Shoulder Instability

​Shoulder instability is one of the many injuries physical therapists treat. There are two main terms we will break down into different categories to think about. They are traumatic and atraumatic shoulder instability.

First is traumatic instability that has occurred from an acute injury such as dislocation. Think about an athlete that has dislocated his or her shoulder during a sporting event or a 40-year-old who has fallen on their shoulder and dislocated it. Both instances are traumatic dislocations that require treatment.​

​With an acute dislocation, the two joint surfaces have completely separated and requires a specific movement to relocate it. There is often severe pain and tissue trauma from the dislocation ranging from capsular or ligamentous disruption, labral tears, depression type fractures on the ball of the joint due to impaction on the socket, and even nerve damage in severe cases. This severe pain may lead to apprehension of movement with muscle guarding and spasms.

Rehabilitation following a traumatic event such as dislocation will focus on pain reduction, possibly a sling to immobilize the shoulder initially, and early controlled passive range of motion of the joint. Time is a component to the rehab process because the damaged tissues must be allowed to heal without overstressing them too early. Initially, strengthening does not become part of the rehab process due to muscle guarding and spasms in the affected tissue. As pain decreases and range of motion improves, patients progress more into specific strengthening, stabilization exercises, and neuromuscular training.

One important aspect of shoulder dislocation that we must also discuss is the incidence of recurrent dislocations. The main factor for determining possibility for another dislocation is the age of the individual at the time of first dislocation. The younger you are, the greater the risk of recurrent dislocation. Research has indicated that patients below 20-years-old have a recurrent rate of 72-100%, 20-30 years old at 70-82%, and over 50 years old at 14-22%. The extent of tissue damage and level of activity the patient wants to return to play a major role in determining whether conservative treatment or surgical options are the better fit.

Now, let’s discuss shoulder instability in the absence of trauma. This type of instability is likely chronic and due to repetitive subluxation or tissue irritation over time. These individuals also present with normal or greater shoulder range of motion in single or multiple planes. Having more motion is not always bad, but when there is excessive motion with joint pain, then we have crossed a threshold and consultation for examining the joint is necessary.

Multidirectional instability is a condition where there is normal to excessive motion from capsular and ligamentous laxity since birth. These people generally have increased motion in several joints throughout the body. Pain typically arises in this person due to repetitive activity involving use of the shoulder in sports, such as pitching. They may tend to have pain in both shoulders because of the nature of gross ligamentous laxity throughout the body, but more prominently on the dominant arm.

Rehab for these individuals is much different than that of traumatic instability from dislocation. Patients with atraumatic shoulder instability have excessive motion, therefore do not need exercises for increasing their motion. They need stability. These patients require early strengthening of shoulder and scapular stabilizing muscles, static and dynamic stability training, proprioception training (joint position training), and neuromuscular control. These patients begin rehab working in mid ranges of motion and progress into upper range or the range of instability complaints prior to return to sport.

Unfortunately, sometimes patients do not respond to conservative treatment for atraumatic shoulder instability. Recurrence of this instability once again focuses on age, but also is affected by activity level and arm dominance. Those who fail conservative care but need to return to higher levels of sport sometimes undergo treatment to improve stability surgically. However, this can impact performance as well since the joint will not have the same motion it once did.

In summary, treatment for both traumatic and atraumatic instability of the shoulder must be tailored to the specific individual and injury, if present. There are many factors that a physical therapist will consider, and only a thorough evaluation of your shoulder joint will provide the necessary direction to get you back to full function or return to sport.