What is the treatment for a 9-year-old with a subluxing shoulder?

Treatment for a 9-Year-Old with a Subluxing Shoulder

For a 9-year-old with a subluxing shoulder, conservative management through observation and physical therapy is the recommended first-line treatment, as surgical intervention during childhood is generally not indicated and may lead to poor outcomes.

Initial Assessment and Diagnosis

Radiographic Evaluation

• Standard radiographs should be obtained first to assess for any bony abnormalities 1
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view to properly evaluate shoulder alignment
  • Upright positioning during imaging is important as malalignment may be underrepresented in supine radiography

Clinical Evaluation

• Assess for:
  • Range of motion limitations
  • Direction of instability
  • Presence of pain with movement
  • Ability to voluntarily sublux the shoulder
  • Any interference with normal function or activities

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Observation and "Skillful Neglect"

   • Long-term studies show favorable outcomes with non-surgical management in children 2
   • Children managed conservatively typically become fully active in their chosen activities

2. Physical Therapy

   • Strengthening exercises focusing on:
     • Rotator cuff muscles
     • Scapular stabilizers
     • Core strengthening
   • Range of motion exercises to maintain shoulder mobility

3. Activity Modification

   • Temporary avoidance of activities that provoke subluxation
   • Gradual return to activities as symptoms improve

4. Patient and Family Education

   • Proper positioning of the shoulder
   • Avoidance of overhead activities that may exacerbate symptoms
   • Understanding that most children outgrow this condition

Second-Line Treatment (if conservative management fails)

1. Supportive Devices

   • Consider shoulder bracing or strapping for temporary symptom relief 1
   • Note: Long-term use of slings is not recommended as it may lead to muscle atrophy

2. Advanced Imaging (only if symptoms persist or worsen)

   • MRI may be considered to evaluate for labral tears or other soft tissue injuries 1

Important Considerations and Caveats

Surgical Intervention

• Surgery is generally NOT recommended for children with voluntary subluxation 2
  • Studies show poor outcomes with surgical intervention during childhood
  • Only 50% of operated shoulders had good results in pediatric patients
  • Complications included recurrent instability, pain, and stiffness

Prognosis

• Voluntary subluxation in children has a favorable long-term prognosis 2
• Most children become fully functional adults without requiring surgical intervention
• No evidence of increased risk of osteoarthritic changes in long-term follow-up studies

Red Flags Requiring Further Evaluation

• Severe pain that doesn't improve with conservative management
• Evidence of neurological compromise
• Inability to perform age-appropriate activities
• Signs of trauma or fracture on imaging

Follow-up Recommendations

• Regular follow-up every 3-6 months to monitor symptoms and function
• Reassess need for intervention if symptoms worsen or fail to improve
• Consider transition to sports medicine or orthopedic specialist if symptoms persist into adolescence

By following this conservative approach, most 9-year-old children with subluxing shoulders will have good outcomes with minimal intervention, avoiding unnecessary surgery and its potential complications.