Initial pre-referral workup

Clinical history

• number of episodes of instability
• inability to play sports
• mechanism of initial instability

Physical examination

Check for anterior apprehension. With the shoulder abducted and externally rotated, push gently from the posterior aspect of the proximal humerus and watch patient for discomfort.

Investigations

• X-ray of shoulder
• most young patients with shoulder instability episode requiring medical reduction should have an MRI scan

GP management

If acute and reduced, sling for comfort and commence physiotherapy.

Whilst risk of re-dislocation is very high in young patients, most patients are suitable for a course of physiotherapy, aimed at regaining range of motion and strengthening dynamic muscle stabilisers to prevent further instability episodes.

Multi-directional instability (MDI) is common in young adolescents, particularly females, and may not have initially a traumatic episode. Symptoms can be vague. Patients can complain more about pain than actual instability episodes. First line management is also physiotherapy.

Indications for specialist referral

Urgent

• shoulder instability that is still dislocated or is irreducible
• a previous dislocation episode with any evidence of fracture on imaging (X-ray, CT, or MRI)

Routine

• two or more recurrent instability episodes
• 'apprehensive' for instability and inability to play sports or participate in activities
• multi-directional instability (MDI) following failure of non-operative physiotherapy