What are the treatment options for shoulder instability, especially after a steroid shot exacerbates the condition?

Treatment Options for Shoulder Instability

For patients with shoulder instability, especially when steroid injections have exacerbated symptoms, physical therapy and surgical interventions should be prioritized over additional injections.

Non-Surgical Management Options

Physical Therapy

• First-line treatment for most cases of shoulder instability
• Focus on strengthening rotator cuff muscles and scapular stabilizers
• Progressive range of motion exercises
• Proprioceptive training to improve joint position sense
• Should be continued for at least 6-8 weeks before considering other interventions

Activity Modification

• Avoid positions that provoke instability
• Temporary restriction of overhead activities
• Gradual return to activities as strength improves

Bracing/Taping

• May provide temporary stability during rehabilitation
• Not recommended as a standalone long-term solution
• Can be used during athletic activities while strengthening progresses

Injectable Therapies (With Caution)

Corticosteroid Injections

• Should be avoided if they previously worsened instability symptoms 1
• Evidence suggests corticosteroids may be detrimental to tendon healing and could potentially worsen instability in some patients
• If considered despite previous adverse response, different injection sites may yield different results:
  • Rotator interval injection may be more effective than intra-articular or subacromial injections for certain conditions 2
  • Multisite injections may be more effective than single intra-articular injections 3

Alternative Injections

• NSAID injections (e.g., ketorolac) may be considered as an alternative to corticosteroids 4
• Some evidence suggests NSAID injections may provide equivalent or superior outcomes compared to corticosteroids for certain shoulder conditions

Surgical Management

Indications for Surgical Referral

• Failed conservative management (3-6 months)
• Recurrent instability despite rehabilitation
• High-demand athletes or workers
• Significant functional limitations
• Associated labral or rotator cuff tears

Surgical Options

1. Arthroscopic Bankart Repair

   • For anterior instability with labral detachment
   • High success rate (85-90%) for first-time dislocations

2. Capsular Shift/Plication

   • For multidirectional instability
   • Tightens loose capsular tissue

3. Latarjet Procedure

   • For instability with significant bone loss
   • Involves transfer of coracoid process to anterior glenoid

4. Rotator Cuff Repair

   • When instability is associated with rotator cuff tears
   • Post-surgical rehabilitation is crucial 5, 6

Treatment Algorithm

1. Initial Assessment

   • Determine type of instability (anterior, posterior, multidirectional)
   • Assess for associated injuries (labral tears, Hill-Sachs lesions)
   • Review previous treatments and response

2. First-Line Treatment

   • Physical therapy (6-12 weeks)
   • Activity modification
   • NSAIDs for pain management

3. If No Improvement After 6-12 Weeks

   • Consider advanced imaging (MRI/MRA)
   • Orthopedic consultation for surgical evaluation

4. Post-Treatment Monitoring

   • Regular assessment of stability, strength, and function
   • Gradual return to activities based on objective improvement measures
   • Long-term strengthening program to prevent recurrence

Cautions and Considerations

• Steroid injections should be used with extreme caution in patients with instability, especially if previous injections worsened symptoms 1
• Patients with a history of steroid-induced symptom exacerbation should be directed toward physical therapy or surgical options rather than additional injections
• Repeated intra-articular corticosteroid injections may have potential long-term negative effects on joint structure 1
• Post-surgical rehabilitation protocols are critical to successful outcomes and should be followed diligently

Remember that the patient's report of increased slipping after steroid injection is a significant clinical finding that should guide treatment away from additional steroid injections and toward other therapeutic options.