42 HOW TO TREAT: SHOULDER INSTABILITY
42 HOW TO TREAT: SHOULDER INSTABILITY
16 MAY 2025 ausdoc. com. au
Figure 12. The apprehension test( left) and the relocation test( right). The arrow indicates the‘ relocating’ force by the examiner.
Figure 13. Reduction manoeuvre for traumatic anterior dislocation.
How to Treat Quiz.
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1. Which THREE statements regarding shoulder instability are correct? a Shoulder instability is characterised by excessive movement of the humeral head within the shoulder joint. b Older athletes who compete in contact sports are at high risk of recurrent instability. c The shoulder is an unstable joint because of a shallow glenoid that only articulates with a small part of the humeral head. d The shoulder joint relies on soft tissue restraints, especially the capsule and ligaments for stability.
2. Which THREE statements regarding traumatic shoulder dislocation are correct? a Posterior dislocation is more common. b Anterior dislocation usually results from a force to an abducted, externally rotated and extended extremity. c Posterior dislocation may be caused by a hit to the anterior shoulder and an axial loading of the adducted internally rotated arm. d A posterior dislocation may also be a result of violent muscle contractions.
3. Which THREE statements regarding shoulder dislocation are correct? a A Hill – Sachs lesion is associated with posterior shoulder dislocation.
b A Bankart lesion is an avulsion of the anterior labrum in anterior shoulder dislocation. c A superior labrum from anterior to posterior( SLAP) tear can result from excessive load through the long head of biceps. d Bony defects can be on the humeral side, glenoid side, or a combination of both.
4. Which TWO are features of an unreduced anterior shoulder dislocation? a The arm is usually abducted and externally rotated. b The arm is usually held in adduction and internal rotation. c The acromion appears prominent. d The patient is unable to rotate the arm externally.
5. Which THREE statements regarding shoulder examination are correct? a It is important to test for axillary nerve sensation over the deltoid after an anterior dislocation. b A positive sulcus sign of more than 1cm is predictive of multidirectional instability. c The O’ Brien test is useful to identify a SLAP tear. d Rotator cuff tears are a relatively common complication of a dislocated shoulder, particularly in the elderly.
6. Which THREE findings may be confirmed on X-ray? a The presence of a rotator cuff tear. b A dislocation. c The direction of a dislocation. d The presence of any fractures.
7. Which TWO statements regarding the immediate management of a shoulder dislocation are correct? a Once muscle spasm occurs it is very difficult to reduce the shoulder joint without anaesthesia. b Always X-ray a suspected dislocated shoulder before attempting a reduction. c Exclude a tear or an avulsion fracture of the rotator cuff, which is more common in older patients. d Patients under 40 can be managed non-operatively as the shoulder becomes tighter with advancing age and recurrence rates are low.
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SHOULDER INSTABILITY
8. Which THREE are part of immobilisation, if required, after a shoulder dislocation? a Use a traditional sling. b Place the arm in external rotation using an external rotation pillow or brace. c Immobilise for three weeks. d Immobilise both during the day and night.
9. Which THREE statements regarding the management of shoulder dislocation are correct? a Surgery is first-line for the management of multidirectional instability. b Pain and osteoarthritis are long-term sequelae of untreated recurrent shoulder dislocations. c Patients should avoid lifting weight for the first six weeks after arthroscopic stabilisation. d Patients can usually return to full work duties and sports after six months, after clearance by the surgeon.
10. Which THREE statements are correct? a Greater tuberosity fractures are associated with anterior dislocation in patients older than 50. b A bony Bankart lesion describes avulsion of the labrum. c Rotator cuff tears in association with a dislocation increase with age. d Recurrent dislocation rates after traumatic instability are high in those aged 17-30. presents with bilateral shoulder pain and instability. She denies any injuries. Physical examination elicits pain when her arm is internally rotated with her shoulder forward flexed to 90 °. The humeral head slides over the glenoid rim both anteriorly and posteriorly with the load and shift test. In the seated position there is a 2cm sulcus present with inferior traction on each arm. X-rays are unremarkable and her MRI shows a capacious capsule without the presence of any labral tears.
Sally is diagnosed with multidirectional instability. The most appropriate treatment is a shoulder physiotherapy program focusing on rotator cuff and periscapular muscle strengthening.
CONCLUSION
SHOULDER instability is a complex musculoskeletal condition that can significantly impact patients’ daily activities and overall quality of life. GPs play a critical role in recognising the signs and symptoms of shoulder instability, initiating appropriate early on-field management and diagnostic evaluations, and providing timely referrals for further management.
RESOURCES:
• George Murrell Shoulders Sydney— Shoulder instability in seven minutes bit. ly / 3CgqZnj
• George Murrell Shoulders Sydney— Shoulder exam in 45 seconds bit. ly / 4ghWdYU
• George Murrell Shoulders Sydney— Examining the shoulder bit. ly / 4axjIw1
References Available on request from howtotreat @ adg. com. au