Conservative treatment of shoulder instability: possibilities, limitations and the risk of re-dislocation
Conservative treatment of shoulder instability: possibilities, limitations and the risk of re-dislocation
The shoulder is one of the most mobile, yet also one of the most unstable joints in the human body. Its stability depends on a complex interplay of bony, ligamentous, and muscular structures. Shoulder instability often occurs after trauma in which the shoulder dislocates from the joint (dislocation). The likelihood of this instability recurring is particularly high in young and active patients. While surgical treatment is often considered the gold standard for long-term stabilization, conservative therapy is often initiated initially. This article highlights conservative treatment options, their limitations, and explains why the risk of recurrence of dislocation is so high with this approach.
Options for conservative therapy
Conservative therapy relies on non-invasive methods aimed at restoring shoulder stability and preventing recurrence. It includes several components:
1. Immobilization after the initial dislocation
After an initial shoulder dislocation, the shoulder is typically immobilized for several weeks to allow the injured soft tissues time to heal. Studies have shown that immobilization in external rotation may be more beneficial than internal rotation, as it promotes healing of the labrum-ligament complex. However, the recurrence rate remains high even after immobilization, especially in young, active patients.
2. Physiotherapy
After the immobilization phase, physiotherapy treatment begins. Therapy focuses on specifically building the muscles responsible for stabilizing the shoulder. These include:
- Rotator cuff: This muscle group stabilizes the humeral head in the acetabulum.
- Periscapular muscles: A stable position of the shoulder blade improves overall shoulder control.
- Proprioception training: Exercises to improve joint awareness help to better control unconscious movements and avoid instability.
3. Adaptation of the activity
Patients are often advised to avoid strenuous activities, particularly contact sports or movements with a high risk of recurrent dislocation. However, this approach requires significant lifestyle restrictions that are not always practical.
Options for conservative therapy
Conservative therapy relies on non-invasive methods aimed at restoring shoulder stability and preventing recurrence. It includes several components:
1. Immobilization after the initial dislocation
After an initial shoulder dislocation, the shoulder is typically immobilized for several weeks to allow the injured soft tissues time to heal. Studies have shown that immobilization in external rotation may be more beneficial than internal rotation, as it promotes healing of the labrum-ligament complex. However, the recurrence rate remains high even after immobilization, especially in young, active patients.
2. Physiotherapy
After the immobilization phase, physiotherapy treatment begins. Therapy focuses on specifically building the muscles responsible for stabilizing the shoulder. These include:
- Rotator cuff: This muscle group stabilizes the humeral head in the acetabulum.
- Periscapular muscles: A stable position of the shoulder blade improves overall shoulder control.
- Proprioception training: Exercises to improve joint awareness help to better control unconscious movements and avoid instability.
3. Adaptation of the activity
Patients are often advised to avoid strenuous activities, particularly contact sports or movements with a high risk of recurrent dislocation. However, this approach requires significant lifestyle restrictions that are not always practical.
Limits of conservative therapy
Despite its advantages in certain situations, conservative therapy reaches its limits for many patients:
1. Immobilization after the initial dislocation
After an initial shoulder dislocation, the shoulder is typically immobilized for several weeks to allow the injured soft tissues time to heal. Studies have shown that immobilization in external rotation may be more beneficial than internal rotation, as it promotes healing of the labrum-ligament complex. However, the recurrence rate remains high even after immobilization, especially in young, active patients.
High recurrence rate
Studies show that the recurrence rate after conservative treatment of shoulder instability is between 50% and 67%. Young patients who are physically active or who participate in contact sports are particularly at high risk. Even with careful implementation of all conservative measures, long-term stability often cannot be guaranteed.
Limited effectiveness in bone defects
After a shoulder dislocation, bone damage to the glenoid or humeral head (Hill-Sachs lesions) is common. These defects play a central role in shoulder stability. If the loss of the glenoid articular surface is 13.5% or more, the risk of recurrence is significantly increased, even with optimal muscle building and physical therapy. Conservative measures cannot correct such structural damage.
Inadequate soft tissue healing
A shoulder dislocation often leads to damage to the stabilizing soft tissues, particularly the labrum and ligaments. Even with intensive conservative treatment, healing of these structures often remains incomplete. Biomechanical stability is therefore not fully restored.
Age and activity level as risk factors
Younger patients have a significantly higher risk of recurrent dislocations. This is because they tend to be more active and their shoulders are subjected to more frequent strain throughout their lives. High-performance athletes and individuals with general joint hyperlaxity are also at greater risk.
Why is the risk of re-dislocation so high with conservative therapy?
Conservative therapy cannot adequately address many of the underlying problems of shoulder instability, leading to a high rate of recurrent dislocations. Here are the main reasons:
1. Inadequate restoration of joint stability
After a dislocation, weakness or dysfunction of the labrum-ligament complex often remains. Even with muscle strengthening, this structural damage cannot always prevent a recurrence. Biomechanically speaking, the contribution of the dynamic stabilizers (muscles) alone is often insufficient to keep the shoulder stable.
2. Presence of bone defects
Bone defects, which often occur after repeated dislocations, significantly reduce shoulder stability. Glenoid defects of more than 15% or an off-track Hill-Sachs lesion significantly increase the risk of recurrent instability.
3. Dynamic loads
The shoulder is continuously exposed to high levels of stress in everyday activities and during sports. Even minor biomechanical instabilities can lead to further dislocations due to repeated stress.
When is surgery necessary?
If conservative therapy fails or certain risk factors are present, surgical stabilization should be considered. Indications for surgery include:
- Multiple dislocations: Despite conservative therapy, the shoulder remains unstable.
- Significant bone defects: Glenoid loss of ≥ 15% or an engaging Hill-Sachs lesion.
- High activity level: Patients who regularly participate in contact sports or have physically demanding jobs.
- Young age: Younger patients usually benefit from early surgical intervention to avoid long-term damage.
Commonly used surgical procedures include arthroscopic Bankart repair and bony reconstructions such as the Latarjet procedure.
Conclusion
Conservative treatment of shoulder instability offers a viable treatment option in certain cases, particularly in cases of first-time dislocation and the absence of significant risk factors. However, its limitations quickly become apparent in patients with bony defects, repeated dislocations, or high activity levels. The high risk of recurrent dislocations highlights the need for a thorough patient assessment and an individualized treatment strategy. While conservative treatment plays an important role, surgical stabilization remains the most promising option for many patients to ensure long-term shoulder stability.