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Atraumatic multidirectional shoulder instability — MSRA MCQ

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ModerateShoulder InjuriesAtraumatic multidirectional shoulder instabilityMSRA

A 22-year-old woman presents with a 5-month history of her right shoulder intermittently ‘slipping out’ when climbing or reaching overhead. There was no preceding injury. It relocates spontaneously within seconds and she has not attended the emergency department. She has similar, less troublesome symptoms on the left. Examination shows full active and passive range of movement, bilateral increased external rotation, a positive sulcus sign, and no focal weakness, sensory loss or vascular abnormality. She is keen to have an operation because the episodes are limiting climbing. What is the most appropriate initial management?

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Correct answer: B — Arrange MSK physiotherapy for scapular stabilisation, proprioception and rotator-cuff strengthening.

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

This is atraumatic multidirectional shoulder instability: the episodes are bilateral, occur without a precipitating traumatic event, self-reduce, and are associated with generalised capsular laxity on examination. There is no persisting deformity, fracture concern, neurovascular deficit or focal weakness to suggest an acute structural injury requiring urgent orthopaedic assessment. Initial treatment is a structured MSK physiotherapy programme focused on scapular control, proprioception and rotator-cuff strengthening. Rehabilitation is the principal first-line intervention and may require a prolonged course. Surgery is generally reserved for persistent, functionally significant instability after appropriately delivered rehabilitation. Routine surgical referral (A) is premature before conservative management. MR arthrography (B) is not the initial primary-care investigation for clinically typical atraumatic instability and would not alter first-line treatment. Sling immobilisation (D) is inappropriate for recurrent atraumatic instability because it promotes stiffness and does not address dynamic shoulder control. Urgent orthopaedic assessment (E) would be appropriate for an unreduced dislocation, significant traumatic instability, fracture, or neurovascular compromise. ([rightdecisions.scot.nhs.uk](https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/instabilityrecurrent-dislocation/?UNLID=&useNavigation=true&utm_source=openai))

Reference: NHS Tayside RefGuide: Instability/Recurrent Dislocation (Not stated; page next review 4 July 2027) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/instabilityrecurrent-dislocation/?UNLID=&useNavigation=true