Shoulder Instability with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum he is the clinical director of Insync Physio in North Burnaby. And we're going to talk about shoulder instability, something that I know quite a bit about just from not, well, I don't nothing about it, but I have experienced a lot of it. How are you doing Iyad? 

Iyad: Good, good Mark. How are you doing? Hopefully your shoulder's not unstable. 

Mark: Well, it's gotten a lot better, but what's sort of the typical cause of that sort of instability that people can have and the pain that comes with it. 

Iyad: Yeah, so broadly speaking, you're going to split them up into two categories. You're going to have somebody who falls into the traumatic category. So like, think of anywhere from a baseball player, diving in with their arms stretched or a mountain biker falling or you know, any kind of impact that causes this. So you have that in some of the contact sports like rugby. So there's a lot of different mechanisms that could cause a shoulder dislocations and then give you, what, basically presents like a loose shoulder where people feel like they can't control it. And it doesn't sit well, the ball, sits in the socket kind of thing. 

And then you have another group where it's a little more interesting. Where are they have a loose shoulder kind of congenitally in a way. So the ligaments and the things that holds the shoulder together passively are just a bit more mobile than you'd want them to be.

And then in that group, you'll get basically what we'd call a multi-directional instability. So it's not going to be just the movement is not going to be excessive in one direction. It tends to be excessive in all directions. Meanwhile, on the traumatic side, for the most part, people tend to acquire this looseness, let's call it, and they would tend to be more one or two directions.

So not necessarily in all planes with the movement, for the ball moving in the socket. So those are the two kind of broadly speaking, those are the two groups that get this. Obviously the treatment for each one will be a bit different. 

So for example, the traumatic people, we will not be the ones usually doing the relocations. It tends to be done by a physician. Most people will go to the ER when they dislocate their shoulder and then have it relocated there. And we're involved after they get it relocated. The care off of that is all ours. And we can talk about their treatment plan from there.

Now, the other group, the rehab tends to be a bit different. We will try to identify, I guess, that they are just that multi-directional instability. And then we would kind of deal with accordingly by a mix of strengthening and proprioception training, which is kind of like your joint position sense.

So help their body identify and figure out where the shoulder is in space to allow their muscles to react in an adequate way. So it's a mix of sensory training and motor training, which is kind of like the typical resisted based program. 

Mark: So weight training of some or resistance training of some kind basically is a big part of that.

Iyad: Of course, we would want to make sure that they're able to handle the forces that they need to put on their shoulder day-to-day. So that's going to be a part of it, but then it's not enough just to kind of do blind strengthening. Sometimes we'd need to also do some kind of coordination training. And this is where the proprioception exercises come in.

Mark: So that's sort of the, what do they call it where you're feeling things in a certain way. What do you call that kind of training? 

Iyad: So here's an example. So the easiest one that most of us are familiar with is how do you stand on one foot with your eyes closed, for example? And the way we do that is we get tons of signals from what we call Somato sensory fibres. So those are things like our skin. Our muscles, inside the muscle there's a thing called the spindle. We also have little organs in our tendons. So all of those things will feed back into our brain. Our brain kind of puts it all together and it responds according to changes in those signals. 

So in doing the training, for example, after an ankle sprain, we would do tons of balance training to help boost that system. And this is kind of, you could think of it, I guess, in loose terms like balance training for your shoulder, in a way.

So we would do you know anything from weight bearing to different kind of more, I call it kind of like when we get you to do a math problem with your shoulder, or we give you a task that involves you needing to balance or coordinate changes in weight and your shoulder just has to kind of learn to balance and stabilize itself.

And we can progress that sometimes by adding a little more complexity like weight-bearing, or like maybe removing some of the visual stimulus, like closing the eyes and things like that to help kind of boost that system a bit more. But that's just kind of broadly speaking in each person's going to come in at a different level. Some people are able to do a lot. They run and, some people are going to be moving a lot slower.

Mark: When these kind of things happen, is it possible for instance, to have like, the way it worked with me was I got throwing injuries without warming up properly, starting too young. And my shoulder was always stiff. Like I lost range of motion in my shoulder. And then doing martial arts, doing jujitsu, got arm barred a few times. And then finally a really good one, I heard a pop in my shoulder and then suddenly the range of motion is back, but it's unstable. Is that fairly typical or possible, obviously it's possible. Is that a typical? 

Iyad: Yeah, so what sometimes you can have is a shoulder that is not fully relocated, so it's kind of sitting slightly out of place. And that depends on if it actually was relocated or not. You could have had, for example, a different kind of stiffness. The stiffness could be protective. It could also be that you just stopped moving in that way to protect yourself. Could be there's a lot of reasons why that could happen.

Now, in your case with the arm bar, you said, yeah, you felt a bit looser, but then it became a bit more unstable. I mean, that would fall into the traumatic kind of thing. And you probably ended up moving the ball the too far forward in the socket. And that's what did that.

We want mobility sometimes, but sometimes too much mobility could be a detriment. Especially if you think about mobility with no end, it could be a bit detrimental sometimes, especially if your muscles and your ligaments are moving past their natural end. So I think that could happen.

But the most typical one would be if somebody's really, really stiff after an episode, it will tend to be because either that the shoulder was not relocated, then they think it's fine. It's just a bit stiff. Or sometimes it could be due to protective stiffness. And in some cases we do ask people to go get to the hospital and get it checked because a dislocation can impact a structure called the axillary nerve.

So usually people with axillary nerve issues will present with a slightly different set of symptoms. And we always are vigilant for that in clinic, just to make sure that there's no nerve involvement because the nerves tends to wrap around kind of the neck of the humerus, which is kind of your shoulder bone.

So yeah, there's lots of things that we'd want to keep an eye out for. And again, each person is different. Some people just have a dislocation, get it relocated and then do very well in rehab. And some people never really cope well with it and might have to consider a surgical route. I guess it depends for the most part on your age, your level of competitive involvement in sports and things like that and how you respond to rehab really. People do really well, but there's still a subset of people who will need a surgical intervention. And we would work really closely with an orthopedic surgeon on the management there. 

Mark: So with all the range of motion that's involved in the shoulder joint, what's kind of the process of diagnosis to try and determine what's going on?

Iyad: Yeah. So the story's a big one, of course. Like you have people coming in they're like I can just feel extra movement, extra clicking. I don't want to really pull my arm up. There's a lot of apprehension that comes with this and the apprehension is actually quite a good sign. Where people feel like their shoulder's, just a bit different and a bit looser.

And there are some clinical tests that we do to test for that, that potentially can strain or stress the capsule, which is, think of the white stuff that you'd see on a drawing. Not the red stuff that are the muscles, but more like the ligamentous tissue. So we would stress those in different planes.

Obviously we do it in a controlled way that we're not just yanking the shoulder really fast and that can help us identify the direction of potential injury. And then from there, we would try to also figure out the baseline for strength and function and then go from there. But yeah, we would want to do some testing to figure out if there has been movement, excessive movement in there, or if it's just apprehension, because sometimes you can create a bit of a fear response. So I've had lots of clients who have tested very normally on the tests, but have a ton of apprehension and they don't let you go there. But the second you rest your hand on their shoulder, they can move really well because the apprehension kind of eases up a bit.

So there are people who we need to train for confidence almost as much as, and kind of to help that nervous system attenuate that response just as much as we need to fix the structures sometimes, you know what I mean? So it's not always a structural damage issue or a structural stretch to the ligaments.

Sometimes people just come so protective of themselves, and this is something that happens, not at a conscious level always because the nervous system is pretty complicated that way. And that's your body's response to excessive movement. You just try to put the kibosh on everything and just pump the brakes.

Mark: So clearly there's no typical course of treatment, but what would, you've mentioned some of the things that are, can you give us some examples of what the people would look at in terms of treatment? 

Iyad: Yeah. So let's say if you come in with full range of motion to start, obviously that shaves off a bit of time. If you're not, then we'll have to look at improving your range of motion again. And then the reason we have that is well after the injury and after the reduction, there's a period sometimes for some people that are going to need to go into a sling. So the sling obviously, immobilizes the shoulder a bit, the sling will also sometimes cause a bit of stiffness. So that's going to be the first bit to start moving the shoulder. And we move it in a way that's not necessarily excessive, but we need to kind of push it a bit. 

And then we start identifying strike deficits. So we would do just kind of your typical rotator cuff strength and also scapular muscle strength. The muscles in the shoulder blade are really important, but the rotator cuff tends to be non-negotiable here again. And then we try to just see the quality of movement and coordination. But then again, this goes back to the same idea of previous things that we talked about.

So for example, if I have a high level baseball player who needs to pitch at a very high speed, their recovery is going to be so different to somebody who fell down the stairs and just needs to be able to walk. And do their own activities of daily living, like, you know, washing their hair or doing your dishes and stuff like that. Brushing their teeth. It's just things like this, that really determined the length of treatment. 

Typically the more you need from your shoulder to the longer you should expect to need to work on it. But this is why it varies because, you know, you could have somebody who just had this at the age of 50 or an 18 year old who is super involved in five sports and just needs their arms for so much more than somebody else. And that's kind of where we can tinker with it and kind of look at developing a very comprehensive program for that person.

Mark: Complicated. Shoulders are complicated. You need expert help. If you're shoulder just doesn't feel right. It's clicking, it's making noise. It hurts to do things. You don't want to reach up over your head anymore. You need to get that looked at and get it looked after. And the experts on this are at Insync Physio. They have two locations. Cambie Street in Vancouver or the North Burnaby office. You can call and book (604) 298-4878. On Cambie at (604) 566-9716. Or for convenience, book online at Both clinics are there. You can see who's available and get in to see them. Get your shoulder looked after. And get back to living your life the way you wanna live it and your sporting life, the way you want to do it. Thanks Iyad. 

Iyad: Thanks Mark.