The document summarizes key studies on the effectiveness of conservative treatment for multidirectional instability (MDI). Three studies found that conservative treatment including strengthening exercises improved some outcomes like muscle activation patterns and kinematics, but did not fully restore shoulders to normal. One study found that after 8 years, only 30% of patients had good results with conservative treatment alone. Overall, the studies suggest that while conservative treatment can provide some benefits for MDI, surgery may be needed for full resolution of symptoms for many patients.

1. Effectiveness of Conservative
Treatment for MDI
Gregory Sabo

2. Objectives
•Define the current clinical scenario and question
•Identify search methods for the best available evidence
for successful treatment of MDI
•Describe the findings of these key studies
•Address the weaknesses of these key studies
•Summarize the implications for practitioners

3. Multidirectional Instability (MDI)
•Numerous etiologies
oTraumatic
oAtraumatic
oCongenital
oMultifactorial
•Symptomatic global laxity of
glenohumeral joint
•Generally younger, active http://test2.aaos.org/oko/topic_images/SPO041.jpg
o<30
•Men = Women
•Orthopedic Research Institute defines as glenohumeral
instability in >1 direction
•Different from unidirectional instability

4. Clinical Scenario
•Complex pathology, difficult to treat
•Two common intervention
approaches
o Surgery ->
Immobilization -> PT
oConservative PT
management
•Conflicting data to suggest
which is best
•Specific pt populations may
benefit more
from one approach vs. another http://redsports.sg/wp-content/uploads/2008/04/clunking-shoulder.jpg

5. Dynamic and Static Restraints
•Labrum and capsule
•Rotator cuff muscles
•Sup/middle/inf
glenohumeral ligaments
•Orientation and size of
the humeral head and glenoid
•Also the coracoacromial lig,
axillary pouch, and
Scapulothoracic muscles and orientation

6. Clinical Scenario Patient Symptoms
•Loosening of the shoulder in all directions
•This my be pronounced while carrying luggage
or turning over while asleep
•Pain may or may not be present
•Sulcus sign
•Patient may feel shoulder slippage or feeling of insecurity with specific activities
•May have normal observation, AROM, PROM, RROM (in test positions), normal
imaging

7. Special Tests
•Rowe Test for MDI
•Sulcus sign
•Load and shift
•Anterior and posterior
drawer in standing or sitting
•Joint glides in supine
•Push-pull test

8. Grades of Humeral Head Translation
Normal laxity- mild amount of translation up to
25%
Grade 1- A feeling of the humeral head riding up to
the glenoid rim 25-50%
Grade 2- A feeling of the humeral head over riding
the rim, but spontaneously reduces >50%
Grade 3- A feeling of the humeral head over the
rim, but remains dislocated

9. Focused Clinical Question
Is conservative rehabilitation alone an effective intervention
in the treatment of multidirectional shoulder instability?

10. Search Strategy
P- Multidirectional shoulder instability
I- Conservative treatment OR therapeutic exercise OR
non-invasive treatment OR strengthening exercise
C- Invasive treatment OR surgery OR capsular shift
O- Presence of symptoms OR recurrence of
dislocation/subluxation OR return to function

11. Search Strategy Cont'd
•Databases used:
oPubmed
oCINAHL
oSPORTDiscus
oPEDro
•Inclusion criteria:
oStudies investigating effectiveness of conservative
treatment
oEnglish language
oHuman participants
oLast 10 years
oStrengthening regimen

12. Search Strategy Cont'd
•Exclusion criteria:
oStudies investigating unidirectional instability
oPatients with current soft tissue or bone injury
oPatients with history of shoulder surgery
oAnimal models

13. Search Results

14. Capsular Shift Surgery
•Capsular shift surgery is the tightening of the capsule,
“shifting” it back into place so that it helps hold the
joint together. It is usually done as an “open” procedure
assisted by an arthroscopy, which is the viewing of the
joint through a magnified scope. The patient is usually
placed into a semi-sitting position on a special bed with
a back that raises up. The patient’s head is stabilized
in a soft, padded head holder.
•Once the capsule is viewed through the arthroscope and the area of
damage located, the open incision is made. The stretched capsule is
brought forward and pulled tighter by folding over itself. It is then sutured

15. Illyés et al (2009)
Study Prospective Cohort
Design
Particip 101 subjects
ants
Control Group: 32 males, 18 females,
average age in mid 20’s
PT Group: 17 males, 15 females, average
age 18
Surgery + PT Group: 7 males, 12 females,
average age in low 30’s
IntervenConservative Group: Education, Mirrors,
tion PNF, biofeedback, strengthening exercises,
closed chain exercises, stamina training
Surgical Group: Open capsular shift,
immobilized in sling for 6 weeks, rehab on
day 1:
aarom elevation to 90, ER to 10 degrees.
After 3 weeks: max ROM without pain.
After 6 weeks: Begin same intervention as
conservative group
Outcom EMG data from pec major, infraspinatus,
e deltoid, upper
Measur trapezius, bicep, tricep, during pull, forward
es punch, elevation, slow/fast overhead throw
Time between first muscle reaching max
activity and last (time broadness)
Normalized maximum amplitudes
Main Only surgical + rehab returned muscles
Finding activity to normal
s
Motion patterns on muscles around joint
with MDI are changed.
Conservative treatment improved time
broadness
to normal, but not for level of muscle
activations (decreased accelerators,
increased
stabilizers).

16. Kiss et al (2010)
Study Non-Randomized Control Trial
Design
Participa 90 subjects
nts
Control Group: 16 males, 9 females,
average age 27
PT Group: 18 males, 16 females, average
age 28
Surgery + PT Group: 12 males, 19 females,
average age 30
Intervent Program consisted of proprioceptive input
ion to improve the sense of joint position, and
on relearning correct movement patterns
with the development of strength and
endurance in the scapulothoracic and
glenohumeral muscles. Mirrors, PNF,
biofeedback were used to retrain patterns of
ST and GH movement. Strength exercises,
closed chain exercises, stamina training
were used to increase stability of muscle
balance and proprioception.
Surgery group had a capsular shift using the
“beach chair” position through an anterior
approach. Surgery was then followed with
postoperative physiotherapy.
Outcom Kinematic characteristics of movement
e measured using the Zebris CMS-HS
Measure movement analysis system.
s
Changes in the electrical potential of the
ant/middle/post parts of the deltoid,
supraspinatus with trapezius, infraspinatus,
biceps brachii, triceps brachii were
recorded.
Maximum muscle contraction was specified
by taking the highest muscle contraction
achieved during various forms of motion.
Bilinear regression line of rhythm was
calculated using 5 parameters of motion
pattern.
Main Patients with MDI had significant
Findings alterations in shoulder kinematics and in
muscle activity compared to controls.

17. Misamore et al (2005)
Study Uncontrolled, Retrospective,
Design Noncomparative Review
Particip 64 patients with atraumatic MDI
ants
21 males, 43 females, average age 18.6
All but 9 participated in sport
IntervenEnrolled in physical therapy program and
tion were placed on home exercise program.
Phase 1 consisted of relative rest from
provocative activities, analgesics, and gentle
ROM exercises. Phase 2 consisted of
rotator cuff and parascapular muscle
strengthening exercises. Slow progressive
strengthening programs were performed
daily at home (15 to 20 min 3x daily).
Phase 3 involved sport specific
exercises if appropriate. Phase 4 involved
returning to sport or work.
Outcom Modified Rowe score (Max of 100 points).
e Includes function, pain, stability, motion.
Measur
es
Main At 2 years surgery had been performed on 20
Finding of the patients to stabilize their shoulder. Of
s the 39 patients not receiving surgery 20 had
good or excellent results regarding pain
relief, 21 had good or excellent results with
stability, 28 reported that the shoulder
condition was better or much better.
At 8 years 1 addition patient received
surgery. Of the 36 non-surgical patients 29
reported no further treatment for their
shoulder instability, none of the patients
were still performing shoulder therapy
exercises. 28 reported persistent problems
with their shoulders, 8 reported no residual
symptoms.
Level 2B
of
Evidenc
e
Conclus At the 8 year follow up 40 of 57 patients
ion (70%) had been treated surgically or had fair
or poor ratings for their shoulders. Only
30% had a good or excellent result based on

18. Ide et al (2003)
Study Prospective Cohort
Design
Particip 46 patients with MDI
ants
12 males, 34 females, average age 20
Interve Prescribed exercise daily for 8 weeks.
ntion Performed exercise in novel shoulder
orthosis to increase scapular inclination and
to stabilize the scapula. Strengthening the
rotator muscles and scapular stabilizers
(serratus anterior, and rhomboids). Isometric
exercises included IR, ER, and isotonic
shoulder strengthening exercises with thera-
band. Wall pushup exercises to strengthen
scapular stabilizers and synchrony training of
the scapulothoracic muscles.
Outco Before and after 8 week program patients
me were evaluated for; shoulder function, pain,
Measur numbness, stability, ROM on a modified
es Rowe grading system. There was then a
follow up at 7 years.
Main Before the rehab program 59 shoulders were
Finding in fair condition and 14 were in poor
s condition. After the rehab program 24
shoulders were in fair condition and 1 was in
poor.
Muscle strength increased by more than 20%
in 22 of 36 shoulders, in 20 of 22 shoulders
good or excellent results were achieved.
Level 2B
of
Eviden
ce
Conclu The aim of rehabilitation should be a gain of
sion 20% in the peak torque of internal and
external rotation and the achievement of
normal muscle balance. Shoulder orthotic
prevents a decrease in scapular inclination;
rather, it increases scapular inclination by
pushing the inferior angle of the scapula and
straightening the thoracic spine. Patients can
achieve stabilization of the glenohumeral
joint and scapula by using the orthosis
correctly. They are permitted to remove the
orthosis after achieving strengthening of the
shoulder muscles upon completion of the
exercise program.

19. Gibson et al (2004)
Study Systematic Review
Design
Particip Adults 16-55 with history of shoulder
ants instability
Excluded stroke, hemiplegia, prior surgery
IntervenNon-operative management including but
tion not limited to immobilization and PT
methods like stretching, strengthening or
stabilization exercises, biofeedback, other
modalities
Outcom Recurrence of instability (redislocation or
e resubluxation)
Measur
es Return to
premorbid function
Alleviation of symptoms
Main Many different intervention protocols, but
Finding mostly based on physiological rationale
s and biological evidence
Paucity of quality trials in this area
Review
limited to qualitative analysis due to poor
reporting in many papers
Current available studies are weak
foundation
Weak but positive trend for conservative
management
Most cohorts found worse outcome with
conservative management, particularly in
those under 30.
Level 1A
of
Evidenc
e
Conclus Weak evidence to support surgery over
ion conservative management.

20. Current Conservative Management
American College of Sports Medicine recommends
strengthening of the scapulothoracic and
glenohumeral muscles
Scapu Mov Muscl Resistance
lothor eme e exercise
acic nt
Fixa Serratu Push up
tion s ant
Fixa Pec Parallel bar
tion minor dip
Fixa Trap Upright row
tion
Fixa Levato Shoulder
tion r shrug
scapul
ae

21. Current Conservative Management
Glenoh Movem Muscle Resista
umeral ent nce
exercis
e
Flexion Ant deltFront
raises
Pec Incline
major bench
(clavicu press
lar
head)
Extensi Latissi Dumbb
on mus ell pull-
dorsi over
Teres Chin-up
major
Pec Bench
major press

22. Current Conservative Management
Glenoh Movem Muscle Resista
umeral ent nce
exercis
e
Abducti Middle Lateral
on delt raises
Suprspi Low
natus pulley
lateral
raises
Adducti Latissi Lat
on mus pull-
dorsi down
Teres Seated
major row
Pec Cable
major crossov
er fly

23. Current Conservative Management
Glenoh Movem Muscle Resista
umeral ent nce
exercis
e
Internal Teres Bent
rotation major row
Subsca One-
pularis arm
dumbbe
ll row
Pec Bench
major press
Ant deltFront
raises
Externa Infraspi Externa
l natus l
rotation rotation
Teres Externa
minor l
rotation
Post Bent-

24. Study findings affecting conservative
management
Study 1 Patients with
MDI have
altered motion
patterns on
muscles around
joint
Study 2 Patients with
MDI had
significant
alterations in
shoulder
kinematics and
in muscle
activation
Study 3 Most patients
who improve
with ther ex
program do so
fairly quickly,

25. Summary and Clinical Implications
•Paucity of good quality studies
oWeak foundation for future research
•Weak evidence to support surgery as a necessity
•Weak evidence to support conservative intervention alone
•Conservative intervention should remain first line
oImprovements should be noticeable early
Absence an indication for surgery
oMost patients will need surgery
• Following surgery
o3-4 weeks immobilization
o12 weeks of Scapular/Glenohumeral strengthening and
stability exercises
o EMG biofeedback can be used in adjunct

26. Gibson, K., A. Growse, L. Korda, E. Wray, and JC MacDermid. "The Effectiveness of Rehabilitation for Nonoperative
Management of Shoulder Instability: a Systematic Review." Journal of Hand Therapy 17.2 (2004): 229-42.
Ide, J., S. Maeda, M. Yamaga, K. Morisawa, and K. Takagi. "Shoulder-strengthening Exercise with an Orthosis for
Multidirectional Shoulder Instability: Quantitative Evaluation of Rotational Shoulder Strength before and after the
Exercise Program." Journal of Shoulder and Elbow Surgery 12.4 (2003): 342-45.
Illyes, A., J. Kiss, and R. Kiss. "Electromyographic Analysis during Pull, Forward Punch, Elevation and Overhead
Throw after Conservative Treatment or Capsular Shift at Patient with Multidirectional Shoulder Joint Instability."
Journal of Electromyography and Kinesiology (2008).
Kiss, Rita M., Árpád Illyés, and Jenő Kiss. "Physiotherapy vs. Capsular Shift and Physiotherapy in Multidirectional
Shoulder Joint Instability." Journal of Electromyography and Kinesiology (2009).
Misamore, G., P. Sallay, and W. Didelot. "A Longitudinal Study of Patients with Multidirectional Instability of the
Shoulder with Seven- to Ten-year Follow-up." Journal of Shoulder and Elbow Surgery 14.5 (2005): 466-70.
American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and
Perscription. 6th ed. Wolters Kluwer; 2010: 1-868.
David J. Magee. Orthopedic Physical Assessment. 5th ed. Saunders Elsevier; 2008: 231-360.

27. Questions?