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Multidirectional Instability >> Treatment

How is MDI (Multidirectional Instability) treated? The treatment for MDI must be individualized for each patient. Non-Operative Treatment Most patients with MDI can be treated non-operatively with a physical therapy program that emphasizes muscular rehabilitation. Rehabilitation focuses on strengthening the rotator cuff muscles and periscapular muscles (those around the scapula). Strengthening these muscles provides dynamic stability to the joint, which is especially important when the static stability provided by the ligaments is lacking. The vast majority of patients (about 90%) who follow a rehabilitation program diligently for at least six months will achieve pain relief. Those who continue with a daily or weekly exercise program as outlined by the doctor are most likely to have a successful recovery. Athletes may also benefit from sport-specific rehabilitation that includes technique evaluation and modification. Often this type of program can help eliminate faulty technique that may have led to the development of symptoms. Patients who do not get relief from symptoms with a physical therapy program are a treatment challenge. Only about 70-80% of these patients eventually achieve long-term stability, with 60-70% reaching the level of athletic participation they enjoyed prior to the instability. Operative Treatment The most challenging patient to treat surgically is the athlete whose symptoms continue following a rehabilitation program. Often athletes are successful in their sport because of increased laxity in the joint; so surgical intervention should only be considered when the patient has a thorough understanding of MDI, and is aware that stability with surgical correction is always achieved at the expense of motion. Patients who can voluntarily dislocate the shoulder are poor surgical candidates; surgery is rarely successful for them. Use the buttons above to see the different steps.   Traditional Approach The traditional surgery for MDI is designed to make the joint capsule smaller and reduce glenohumeral movement. This open surgical procedure is called an extensive inferior capsular release and imbrication. The lower portion of the joint capsule is cut and overlapped to tighten the ligaments and make the capsule smaller. During this procedure, the subscapularis muscle is detached so the surgeon can access the joint capsule. It is reattached at the end of the procedure. The success rate of this procedure is about 75% in a group of carefully selected individuals (those who were determined to be good surgical candidates after a careful history and examination). Since there can be a substantial loss of motion with this procedure, athletes may not be able to return to competition after surgery. Arthroscopic Techniques Recently, new arthroscopic techniques have been developed to correct multidirectional instability. Capsular plication (a pleating and stitching technique) uses arthroscopic sutures to reduce the size of the joint capsule. Thermal capsulorrhaphy is a technique that uses thermal energy to shrink the capsule. This method is being evaluated and looks promising, as it is less invasive and may reduce loss of motion. These arthroscopic techniques are very exciting, but remain experimental, especially for athletes who require stability and the preservation of motion. What types of complications may occur? The most common complication is recurrent instability, which can happen in 20% or more cases, even with carefully chosen patients. Post-operative stiffness and loss of motion are also complications; however, loss of motion is often an acceptable result of achieving stability. An average loss of motion in external rotation is about 10 degrees. A loss of motion greater than that occurs in about 5% of the cases. Other small risks (less than 1%) common to most surgery procedures include infection, nerve damage, or blood vessel injury.