What should be done for a questionable mild medial subluxation of the Glenohumeral joint?

Management of Questionable Mild Medial Subluxation of the Glenohumeral Joint

For questionable mild medial subluxation of the glenohumeral joint, initial conservative management with physical therapy focusing on rotator cuff and periscapular muscle strengthening is recommended as first-line treatment, with advanced imaging reserved for cases that fail to improve.

Diagnostic Approach

Initial Assessment

• Evaluate for signs of instability, including apprehension and pain with provocative maneuvers
• Assess for associated conditions such as glenohumeral osteoarthritis which may contribute to or result from subluxation
• Obtain standard radiographs as the initial imaging study, including:
  • Anteroposterior (AP) view in neutral position
  • Grashey view (30° posterior oblique) to profile the glenohumeral joint 1
  • Axillary lateral view or scapular Y view to assess for instability or dislocation 1

Advanced Imaging

• If radiographs are noncontributory and symptoms persist:
  • MRI without contrast is appropriate for evaluating associated soft tissue pathology (rated 7/9 by ACR) 1
  • MR arthrography is preferred if labral pathology is suspected (rated 9/9 by ACR) 1

Treatment Algorithm

1. Conservative Management (First-Line)

• Physical therapy program focused on strengthening rotator cuff and periscapular muscles
  • This approach has shown a 63% success rate in patients with posterior subluxation 2
• NSAIDs for pain control and anti-inflammatory effects
  • No evidence suggests negative effects on tendon healing 3

2. Interventional Options (For Persistent Symptoms)

• Injectable viscosupplementation may be considered
  • Rated as a weak recommendation (Grade C) by AAOS for glenohumeral osteoarthritis 1
• Corticosteroid injections have insufficient evidence to recommend for or against their use 1

3. Surgical Management (For Refractory Cases)

• Surgical intervention should be considered when:

  • Conservative measures fail after an adequate trial (typically 3-6 months)
  • Symptoms are severely disabling
  • There is evidence of progressive joint damage

• Surgical options may include:

  • Capsulorrhaphy (with or without bone block) for persistent posterior subluxation
    • Has shown a 91% success rate in patients with severe symptoms 2
  • Arthroscopic treatment for associated labral tears or other soft tissue pathology

Important Considerations and Caveats

• Muscle Quality Assessment: Preoperative evaluation of rotator cuff muscle quality is crucial as fatty degeneration and atrophy correlate with worse outcomes 3

• Beware of Progressive Joint Damage: Static posterior subluxation may represent an early stage of glenohumeral arthritis that can progress over time 4

• Surgical Outcomes Warning: Attempts to surgically correct static posterior subluxation have shown limited success with persistent or recurrent subluxation in some studies 4

• Multidirectional Instability: Consider this diagnosis when symptoms of apprehension and instability occur in more than one direction 5

• Age Considerations: For younger patients (<50 years), there is concern about performing shoulder arthroplasty due to potential risks of prosthetic loosening and decreased survivorship 1

By following this structured approach, most patients with mild medial subluxation of the glenohumeral joint can achieve satisfactory outcomes with appropriate management tailored to their specific pathology and symptom severity.