Clinical Review

Management of the unstable shoulder

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2537 (Published 28 May 2015) Cite this as: BMJ 2015;350:h2537
  1. Tanujan Thangarajah, research fellow/specialist trainee year 51,
  2. Simon Lambert, consultant shoulder and elbow surgeon2
  1. 1John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
  2. 2Shoulder and Elbow Service, Royal National Orthopaedic Hospital, Stanmore, UK
  1. Correspondence to: T Thangarajah tanujan1{at}hotmail.com

The bottom line

  • Shoulder instability is characterised by abnormal movement of the humeral head resulting in pain, subluxation, or dislocation

  • Three types of shoulder instability exist: traumatic, atraumatic, and muscle patterning, but they can occur together, in combination, or sequentially over time

  • Treatment is specific to the type of instability—non-operative management is indicated for all those with a muscle patterning component to their instability, even in the presence of a structural lesion, and surgical stabilisation is indicated when instability is either purely structural or persists despite physiotherapy

  • Arthritis, a common long term sequela of an unstable shoulder, may be indicated by a painful, stiff shoulder many years after the instability has been treated

The shoulder is the most commonly dislocated joint in the human body. The incidence of shoulder dislocation is increasing.1 Recurrence is common and occurs in as many as 67% of cases.2 Patients often mention a painful, weak arm and a shoulder that readily dislocates with trivial movements. These disabling symptoms can lead to multiple hospital admissions, decreased ability to participate in high level activities, fewer employment opportunities, and a reduction in overall health.3 The “unstable shoulder” has therefore become a relatively common problem seen in primary healthcare, with a reported incidence rate of 2.8%.4

The aim of this review is to provide a simple framework for the clinical assessment, investigation, and treatment of the unstable shoulder for non-specialists and to highlight key patient groups that benefit from early specialist input.

Sources and selection criteria

We searched Medline and the Cochrane library using the terms “shoulder instability”, “shoulder dislocation”, “clinical assessment of shoulder instability”, and “treatment of shoulder instability”. Only articles published in English were included. Data were primarily collated from observational studies, case series, and randomised controlled trials.

How does a shoulder become unstable?

When a shoulder joint is dislocated by external force (a traumatic dislocation), …

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