed. The examination is misleading and a waste of time unless the muscles are relaxed. Note the position. His elbow resting on your hip. You supporting his upper arm and his forearm. Have him raise his elbow about an inch and report if it hurts. Is that uncomfortable? Not too much. Next, have him try to push you away, pushing his hand against your shoulder. Attempt to push me that way. Is that uncomfortable? That's a little bit more. Now, you forcibly try to subluxate the shoulder. Grasp the arm like this with the fingers on the posterior humeral head and attempt to displace the head anteriorly and inferiorly. Sometimes, you can feel a click. Note any muscle tensing or any facial expressions that indicates pain. In subluxation, pain always occurs with forward displacement of the humeral head on the glenoid. Then take firm hold of the upper arm like this and repeat the motion. Rattle your shoulder backward. No problem. Come forward. Good. Now, I'd like to have you get up and lay down on the examining table and we'll examine you lying down. Take those. The remaining steps are done with the patient supine. In fact, if he has difficulty relaxing, this may be the only portion you can do. Place your elbow up on my waist. Now, is that uncomfortable? Nothing. Okay, relax completely now. With his elbow resting on your hip and his arm over his head, observe as he makes a throwing motion toward the ceiling. Is that uncomfortable? Not too much. Okay, relax completely. Relax completely. Good. Finally, with your fingers in front and behind as before, attempt to subluxate the humeral head. In the examination procedure, the importance of relaxation cannot be overemphasized. Tense muscles can stabilize the joint so that it allows no subluxation. X-rays should always be obtained in evaluating a patient with shoulder subluxation. Specify the modified axillary view, preferred to here as the west point view. This is the only projection that will show a bank heart lesion. On the skeleton, we can see what this view reveals. It provides a picture of the anterior glenoid and allows you to determine whether there is any anterior glenoid defect. First, make sure the exposure has been made from the proper angle. Then, see if it reveals a defect. As a result of a ligamentous tear, an evulsion fracture, or later ligamentous calcification, there may be a glenoid defect that shows up on the west point view, like this. The finding confirms subluxating shoulder. What's more, some 80% of subluxation cases diagnosed by clinical examination reveal a discernible defect on the west point view. That's why the X-ray is such an important part of the clinical data for diagnosis. Mr. Peebles, we've finished with the evaluation of your shoulder, and I do not believe that you have a shoulder problem which is amenable to surgery at this time. However, not every patient with a positive diagnosis is a candidate for surgery. Factors to consider include the types of activities which cause the problem, how important those activities are to the patient, and whether he could expect a return to them if surgically treated. Generally speaking, you cannot expect to restore a patient to violent activities, such as the javelin throw. You can expect to control subluxation with activities of daily living. Overall, you are on good ground to recommend surgery if you feel the activity causing the problem is one that the patient can be returned to by operating, if the patient has a significant disability, and if there are specific surgical indications. We can much benefit you with the surgical procedure on your shoulder. Experience of army surgeons with a large number of cases has led to the selection of the bank heart technique with certain modifications as you will see. For clarity of understanding, the coracoid is circled, and the location of skin incision is marked. Locate the position to begin by palpating the coracoid. The skin incision is made over the delto pectoral groove. Bluntly enter the delto pectoral interval. It is not necessary to visualize the cephalic vein, but if identified, it can go either way. Retract the deltoid laterally. The pectoralis major is retracted medially, revealing the conjoined tendon and the subscapularis tendon. Reposition the retractor under the conjoined tendon and retract it medially. Measure 1 centimeter medial to the bicepital groove with your index finger. Divide the subscapularis tendon at this point. You tag the end of the subscapularis. The subscapularis tendon is sharply dissected off the anterior capsule and anterior glenoid. Then move the medial retractor another layer down. So it is retracting the subscapularis as well as the pectoralis major and the conjoined tendon. The entire anterior capsule and anterior glenoid are now exposed to view. Next, a T-cut in the anterior capsule. Make the vertical portion of the T 1 centimeter medial to the stub of the subscapularis tendon. Then make the horizontal cut down to the anterior glenoid rim. The horizontal corners of the T are tagged and then retracted medially. In this view, the bank heart lesion is particularly well visualized. All patients with subluxating shoulders will have an anterior glenoid lesion, although not usually as large as this. With the humeral head retractor providing you a little additional room to work, correct the defect in the anterior glenoid. It is absolutely essential that you do an extremely thorough job of curatage. Otherwise, the capsule may not adhere to the glenoid, making the operation a failure. After curating, you will suture the anterior capsule. The bank heart procedure requires you to pass sutures through the glenoid. However, experience has shown that this is unnecessary. The recommended technique is to pass sutures through the soft tissues of the glenoid at the capsular insertion. Then pass the suture through the lateral portion of the anterior capsule. As shown in a front view of the joint, you suture in three places. The shoulder is internally rotated and sutures are tied. The lateral margin of the T capsule is thus brought to the anterior glenoid rim. These sutures form the first of what will be three levels of repair. In the second layer of repair, the previously tagged corners of the T are sutured to the stub of the subscapularis. Note that the inferior leaf of the T is maximally displaced cephalad, and the superior leaf is displaced cordad. This overlapping and suturing of the medial leaves of the capsule completes the second level of repair. After completing the second level, check the motion. If the repair is correct to this point, the arm should externally rotate no farther than neutral, showing that repair has been done to the proper degree of tightness. The third layer of repair consists of rejoining the subscapularis tendon. Note an important distinction. Some other procedures achieve shoulder stability by shortening the subscapularis tendon, thus limiting external rotation. As in the bank heart procedure, you use minimal overlap. Done this way, shoulder motion and power will come back much more quickly and completely without any sacrifice of shoulder stability. So repair the subscapularis with the least practical amount of overlap. Skin closure is standard. Following surgery, a soft velpo dressing is used for the first four weeks. During weeks four to six, rehabilitation is begun with gentle motion. Active resistive exercises with increasing weight are given from six weeks through six months. No passive exercises are used. Recovery of full strength and almost full range of motion can be expected somewhere between six and 12 months. In the past, muscular development and hypertrophy have been considered as solutions to the problem of subluxation. But experience of army surgeons shows that they are not. For example, the particularly well-developed young man you see here is a subluxator. He is living proof, just one of many, that physical therapy is not a solution to the problem. Surgery, when indicated, is a solution. And the results as testified by the patients themselves in West Point Survey are highly successful. Full or nearly full recovery of normal shoulder use can be expected in most cases. With accurate diagnosis, properly applied surgical indications, and the techniques shown in this film, subluxation surgery can be approached with a high degree of confidence.