Multidirectional Instability in the Female Athlete

Multidirectional instability of the shoulder (MDI) is the least common form of shoulder instability. It is characterized by a global laxity of the joint capsule that leads to symptomatic inferior instability in addition to anterior or posterior instability or both. Patients with MDI are atypical in that they often have no history of trauma and may present with only vague complaints. They tend to have a loose, patulous inferior capsule in addition to altered glenohumeral and scapulothoracic mechanics, which contribute to instability. Female athletes may be particularly susceptible to MDI because of an increased predisposition to joint hyperlaxity. In addition, female athletes tend to favor sports that both reward and demand flexibility such as gymnastics, ice skating, diving, yoga, and cheerleading, which may cause MDI to become more symptomatic. The goals of treatment include pain relief, functional rehabilitation, and return to sport. Most patients respond well to a rehabilitation protocol involving strengthening of the rotator cuff, scapular stabilization exercises, and proprioceptive training exercises. For patients who fail to respond to conservative treatment, open or arthroscopic capsular shift may be performed, with the technique tailored to the patient’s individual pathology. Postoperative rehabilitation aims to restore range of motion, flexibility, and strength while protecting the integrity of the surgical repair. With close adherence to a well-designed rehabilitation protocol, patients may achieve predictably good outcomes, with a low recurrence rate of instability and a high rate of return to sports. Patients should be advised that surgery may decrease their range of motion, and that they may not be able to return to the same level of athletic competition.