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Shoulder instability

The shoulder joint comprises of three bones: the humerus (upper arm bone), the clavicle (collar bone), and the scapula (shoulder blade) which are interlinked by muscles, tendons and ligaments. It is a very complex joint, the most mobile of the body and enable a wide range of movements.

The humeral head is ball shaped that partially fits into a cavity or socket called glenoid (the joint component of the scapula). The glenoid is quite shallow allowing for the wide range of movement at this joint. Stability is achieved by connecting ligaments and the shoulder labrum, a special type of cartilage which provides a greater surface area for the bones to form continuity with one another. The humerus remains close to the glenoid thanks to a tight fibrous cuff, comprised of the joint capsule, and the stabilising action of the powerful rotator cuff muscles surrounding it. Above the humeral head is a bony prominence arising from the scapula, called acromion, which in the space below (subacromial space) flow the tendons of the rotator cuff muscles. In this space the shoulder tendons pass over each other during shoulder movements.

The efficiency of these movements is achieved due to the presence of bursae (naturally lubricated linings between adjacent structures), with the subacromial bursa being the largest in this region. In addition to providing stability, they permit the lifting and rotating of the arm itself. The two tendons of the biceps and of the pectoralis major muscles insert near the humeral head. This whole complex is covered by the deltoid muscle.

Shoulder instability

When talking about unstable shoulder, different nosologic schemes are to be taken into consideration, such as dislocations, subdislocations and the pathology of iper-laxation. 

Various classifications have been proposed, but we will refer to that instability that involves patients with signs of congenital generalised laxity, associated with bilateral and multidirectional (anterior, posterior and inferior) instability of the shoulder.

The instability can also affect sportspeople such as gymnasts, volleyball players, weightlifters and swimmers.  
The traumatic mechanism is to be found in the repetition of overhead movements that, due to the joint laxity, provoke anomalous mechanic stimulus on the nervous structures and periarticular soft tissues (repeated microtraumas) that lead to pain.

If you entered this section, it means that you probably are starting feeling pain in your shoulder or that you are suffering from disturbances such as “dead arm” or paresthesia of the superior limb when performing daily or sportive activities. You might also have faced different times a dislocation or subdislocation without a meaningful trauma.

The physichian will prescribe for you further examinations to detect which are the conditions of capsular, tendinous, muscular  and annulet structures. 
The conservative treatment represents the first approach to the management of this complex clinic situation. The work is mainly finalised to improving the joint biomechanics though exercises for those muscles that stabilise the articulation. 
In particular, in the overhead sports it is necessary to reinforce all the cuff’s muscles, since they are involved in the control of the humeral translation. The recovery of the neuromuscular control is essential, as the deficit in co-ordination for these patients is typical. Co-ordination exercises can find a proper space in rehabilitation on the field, where the patient will undergo dynamic and more specific exercises.

After the failure of at least 6 month of conservative therapy, a surgical intervention will be necessary and an appropriate rehabilitative treatment will follow.

Surgical treatments for shoulder instability

Episodes of relapsing dislocation or chronic instability need to be evaluated to choose the surgical treatment more proper. Surgery can restore the control over the scapula-humeral articulation, improving the containing effect of the structures devoted to the static stability, such as the capsule and the glenoid labrum. Your orthopaedist will ask you how long ago the shoulder started giving you worries, in which direction it moves, which your lifestyle is and whether you play sports, evaluating at the same time the anatomic damages described by the CT scan or MRI. He will decide on the basis of this information the type of surgery that could be performed both in arthroscopy or open-pit.

After surgery pain will be quite intense, but painkillers and ice will be used to control it.

You will be discharged with a brace that will prevent you from using the superior limb and you will be asked to abide by a series of behaviours while at home.After, you will be able to start a rehabilitation path to recover as soon as possible all the normal functions of the limb.

Shoulder instability - Rehabilitation

The rehabilitation path for shoulder instability has the purpose to achieve the maximum functional recovery and its very early start is due to the fact that in this way it can act promptly to work in a specific manner on the extra rotation.

The rehabilitation process consists in five stages:

  • First phase: (4 weeks post-surgery)

The removal of the shoulder brace is generally already painless, it persist only analgesic contractures and swelling. It then proceeds with physical therapies and decontracture work on the shoulder girdle, combined with active and active/assisted mobilization. In this phase, the recovery is also obtained through the hydrokinetic therapy where it urges the shoulder at 90 ° of elevation and abduction. The patients/athletes at this stage begin the reconditioning of athletic aerobic work, in water.

  • Second phase: Full recovery of range of motion (4th-5th week post-surgery)

The first objective of this phase is to give the patient full articulation of the shoulder in order to carry out the daily life activities (driving, working, etc.). This is achieved by inserting, beside active mobilization, also the passive one done by the rehabilitator, on all directions. You will be given greater importance to the capsular stretching and the recovery of rotations.

  • Third phase: Strength recovery  (5th-8th week post-surgery)

Once  full range of motion is obtained you begin to strengthen the whole shoulder girdle, correcting any dyskinesias present even before the operation, by strengthening the muscles of the arm, by associating more capsule assisted stretching. The return to sports cannot be separated from core stability work at this stage.

  •  Fourth phase: Recovery of proprioceptive abilities (7th-9th week post-surgery)

The shoulder, which now has an appropriate level of strength, begins to undergo the stress of all directions, with increasing intensity (handball, unstable, launches, etc.). In this phase of rehabilitation begins the specific job without the use of tools. You start the preliminary preparation for the field, with sessions of neuroplasticity in the water. A functional evaluation test is performed to monitor the level of shape reached.

  • Fifth phase: Recovery of the specific gesture (8 th -12 th week post-surgery)

The shoulder now has reached the maximum recovery in a "protected" environment: now you must begin to rediscover the specific gesture and then start rehabilitation on the sports field. This step is a progression that sees the use of unstable surfaces, launch to different degrees with progressive-diameter balls, insert contrasts with fixed shapes, contrasts against the moving shapes, use the sports equipment (rackets, golf clubs, etc.) with both constraints and resistances is free.

At this time you will have recovered the complete gestures and you can start to practice any sport.

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