What is the treatment for shoulder instability characterized by popping and shifting with external movement?

Treatment for Shoulder Instability with Popping and Shifting

The treatment for shoulder instability characterized by popping and shifting with external movement should focus on strengthening the rotator cuff and scapular stabilizers, with rehabilitation aimed at restoring proper shoulder mechanics and range of motion. 1

Assessment and Diagnosis

Before initiating treatment, proper assessment is crucial:

• Evaluate tone, strength, changes in soft tissues, and alignment of joints in the shoulder girdle 1
• Assess for specific signs of instability including pain during movement, decreased velocity or precision of movement, and popping/shifting sensations 1
• Consider the mechanism of instability - whether traumatic or from repetitive microtrauma 2
• Determine if the instability is anterior (most common), posterior, or multidirectional 3

Conservative Treatment Approach

Initial Phase

• Complete rest from aggravating activities until symptoms resolve 1
• Ice, heat, and soft tissue massage to reduce pain and inflammation 1
• Pain management with non-opioid analgesics such as acetaminophen or ibuprofen if not contraindicated 1

Rehabilitation Program

• Rotator cuff and scapular stabilizer strengthening exercises 1
• Re-establish proper mechanics of the shoulder and spine 1
• Restore range of motion through gentle stretching and mobilization techniques 1
• Focus on increasing external rotation and abduction 1
• Implement proprioceptive control exercises to improve stability 3

Progressive Strengthening

• Gradually increase active range of motion while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Progress to dynamic stabilization exercises 1
• Incorporate core and lumbopelvic strengthening 1
• Advance to plyometric program and endurance drills for athletes 1

Special Considerations for Athletes

For throwing athletes with shoulder instability:

• Implement a progressive throwing program emphasizing proper mechanics 1
• Duration typically 1-3 months depending on injury severity 1
• Return to competition only after completing a functional, progressive throwing program without symptoms 1
• Avoid overhead pulleys which encourage uncontrolled abduction 1
• For baseball pitchers: adhere to age-appropriate pitch counts and rest periods 1

Surgical Considerations

Surgery may be considered in cases of:

• Recurrent instability despite appropriate conservative management 2
• Young, active patients with high risk of recurrence 4
• Athletes in overhead or collision sports 5
• Presence of significant anatomical lesions (Bankart lesion, Hill-Sachs defect) 6

Return to Activity Protocol

• Return to normal activities only after achieving pain-free motion and strength 1
• For athletes: complete a sport-specific functional progression 5
• Goal is to reach at least 90% strength in the injured shoulder compared to the uninjured side 6
• Continue maintenance exercises to prevent recurrence 3

Common Pitfalls to Avoid

• Returning to activity too soon before adequate healing and strengthening 1
• Using overhead pulleys in rehabilitation, which can worsen instability 1
• Failing to address the entire kinetic chain (including scapular mechanics and core strength) 1
• Overlooking subtle signs of instability in the absence of frank dislocation 5
• For throwing athletes: ignoring proper mechanics and overuse factors 1

The key to successful management of shoulder instability is early identification, appropriate rest, and a structured rehabilitation program focusing on strengthening the dynamic stabilizers of the shoulder, with consideration for surgical intervention in select cases where conservative management fails.