Shoulder instability occurs when the head of the humerus repeatedly slips out of the glenoid. This condition typically develops after a traumatic event that damages the static stabilizers of the joint, such as the ligaments and the labrum. The repetitive slipping manifests as either a dislocation (complete separation of joint surfaces) or a subluxation (partial slipping that spontaneously reduces). Instability leads to pain and apprehension with certain movements, requiring comprehensive treatment to prevent future episodes.
Initial Non-Surgical Treatment Pathways
The first step in managing shoulder instability often involves a focused non-operative approach, particularly after a first-time episode or in cases of subluxation without significant structural damage. This initial pathway centers on physical therapy (PT) aimed at enhancing the shoulder’s dynamic stabilizing system. The primary goal is to strengthen the rotator cuff muscles and the scapular stabilizers to provide muscular control that compensates for damaged ligaments and the labrum.
Physical therapy begins by restoring pain-free range of motion (ROM) through gentle exercises, followed by isometric strengthening in protected positions. The program progresses to exercises targeting the smaller muscles responsible for glenohumeral joint control, such as side-lying external rotation. Emphasis is also placed on the periscapular muscles, including the serratus anterior and trapezius, which stabilize the shoulder blade and create a solid base for arm movement.
Activity modification is another component, requiring the patient to avoid positions that cause a feeling of apprehension or instability, such as excessive external rotation and abduction. In the acute phase, temporary use of a sling or brace may be necessary to protect the joint. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used concurrently to manage pain and inflammation, supporting the patient’s ability to participate fully in the rehabilitation program.
Criteria for Surgical Intervention and Procedure Types
Surgical intervention becomes a consideration when conservative management fails to restore stability, or if initial imaging reveals severe damage that predisposes the patient to recurrent episodes. Indications for surgery include persistent, recurrent dislocations, instability that significantly impacts daily or athletic life, or the presence of specific structural injuries. A major tear of the labrum (Bankart lesion) or bone loss from the socket (glenoid) or the humeral head (Hill-Sachs lesion) often necessitates surgical repair.
The choice of surgical technique depends largely on the type and extent of the structural damage. For instability primarily involving soft tissue damage, the Arthroscopic Bankart Repair is the standard treatment. This minimally invasive procedure uses small instruments and anchors to reattach the torn labrum and ligaments back to the glenoid rim, restoring the joint’s native anatomy. This approach is preferred in patients with minimal or no bone loss.
When significant bone loss is present on the glenoid, or in cases of multiple recurrent dislocations, a Bony Reconstruction procedure is often performed. The Latarjet procedure is the most common example, involving the transfer of the coracoid process and its attached tendons to the front of the glenoid. This bone block acts as a physical barrier to dislocation, while the transferred muscles create a dynamic sling effect that helps stabilize the joint.
Structured Rehabilitation and Long-Term Recovery
Following any major treatment, a structured rehabilitation program is implemented to ensure a successful return to full function. This multi-phase protocol progresses gradually, respecting the biological healing time of the repaired tissues. The initial Protection Phase often involves a period of immobilization, especially after surgery, which typically lasts three to six weeks, allowing the soft tissues or bony transfer to heal.
The next stage is the Passive and Active-Assisted Range of Motion Phase, where the focus shifts to carefully regaining movement without placing undue stress on the repair. A therapist moves the arm (passive ROM), or the patient uses their unaffected arm to assist (active-assisted ROM), working within established safe limits to prevent stiffness. This phase is followed by the Active Strengthening Phase, where the patient begins active muscle contractions and light resistance training, generally starting around eight to twelve weeks post-treatment.
Strengthening progresses from light resistance band exercises to heavier weights, targeting the rotator cuff and scapular muscles to improve dynamic stability and endurance. The final Functional Phase involves sport-specific or work-specific training, incorporating plyometrics and high-speed movements to prepare the joint for a full return to activity. Full recovery and return to contact or overhead sports can take between six and nine months, and patient adherence to the long-term exercise regimen is paramount for minimizing the risk of future instability.