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Recurrent traumatic anterior glenohumeral instability — MSRA MCQ

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HardShoulder InjuriesRecurrent traumatic anterior glenohumeral instabilityMSRA

A 28-year-old firefighter attends general practice 4 months after a first traumatic anterior shoulder dislocation sustained during a fall at work. It was reduced in the emergency department; radiographs before and after reduction showed no fracture and a concentrically reduced joint. He subsequently completed a 12-week supervised shoulder-stabilisation rehabilitation programme. He has since experienced three further episodes while his arm was forced into abduction and external rotation. Each caused immediate severe pain and visible alteration in shoulder contour, but settled spontaneously within minutes. He has stopped operational duties because he is apprehensive when reaching overhead. He has no current pain at rest, deformity, paraesthesia or vascular symptoms. Active and passive movements are full. Apprehension testing reproduces his symptoms, which resolve with relocation testing. Rotator-cuff strength, deltoid power, distal pulses and upper-limb neurology are normal. What is the most appropriate next step in management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Make an elective referral through the local MSK or orthopaedic shoulder pathway for specialist assessment of recurrent instability

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

This is recurrent traumatic anterior glenohumeral instability. The recurrent episodes occur in the characteristic vulnerable position of abduction with external rotation, produce transient deformity, and are supported by a positive apprehension-relocation response. Although each episode has spontaneously reduced, he has had recurrent instability despite a completed, supervised stabilisation programme and now has major occupational restriction. Elective specialist assessment through the locally commissioned MSK or orthopaedic shoulder pathway is therefore appropriate. NHS guidance for recurrent shoulder dislocation states that patients whose shoulder has dislocated more than once should be reviewed by orthopaedics; a UK MSK pathway similarly identifies recurrent glenohumeral instability, particularly despite individualised rehabilitation, as an indication for escalation. Specialist assessment determines whether further imaging and stabilisation are indicated. A is attractive because rehabilitation remains integral to management, but rehabilitation alone has already failed to prevent recurrent episodes. B is premature: MRI or MR arthrography may be needed for specialist planning, but should not delay referral where recurrent instability is established. D would be appropriate for a shoulder that remains dislocated or has acute neurovascular compromise; neither is present. E treats subacromial pain rather than mechanical glenohumeral instability and is unsupported by this presentation.

Reference: Recurrent dislocation of the Shoulder: Fracture Care Team Shared Care Plan (November 2025) — https://www.esht.nhs.uk/wp-content/uploads/2026/01/2061.pdf Shoulder and Elbow Triage Guidance 2025 (2025) — https://eastsussexmsk.nhs.uk/wp-content/uploads/2025/07/Shoulder-Elbow-Triage-Guidance-2025.pdf A systematic review and meta-analysis of operative versus non-operative management for first time traumatic anterior shoulder dislocation in young adults (2025) — https://pubmed.ncbi.nlm.nih.gov/39552694/