Atraumatic shoulder instability

Patient resources

Definition

Abnormal motion or position of the shoulder that can lead to pain, subluxation, dislocation and functional impairment, which happens without any history of a significant preceding injury (BESS 2019).

Typical signs and symptoms

Vague onset of symptoms
Absence of significant traumatic event in history
Possibly a Beighton score suggestive of hypermobility
More commonly experience subluxations than dislocations
Feeling of shoulder insecurity or distrust on movement, but also can occur in resting postures
Pain local to shoulder, commonly around long head of biceps
Inability to perform overhead tasks due to pain, weakness or apprehension
A small subgroup can develop involuntary muscle patterning habits

Prevalence and risk factors

Around 4% of those with shoulder instability have atraumatic instability
Younger patients <25 years old
Female > male
Risk factors: hypermobility, unbalanced muscle recruitment around the shoulder, overhead sports/ using shoulder at extremes of motion e.g. throwing activity, swimming.

Prognosis/ risk factors for poor outcomes

Between 50-80% of patients have a good outcome with non-operative management. Prognosis will depend on classification and individual contributing factors including self-efficacy, fear avoidance and psychosocial factors.

Differential diagnoses

rotator cuff related shoulder pain
calcific tendinopathy
acromioclavicular joint disorders
extrinsic sources such as the cervical spine, visceral referred pain, and peripheral nerve lesions.

Relevant standards and guidelines

BESS Patient Care Pathway: Atraumatic Shoulder Instability

P.A & M.A – 15-7-26

Who can refer:

All primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP Where To Find Us – Musculoskeletal Physiotherapy)
Secondary care consultants and associated teams
MSK physiotherapists who identify patients with suspected serious conditions of the shoulder or elbow shoulder follow agreed pathways and processes NHS Lothian Integrated Shoulder & Elbow Service

Who and How to refer:

Condition	Referral Type	Referral destination and process
Suspected septic arthritis/ septic bursitis	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000
Suspected facture or dislocation	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000
Suspected acute distal biceps rupture	Same day	Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000
Suspected acute traumatic rotator cuff tear in the younger patient	Urgent	Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow & Shoulder
Suspected malignancy/ tumour specific to shoulder*	Urgent	Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow & Shoulder
Suspected inflammatory condition		Consider referral to Rheumatology – see RefHelp Rheumatology.
Suspected neurological condition		Consider referral to Neurology – see RefHelp Neurology.

* Please also see Sarcoma – RefHelp. If clinical assessment leads to a very strong suspicion of suspected underlying malignancy, with no specific localising signs or symptoms to suggest a specific underlying primary, consider recommendations and referral options detailed on GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp

Who not to refer:

Patients who have the presence of significant red flags/ suspicion of serious shoulder and elbow conditions or have suspected inflammatory condition – see serious shoulder & elbow conditions
Age <16

Other considerations

Patients aged under 18 years, those with 20% absence from school, or 3-month absence from work should be referred to specialist shoulder service.
A suspected unreduced dislocation is a red flag and should be managed as an emergency. See red flags pathway.
Traumatic instability should be assessed in an Orthopaedic clinic to determine management course.
Those with significant functional impairment can be resistant to usual conservative measures and may benefit from a multidisciplinary team approach to address psychosocial factors and other barriers to recovery.
Those with frequent emergency department attendance should be referred to specialist shoulder service.

For further information see associated sections