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Multidirectional instability of the shoulder

David J Berkoff, MD, FAAEM, CAQSM
Section Editor
Karl B Fields, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Multidirectional instability (MDI) of the shoulder is defined as symptomatic laxity of the glenohumeral joint. Patients with this disorder have excessive laxity of the joint capsule in more than one or in all directions (anterior, inferior, and posterior) and have difficulty maintaining the head of the humerus centered within the glenoid fossa.

The clinical presentation, diagnosis, and management of MDI of the glenohumeral joint will be reviewed here. The general evaluation of adults with undifferentiated shoulder complaints, shoulder dislocation, and other common shoulder ailments, such as impingement or rotator cuff tendinopathy, are discussed separately. (See "Evaluation of the patient with shoulder complaints" and "Shoulder dislocation and reduction" and "Shoulder impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)


In the medical literature, a number of definitions exist for multidirectional instability (MDI) of the shoulder, making classification of these patients difficult. To clarify, glenohumeral laxity and instability are not synonymous [1]. Instability implies dysfunction. It can be voluntary or involuntary, unidirectional or multidirectional, and traumatic or nontraumatic. Patients with ligamentous laxity often have no complaints and require no intervention, while those with instability are by definition symptomatic.

The distinction between laxity and instability applies to physical examination findings as well. A patient whose shoulder can be subluxated in one or multiple directions but is asymptomatic has laxity without instability and requires no intervention. In contrast, a patient who presents with shoulder or proximal upper extremity pain, weakness, fatigue, or paresthesias may have laxity with instability. Patients with MDI of the glenohumeral joint often have laxity in both the asymptomatic and symptomatic shoulder, but only the symptomatic shoulder is classified as having instability.


The basic anatomy and biomechanics of the shoulder complex are reviewed separately. (See "Evaluation of the patient with shoulder complaints", section on 'Anatomy and biomechanics'.)

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Literature review current through: Nov 2017. | This topic last updated: Dec 02, 2016.
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