Review Question - QID 218182

A short course of immobilization (1 week or less) has similar rates of recurrent instability as prolonged immobilization (3 weeks or longer).

Anterior shoulder instability is one of the most common shoulder injuries occurring with an anteriorly directed force on the arm with the shoulder in an abducted and externally rotated position. Diagnosis is made clinically with a history of instability and positive anterior instability with provocative tests and confirmed with an MRI. Nonoperative treatment consists of immobilization until pain resolves followed by early motion. Studies have not demonstrated any benefit with prolonged periods of immobilization (3 weeks) compared to a short course of immobilization (1 week). Initial immobilization can be in internal or external rotation with no clear consensus for either position. Physical therapy focuses on safely regaining motion, strengthening the dynamic shoulder, and proprioceptive training. Nonoperative treatment can allow patients to return to activities as early as 2-3 weeks after an instability event, however, patients should be counseled that they are at higher risk for recurrent instability, and that subsequent instability events may result in more extensive labral injury, greater bone loss, and higher rates of instability even after arthroscopic Bankart repair. While bracing is used in many nonoperative protocols, there is no good evidence to indicate it reduces the risk of instability. Operative treatment includes both soft-tissue and bony stabilization procedures which are indicated based on risk factors, size of bony defects, and surgeon preference.

Owens et al review the management of in-season anterior shoulder instability noting that there is limited evidence to guide decision-making. Rehabilitation may allow a return to sport within 3 weeks, but there is a moderate risk of recurrence. In contrast, surgical management with arthroscopic or open Bankart repair has lower rates of recurrent instability but the athlete will be out for an extended period of time and will most likely miss the remainder of the season. Several factors should be considered when determining the optimal treatment including age, activity level, sports-specific demands, natural history of shoulder instability, findings on examination and imaging, the athlete's goals, and motivation.

Dickens et al. prospectively analyzed 45 contact collegiate athletes treated either nonoperatively or with arthroscopic stabilization to evaluate return to play and recurrent instability in the season following an anterior shoulder instability event. Of those treated nonoperatively, 40% were able to return to play without recurrence during the following season. Of those treated surgically, 90% were able to return to play without recurrence during the following season. The authors concluded that collegiate contact athletes are more likely to return to sport without recurrent instability the following season if they undergo arthroscopic stabilization than nonoperative treatment.

Figure A is an MRI of the shoulder with a Bankart lesion.

Incorrect Answers:
Answer 1: There is no evidence to indicate that bracing reduces the rates of recurrent instability.
Answer 3: Several studies have shown a lower recurrence rate and a higher RTP rate following arthroscopic Bankart repair compared to non-operative treatment for first-time dislocators and the decision should be made based on the patient's goals and risk for recurrence.
Answer 4: Given his age and participation in contact sports he is at moderate to high risk for recurrent instability.
Answer 5: Recurrent instability may result in more extensive labral injury, greater bone loss, and higher failure rates following arthroscopic Bankart repair.