The Management of Atraumatic Shoulder Instability
Main Article Content
Abstract
The definition of atraumatic shoulder instability is ‘abnormal motion or position of the shoulder that leads to pain, subluxations, dislocations and functional impairment…. Without any history of a significant preceding injury’.
Atraumatic shoulder instability can be a severely disabling condition resulting in reduced quality of life, even simple daily tasks such as reaching for a glass may lead to subluxation and pain.
The management of ASI remains a challenging and under-researched area. This is in part due to the multiple potential underlying causes which can co-exist in each presentation, and the strong association with psychosocial co-morbidities that can negatively impact engagement with treatment and post-operative outcomes.
This review will detail the anatomical and biomechanical basis of ASI, the essential considerations in clinical assessment and investigation, as well as the current evidence and ongoing controversies regarding management.
Keywords:
Shoulder, glenohumeral, atraumatic, instability, dislocation, multidirectional
Article Details
How to Cite
LEBE, Moritz et al.
The Management of Atraumatic Shoulder Instability.
Medical Research Archives, [S.l.], v. 13, n. 5, may 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6467>. Date accessed: 21 june 2025.
doi: https://doi.org/10.18103/mra.v13i5.6467.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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Lebe M, Burns SA, Falworth M, Higgs DS, Rudge WB, Majed A. Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int. 2021 Sep 17;5(6):955-959. doi: 10.1016/j.jseint.2021.08.001. PMID: 34766069; PMCID: PMC8570950.
2. Johannessen EC, Reiten HS, Løvaas H, et al. Shoulder function, pain and health related quality of life in adults with joint hyper- mobility syndrome/Ehlers–Danlos syndrome-hypermobility type. Disabil Rehabil. 2016; 38: 1382–1390.
3. Neer CS II, Foster CR, Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980. 62:897–908
4. Neer CS. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect. 1985;34:232-8.
5. Moroder P, Danzinger V, Maziak N, Plachel F, Pauly S, Scheibel M et al. Characteristics of functional shoulder instability. J Shoulder Elbow Surg. 2020 Jan;29(1):68-78. doi: 10.1016/j.jse.2019.05.025.
6. Moroder P, Plachel F, Van-Vliet H, Adamczewski C, Danzinger V. Shoulder-Pacemaker Treatment Concept for Posterior Positional Functional Shoulder Instability: A Prospective Clinical Trial. Am J Sports Med. 2020 Jul;48(9):2097-2104. doi: 10.1177/0363546520933841.
7. Matsen FA III, Thomas SC, Rockwood CA Jr, Wirth MA. Glenohumeral instability. In: Rockwood CA Jr, Matsen FA III (eds) The shoulder, vol 1. 2005 Saunders, Philadelphia, pp 611–754
8. Angus Lewis, T Kitamura, J.I.L Bayley. The classification of shoulder instability: new light through old windows!. Current Orthopaedics, 2004. Volume 18, Issue 2. Pages 97-108, ISSN 0268-0890,doi.org/10.1016/j.cuor.2004.04.002.
9. Longo UG, Rizzello G, Loppini M, et al. Multidirectional instability of the shoulder: a systematic review. Arthroscopy 2015; 31: 2431–2443.
10. Krøner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989;108:288-90.
11. Rodeo SA, Suzuki K, Yamauchi M, Bhargava M, Warren RF. Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med. 1998. 26:634–643
12. Howard A, Powell JL, Gibson J, Hawkes D, Kemp GJ, Frostick SP. A functional Magnetic Resonance Imaging study of patients with Polar Type II/III complex shoulder instability. Sci Rep. 2019 Apr 18;9(1):6271. doi: 10.1038/s41598-019-42754-1.
13. Bahu MJ, Trentacosta N, Vorys GC, Covey AS, Ahmad CS. Multidirectional instability: evaluation and treatment options. Clin Sports Med. 2008;27(4):671-689.
14. Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992. 20:675–685
15. Nyiri P, Illyés A, Kiss R, Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg. 2010 Sep;19(6):802-13. doi: 10.1016/j.jse.2010.05.008. PMID: 20713276.
16. Lebe M, Burns SA, Falworth M, Higgs DS, Rudge WB, Majed A. Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int. 2021 Sep 17;5(6):955-959. doi: 10.1016/j.jseint.2021.08.001. PMID: 34766069; PMCID:
17. Barrett C. The clinical physiotherapy assessment of non-traumatic shoulder instability. Shoulder and Elbow. 2015 Vol 7 (I) 60 0- 71. DOI: 10.11771/1758573214548934
18. Jaggi A, Noorani A, Malone A, Cowan J, Lambert S and Bayley I. Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg 2012; 6: 101–7.
19. Grahame R, Bird HA and Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol 2000; 27: 1777–1779.
20. Malfait F, Francomano C, Byers P, et al. The 2017 inter- national classification of the Ehlers-Danlos syndromes. Am J Med Genet Part C Semin Med Genet 2017; 175C: 8–26.
21. Castori M, Tinkle B, Levy H, et al. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet 2017; 175: 148–157.
22. Mathias C, Low D, Iodice V, Owens A, Kirbis M and Grahame R. Postural tachycardia syndrome – current experience and concepts. Nat Rev Neurol 2012; 8: 22–34.
23. Merolla G, Cerciello S, Chillemi C, Paladini P, De Santis E, Porcellini G. Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol. 2015 Aug;25(6):975-85. doi: 10.1007/s00590-015-1606-5.
24. Schaeffeler C, Waldt S, Bauer JS, Kirchhoff C, Haller B, Schro ̈der M et al. MR arthrography including abduction and external rotation images in the assessment of atraumatic multidirectional instability of the shoulder. Eur Radiol 2014. 24:1376–1385
25. Moroder P, Danzinger V, Maziak N, Plachel F, Pauly S, Scheibel M, Minkus M. Characteristics of functional shoulder instability. J Shoulder Elbow Surg. 2020 Jan;29(1):68-78. doi: 10.1016/j.jse.2019.05.025.
26. Van der Linde JA, Bosmans JE, Ter Meulen DP, van Kampen DA, van Deurzen DF, Haverlag R et al. Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients. Shoulder Elbow. 2019 Aug;11(4):265-274. doi: 10.1177/1758573218773543.
27. Cho C.H., Seo H.J., Bae K.C., Lee K.J., Hwang I., Warner J.J. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg. 2013;22:1160–1166. doi: 10.1016/j.jse.2013.02.006.
28. Tashjian R.Z., Henn R.F., Kang L., Green A. The effect of comorbidity on self-assessed function in patients with a chronic rotator cuff tear. J Bone Joint Surg Am. 2004;86-A:355–362. doi: 10.2106/00004623-200402000-00020.
29. Raja, Senthooran et al. Abstract: Arthroscopic Stabilisation of Atraumatic Shoulder Instability: Minimum Two Year Outcomes. Journal of Shoulder and Elbow Surgery, 2021. Volume 30, Issue 7, e433
30. Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992 Jul;74(6):890-6. PMID: 1634579.
31. McIntyre K, Bélanger A, Dhir J, Somerville L, Watson L, Willis M, Sadi J. Evidence-based conservative rehabilitation for posterior glenohumeral instability: A systematic review. Phys Ther Sport. 2016 Nov;22:94-100. doi: 10.1016/j.ptsp.2016.06.002.
32. Douglas T, Jaggi A, Grange S, Lambert S. Prospective 2 year follow up of patient and diagnosis specific specialist physiotherapy treatment for patients with atraumatic shoulder instability. Abstract submission - British Elbow and Shoulder Society Annual Scientific Meeting 2009.
33. Burkhead WZ Jr and Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992; 74: 890–896.
34. Watson L, Balster S, Lenssen R, et al. The effects of a conservative rehabilitation program for multidirectional instability of the shoulder. J Shoulder Elbow Surg 2018; 27: 104–111.
35. Scott M, Sachinis NP, Gooding B. The role of structured physiotherapy in treating patients with atraumatic shoulder instability: Medium term results from a case series. Shoulder Elbow. 2020 Feb;12(1):63-70. doi: 10.1177/1758573218825392.
36. Bateman M, Smith BE, Osborne SE, Wilkes SR. Physiotherapy treatment for atraumatic recurrent shoulder instability: early results of a specific exercise protocol using pathology-specific outcome measures. Shoulder Elbow. 2015 Oct;7(4):282-8. doi: 10.1177/1758573215592266.
37. Griffin J, Jaggi A, Daniell H, Chester R. A systematic review to compare physiotherapy treatment programmes for atraumatic shoulder instability. Shoulder Elbow. 2023 Aug;15(4):448-460. doi: 10.1177/17585732221080730.
38. Warby SA, Ford JJ, Hahne AJ, et al. Comparison of 2 exercise rehabilitation programs for multidirectional instability of the glenohumeral joint: a randomized con- trolled trial. Am J Sports Med 2018; 46: 87–97.
39. Jaggi A, Cartwright J. Treating both head & shoulders; introduction of a joint psychiatry liaison and atraumatic shoulder instability clinic – a quality improvement project. Abstract submission - British Elbow and Shoulder Society Annual Scientific Meeting 2025.
40. Sinha A, Higginson DW and Vickers A. Use of botulinum A toxin in irreducible shoulder dislocation caused by spasm of pectoralis major. J Shoulder Elbow Surg 1999; 8: 75–76.
41. Beall, M. S., Jr., Diefenbach, G., & Allen, A. Electromyographic biofeedback in the treatment of voluntary posterior instability of the shoulder. American Journal of Sports Medicine, 1987. 15(2), 175e178.
42. Young, M. S. Electromyographic use in the treatment of voluntary posterior dislocation of the shoulder: A case study. Journal of Orthopaedic and Sports Physical Therapy, 1994. 20(3), 171e175.
43. Jaggi A, Herbert RD, Alexander S, Majed A, Butt D, Higgs D, Rudge W, Ginn KA. Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial. Br J Sports Med. 2023 Dec;57(23):1484-1489. doi: 10.1136/bjsports-2022-106596.
44. Chen D, Goldberg J, Herald J, Critchley I, Barmare A. Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2016 Feb;24(2):630-9. doi: 10.1007/s00167-015-3901-4.
45. Lebe M. Functional outcome of multidirectional shoulder instability treated surgically and non-surgically: A systematic review of recent literature and meta- analysis. 2018. Dissertation MSc Orthopaedic Trauma Sciences Queen Mary University London
46. Nyiri P, Illyés A, Kiss R, Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg. 2010 Sep;19(6):802-13. doi: 10.1016/j.jse.2010.05.008.
47. Walch G, Agostini JY, Levigne C, Nove-Josserand L. Recurrent anterior and multidirectional instability of the shoulder. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(8):682-690.
48. Ropars M, Cretual A, Kaila R, Bonan I, Hervé A, Thomazeau H. Diagnosis and treatment of anteroinferior capsular redundancy associated with anterior shoulder instability using an open Latarjet procedure and capsulorrhaphy. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3756-3764.
49. Boileau P, Clowez G, Bouacida S, Walch G, Trojani C, Schwartz DG. The Arthroscopic Trillat Procedure Is a Valuable Treatment Option for Recurrent Anterior Instability in Young Athletes With Shoulder Hyperlaxity. Arthroscopy. 2023 Apr;39(4):948-958. doi: 10.1016/j.arthro.2022.10.046.
Lebe M, Burns SA, Falworth M, Higgs DS, Rudge WB, Majed A. Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int. 2021 Sep 17;5(6):955-959. doi: 10.1016/j.jseint.2021.08.001. PMID: 34766069; PMCID: PMC8570950.
2. Johannessen EC, Reiten HS, Løvaas H, et al. Shoulder function, pain and health related quality of life in adults with joint hyper- mobility syndrome/Ehlers–Danlos syndrome-hypermobility type. Disabil Rehabil. 2016; 38: 1382–1390.
3. Neer CS II, Foster CR, Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980. 62:897–908
4. Neer CS. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect. 1985;34:232-8.
5. Moroder P, Danzinger V, Maziak N, Plachel F, Pauly S, Scheibel M et al. Characteristics of functional shoulder instability. J Shoulder Elbow Surg. 2020 Jan;29(1):68-78. doi: 10.1016/j.jse.2019.05.025.
6. Moroder P, Plachel F, Van-Vliet H, Adamczewski C, Danzinger V. Shoulder-Pacemaker Treatment Concept for Posterior Positional Functional Shoulder Instability: A Prospective Clinical Trial. Am J Sports Med. 2020 Jul;48(9):2097-2104. doi: 10.1177/0363546520933841.
7. Matsen FA III, Thomas SC, Rockwood CA Jr, Wirth MA. Glenohumeral instability. In: Rockwood CA Jr, Matsen FA III (eds) The shoulder, vol 1. 2005 Saunders, Philadelphia, pp 611–754
8. Angus Lewis, T Kitamura, J.I.L Bayley. The classification of shoulder instability: new light through old windows!. Current Orthopaedics, 2004. Volume 18, Issue 2. Pages 97-108, ISSN 0268-0890,doi.org/10.1016/j.cuor.2004.04.002.
9. Longo UG, Rizzello G, Loppini M, et al. Multidirectional instability of the shoulder: a systematic review. Arthroscopy 2015; 31: 2431–2443.
10. Krøner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989;108:288-90.
11. Rodeo SA, Suzuki K, Yamauchi M, Bhargava M, Warren RF. Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med. 1998. 26:634–643
12. Howard A, Powell JL, Gibson J, Hawkes D, Kemp GJ, Frostick SP. A functional Magnetic Resonance Imaging study of patients with Polar Type II/III complex shoulder instability. Sci Rep. 2019 Apr 18;9(1):6271. doi: 10.1038/s41598-019-42754-1.
13. Bahu MJ, Trentacosta N, Vorys GC, Covey AS, Ahmad CS. Multidirectional instability: evaluation and treatment options. Clin Sports Med. 2008;27(4):671-689.
14. Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992. 20:675–685
15. Nyiri P, Illyés A, Kiss R, Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg. 2010 Sep;19(6):802-13. doi: 10.1016/j.jse.2010.05.008. PMID: 20713276.
16. Lebe M, Burns SA, Falworth M, Higgs DS, Rudge WB, Majed A. Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int. 2021 Sep 17;5(6):955-959. doi: 10.1016/j.jseint.2021.08.001. PMID: 34766069; PMCID:
17. Barrett C. The clinical physiotherapy assessment of non-traumatic shoulder instability. Shoulder and Elbow. 2015 Vol 7 (I) 60 0- 71. DOI: 10.11771/1758573214548934
18. Jaggi A, Noorani A, Malone A, Cowan J, Lambert S and Bayley I. Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg 2012; 6: 101–7.
19. Grahame R, Bird HA and Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol 2000; 27: 1777–1779.
20. Malfait F, Francomano C, Byers P, et al. The 2017 inter- national classification of the Ehlers-Danlos syndromes. Am J Med Genet Part C Semin Med Genet 2017; 175C: 8–26.
21. Castori M, Tinkle B, Levy H, et al. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet 2017; 175: 148–157.
22. Mathias C, Low D, Iodice V, Owens A, Kirbis M and Grahame R. Postural tachycardia syndrome – current experience and concepts. Nat Rev Neurol 2012; 8: 22–34.
23. Merolla G, Cerciello S, Chillemi C, Paladini P, De Santis E, Porcellini G. Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol. 2015 Aug;25(6):975-85. doi: 10.1007/s00590-015-1606-5.
24. Schaeffeler C, Waldt S, Bauer JS, Kirchhoff C, Haller B, Schro ̈der M et al. MR arthrography including abduction and external rotation images in the assessment of atraumatic multidirectional instability of the shoulder. Eur Radiol 2014. 24:1376–1385
25. Moroder P, Danzinger V, Maziak N, Plachel F, Pauly S, Scheibel M, Minkus M. Characteristics of functional shoulder instability. J Shoulder Elbow Surg. 2020 Jan;29(1):68-78. doi: 10.1016/j.jse.2019.05.025.
26. Van der Linde JA, Bosmans JE, Ter Meulen DP, van Kampen DA, van Deurzen DF, Haverlag R et al. Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients. Shoulder Elbow. 2019 Aug;11(4):265-274. doi: 10.1177/1758573218773543.
27. Cho C.H., Seo H.J., Bae K.C., Lee K.J., Hwang I., Warner J.J. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg. 2013;22:1160–1166. doi: 10.1016/j.jse.2013.02.006.
28. Tashjian R.Z., Henn R.F., Kang L., Green A. The effect of comorbidity on self-assessed function in patients with a chronic rotator cuff tear. J Bone Joint Surg Am. 2004;86-A:355–362. doi: 10.2106/00004623-200402000-00020.
29. Raja, Senthooran et al. Abstract: Arthroscopic Stabilisation of Atraumatic Shoulder Instability: Minimum Two Year Outcomes. Journal of Shoulder and Elbow Surgery, 2021. Volume 30, Issue 7, e433
30. Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992 Jul;74(6):890-6. PMID: 1634579.
31. McIntyre K, Bélanger A, Dhir J, Somerville L, Watson L, Willis M, Sadi J. Evidence-based conservative rehabilitation for posterior glenohumeral instability: A systematic review. Phys Ther Sport. 2016 Nov;22:94-100. doi: 10.1016/j.ptsp.2016.06.002.
32. Douglas T, Jaggi A, Grange S, Lambert S. Prospective 2 year follow up of patient and diagnosis specific specialist physiotherapy treatment for patients with atraumatic shoulder instability. Abstract submission - British Elbow and Shoulder Society Annual Scientific Meeting 2009.
33. Burkhead WZ Jr and Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992; 74: 890–896.
34. Watson L, Balster S, Lenssen R, et al. The effects of a conservative rehabilitation program for multidirectional instability of the shoulder. J Shoulder Elbow Surg 2018; 27: 104–111.
35. Scott M, Sachinis NP, Gooding B. The role of structured physiotherapy in treating patients with atraumatic shoulder instability: Medium term results from a case series. Shoulder Elbow. 2020 Feb;12(1):63-70. doi: 10.1177/1758573218825392.
36. Bateman M, Smith BE, Osborne SE, Wilkes SR. Physiotherapy treatment for atraumatic recurrent shoulder instability: early results of a specific exercise protocol using pathology-specific outcome measures. Shoulder Elbow. 2015 Oct;7(4):282-8. doi: 10.1177/1758573215592266.
37. Griffin J, Jaggi A, Daniell H, Chester R. A systematic review to compare physiotherapy treatment programmes for atraumatic shoulder instability. Shoulder Elbow. 2023 Aug;15(4):448-460. doi: 10.1177/17585732221080730.
38. Warby SA, Ford JJ, Hahne AJ, et al. Comparison of 2 exercise rehabilitation programs for multidirectional instability of the glenohumeral joint: a randomized con- trolled trial. Am J Sports Med 2018; 46: 87–97.
39. Jaggi A, Cartwright J. Treating both head & shoulders; introduction of a joint psychiatry liaison and atraumatic shoulder instability clinic – a quality improvement project. Abstract submission - British Elbow and Shoulder Society Annual Scientific Meeting 2025.
40. Sinha A, Higginson DW and Vickers A. Use of botulinum A toxin in irreducible shoulder dislocation caused by spasm of pectoralis major. J Shoulder Elbow Surg 1999; 8: 75–76.
41. Beall, M. S., Jr., Diefenbach, G., & Allen, A. Electromyographic biofeedback in the treatment of voluntary posterior instability of the shoulder. American Journal of Sports Medicine, 1987. 15(2), 175e178.
42. Young, M. S. Electromyographic use in the treatment of voluntary posterior dislocation of the shoulder: A case study. Journal of Orthopaedic and Sports Physical Therapy, 1994. 20(3), 171e175.
43. Jaggi A, Herbert RD, Alexander S, Majed A, Butt D, Higgs D, Rudge W, Ginn KA. Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial. Br J Sports Med. 2023 Dec;57(23):1484-1489. doi: 10.1136/bjsports-2022-106596.
44. Chen D, Goldberg J, Herald J, Critchley I, Barmare A. Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2016 Feb;24(2):630-9. doi: 10.1007/s00167-015-3901-4.
45. Lebe M. Functional outcome of multidirectional shoulder instability treated surgically and non-surgically: A systematic review of recent literature and meta- analysis. 2018. Dissertation MSc Orthopaedic Trauma Sciences Queen Mary University London
46. Nyiri P, Illyés A, Kiss R, Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg. 2010 Sep;19(6):802-13. doi: 10.1016/j.jse.2010.05.008.
47. Walch G, Agostini JY, Levigne C, Nove-Josserand L. Recurrent anterior and multidirectional instability of the shoulder. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(8):682-690.
48. Ropars M, Cretual A, Kaila R, Bonan I, Hervé A, Thomazeau H. Diagnosis and treatment of anteroinferior capsular redundancy associated with anterior shoulder instability using an open Latarjet procedure and capsulorrhaphy. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3756-3764.
49. Boileau P, Clowez G, Bouacida S, Walch G, Trojani C, Schwartz DG. The Arthroscopic Trillat Procedure Is a Valuable Treatment Option for Recurrent Anterior Instability in Young Athletes With Shoulder Hyperlaxity. Arthroscopy. 2023 Apr;39(4):948-958. doi: 10.1016/j.arthro.2022.10.046.