From the Guidelines
The initial management for shoulder instability should prioritize a conservative approach, focusing on physical therapy and activity modification to strengthen the rotator cuff muscles and scapular stabilizers, as this method has been shown to be effective in reducing pain and inflammation, and improving quality of life. When considering the management of shoulder instability, it's crucial to understand that younger patients are more likely to have labroligamentous injury and persistent instability after dislocation compared with older patients 1. The conservative management approach typically involves:
- Rest, ice, and anti-inflammatory medications like ibuprofen or naproxen to reduce pain and inflammation
- Physical therapy, focusing on strengthening the rotator cuff muscles and scapular stabilizers through exercises such as internal/external rotation with resistance bands, scapular retraction, and proprioceptive training
- Activity modification, avoiding positions that provoke instability, particularly overhead activities and extreme ranges of motion
- Immobilization in a sling for 1-3 weeks may be recommended for acute dislocations, followed by gradual rehabilitation This approach is particularly effective for patients with traumatic first-time dislocations, SLAP lesions, or multidirectional instability, as it works by strengthening the dynamic stabilizers of the shoulder to compensate for compromised static stabilizers (labrum, capsule, ligaments) 1. Surgical intervention is generally considered only after failed conservative management or in cases of recurrent instability, particularly in young, athletic individuals. It's also important to assess both osseous and labroligamentous pathology in patients with shoulder dislocation or instability, as coexisting humeral avulsion of the glenohumeral ligament and significant glenoid bone loss have been found in up to 10% of patients with recurrent shoulder instability 1. Glenoid morphology and bone loss can play a significant factor in recurrent shoulder dislocations, which may require bone grafting in order to restore stability 1.
From the Research
Initial Management for Shoulder Instability
The initial management for shoulder instability involves a well-defined program that emphasizes early diminution in the patient's symptoms, appropriate immobilization, and a well-defined precise rehabilitation program 2.
- Immobilization should be considered in younger patients less than 20 years of age for between 3 to 4 weeks in order to enhance capsulolabral complex healing.
- Older patients may be immobilized for a shorter period of time.
- Analgesic medication and local physical therapeutic modalities may be used to decrease the patient's symptomatic complaints.
Rehabilitation Program
Once the immobilization period has ended, a precise and specific rehabilitation program tailored for the individual needs of the patient should be undertaken 2.
- The rehabilitation program should emphasize early and safe regaining of normal ROM, strengthening of the dynamic stabilizers of the shoulder, and strengthening of the scapular stabilizing muscles of the shoulder.
- Rehabilitation programs that enhance the patient's neuromuscular control over the glenohumeral joint should be considered in the conservative management of the unstable shoulder.
Classification and Management
Classification of shoulder instability is crucial for effective management, recognizing both structural and non-structural components 3.
- Structural causes can be addressed with surgical intervention, but non-structural causes such as altered neuromuscular control within the rotator cuff should be addressed conservatively.
- A thorough evaluation of each patient is necessary to identify the etiology of the instability and to expect a successful result from conservative treatment 4.
Treatment Options
Treatment options for shoulder instability include exercise programs, which have been shown to be effective in some cases 4, 5.
- Patients with multidirectional instability may be treated with a physical therapy program, and those who fail non-operative treatment are candidates for arthroscopic or open stabilization procedures 6.