Abstract

Nonoperative management after shoulder dislocation or subluxation remains a challenging and complex task. Accurate diagnosis of the condition and shared decision-making regarding operative and nonoperative management and timing of return to play is required. In this Current Clinical Concepts paper, we introduce a shoulder instability framework that addresses these fundamental clinical dilemmas. Valid clinical prognostic tools that can be used to predict recurrent shoulder instability are reviewed. The process of shared decision-making in the realm of shoulder instability is presented. Finally, a framework for progressive rehabilitation that addresses deficits in motor control, strength, and endurance in scapular and shoulder musculature is provided to guide patients from an initial instability event through to return to play. Shoulder instability is defined as the inability to maintain the humeral head within the glenoid fossa.1 Traditionally, researchers have focused on both the assessment and outcomes of operative management of shoulder instability.2,3 Even though authors of individual studies have reported recurrence rates as high as 75% to 100%,2,3 evidence from 2 systematic reviews indicated a much lower recurrence rate of 21% to 39% across all populations.4,5 Therefore, many patients would likely benefit from and be appropriate for nonoperative management. Unfortunately, literature detailing specific nonoperative interventions is limited.6,7 In addition, some patients with chronic shoulder microinstability are misdiagnosed and may not have responded to traditional shoulder rehabilitation programs. Ultimately, direct-access or first-contact clinicians face at least 3 clinical decisions: (1) determining the patient’s correct diagnosis; (2) identifying if the patient should be managed operatively or nonoperatively (incorporating multiple biopsychosocial factors); and (3) if the patient chooses nonoperative intervention, deciding which interventions should be provided to maximize the outcome. The purpose of this clinical concepts paper is to share a framework for managing shoulder instability that addresses these 3 fundamental concerns.

Document Type

Article

Publication Date

2024

Notes/Citation Information

Journal of Athletic Training 2024;59(3):243–254

Digital Object Identifier (DOI)

doi: 10.4085/1062-6050-0468.22

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