Shoulder Dislocation in Older Patients Poses Different Challenges in Diagnosis, Treatment

Rotator cuff tears more common, but recurrence less likely compared to younger patients

ROSEMONT, Ill., Oct. 4, 2012 /PRNewswire-USNewswire/ -- Although shoulder dislocation can occur at about the same rates in both younger and older patients, injuries in older patients are more likely to be overlooked or misdiagnosed, resulting in years of persistent pain and disability. A new study published in the October 2012 issue of the Journal of the American Academy of Orthopaedic Surgeons examines the differences in dislocation injuries between older and younger patients and suggests an approach to evaluate older patients that could help improve diagnosis and management of interrelated injuries.

Study lead author Anand Murthi, MD says understanding the very different ways shoulder dislocation can affect patients over 40 years of age is the first step in making an accurate diagnosis of dislocation-related injuries.

"Older patients are much more likely to experience injury to the rotator cuff, the group of tendons, ligaments and other structures that help give the shoulder its range of motion," Dr. Murthi explained. "This is because the rotator cuff tissue becomes weaker and more brittle as a result of aging and therefore tears more easily.

"By comparison, younger patients with healthier, stronger rotator cuff tissues are more likely to experience injury in other areas of the shoulder," he said. "Unfortunately, although rotator cuff tears are common in older patients, they are often missed during evaluation of the patient."

Older patients may also be reluctant for surgery, he added, resulting in more conservative treatment with anti-inflammatory drugs and cortisone injections, which can temporarily provide relief, but do not treat the underlying cause.

By the Numbers
According to the literature review:

• About one-fifth of shoulder dislocations occur in patients aged 60 years or more
• The rate of recurrent shoulder dislocations occur in as many as 90 percent of patients in their 20s and 30s, but in less than 10 percent of patients aged 40 and older
• Differences in the way injuries affect the shoulder components are largely responsible for the increased incidence of recurrence in younger patients, as well as the increased incidence of rotator cuff tears in older patients
• In older patients aged 60 and older, the incidence of rotator cuff tears in shoulder dislocation ranges from 35 percent to 86 percent

Despite these increased risks for age-related injuries, there is some good news: Patients over 40 who experience shoulder dislocation are less likely than younger patients to experience a recurrence of the dislocation. Why? Because the rotator cuff, which is most commonly injured in older patients, plays a minimal role in shoulder stability.

"By comparison, in younger patients, the ligaments and other tissues which are most commonly involved in shoulder dislocation are also the structures which are largely responsible for the shoulder's stability, placing these patients at greater risk for recurrence," said Dr. Murthi. "The rotator cuff plays a significantly lesser role in stability, and so older patients have a decreased risk of recurrence."

Signs to Watch
Today's older patients population is much more active than patients in the same age group a decade ago. Careful evaluation of all shoulder injuries in this group is important to avoid mismanagement of the injuries. Telltale symptoms such as persistent pain or tenderness, inability to raise the arm with the shoulder, tingling in the hand, weakness or decreased temperature in the arm or hand, and lack of or diminished sensation in or near the injured area may indicate their injuries are not fully healed. "If older patients have shoulder pain that is not relieved with rest, ice and anti-inflammatories, then they should seek out treatment by a shoulder specialist or orthopedic surgeon," Dr. Murthi said. "This is especially true if they've recently had trauma to the shoulder."

Preventing injury
Being aware of the signs of untreated or misdiagnosed injury is important, but it's even more critical to take steps to prevent those injuries from occurring in the first place. "Older patients can maintain their flexibility with a good stretching program, especially if they develop stiffness, which often leads to pain and dysfunction," said Dr. Murthi. "Fall prevention is also very important in the older population, as traumatic shoulder injuries and shoulder dislocations from falls can lead to traumatic rotator cuff tears. Older patients often let these injuries wait for treatment, but early diagnosis and repair of these injuries are the key components to ensuring these patients have the best outcomes possible," he said. "With careful evaluation and management, including physical therapy as needed, most older patients can expect to return to the level of activity they enjoyed prior to their shoulder injury."

October 2012 Full JAAOS Table of Contents

• Shoulder Dislocation in the Older Patient
• Arthritis of the Distal Radioulnar Joint: From Darrach to Total Joint Arthroplasty
• Graft Tensioning During Knee Ligament Reconstruction: Principles and practice
• Malignant Osseous Tumors of the Pediatric Spine
• Principles of Rotationplasty
• On the Horizon From the ORS: Sex Differences in OA of the Knee Progenitor Cells
• On the Horizon From the ORS: The Various Roles of Osteocyte Signaling in Bone
• On the Horizon From the ORS: Endothelial Progenitor Cells

For more information on rotator cuff injuries:

• Rotator Cuff Shoulder Conditioning Program
• Rotator Cuff Tears
• Rotator Cuff Tears: Frequently Asked Questions

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SOURCE Journal of the American Academy of Orthopaedic Surgeons