Shoulder Pain Management

Shoulder Instability

Shoulder instability is treated by reducing the excessive translation of the humeral head with normal physiologic glenohumeral motion.

Treatment Options
• NSAIDs and analgesia as necessary
• Recurrent dislocations and instability in males may require surgical stabilization
• Multidirectional instability in females, related to ligament laxity, does well with muscle strengthening
• Age-related stiffening of the joints relieves symptoms

Key Clinical Considerations

Multidirectional Instability
• Physical therapy is the mainstay of treatment in patients who have primarily multidirectional instability.
• Patients should be educated that the shoulder has become deconditioned and that a regular exercise program that strengthens the scapula stabilizers, rotator cuff muscles and deltoid can help to regain neuromotor control.
• Phase one of the exercise program is aimed at restoring the strength of the deltoid and rotator cuff muscles. Once this is achieved, the patients are advanced to phase two with the addition of scapula stabilization exercises.
• Therapy should be carried out for a minimum of 6 months, after which the patient is given a maintenance program that should be continued indefinitely.
• Patients who present with significant discomfort and who have difficulty progressing during therapy can be given a short course of analgesics or NSAIDs.

Unidirectional Instability
• Treatment principles remain the same as multidirectional instability.
• Most patients have experienced a traumatic anterior dislocation (posterior dislocations are rare, occurring primarily in seizure and electrocution victims) and may require an initial period of sling immobilization to relieve symptoms.
• Sling immobilization should be as brief as possible in order to regain full, active shoulder range-of-motion.
• Patients are started in a therapy program as soon as symptoms allow and continue this program until strength and range-of-motion are near symmetric to the uninvolved shoulder.

Patient Considerations

Multidirectional Instability

Approximately 90% of patients can expect a satisfactory result with therapy alone in the setting of multidirectional instability.¹ Patients who continue to experience symptoms despite compliance with a therapy program after 6 months may be candidates for surgical intervention. Patients should be counseled at the time of diagnosis that multidirectional instability will not typically persist into late adulthood, as the glenohumeral joint and surrounding capsular structures will likely stiffen with age.

Unidirectional Instability

Reports of success with therapy vary; however, most studies show that younger patients (<40 years) have a high likelihood of recurrence, which may be as high as 85%.¹ Older patients (>35–40 years) who sustain a dislocation are typically treated with conservative management alone, as recurrence in this patient population is less likely. Patients with anterior instability who continue to experience instability after a comprehensive rehabilitation program may be candidates for surgical intervention.

Clinical Course

If conservative measures fail to relieve either type of instability and the patient continues to have difficulty with activities of daily living, exercise or work-related activities, referral for a surgical consult may be appropriate. When considering surgical intervention, multiple variables such as age, degree of activity restriction, hand dominance, patient expectations and occupational considerations all play a factor in predicting successful outcomes. Surgical options include arthroscopic or open capsular shift (multidirectional instability) or anterior inferior glenohumeral ligament repair (unidirectional anterior instability). Typically, the clinical symptoms of multidirectional instability resolve with age as stiffening of the joints may reduce the sense of instability.

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

References