Multidirectional Shoulder Instability: Treatment

Abstract

Background:The treatment of multidirectional instability of the shoulder is complex. The surgeon should have a clear understanding of the role of hiperlaxity, anatomical variations, muscle misbalance and possible traumatic incidents in each patient.Methods:A review of the relevant literature was performed including indexed journals in English and Spanish. The review was focused in both surgical and conservative management of multidirectional shoulder instability.Results:Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder. The presence of a significant traumatic incident, anatomic alterations and psychological problems are widely considered to be poor prognostic factors for conservative treatment. Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.When conservative treatment fails, a surgical intervention is warranted. Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes. Thermal or laser capsuloraphy is no longer recommended.Conclusion:Multidirectional instability is a complex problem. Conservative management with focus on strengthening and balancing of the dynamic shoulder stabilizers is the first alternative. Some patients will fare poorly and require either open or arthroscopic capsular plication.

Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint

“…The rationale is that improving scapular, rotator cuff and deltoid function compensates for a lack of passive stability and restores active control of the shoulder [ 32 , 53 , 61 , 78 ]. In a small sub-group of patients whose acquired lesions result in failure of conservative management, surgery may be considered, and only when faulty mechanics have been largely resolved [ 1 , 54 , 63 , 79 , 80 ]. Early surgical referral may be warranted in an MDI patient who has sustained a significant traumatic structural lesion [ 55 ].…”

“…While there are discrepancies in the explicit definition, most authors agree that multidirectional instability (MDI) is the symptomatic subluxation and/or dislocation of the glenohumeral joint in the inferior as well as anterior and/or posterior directions [ 1 , 2 , 3 , 4 ]. The glenohumeral joint subluxations or dislocations that occur in MDI cause pain and disability in sports, occupations, and activities of daily living.…”

Multidirectional instability of the shoulder: surgical techniques and clinical outcome

“…Current findings suggest that benefits of rotator interval closure arise from superior glenohumeral ligament (SGHL). Therefore, closure of the interval should be performed in a manner to repair SGHL to its native insertion site (34). Good clinical reports have been reported following MDI surgery, with or without rotator interval closure (44,55).…”

“…Arthroscopic techniques are less invasive compared to open techniques, provide opportunity to preserve dynamic stabilizers (such as subscapularis muscle) and provide better visualization and opportunity to approach accompanying intra-articular lesions and capsulolabral changes which are specific to MDI such as redundant inferior capsule. Therefore, It has become the preferred method in current practice ( 34 ). Another advantage of arthroscopic techniques is that anteroinferior and posteroinferior patulous capsule can be approached in a single intervention and also they provide the opportunity to approach each region selectively ( 11 ).…”

Whole Glenoid Reconstruction for Multidirectional Instability of the Shoulder

“…The anatomic abnormality includes mainly glenoid and labrum dysplasia that results in a small and flat glenoid without labrum concavity and the capsule ligament dysplasia featured by too thin and redundant capsule. 2 , 3 Nonoptimal healing may be related to the special physical features of the patients. Thus we developed a procedure named whole glenoid reconstruction, which includes mainly 270° glenoid bone grafting and capsule labrum reconstruction to address the glenoid and labrum dysplasia, and glenohumeral ligament reconstruction with internal bracing to address the capsule dysplasia and the low healing potential.…”