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Atraumatic multidirectional shoulder instability — MSRA MCQ

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HardShoulder InjuriesAtraumatic multidirectional shoulder instabilityMSRA

A 22-year-old woman presents with an 18-month history of recurrent right shoulder “slipping” and pain when reaching overhead or carrying trays at work. Episodes began gradually, without a significant injury or first dislocation. She can voluntarily reproduce a posterior subluxation. Examination shows generalised joint hypermobility, scapular dyskinesis and apprehension at the extremes of movement, but full power when coached and no focal rotator-cuff weakness. Plain shoulder radiographs are normal. There is no neck pain, sensory loss, vascular abnormality or history suggesting inflammatory disease. What is the most appropriate next management step?

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Correct answer: D — Refer for prolonged specialist MSK physiotherapy focused on scapular control, proprioception and rotator-cuff rehabilitation

Explanation lettering: C = shown as B · E = shown as C · B = shown as D · D = shown as E

This is atraumatic shoulder instability, likely multidirectional, rather than instability following a discrete structural traumatic event. The gradual onset, voluntary posterior subluxation, generalised hypermobility, scapular dyskinesis and normal radiographs support abnormal muscle patterning and capsuloligamentous laxity. First-line management is prolonged, targeted rehabilitation addressing scapular stabilisation, proprioception and rotator-cuff control; improvement may require 1 year or longer. A is inappropriate because surgery is rarely required in atraumatic instability and should not precede a substantial rehabilitation programme. C is attractive because weakness can suggest cuff pathology, but she has no traumatic mechanism, no objective focal weakness and preserved coached power. D is plausible in recurrent instability, but imaging is not required before initiating rehabilitation where the presentation is clearly atraumatic and there are no red flags or features requiring operative planning. E may be relevant for short-term comfort after some acute injuries, but immobilisation neither addresses the underlying motor-control problem nor constitutes appropriate management of chronic atraumatic instability.

Reference: Atraumatic shoulder instability (Last reviewed 31 July 2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/orthopaedic/shoulder/atraumatic-shoulder-instability/ Instability/Recurrent Dislocation (Checked August 2026; next review date 4 July 2027) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/instabilityrecurrent-dislocation/?organization=nhs-tayside