A painful and unstable shoulder is described as shoulder pain caused by irritation of shoulder joint structures such as the joint, capsule lining, tendons, ligaments, bursa and muscles and is due to the elaborate system of both static and dynamic stabilisers being compromised. The terminology often used is glenohumeral instability or multi-directional instability of the shoulder and can be a major problem for repetitive throwing or overhead athletes and active individuals.
Symptoms of a painful and unstable shoulder can be generalised shoulder pain or anterior shoulder pain that is deep and persistent, feelings of instability or laxity and apprehension to move the shoulder in overhead or behind the head actions. Treatment of the painful and unstable shoulder needs to first focus on settling the shoulder down with passive techniques to reduce pain and irritation. The next phase needs to combine active interventions such as isometric, concentric and eccentric movements directed at the glenohumeral joint, the scapula and the back muscles. Common conditions that are more likely to present as a painful and unstable shoulder include: recurrent dislocations, and a labral tear (SLAP lesion).
Frequently Asked Questions
How does a painful and unstable shoulder present?
A person with a painful and unstable shoulder will report pain, weakness, limited range of motion and a feeling of instability. Pain can be sharp or aching and located around the shoulder joint with a possibility of radiating down the arm. The affected shoulder may be weak and you may experience difficulty with overhead activities such as washing your hair, and reaching into a cupboard. Range of motion can be compromised and there can be guarding or protection by the injured person to limit painful movements. Instability can be described as a feeling of looseness, slipping out of place, or giving way.
How is a painful and unstable shoulder diagnosed?
There are no standardised guidelines for diagnosing a painful and unstable shoulder. A thorough clinical history and examination is used in an assessment of a painful and unstable shoulder. You may be asked about the mechanism of injury, occupation, and sports participation. The physical examination may include testing of rotator cuff strength, neurological signs, and sulcus sign among other special tests.
Diagnostic imaging can be used to see the rotator cuff and any damage to surrounding structures that may be present. An MRI is preferred for labral injuries and other soft tissue injuries and a CT is preferred for glenohumeral bone loss.
How is a painful and unstable shoulder treated?
Non-surgical management can be applied to patients who are first-time dislocators, and without glenohumeral bone lesions, who are not engaged in high-risk activities. There is no evidence to support corticosteroid injections for those with anterior shoulder instability (ASI). Conservative management will involve a period of immobilisation, followed by range of motion and strength exercises.
Risk factors for poor outcomes of conservative management include higher levels of initial pain, recurrent instability, seizure disorders, smokers, severe glenoid bone loss, low-energy mechanism of injury, concomitant soft tissue injuries, collision and competitive athletes.
Surgical management is considered for patients with primary or recurrent instability with an anterior labral tear, minimal glenoid bone loss, and/or an on-track Hill-Sachs lesion. An arthroscopic Bankart repair is the most commonly used surgical procedure for ASI and aims to repair the labrum to restore the stabilising effects of the glenohumeral soft tissue. Other surgical interventions include remplissage, latarjet procedure, and glenoid bone grafting. Revision surgery may be required for people with primary treatment failure manifesting as symptomatic apprehension, sublaxation, dislocation, functional limitations, further intra-articular injury, or symptomatic hardware failure.