Multidirectional Shoulder Instability: Treatment

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.