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Multidirectional Instability

Multidirectional shoulder instability is the feeling of "looseness" of the shoulder joint in various directions

multidirectional instability

If you are a regular athlete or avid gym-goer and you start experiencing unexplained looseness or weakness along with pain and inflammation in your shoulder joints, you may be experiencing multidirectional shoulder instability (also referred to as atraumatic shoulder instability).

It refers to looseness or laxity in the glenohumeral shoulder joint.

These types of injuries are common amongst people who participate in various contact and non-contact sports along with people who work out regularly.

Multidirectional instability can also occur as a result of acute injury or trauma to the shoulder.

That said, multidirectional shoulder instability generally occurs due to weakness of the shoulder joint and shoulder blade muscles, due to repetitive overuse.

Athletes and individuals who work extremely physical jobs – particularly those that require a lot of overhead movement such as construction – are more prone to shoulder joint looseness or laxity.

multidirectional shoulder instability

What is multidirectional instability of the shoulder?

Multidirectional shoulder instability or atraumatic shoulder instability is generalized laxity in the glenohumeral shoulder joint (glenohumeral instability) in multiple directions.

The feeling of looseness – usually accompanied by some pain and inflammation – involves the ball of the shoulder joint slipping in and out of its socket in various directions, including forward or anterior, backward or posterior, and downward or inferior.

What causes multidirectional shoulder instability?

Overuse of the shoulder and constant repetitive movements can contribute to multidirectional shoulder instability, and it’s more prevalent in older individuals, due to the natural decline and stiffening of the tissues around the shoulder.

People who regularly participate in activities like AFL, baseball or swimming are more prone to this problem; other contributing factors include congenital shoulder joint looseness, muscular imbalances and shoulder structure variations, and shoulder blade position (see shoulder blade pain).

The muscles in your shoulder joints

Your shoulder joints are made up of a complex network of muscles, tendons, ligaments, and bones. It is a ball and socket joint (and multidirectional instability occurs when the ball slips or shifts in its socket, causing pain and weakness).

shoulder ligaments

The shoulder is made of three different bones – the humerus or the “ball”, the scapula or the “socket” and the clavicle that attaches it all to the rest of your body. There are four tendons that make up the rotator cuff which keeps your arm centered in the shoulder socket.

It’s all surrounded by the shoulder capsule, or the ligaments and tissue that hold everything together, attach the bones to the muscles, and let you move and rotate your shoulder.

The shoulder capsule is lined by a thin membrane called synovium, which produces the fluid that lubricates the joint and allows you to move your arms smoothly when everything is working normally.

The bursa sacs – small fluid-filled sacs located on the top of the shoulder joint – also provide further padding that allows you to raise, rotate, and otherwise move your arms.

Have intense pain around your shoulder? You may have inflammation in the bursal sac around your shoulder joints.

What are the signs and symptoms of multidirectional instability?

People with multidirectional shoulder instability often complain that it feels like the ball of their shoulder joint feels like it is slipping out of its position in the socket and that they need to modify their activity to prevent that from happening. Or they need to avoid certain types of activities or movements altogether.

The location and its intensity can vary from the front of the shoulder or throughout the entire joint depending on the activity that causes the pain.

Symptoms can vary widely depending on a range of factors including congenital or structural issues, previous injuries, and the type of activity or sports you regularly engage in.

However, signs of multidirectional instability often include pain and the feeling of slipping or instability while pushing, pulling, or carrying heavy objects, performing activities that involve lifting your arms over your head, and pain in the shoulder during exercise in general.

You may also feel numbness and tingling in the arm and shoulder area, clicking or popping sensations, and a constant feeling that your shoulder is shifting positions (even when you’re at rest e.g. relaxing in bed).

Increased fatigue during workouts or other repetitive activities and a decrease in performance while playing sports may also be a problem.

You may even fear putting your shoulder in certain positions and overcompensate by changing your form, potentially causing even more instability and other shoulder issues.

All of these symptoms are important signs that you should see an orthopaedic surgeon as soon as possible in order to diagnose your shoulder joint pain and determine the appropriate course of treatment.

glenohumeral instability

How is multidirectional shoulder instability diagnosed?

The evaluation and treatment process for multidirectional shoulder instability involves providing your doctor with a detailed history of your health, particularly any injuries to the shoulder, arm, or back.

They will perform a physical exam to assess the mobility of your shoulder along with the strength of your rotator cuff and scapular muscles; they will also assess your core strength, joint-body awareness and internal body awareness, and overall muscle control.

Your doctor or physiotherapist will also perform a series of shoulder instability tests, such as gently pulling your arm downward to check for increased movement in the joint, and pushing backward or forward on the arm bone to see if there is increased mobility in the shoulder.

Heightened mobility in the shoulder joint is one of the key signs of shoulder instability that doctors are looking for during this process.

X-rays and MRIs (magnetic resonance imaging) may be also be part of the diagnostic process in order to rule out bone fractures, muscle tears, and other issues that may be related to shoulder instability.

The symptoms of multidirectional shoulder instability or loose shoulders can be extremely varied and dependent on the source or reason for the problem, any pre-existing issues, and even the sports you play, your gym regimen, or the type of work you do.

loose shoulders

Nonsurgical multidirectional shoulder instability treatments

Physical therapy / physiotherapy and specific exercises are often prescribed as a treatment for multidirectional shoulder instability.

A physical therapist with experience treating shoulder instability will start by assessing your particular problem areas, looking for muscular imbalance and weakness.

Managing pain and inflammation is also important, of course.

Your doctor and physiotherapist will teach you techniques to manage pain (including using ice and heat) and design treatments for shoulder instability that’s unique to you.

You will also be advised to limit, modify, or even cease any physical activity or sports that may aggravate your shoulder.

Physiotherapy for multidirectional shoulder instability generally involves light exercises that involve keeping your shoulder close to the body at first (in order to minimize pain and further injury); once your shoulder strength and stability increase, you’ll be able to do more dynamic and intense movements.

The focus of these exercises will be on improving your shoulder, but your therapist should also help you work on your core strength and if applicable, the ability to return to your chosen sport and job as soon as possible.

It’s important to work with a physiotherapist who not only has experience treating multidirectional shoulder instability, but one who understands your long term goals and the demands and stress of not only the activities that led to your shoulder issues, but your everyday life.

Surgery For multidirectional shoulder instability

In more extreme or painful cases of shoulder instability, surgery may be recommended, especially if extended physiotherapy and rehabilitation programs haven’t been able to control or improve the problem.

The goal of these surgeries is to tighten and reduce the size of the shoulder capsule, increasing stability and reducing pain.

There are two types of surgeries that may be performed for multidirectional shoulder instability – traditional or “open” surgery, or arthroscopic surgery.

The traditional surgery is referred as an extensive inferior capsular release and imbrication, and it is meant to tighten or reduce the size of the joint capsule, reducing glenohumeral movement.

It involves detaching and releasing the subscapularis muscle, giving the surgeon access to the joint capsule for the procedure.

This option does involve running the risk of a substantial decrease in your range of motion, so it is not always recommended for serious athletes.

On the other hand, some more recently developed arthroscopy options are becoming increasingly successful options.

During arthroscopic surgery to treat shoulder instability, either capsular plication (a technique using arthroscopic sutures) or thermal capsulorrhaphy (a less invasive method using thermal energy) are used to shrink the shoulder capsule.

mdi shoulder

Recovering From multidirectional shoulder instability

Healing from multidirectional shoulder instability or mdi shoulder is typically a long process, requiring regular physiotherapy for 6 months or more even if your instability doesn’t require surgery.

If you do require surgery for multidirectional instability, you may have to wear a sling for up to 6 weeks.

You’ll also have a slow but steady physiotherapy program aimed at restoring motion and strengthening your shoulder, upper arm, and core strength; the type of program depends on whether you had open or traditional surgery or arthroscopic shoulder surgery.

Traditional surgery for shoulder instability involves a regimen designed to protect the suscapularis muscle (which is detached during surgery), while shoulder arthroscopies require a longer period of immobility and rest so scar tissue can form and heal properly from thermal treatments used during the procedure (causing a greater risk of stretching and further damage if it is not allowed to heal).

You’ll be restricted from full participation in sports and other strenuous activities for at least 9 to 12 months after your surgery.

How can multidirectional shoulder instability be prevented?

Multidirectional shoulder instability and related issues can often be prevented through proper shoulder mechanics and working to strengthen the muscles of the shoulder through body awareness, muscle control, and maintaining good form (consider working with a personal trainer or coach who has experience training individuals with shoulder instability).

You should also be careful to avoid overuse, since constant repetitive motion is often what causes shoulder instability and related damage.

Practice is important, but so is rest and recovery time.

If you think you may be suffering from multidirectional shoulder instability or a similar problem, contact an orthopaedic surgeon who has experience dealing with athletes and other individuals with these type of injuries as soon as possible.

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