{"id":28964,"date":"2026-07-15T12:29:38","date_gmt":"2026-07-15T11:29:38","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=28964"},"modified":"2026-08-07T08:12:31","modified_gmt":"2026-08-07T07:12:31","slug":"atraumatic-shoulder-instability","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/atraumatic-shoulder-instability\/","title":{"rendered":"Atraumatic shoulder instability"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><strong>Patient resources<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/services.nhslothian.scot\/musculoskeletal\/self-help-information\/\" target=\"_blank\" rel=\"noreferrer noopener\">NHS Lothian MSK Self Help Resources Webpage<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.sussexmskpartnershipcentral.co.uk\/wp-content\/uploads\/2020\/07\/Shoulder-Instability-Rehabilitation-Programme-min.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Derby Shoulder Instability Program<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.shoulderdoc.co.uk\/article\/644\" target=\"_blank\" rel=\"noreferrer noopener\">Shoulder Doc: Atraumatic Instability<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Definition<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Typical signs and symptoms<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Vague onset of symptoms<\/li>\n\n\n\n<li>Absence of significant traumatic event in history<\/li>\n\n\n\n<li>Possibly a Beighton score suggestive of hypermobility<\/li>\n\n\n\n<li>More commonly experience subluxations than dislocations<\/li>\n\n\n\n<li>Feeling of shoulder insecurity or distrust on movement, but also can occur in resting postures<\/li>\n\n\n\n<li>Pain local to shoulder, commonly around long head of biceps<\/li>\n\n\n\n<li>Inability to perform overhead tasks due to pain, weakness or apprehension<\/li>\n\n\n\n<li>A small subgroup can develop involuntary muscle patterning habits<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Prevalence and risk factors<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Around 4% of those with shoulder instability have atraumatic instability<\/li>\n\n\n\n<li>Younger patients &lt;25 years old<\/li>\n\n\n\n<li>Female &gt; male<\/li>\n\n\n\n<li>Risk factors: hypermobility, unbalanced muscle recruitment around the shoulder, overhead sports\/ using shoulder at extremes of motion e.g. throwing activity, swimming.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Prognosis\/ risk factors for poor outcomes<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Between 50-80% of patients have a good outcome with non-operative management.&nbsp;&nbsp;Prognosis will depend on classification and individual contributing factors including self-efficacy, fear avoidance and psychosocial factors.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Differential diagnoses<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>rotator cuff related shoulder pain<\/li>\n\n\n\n<li>calcific tendinopathy<\/li>\n\n\n\n<li>acromioclavicular joint disorders<\/li>\n\n\n\n<li><a href=\"https:\/\/www.rightdecisions.scot.nhs.uk\/msk-pathways\/shoulder-elbow-pathways\/supporting-information-on-relevant-conditions\/other-conditions-to-consider\/\" target=\"_blank\" rel=\"noreferrer noopener\">extrinsic sources<\/a>&nbsp;such as the cervical spine, visceral referred pain, and peripheral nerve lesions.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Relevant standards and guidelines<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/bess.ac.uk\/wp-content\/uploads\/2020\/06\/Atraumatic-Shoulder-Instability.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">BESS Patient Care Pathway: Atraumatic Shoulder Instability<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>P.A &amp; M.A &#8211; 15-7-26<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who can refer: <\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>All primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners <\/li>\n\n\n\n<li>Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP <a href=\"https:\/\/services.nhslothian.scot\/musculoskeletal\/where-to-find-us\/\" target=\"_blank\" rel=\"noreferrer noopener\">Where To Find Us \u2013 Musculoskeletal Physiotherapy<\/a>)<\/li>\n\n\n\n<li>Secondary care consultants and associated teams<\/li>\n\n\n\n<li>MSK physiotherapists who identify patients with suspected serious conditions of the shoulder or elbow shoulder follow agreed pathways and processes <a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx\" target=\"_blank\" rel=\"noreferrer noopener\">NHS Lothian Integrated Shoulder &amp; Elbow Service<\/a><\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who and How to refer:<\/h4>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\"><table><thead><tr><th>Condition<\/th><th>Referral Type<\/th><th>Referral destination and process<\/th><\/tr><\/thead><tbody><tr><td><strong>Suspected septic arthritis\/ septic bursitis<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected facture or dislocation<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected acute distal biceps rupture<\/strong><\/td><td>Same day<\/td><td><strong>Orthopaedic registrar<\/strong> via Flow navigation centre on 03000 134000\/ on call Orthopaedic registrar via switchboard 0131 242 1000<\/td><\/tr><tr><td><strong>Suspected acute traumatic rotator cuff tear in the younger patient<\/strong><\/td><td>Urgent<\/td><td><strong>Orthopaedics<\/strong> via SCI gateway &gt; Lauriston Buildings &gt; Orthopaedics- Elbow &amp; Shoulder<\/td><\/tr><tr><td><strong>Suspected malignancy\/ tumour specific to shoulder*<\/strong><\/td><td>Urgent<\/td><td><strong>Orthopaedics<\/strong> via SCI gateway &gt; Lauriston Buildings &gt; Orthopaedics- Elbow &amp; Shoulder<\/td><\/tr><tr><td><strong>Suspected inflammatory condition<\/strong><\/td><td>&nbsp;<\/td><td>Consider referral to <strong>Rheumatology<\/strong> \u2013 see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/rheumatology-2\/\" target=\"_blank\" rel=\"noreferrer noopener\">RefHelp Rheumatology.<\/a><\/td><\/tr><tr><td><strong>Suspected neurological condition<\/strong><\/td><td>&nbsp;<\/td><td>Consider referral to <strong>Neurology<\/strong> \u2013 see&nbsp;<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/neurology\/\" target=\"_blank\" rel=\"noreferrer noopener\">RefHelp Neurology.<\/a><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">* <em>Please also see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/orthopaedics\/sarcoma\/\" target=\"_blank\" rel=\"noreferrer noopener\">Sarcoma \u2013 RefHelp<\/a>. 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&nbsp;detailed on <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/paediatric-radiology\/gpaccesstoctforsuspectedcancernoclinicallyobviousprimary\/\" target=\"_blank\" rel=\"noreferrer noopener\">GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) \u2013 RefHelp<\/a><\/em><\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients who have the presence of significant red flags\/ suspicion of serious shoulder and elbow conditions or have suspected inflammatory condition &#8211; see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/serious-shoulder-and-elbow-conditions-red-flags\/\" data-type=\"link\" data-id=\"https:\/\/apps.nhslothian.scot\/refhelp\/serious-shoulder-and-elbow-conditions-red-flags\/\" target=\"_blank\" rel=\"noreferrer noopener\">serious shoulder &amp; elbow conditions<\/a><\/li>\n\n\n\n<li>Age &lt;16<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Other considerations<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients aged under 18 years, those with 20% absence from school, or 3-month absence from work should be referred to specialist shoulder service.<\/li>\n\n\n\n<li>A suspected unreduced dislocation is a red flag and should be managed as an emergency. See red flags pathway.<\/li>\n\n\n\n<li>Traumatic instability should be assessed in an Orthopaedic clinic to determine management course.<\/li>\n\n\n\n<li>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.<\/li>\n\n\n\n<li>Those with frequent emergency department attendance should be referred to specialist shoulder service.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">For further information see associated sections<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<ul class=\"wp-block-list\">\n<li>Link to NHS Lothian patient internet site including patient information resources \u2013&nbsp;<a href=\"https:\/\/services.nhslothian.scot\/ises\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/services.nhslothian.scot\/ISES\/Pages\/default.aspx<\/a><\/li>\n\n\n\n<li>Link to NHS Inform page shoulder &nbsp;problems&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/shoulder-problems\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/shoulder-problems<\/a><\/li>\n\n\n\n<li>Link to NHS Inform shoulder problems- Patient self help guide&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/self-help-guides\/self-help-guide-shoulder-pain\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/self-help-guides\/self-help-guide-shoulder-pain<\/a><\/li>\n\n\n\n<li>Link to NHS Inform page elbow problems&nbsp;<a href=\"https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/elbow-problems\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhsinform.scot\/illnesses-and-conditions\/muscle-bone-and-joints\/self-management-advice\/elbow-problems<\/a><\/li>\n\n\n\n<li>Link to intranet site NHS Lothian Integrated Shoulder and Elbow Service&nbsp;<a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/physiotherapy\/NHSLIntegratedShoulderandElbowService\/Pages\/default.aspx<\/a><\/li>\n<\/ul>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Patient resources NHS Lothian MSK Self Help Resources Webpage Derby Shoulder Instability Program Shoulder Doc: Atraumatic Instability 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 Prevalence and risk factors<\/p>\n","protected":false},"author":20,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[1415,1414],"class_list":["post-28964","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-atraumatic-shoulder-instability","category-https-apps-nhslothian-scot-refhelp-shoulder-conditions"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"mariamazoysaavedra","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/mariamazoysaavedra\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/musculoskeletal-physiotherapy\/shoulder-elbow\/https-apps-nhslothian-scot-refhelp-shoulder-conditions\/https-apps-nhslothian-scot-refhelp-atraumatic-shoulder-instability\/\" rel=\"tag\">Atraumatic shoulder instability<\/a><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/musculoskeletal-physiotherapy\/shoulder-elbow\/https-apps-nhslothian-scot-refhelp-shoulder-conditions\/\" rel=\"tag\">Shoulder conditions<\/a>","rttpg_excerpt":"Patient resources NHS Lothian MSK Self Help Resources Webpage Derby Shoulder Instability Program Shoulder Doc: Atraumatic Instability 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 Prevalence and risk factors","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28964","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/20"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=28964"}],"version-history":[{"count":4,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28964\/revisions"}],"predecessor-version":[{"id":29408,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/28964\/revisions\/29408"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=28964"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=28964"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}