Physiotherapy versus surgery for shoulder instability

EvidenceSearch4U logoQuestion 

In patients with shoulder instability (atraumatic and traumatic) is the use of functional electrical stimulation/physiotherapy better than surgery in improving pain/function.

PICO terms

Population / Problem: Pediatrics with shoulder instability
Intervention: physiotherapy, functional electrical stimulation
Comparison: surgery
Outcome: pain, function, apprehension


None of the papers identified were concerned with paediatric patients, and it was not possible to find any papers concerned with functional electrical stimulation as a technique.

Top papers identified

Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability.

Source: Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons … [et al.]; Sep 2010; vol. 19 (no. 6); p. 802-813

Publication Date: Sep 2010

Publication Type(s): Comparative Study; Journal Article

Author(s): Nyiri, Péter; Illyés, Arpád; Kiss, Rita; Kiss, Jeno

Abstract:This study compared the kinematic parameters and activity pattern of muscles around the glenohumeral joint in multidirectional instability (MDI) treated by only physiotherapy and by capsular shift and physiotherapy, before and after treatment, to test the hypothesis that the surgery group would demonstrate better kinematic and muscle activity than the physiotherapy group. The study comprised 32 patients with MDI treated with only physiotherapy, 19 patients with MDI treated by capsular shift and physiotherapy, and 50 healthy shoulders as the control group. The investigated kinematic parameters were the range of humeral elevation in the scapular plane, the scapulothoracic and glenohumeral angle, the scapulothoracic and glenohumeral rhythms, and relative displacement between the rotational centers of the humerus and the scapula. The muscle activity was modeled by the on-off pattern of muscles around the shoulder. Before treatment, increased relative displacement between the rotational centers of the scapula and the humerus and different regression lines were observed in MDI patients. The physiotherapy strengthened the muscles, but regression lines remained monolinear. Capsular shift and physiotherapy resulted in bilinear regression lines and normal relative displacement between the rotation center of scapula and humerus was restored. After surgery and physiotherapy the activity pattern of muscles was almost normal. The significant alterations in kinematic parameters in MDI patients cannot be completely normalized by physiotherapy only. After the capsular shift and postoperative physiotherapy, the bilinear regression lines (angulation at 60 degrees ), the normal relative displacement between the rotational centers of scapula and humerus, and the normal muscular activity pattern were restored to normal ranges and maintained for at least 4 years. (c) 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

Database: Medline

Evidence in managing traumatic anterior shoulder instability: a scoping review.

Source: British journal of sports medicine; Mar 2015; vol. 49 (no. 5); p. 307-311

Publication Date: Mar 2015

Publication Type(s): Research Support, Non-u.s. Gov’t; Journal Article; Review

Author(s): Monk, A Paul; Garfjeld Roberts, Patrick; Logishetty, Kartik; Price, Andrew J; Kulkarni, Rohit; Rangan, Amar; Rees, Jonathan L

Abstract:Traumatic anterior shoulder instability (TASI) accounts for 95% of glenohumeral dislocations and is associated with soft tissue and bony pathoanatomies. Non-operative treatments include slings, bracing and physiotherapy. Operative treatment is common, including bony and soft-tissue reconstructions performed through open or arthroscopic approaches. There is management variation in patient pathways for TASI including when to refer and when to operate. A scoping review of systematic reviews, randomised controlled trials, comparing operative with non-operative treatments and different operative treatments were the methods followed. Search was conducted for online bibliographic databases and reference lists of relevant articles from 2002 to 2012. Systematic reviews were appraised using AMSTAR (assessment of multiple systematic reviews) criteria. Controlled trials were appraised using the CONSORT (consolidation of standards of reporting trials) tool. Analysis of the reviews did not offer strong evidence for a best treatment option for TASI. No studies directly compare open, arthroscopic and structured rehabilitation programmes. Evaluation of arthroscopic studies and comparison to open procedures was difficult, as many of the arthroscopic techniques included are no longer used. Recurrence rate was generally considered the best measure of operative success, but was poorly documented throughout all studies. There was conflicting evidence on the optimal timing of intervention and no consensus on any scoring system or outcome measure. There is no agreement about which validated outcome tool should be used for assessing shoulder instability in patients. There is limited evidence regarding the comparative effectiveness of surgical and non-surgical treatment of TASI, including a lack of evidence regarding the optimal timing of such treatments. There is a need for a well-structured randomised control trial to assess the efficacy of surgical and non-surgical interventions for this common type of shoulder instability. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to

Database: Medline

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation.

Source: Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association; Jan 2005; vol. 21 (no. 1); p. 55-63

Publication Date: Jan 2005

Publication Type(s): Comparative Study; Randomized Controlled Trial; Clinical Trial; Journal Article

Author(s): Kirkley, Alexandra; Werstine, Robert; Ratjek, Andrew; Griffin, Sharon

Abstract:To report the long-term results of a prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation after a first traumatic anterior dislocation of the shoulder. Randomized clinical trial. Forty subjects younger than 30 years with a first traumatic anterior shoulder dislocation were randomized to receive immediate anterior stabilization plus rehabilitation or immobilization followed by rehabilitation. Patients completed the American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH), and the Western Ontario Shoulder Instability Index (WOSI) questionnaires. At an average follow-up of 75 months, there was a significant difference in the rate of redislocation between the groups but no statistical significant difference in shoulder function with the ASES or the DASH. The mean difference between the 2 groups with the WOSI estimates a small, but clinically significant difference. It is recommended that immediate arthroscopic stabilization is the treatment of choice in a subset of patients who are younger than 30 years and are higher level athletes, and the timing for surgery is good or their sport is risky, i.e., rugby, football, kayaking, rock climbing. Level II.

Database: Medline

Source: The Cochrane database of systematic reviews; 2004 (no. 1); p. CD004325

Publication Date: 2004

Publication Type(s): Comparative Study; Journal Article; Review

Author(s): Handoll, H H G; Almaiyah, M A; Rangan, A

Abstract: Acute anterior shoulder dislocation is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to re-dislocation, especially in active young adults. We aimed to compare surgical versus non-surgical treatment for acute anterior dislocation of the shoulder. We searched the Cochrane Musculoskeletal Injuries Group specialised register (August 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to September week 3 2003), EMBASE (1988 to 2003 week 39), the National Research Register (UK) (Issue 3, 2003), conference proceedings and reference lists of articles. Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute anterior shoulder dislocation. Selection of the included trials was by all three reviewers. Two reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. Five studies were included. These involved a total of 239 young (mainly aged around 22 years) active and mainly male people, all of whom had had a primary (first time) traumatic anterior shoulder dislocation. Methodological quality was variable, but notably there was insufficient information to judge whether allocation was effectively concealed in all five trials. Two trials, involving 115 participants, were only reported in conference abstracts.One trial involving military personnel reported that all had returned to active duty. Another trial reported similar numbers in the two intervention groups with reduced sports participation, and a third trial reported that significantly fewer people in the surgical group failed to attain previous levels of sports activity. Pooled results from all five trials showed that subsequent instability, either redislocation or subluxation, was statistically significantly less frequent in the surgical group (relative risk (RR) 0.20; 95%confidence interval (CI) 0.11 to 0.33). This result remained statistically significant (RR 0.32, 95%CI 0.17 to 0.59) for the three trials reported in full. Half (17/33) of the conservatively treated patients with shoulder instability in these three trials opted for subsequent surgery.Different, mainly patient-rated, functional assessment measures for the shoulder were recorded in the five trials. The results were more favourable, usually statistically significantly so, in the surgically treated group. Aside from a septic joint in a surgically treated patient, there were no other treatment complications reported. There was no information on shoulder pain, long-term complications such as osteoarthritis or on service utilisation and resource use. The limited evidence available supports primary surgery for young adults, usually male, engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine whether non-surgical treatment should not remain the prime treatment option for other categories of patient. Sufficiently powered, good quality and adequately reported randomised trials of good standard surgical treatment versus good standard conservative treatment for well-defined injuries are required; in particular, for patient categories at lower risk of activity-limiting recurrence. Long term surveillance of outcome, looking at shoulder disorders including osteoarthritis is also required. Reviews comparing different surgical interventions and different conservative interventions including rehabilitation are needed.

Database: Medline