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The condition of the shoulder suffering from instability in many different directions is encountered moderately often, happening in both shoulders and unrelated to any physical incident. The lax nature of the capsular bag around the shoulder is the reason that these instability problems are occurring. The high degree of anatomical joint mobility is an indication of the lax nature of the shoulder ligaments and capsule, with patients describing an unstable joint which might dislocate or at least partially do so (subluxate). Obvious joint abnormalities are not always present and patients may just complain of pain.

Conservative treatment is the first line of management for this condition, with physiotherapy treatment consisting of strengthening of the muscular parts of the scapular stability and rotator cuff systems. Once conservative treatment has been attempted and not been successful then consideration can be given to surgery. Surgery can tighten up the shoulder capsule, increasing the strength of the static stabilisers. Typically surgery has been done in open technique but arthroscopic technique is become more prevalent.

How many people in the population suffer from multidirectional instability is not known and a much more common situation is to acquire instability of the shoulder due to an accident or incident which results in dislocation. TUBS is an acronym for this problem:

* Traumatic onset

* Unidirectional – the instability is only in one joint movement direction

* Bankart lesion (damage to the rim around the shoulder socket)

* Surgery – is a common requirement

A single or repetitive dislocation of a shoulder joint traumatically can lead to the generalised instability problem described in TUBS.

The multidirectional type of shoulder dislocation is summarised by AMBRI, standing for:

* Atraumatic – there was no accident or injury to explain the onset

* Multidirectional – all the shoulder ranges of movement are lax

* Bilateral – both shoulders are always involved due to general laxity

* Rehabilitation is the first line of treatment with a physiotherapist

* I stands for the techniques of surgery and where this is performed.

The shoulder joint has a very high degree of mobility and is designed to allow us to place our hands where we want to within our visual fields, enabling us to perform actions while we watch. We have sacrificed stability of this joint for its mobility, leading to consequent problems when the shoulder is stresses in various ways.

Thinking about the stability of the shoulder it is helpful to concentrate on a few concepts. The idea of balance is related to the way the head of the humerus centres itself on the socket accurately. The main muscles responsible for maintaining this anatomical alignment are those of the rotator cuff, keeping the joint in line as the larger movement muscles do their actions. If an imbalance or weakness develops in the muscles of the scapula or the rotator cuff then the balance can be disturbed. A cartilage rim around the socket, the glenoid labrum, deepens the socket and the muscles compress the two parts together, enhancing stability.

An upward movement of the humeral head on the socket is undesirable and this tendency is resisted by the compressive force of the rotator cuff and by the curve of the upper socket area. The joint surfaces have some adhesion as they are wetted by the synovial fluid, with air being pressed out of the joint by the tight fit of the rounded ball and the depth of the socket, creating a degree of suction effect to enhance stability. Some amount of negative pressure which develops in a tight joint also adds to the effect. The stability which is improved by these effects is in the mid-range of the joint\’s movement, where there is least stability from the ligaments.

The joint capsule acts passively to hold back excessive movement of the shoulder and keep it within safe limits, with thickened areas of the capsule developed into the ligaments of the shoulder, the most important of which is the inferior glenohumeral ligament. This does not mean that the muscles, the dynamic stabilisers of the shoulder system, are not very important in the normal function of the shoulder. Physiotherapy concentrates on strengthening and re-educating the rotator cuff and scapular stability muscles.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in London, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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