What is the treatment approach for a patient with multi-directional shoulder instability?

Treatment Approach for Multidirectional Shoulder Instability

The initial treatment for multidirectional shoulder instability should be conservative with a structured rehabilitation program focused on strengthening the rotator cuff and periscapular muscles, with surgery reserved only for patients who fail a 6-month trial of appropriate physical therapy. 1, 2

Diagnostic Evaluation

Before initiating treatment, proper evaluation is essential:

• Imaging studies:

  • Initial radiographs should include AP views in internal and external rotation and an axillary or scapula-Y view 3
  • MR arthrography is the preferred advanced imaging modality for evaluating shoulder instability 3
  • MR arthrography has higher sensitivity for detecting labral tears and glenohumeral ligament injuries compared to standard MRI 3

• Clinical assessment:

  • Evaluate for global laxity (anterior, inferior, and posterior) of the glenohumeral joint
  • Assess for rotator interval capsule defects
  • Note that symptoms often occur in midrange of motion rather than at extremes
  • Pain is frequently the chief complaint rather than frank instability 1

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Structured rehabilitation program (6-month trial) 1, 2:

   • Rotator cuff strengthening exercises
   • Periscapular muscle strengthening
   • Scapular stabilization exercises
   • Proprioceptive training
   • Correction of abnormal movement patterns

2. Activity modification:

   • Avoid positions that provoke symptoms
   • Temporarily limit overhead activities
   • Gradual return to activities as strength improves

Second-Line Treatment: Surgical Intervention

If conservative management fails after 6 months of appropriate therapy, surgical options include:

1. Arthroscopic techniques 4, 5:

   • Capsular plication to reduce capsular volume
   • Repair of rotator interval defects
   • Labral reattachment if indicated
   • Post-operative immobilization for 6 weeks followed by rehabilitation 4

2. Open procedures 1:

   • Inferior capsular shift (considered the gold standard open procedure)
   • Addresses global capsular laxity and rotator interval defects

Special Considerations

• Posterior glenoid dysplasia: May require additional procedures such as posterior bone block 5
• Capsular insufficiency: In cases with underlying soft tissue disorders or multiple failed surgeries, more complex salvage procedures may be needed 5
• Contralateral shoulder: Often equally lax but asymptomatic, suggesting factors beyond capsular laxity contribute to symptoms 1

Common Pitfalls to Avoid

1. Rushing to surgery: Many patients can be successfully managed with proper rehabilitation; surgery should not be the first option 1

2. Inadequate rehabilitation: Physical therapy must be specific and targeted at rotator cuff and periscapular strengthening, not just general shoulder exercises

3. Misdiagnosis: MDI must be distinguished from unidirectional instability, which may require different treatment approaches 4

4. Neglecting proprioceptive training: Defective proprioceptive responses may contribute to MDI and should be addressed in rehabilitation 1

5. Insufficient post-surgical rehabilitation: Even after successful surgery, rehabilitation is essential for optimal outcomes

By following this structured approach to multidirectional shoulder instability, clinicians can effectively manage this challenging condition while minimizing unnecessary interventions and optimizing patient outcomes.