Shoulder Instability: Causes and when to seek treatment

This post was written by Dr. Robert Klitzman, MD, sports medicine surgeon, Parkview Orthopedics.  
 

Shoulder instability is a common cause of shoulder pain, especially among athletes, active adults and individuals who naturally have more flexibility in their joints. But how do you know when to seek medical attention? Here, we cover the  key differences between traumatic and atraumatic shoulder instability, the warning signs to watch for and how treatment varies depending on the cause. 
 

What Is shoulder instability?  

Shoulder instability occurs when the ball of the shoulder joint (the humeral head) does not stay centered in the socket (the glenoid). This situation can lead to pain, weakness and shoulder dislocations. 
 

There are two main types: 
 

Traumatic shoulder instability 
 

This type occurs after a specific injury, most commonly in contact sports like football or hockey. A traumatic dislocation usually has no warning signs. It often happens suddenly because of a: 
 

• tackle

• collision 

• fall 

• sports-related impact 

In addition to dislocation, this type of injury almost always involves structural damage, typically a torn labrum, and occasionally bone injury. 
 

Atraumatic shoulder instability 
 

Atraumatic instability is related to joint flexibility, sometimes called being “double-jointed.” People with this type of instability tend to be naturally more stretchy in their ligaments. 
 

Common signs include being able to: 
 

• Bend the thumb down to the wrist 

• Touch palms to the floor with knees straight 

• Hyperextend joints more than most people 

For this group, the earliest warning sign is usually gradual shoulder pain, not an injury event. They may experience feelings of looseness or partial slipping. 

 

Can flexibility-related instability be prevented? 

While you can’t change your natural joint flexibility, you can strengthen the structures that stabilize the shoulder. Surgery is not even close to the first option. You can still stabilize the shoulder using the muscles of the shoulder. 
 

Physical therapy is the first line of treatment for atraumatic instability. Targeted exercises, especially those that strengthen the rotator cuff muscles, help support the joint and significantly reduce instability.

 

Traumatic vs. atraumatic instability: How treatment differs 

The treatment pathway looks very different depending on the type of instability.

Traumatic shoulder instability treatment: For young athletes (such as an 18-year-old football player), the likelihood of needing surgery after a traumatic dislocation is extremely high, over 90%. The dislocation usually tears the labrum and sometimes damages bone. Without repair, the shoulder is highly likely to dislocate again. 

The caveat would be in-season athletes may undergo rehab and wear a stabilizing brace to return to play temporarily. Surgery often occurs after the season, unless the damage is severe. 

Atraumatic shoulder instability treatment: This group almost always begins with physical therapy. The goals are to strengthen the rotator cuff and train the stabilizing muscles around the shoulder. If the patient completes a full course of therapy and still has instability, surgery may be considered.  

That said, many with atraumatic shoulder instability never need surgical intervention, even if they’ve experienced a dislocation. People with naturally flexible joints can sometimes dislocate their shoulder without tearing the labrum. If the soft tissues remain intact, strengthening alone may restore stability. 

 

What does shoulder instability surgery involve? 
 

Both traumatic and atraumatic shoulder instability repairs can be treated arthroscopically, meaning minimally invasive surgery using small incisions and a camera. 
 

For traumatic instability, surgery can include: 
 

• Labral repair 

• Fixing broken pieces of bone on the socket 

• Repairing a Hill-Sachs lesion (a divot in the humeral head caused by the dislocation) 

For atraumatic instability, procedures may include:
 

• Repairing a torn labrum (if present) 

• Tightening the joint capsule to prevent excessive movement 

Adults over 50: Older patients who suffer a traumatic dislocation, often from a fall rather than sports, commonly tear the rotator cuff. In these cases, surgery often includes: 
 

• Rotator cuff repair 

• Labral repair 

• Addressing any additional instability 
  
   

 Benefits of arthroscopic shoulder surgery 

While arthroscopy does not necessarily shorten the overall healing time, it provides important benefits, such as: 
 

• Smaller incisions 

• Less incisional pain 

• Less disruption to surrounding tissues 

• Quicker return to daily activities in early recovery 

 
Rehabilitation is essential after surgery for all groups. 

 

When should you see a doctor about shoulder pain or instability? 

Whether your instability is injury-based or related to natural flexibility, you shouldn’t ignore symptoms. 

Seek care if you experience:  
 

• Recurrent shoulder pain 

• A feeling that the shoulder is slipping or shifting 

• Partial dislocations (subluxations) 

• A full dislocation 

• Trouble lifting the arm 

• Weakness or instability during activity 

Early assessment can prevent worsening instability and reduce the risk of long-term joint damage. If you're having pain or dislocations, or even partial dislocations, see a physician. Most likely you'll start with physical therapy to help stabilize the shoulder and decrease pain. 

 

Final thoughts