Search tips
Search criteria 


Logo of jathtrainLink to Publisher's site
J Athl Train. 2000 Jul-Sep; 35(3): 278–285.
PMCID: PMC1323390

Understanding Multidirectional Instability of the Shoulder



To provide an overview of the evaluation and treatment of the patient with multidirectional shoulder instability.

Data Sources:

I searched MEDLINE for the years from 1980 to 2000 using the key words “shoulder joint,” “instability,” “dislocation,” “multidirectional shoulder instability,” and “inferior capsular shift.”

Data Synthesis:

Multidirectional instability is symptomatic glenohumeral subluxation or dislocation in more than 1 direction: anterior, inferior, or posterior. The primary pathology is a loose and patulous capsule, and the entity is more common than previously recognized. Multidirectional instability affects young, sedentary patients with generalized ligamentous laxity, often with bilateral symptoms and an atraumatic history, but it also affects athletes, many of whom have sustained injuries. Patients with multidirectional instability may also have Bankart lesions and humeral head impression defects.


Patients with multidirectional instability must be identified before appropriate treatment can be initiated. If a course of rehabilitation fails to improve the patient's symptoms, an inferior capsular shift procedure has been demonstrated to be an effective surgical option.

Full text

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (2.7M), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Neer CS, 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980 Sep;62(6):897–908. [PubMed]
  • Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the shoulder. A preliminary report on a clinical, electromyographic, and psychiatric study of twenty-six patients. J Bone Joint Surg Am. 1973 Apr;55(3):445–460. [PubMed]
  • Neer CS., 2nd Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect. 1985;34:232–238. [PubMed]
  • Arendt EA. Multidirectional shoulder instability. Orthopedics. 1988 Jan;11(1):113–120. [PubMed]
  • Bigliani LU, Weinstein DM, Glasgow MT, Pollock RG, Flatow EL. Glenohumeral arthroplasty for arthritis after instability surgery. J Shoulder Elbow Surg. 1995 Mar-Apr;4(2):87–94. [PubMed]
  • Hawkins RJ, Angelo RL. Glenohumeral osteoarthrosis. A late complication of the Putti-Platt repair. J Bone Joint Surg Am. 1990 Sep;72(8):1193–1197. [PubMed]
  • Hawkins RH, Hawkins RJ. Failed anterior reconstruction for shoulder instability. J Bone Joint Surg Br. 1985 Nov;67(5):709–714. [PubMed]
  • Lusardi DA, Wirth MA, Wurtz D, Rockwood CA., Jr Loss of external rotation following anterior capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 1993 Aug;75(8):1185–1192. [PubMed]
  • MacDonald PB, Hawkins RJ, Fowler PJ, Miniaci A. Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am. 1992 Jun;74(5):734–737. [PubMed]
  • Mallon WJ, Speer KP. Multidirectional instability: current concepts. J Shoulder Elbow Surg. 1995 Jan-Feb;4(1 Pt 1):54–64. [PubMed]
  • O'Driscoll SW, Evans DC. Long-term results of staple capsulorrhaphy for anterior instability of the shoulder. J Bone Joint Surg Am. 1993 Feb;75(2):249–258. [PubMed]
  • Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984 Feb;66(2):159–168. [PubMed]
  • Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983 Apr;65(4):456–460. [PubMed]
  • Young DC, Rockwood CA., Jr Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am. 1991 Aug;73(7):969–981. [PubMed]
  • Zuckerman JD, Matsen FA., 3rd Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am. 1984 Feb;66(2):175–180. [PubMed]
  • Bigliani LU, Kurzweil PR, Schwartzbach CC, Wolfe IN, Flatow EL. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med. 1994 Sep-Oct;22(5):578–584. [PubMed]
  • Ozaki J. Glenohumeral movements of the involuntary inferior and multidirectional instability. Clin Orthop Relat Res. 1989 Jan;(238):107–111. [PubMed]
  • CARTER C, SWEETNAM R. Recurrent dislocation of the patella and of the shoulder. Their association with familial joint laxity. J Bone Joint Surg Br. 1960 Nov;42-R:721–727. [PubMed]
  • Emery RJ, Mullaji AB. Glenohumeral joint instability in normal adolescents. Incidence and significance. J Bone Joint Surg Br. 1991 May;73(3):406–408. [PubMed]
  • Finsterbush A, Pogrund H. The hypermobility syndrome. Musculoskeletal complaints in 100 consecutive cases of generalized joint hypermobility. Clin Orthop Relat Res. 1982 Aug;(168):124–127. [PubMed]
  • Jerosch J, Castro WH. Shoulder instability in Ehlers-Danlos syndrome. An indication for surgical treatment? Acta Orthop Belg. 1990;56(2):451–453. [PubMed]
  • Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder. Clin Orthop Relat Res. 1993 Jun;(291):7–19. [PubMed]
  • Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the patient under anesthesia. J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):286–292. [PubMed]
  • Jalovaara P, Myllylä V, Päivänsalo M. Autotraction stress roentgenography for demonstration anterior and inferior instability of the shoulder joint. Clin Orthop Relat Res. 1992 Nov;(284):136–143. [PubMed]
  • 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):890–896. [PubMed]
  • Gibb TD, Sidles JA, Harryman DT, 2nd, McQuade KJ, Matsen FA., 3rd The effect of capsular venting on glenohumeral laxity. Clin Orthop Relat Res. 1991 Jul;(268):120–127. [PubMed]
  • Habermeyer P, Schuller U, Wiedemann E. The intra-articular pressure of the shoulder: an experimental study on the role of the glenoid labrum in stabilizing the joint. Arthroscopy. 1992;8(2):166–172. [PubMed]
  • Kronberg M, Broström LA, Németh G. Differences in shoulder muscle activity between patients with generalized joint laxity and normal controls. Clin Orthop Relat Res. 1991 Aug;(269):181–192. [PubMed]
  • Cordasco FA, Wolfe IN, Wootten ME, Bigliani LU. An electromyographic analysis of the shoulder during a medicine ball rehabilitation program. Am J Sports Med. 1996 May-Jun;24(3):386–392. [PubMed]
  • Beall MS, Jr, Diefenbach G, Allen A. Electromyographic biofeedback in the treatment of voluntary posterior instability of the shoulder. Am J Sports Med. 1987 Mar-Apr;15(2):175–178. [PubMed]
  • Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensile properties of the inferior glenohumeral ligament. J Orthop Res. 1992 Mar;10(2):187–197. [PubMed]
  • Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF. Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am. 1994 Dec;76(12):1819–1826. [PubMed]
  • Harryman DT, 2nd, Sidles JA, Harris SL, Matsen FA., 3rd The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am. 1992 Jan;74(1):53–66. [PubMed]
  • O'Brien SJ, Neves MC, Arnoczky SP, Rozbruck SR, Dicarlo EF, Warren RF, Schwartz R, Wickiewicz TL. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med. 1990 Sep-Oct;18(5):449–456. [PubMed]
  • Speer KP, Deng X, Torzilli PA, Altchek DA, Warren RF. Strategies for an anterior capsular shift of the shoulder. A biomechanical comparison. Am J Sports Med. 1995 May-Jun;23(3):264–269. [PubMed]
  • Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):675–685. [PubMed]
  • Cofield RH, Nessler JP, Weinstabl R. Diagnosis of shoulder instability by examination under anesthesia. Clin Orthop Relat Res. 1993 Jun;(291):45–53. [PubMed]
  • Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am. 1992 Dec;74(10):1516–1521. [PubMed]
  • Wirth MA, Blatter G, Rockwood CA., Jr The capsular imbrication procedure for recurrent anterior instability of the shoulder. J Bone Joint Surg Am. 1996 Feb;78(2):246–259. [PubMed]
  • Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991 Jan;73(1):105–112. [PubMed]
  • Warner JJ, Johnson D, Miller M, Caborn DN. Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg. 1995 Sep-Oct;4(5):352–364. [PubMed]
  • Field LD, Warren RF, O'Brien SJ, Altchek DW, Wickiewicz TL. Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med. 1995 Sep-Oct;23(5):557–563. [PubMed]
  • Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop Relat Res. 1987 Oct;(223):44–50. [PubMed]
  • Duncan R, Savoie FH., 3rd Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: a preliminary report. Arthroscopy. 1993;9(1):24–27. [PubMed]
  • Hayashi K, Thabit G, 3rd, Massa KL, Bogdanske JJ, Cooley AJ, Orwin JF, Markel MD. The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule. Am J Sports Med. 1997 Jan-Feb;25(1):107–112. [PubMed]
  • Mok DW, Fogg AJ, Hokan R, Bayley JI. The diagnostic value of arthroscopy in glenohumeral instability. J Bone Joint Surg Br. 1990 Jul;72(4):698–700. [PubMed]
  • Lebar RD, Alexander AH. Multidirectional shoulder instability. Clinical results of inferior capsular shift in an active-duty population. Am J Sports Med. 1992 Mar-Apr;20(2):193–198. [PubMed]

Articles from Journal of Athletic Training are provided here courtesy of National Athletic Trainers Association