Q: Can you walk me through the typical treatment for a problem of shoulder instability? I don't know how it happened, but I ended up with one shoulder that just doesn't work normally. The physician who examined me called it unidirectional instability. I'm set up to start physiotherapy next week but what's the big picture look like for something like this?

A: Shoulder instability can be very complex ranging from painful loss of motion to shoulder dislocation. Surgery to restore a pain free, stable joint requires careful examination by the surgeon. Before a decision can be made what surgical technique should be used, it is important to identify whether the patient has a unidirectional or multidirectional instability. It sounds like you have completed this step in the process.

A unidirectional instability means the shoulder has too much movement in one direction only. Multidirectional instability refers to a shoulder joint that has too much movement or laxity in several different directions at the same time.

Most of the time, this type of problem is caused by laxity or looseness of the shoulder capsule or damage to the capsule and labrum. The labrum is an extra rim of cartilage around the shoulder socket designed to give it a little more depth and holding power.

Treatment can begin with conservative (nonoperative) care with a physiotherapist. You are headed toward step number two! This consists of a rehab program of rotator cuff strengthening exercises, scapular stabilization, and therapy to restore normal proprioception (joint's sense of position). A physiotherapist will set up and supervise the program. The therapist will pay close attention to helping you regain normal motor control, strength, endurance, and stability.

If a nonoperative approach fails to restore shoulder stability, then surgery to correct the capsular laxity may be required. After surgery, shoulder rehab is important. During the first six weeks, the patient wears an immobilizer to protect the healing tissue and does pendulum (Codman) exercises to keep the joint moving without disrupting the incision site. Six weeks after surgery, a rehab program of stretching and strengthening program is started.

Most of the time, this approach is successful but there are cases where surgery fails to achieve the desired results. Failure is most likely when the surgeon does not address the specific type of capsular laxity present. Other risk factors for a failed stabilization procedure include untreated lesions, stretched ligaments, bone loss, or compression fracture of the shoulder glenoid surface. The glenoid is the shallow shoulder socket.

A failed result after shoulder stabilization surgery is not the end of the line. Revision surgery can be done to address the ongoing laxity or instability. At this point, it is very important again that the surgeon re-evaluate you and make sure all aspects of the problem have been identified. There are fewer problems after revision stabilization procedures when the patients are young (less than 35 years old), have good bone density, and have not had other previous shoulder surgeries.

Reference: Aaron J. Bois, MD, MSc, FRCSC, and Michael A. Wirth, MD. Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder. In The Journal of Bone and Joint Surgery. April 2012. Vol. 94A. No. 8. Pp. 749-756.

The Cambridge Physiotherapy provides services for physiotherapy in Cambridge, Galt, and Preston.