Shoulder Pain Management

Dislocation and Separation

In adolescents and young adults, instability of the glenohumeral joint is a common cause of disability and pain. Patients can have a variety of symptoms and, in many instances, the description of instability can be vague.

Key Observations
• The condition is a common cause of disability and pain in adolescents and young adults
• Unidirectional instability usually is more common in males¹
• Multidirectional instability usually is more common in females¹

Clinical Clues

Physical examinations for suspected instability can be deceiving. First, the cervical spine should be examined to rule out any abnormalities, such as radiculopathy or spondylosis that may the cause of referred pain. Ligamentous laxity should be examined to determine its contribution to instability. In general, ligamentous laxity can be assessed by the presence of elbow hyperextension, metacarpophalangeal joint hyperextension, leg hyperextension or recurvatum, patella subluxation and the ability of the abducted thumb to reach the forearm (Fig. 1). Any positive test for laxity may indicate an underlying connective tissue disorder such as Marfan or Ehlers-Danlos syndromes. Patients with these disorders do poorly with surgical treatment.²

Figure 1: Example of metacarpophalangeal joint hyperextension in a patient with multidirectional instability.³

The patient should be inspected for muscle atrophy. Muscle testing and a complete neurovascular examination should be performed and results compared with the contralateral extremity. Nerve injuries have been identified in 32% to 65% of patients with dislocations.⁴ Range of motion testing is actively and passively assessed and compared with the contralateral extremity.⁵

Patients with unidirectional instability in the anterior plane may be apprehensive as their shoulder is abducted and externally rotated in the supine position, because this maneuver reproduces the sensation of an impending dislocation.

Clinical Course

The clinical symptoms of multidirectional instability may resolve with age. The natural stiffening of the joints with age reduces the sense of instability. Therefore, most patients can be treated conservatively, and their symptoms resolve with time.

Know When to Refer
• Failure of conservative treatment after 6 months of rehabilitation
• Concomitant rotator cuff tears
• Associated fracture around the shoulder
• Suspected neurovascular injury
• Locked dislocation
• Frozen shoulder
• Ganglion cyst of the shoulder

The ICD9 code for osteoarthritis of the AC joint is 716.91 (Unspecified Other joint derangement, not elsewhere classified, involving shoulder region).

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References