Progression from Shoulder Instability to Stiffness

This session included presentations on: Current concepts in glenohumeral instability; A paradox in the shoulder: the stiff unstable shoulder; Imaging instability; Progression from instability to OA; and Non-operative management of shoulder instability.

Shoulder instability was defined as the pathologic, excessive translation of the humeral head on the glenoid during shoulder motion that manifests in pain and clinical symptoms of subluxation or dislocation. Imaging plays a key role in the work-up of glenohumeral joint instability, where the inferior glenohumeral ligament and the glenoid labrum are of particular interest, and extensive labral injuries are common in young athletes. Conventional MRI is sufficient for the characterisation of labral pathology in most acute/sub-acute cases, whereas MRI arthrography is better for detecting subtle lesions in chronic instability. Surgery is needed to correct anatomical abnormalities and often also to treat athletes who are first-time dislocators, as otherwise they often progress to recurrent dislocators. Consideration should be made of age, extent of labral injury, sport, and current commitments. Shoulder instability can be associated with stiffness, for example capsulitis/capsular contracture can follow dislocation, or dislocation can occur with pre-existing early OA. Capsular hydrodilation has transformed the treatment of capsular contracture and can also be used to allow surgery for instability when accompanied with contracture at the time of surgery. Stabilising the shoulder can also help prevent progression to OA, which only needs to be treated if it becomes symptomatic. Surgery is, however, not necessary for patients with atraumatic instability, voluntary instability, isolated hyperlaxity or instability associated to scapular dyskinesia. In these situations, non-operative management, including physical therapy, recovery of ROM in safe positions, building cuff strength and above all developing good movement patterns and scapular control, is very effective.