REVIEW ARTICLE
Multidirectional Instability of the Shoulder: Treatment
Options and Considerations
Matthew J. Best, MD and Miho J. Tanaka, MD
Abstract: Multidirectional instability (MDI) is a debilitating condition
that involves chronic subluxation or dislocation of the shoulder in > 1
direction. Numerous proposed mechanisms of MDI exist, which
occurs in the setting of redundant capsular tissue. Symptoms can range
from recurrent dislocations or subluxations to vague aching pain that
disrupts activities of daily living. Magnetic resonance imaging is often
performed during evaluation of this condition, although magnetic
resonance arthrography may provide more detailed images of the
patulous capsule. In the absence of a well-defined traumatic cause,
such as a labral tear, initial treatment for MDI is a structured reha-
bilitation program with exercises aimed at strengthening the rotator
cuff and periscapular muscles to improve scapular kinematics. Patients
with recalcitrant symptoms may benefit from surgical stabilization,
including open capsular shift or arthroscopic capsular plication, aimed
at decreasing capsular volume and improving stability.
Key Words: arthroscopic capsular plication, glenohumeral joint,
ligamentous laxity, multidirectional instability, open capsular shift,
shoulder instability
(Sports Med Arthrosc Rev 2018;26:113–119)
M ultidirectional instability (MDI) is a condition involving
symptomatic subluxation or dislocation of the gleno-
humeral joint that occurs in > 1 direction.1–5 The condition
often occurs concomitantly or in association with generalized
ligamentous joint laxity with or without congenital disorders,
such as Ehlers-Danlos or Marfan syndrome, or it may be
caused by repetitive microtrauma as commonly seen in
swimmers, weightlifters, and gymnasts.6–10 The term “insta-
bility” refers to pathologic symptoms and loss of function
related to abnormal shoulder translation, whereas the term
“laxity” is used to refer to asymptomatic, physiological trans-
lation of the shoulder joint.11,12 In patients with MDI, reports
of the prevalence of ligamentous laxity has been reported to
range from 47% to 76%.5,13,14 A common finding in MDI that
may differentiate it from other conditions is the presence of a
redundant or patulous capsule.5 Distinguishing MDI from
unidirectional shoulder instability is critical for providing
appropriate treatment because many surgical techniques for
unidirectional instability, such as anterior stabilization, Bankart
repair, and posterior capsular plication, do not address the
redundant inferior capsule seen in MDI and can lead to early
failure and recurrent instability.5 Although initial treatment of
MDI involves a comprehensive rehabilitation program, open
and arthroscopic stabilization techniques have been described
for patients in whom nonoperative treatment has failed.
From the Department of Orthopaedic Surgery, The Johns Hopkins
University, Baltimore, MD.
Disclosure: The authors declare no conflict of interest.
Reprints: Miho J. Tanaka, MD, Department of Orthopaedic Surgery,
The Johns Hopkins University, 601 N. Caroline St., Suite 5250,
Baltimore, MD 21287.
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
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ETIOLOGY
MDI is often classified as traumatic or atraumatic, with
or without associated laxity.15 MDI can be caused by a major
traumatic event, such as those seen in patients with labral
tears.13,16,17 These patients often respond well to surgery that
addresses the structural lesion. More commonly, MDI occurs
in the absence of macrotrauma, in association with repetitive
microtrauma from overuse or in association with ligamentous
hyperlaxity. Higher prevalence of MDI is seen in swimmers,
gymnasts, volleyball players, weightlifters, and others who
often perform repetitive overhead activities. Patients who have
disorders with hyperlaxity components, such as Ehlers-Danlos
or Marfan syndrome, are also at higher risk for developing
MDI.6–10
Several structural contributors to MDI have been described.
Static restraints of the glenohumeral joint include the glenoid
concavity, labrum, glenohumeral ligaments, and negative intra-
articular pressure.18–23 Dynamic restraints of the glenohumeral
joint consist of the rotator cuff and periscapular musculature.
Inferior capsular redundancy was described originally by Neer
and Foster5 as the underlying cause of MDI, and although this
anatomic characteristic may predispose to instability, it can also
be found in patients without MDI. The authors noted that in
these patients with ligamentous laxity or capsular redundancy,
repetitive use from work, sports, or activities of daily living can
lead to the development symptomatic instability or MDI.
Macrotrauma or repetitive microtrauma from overuse
can lead to insufficiency of the static and dynamic stabilizers
of the glenohumeral joint. The rotator cuff contributes
to stability through concavity compression or compression
and centering of the humeral head against the glenoid. In
patients with MDI, abnormal rotator cuff function may lead
to off-centering of the humeral head within the glenoid and
may contribute to shoulder instability.24 Periscapular mus-
culature and scapular kinematics aid in dynamic stabiliza-
tion by adjusting the position and relative version of the
glenoid and may be altered in patients with MDI.25
HISTORY AND EXAMINATION
Patients with MDI can present with various and sometimes
nonspecific symptoms ranging from nonfocal shoulder pain to
daily, recurrent shoulder dislocations. They may report a history
of multiple dislocations or subluxations, which may occur spor-
adically or with specific activities or positions. A thorough history
and physical examination are important to differentiate patients
with MDI from those with unidirectional instability. Patients
with longstanding instability may learn to avoid certain positions
or activities that lead to instability episodes, and careful history
taking can elicit the direction of instability that may be present.
Patients with anterior instability may avoid overhead activities or
abduction and external rotation. Those complaining of posterior
instability may experience pain or instability episodes with the
arm forward flexed and internally rotated, such as when pushing
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Best and Tanaka
open a door. Patients with inferior instability may experience
pain or instability episodes when carrying heavy bags or luggage.
Patients who are able to demonstrate positions that lead to
instability but attempt to avoid those positions in their daily lives
may have better outcomes after surgery and should be differ-
entiated from voluntary, or willful, dislocators who may respond
poorly to surgery.12
Scapular motion should be observed on every patient being
evaluated for instability as scapular dyskinesia, and altered
mechanics have been shown to occur at higher rates in patients
with MDI compared with asymptomatic controls25 and may
contribute to both pain and instability in these patients. Finally,
a standard assessment of strength and range of motion with
comparison to the contralateral, unaffected shoulder should be
performed in all patients and can be important to detect asym-
metry, particularly in patients with generalized laxity.
Any history of generalized ligamentous laxity should be
investigated because surgery is less successful in these
patients.26 During examination, Beighton criteria can be used
to guide assessment of hypermobility: hyperextension of the
elbow or knee > 10 degrees, thumb opposition to the ipsi-
lateral forearm, > 90 degrees of small finger dorsiflexion, and
ability to place the palms flat on the ground while bending at
the trunk.27 The first 4 criteria can be assessed bilaterally and
one point should be scored for each positive maneuver. A final
point should be scored for the final criterion of forward trunk
bending, which provides a maximum score of 9 points. A
higher score, correlates with a higher likelihood of ligamentous
laxity. Cameron et al28 showed that patients who had a score
of ≥ 2 on the Beighton scale were more than twice as likely to
have reported a history of glenohumeral instability compared
with those with lower Beighton scores.28
Examination maneuvers to evaluate shoulder instability
include the load-and-shift test, as well as the evaluation for
presence of a sulcus sign (Fig. 1), the hyperabduction
maneuver, the apprehension test, the relocation test, and the
posterior jerk test. The load-and-shift test is performed with
the patient supine. An axial load is applied to the humerus,
FIGURE 1. The load-and-shift test. An axial force is applied to the
arm (black arrow) and the humerus is translated anteriorly and
posteriorly (white arrow) along the glenoid.
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
and then the humerus is translated anteriorly and posteriorly
about the glenoid to assess humeral translation (Fig. 1).
Grade 1 indicates humeral head translation to the glenoid
rim; grade 2, humeral head translation over the glenoid rim
with spontaneous reduction; and grade 3, humeral head
subluxation over the glenoid rim requiring manual reduction.
The sulcus sign refers to the concavity between the edge
of the acromion and the head of the humerus that can be
visualized after application of an inferior force to the
adducted arm (Fig. 2). The sulcus represents the acromio-
humeral interval and grading is as follows: grade 1, acro-
miohumeral distance <1 cm; grade 2, 1 to 2 cm; and grade
3, > 2 cm of acromiohumeral distance. The patient should
be asked if the maneuver reproduces the symptoms of
instability as this sign can also be found in those without
shoulder instability. In a study of 178 asymptomatic ath-
letes, McFarland et al29 showed that 9% of female athletes
and 3% of male athletes had a grade 3 sulcus sign without
clinical symptoms of instability.29 Gagey and Gagey30
described the hyperabduction test in which the examiner
passively abducts the arm while stabilizing the shoulder
girdle (Fig. 3). In their study of 90 patients with instability,
85% of patients demonstrated passive abduction > 105
degrees in the affected shoulder, whereas the unaffected
shoulder demonstrated abduction of ≤ 90 degrees. The
authors noted that all patients who had passive shoulder
abduction > 105 degrees had labral pathology at time of
surgery and concluded that this exam finding is associated
with laxity of the inferior glenohumeral ligament.30 The
apprehension test is performed with the arm in abduction
and external rotation and is considered positive if the patient
feels apprehensive, or concerned the shoulder will dislocate
(Fig. 4).31 The relocation test is performed with the patient
supine with the shoulder hanging off the table. The arm is
brought into abduction and external rotation until pain is
felt at which point the examiner places and posterior force
on the humeral head. Pain relief with this posterior force
indicates a positive relocation test.32 The posterior jerk test
is performed with the arm in flexion, adduction, and internal
rotation, and an axial force is applied to the humerus, which
can cause a posterior subluxation or “clunk” of the humeral
head over the glenoid rim.33
IMAGING
Although frequently normal in patients with MDI,
conventional radiographs can be obtained to assess the
position of the humeral head relative to the glenoid, as well
as to assess for major glenoid or humeral osseous defects.
Computed tomography scans may also be used to assess for
osseous abnormalities, such as glenoid bone loss or dys-
plasia. Magnetic resonance imaging (MRI) remains the
“gold standard” of imaging for patients with shoulder
instability because it allows assessment of the capsu-
loligamentous structures and evaluation of redundancy of
the joint capsule. Magnetic resonance arthrography (MRA)
has been shown to be of more diagnostic value than
standard MRI given its ability to measure the volume of the
capsule (Fig. 5).34 Schaeffeler et al35 assessed the use of
MRA for evaluating capsular redundancy in patients with
MDI. The authors performed MRA of the shoulder in
abduction and external rotation which allowed for better
evaluation of the anteroinferior glenohumeral ligament and
inferior capsule. The presence of a layer of contrast between
the humeral head and anteroinferior glenohumeral ligament
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
FIGURE 2. Sulcus sign of the shoulder. A, The examiner applies an inferior force (white arrow) with the shoulder in an adducted position.
B, The examiner then evaluates for the presence of a concavity between the acromion and humeral head (black arrow).
(crescent sign) and a triangular space between the ante-
roinferior glenohumeral ligament and glenoid (triangle sign)
were assessed with the shoulder abducted and externally
rotated. The presence of both of these signs on MRA was up
to 90% sensitive and 94% specific in diagnosing MDI.35
Various measurement techniques have been described for
assessing increased rotator interval width and joint-capsule
widening, which can be seen in patients with MDI.36–38 Lee
et al38 assessed rotator interval width and capsular dimen-
sions in patients with MDI using MRA. They showed a
rotator interval width > 15.2 mm or a depth > 6.4 mm had
> 79% sensitivity and > 62% specificity for MDI.38 Hsu
et al39 assessed superior capsular elongation using MRA in
patients with MDI. They found that the linear distance and
cross-sectional area under the supraspinatus tendon, as well
as the rotator interval were all significantly increased in
patients with MDI. Linear distance under the supraspinatus
FIGURE 3. The hyperabduction test. The examiner abducts the
arm (black arrow) while stabilizing the shoulder with the contra-
lateral hand. Passive abduction > 105 degrees is associated with
laxity of the inferior glenohumeral ligament.
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Multidirectional Instability of the Shoulder
tendon of > 1.6 mm had a specificity of 95% and a sensi-
tivity of 90% for MDI, whereas an area under the rotator
interval of > 1.4 cm2 had a sensitivity and specificity of
90%.39
NONSURGICAL TREATMENT
The most common initial treatment for patients with
MDI is a comprehensive rehabilitation program.12 The
focus of therapy involves strengthening of the rotator cuff
and scapular stabilizing exercises to improve stability of the
shoulder, as patients with MDI typically have altered
scapular kinematics and deficiency in upward scapular
rotation.25,40 At least 6 months of therapy is typically
attempted before considering surgical treatment.41 Few
studies have described a detailed and specific rehabilitation
protocol for patients with instability.42,43 Watson et al42
created a 6-stage program for patients with MDI that
focuses more on functional position exercises and improving
scapula kinematics. Specific exercises for scapular kinematics
include standing or side-lying scapula upward rotation
FIGURE 4. The apprehension test. The apprehension test is per-
formed with the arm in abduction and external rotation and is
considered positive if the patient feels apprehensive, or concerned
the shoulder will dislocate.
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Best and Tanaka
FIGURE 5. Sagital (A) and coronal (B) magnetic resonance arthrography images showing a patulous inferior capsule in a patient with
multidirectional instability.
movements as well as internal and external rotation drills
with resistance bands.42
Warby et al44 conducted a systematic review evaluating
the effect of exercise-based therapy on outcomes in patients
with MDI. Seven studies met their inclusion criteria and
showed low-quality evidence for improvement in the Rowe
score, shoulder kinematics, peak strength, and patient-
reported overall status rating. The authors acknowledge that
their review was limited by heterogeneity of the patient
populations in the studies.44 Burkhead and Rockwood43
studied the outcomes of 115 patients (140 shoulders) with
traumatic or atraumatic anterior, posterior, or multidirec-
tional shoulder instability who participated in a structured
exercise program. The 3-month to 4-month exercise pro-
gram was designed to strengthen the deltoid and rotator cuff
muscles according to a progressive resistance-training prin-
ciple. Good or excellent outcomes were achieved by 80% of
patients with atraumatic instability and only 16% of patients
with traumatic instability. Of patients with MDI, 90% had
good or excellent outcomes.43 Long-term outcomes in
patients with MDI treated with an exercise program have
been reported as poor in half of patients at 8 years,45
although this result may be confounded by the young age
and active lifestyle of these patients. Although research on
exercise-based therapy for MDI is limited by low-level evi-
dence, heterogeneous patient samples, and lack of adequate
preintervention and postintervention measures, treatment of
patients with MDI should begin with a structured, com-
prehensive rehabilitation program focused on periscapular
muscle and rotator cuff strengthening. Physicians should be
aware that outcomes of nonoperative treatment might be
less successful in patients with a history of traumatic insta-
bility and in young, athletic patients.
SURGICAL TREATMENT
Surgical treatment is an option for patients with
recurrent instability that does not improve with extensive
physical therapy. A biomechanical analysis by Nyiri et al46
showed that altered shoulder kinematics in patients with
MDI cannot be restored fully with physical therapy alone.
In addition, surgery may be needed to restore normal muscle
activity in patients for whom nonoperative treatment
fails.41,47,48 Warby et al49 performed a systematic review of
exercise-based treatment compared with surgery for patients
with MDI. The review included 4 nonrandomized studies
that included patients who underwent exercise-based treat-
ment or surgical treatment. The authors found that surgery
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
was superior to exercise therapy for shoulder kinematics and
return to sport or work, whereas exercise therapy was
superior to surgical treatment in patient satisfaction scores.
The authors note that the studies included in their review
contained heterogeneous patient samples, used what they
described as inappropriate outcome measures, lacked pre-
intervention data, and were not randomized.49 Surgical
stabilization procedures should be customized for each
patient, based on the anatomic deficit and direction of
symptomatic instability. Various surgical options have been
described,5,16,19,50 including thermal capsulorrhaphy, open
inferior capsular shift, arthroscopic capsular plication, and
labral repair in young patients. Thermal capsulorrhaphy is
associated with high failure rates and numerous complica-
tions and is no longer used for patients with MDI.50,51
Open Inferior Capsular Shift
Originally described by Neer and Foster5 in 1980, the
open inferior capsular shift has been a mainstay of surgical
treatment for MDI. This procedure has been described to
decrease the capsular volume and improve stability in
multiple planes. Through a deltopectoral approach, the
subscapularis is released or split,52–54 and a T-shaped cap-
sulotomy performed. The capsule is first detached from its
humeral insertion then shifted to the opposite side of the
calcar to address redundancy of the inferior pouch. A por-
tion of the overlying subscapularis tendon is used to rein-
force this repair. Finally, the subscapularis is closed in a
separate layer from the capsular repair (Fig. 6). In 36
patients (40 shoulders), Neer and Foster5 reported only 1
unsatisfactory outcome in their original series.
The capsular shift procedure is based on the premise of
inferior capsular redundancy and its role in MDI. The
decrease in capsular volume is proportional to the capsular
shift. Miller et al55 compared the capsular volume reduction
achieved using different capsular shift techniques. The hum-
eral capsular shift decreased capsular volume significantly
more than did the glenoid capsular shift. Using an open
technique, capsular volume reduction has been reported up to
50%, although the clinical significance in percentage of vol-
ume reduction is unknown. Since the original series by Neer
and Foster,5 studies have shown good outcomes in up to 95%
of patients after inferior capsular shift.13,17 Subsequent stud-
ies have also reported good outcomes with low recurrence
rates after open stabilization. In a systematic review, Longo
et al56 reported a redislocation rate of only 7.5% of 226
shoulders at 4-year follow-up.
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018 Multidirectional Instability of the Shoulder

FIGURE 6. Illustration of the inferior capsular shift procedure. A, Horizontal capsulotomy is performed (dotted red line) to produce
superior-A and inferior-B capsular flaps. B, Capsular flaps are advanced in the direction of the red arrows, and a capsular shift is
performed. This maneuver reduces the volume of the capsule. C, Capsular flaps are repaired and now overlap flap-A has been shifted
inferiorly while flap-B has been shifted superiorly.

Arthroscopic Capsular Plication glenoid to maintain visualization and control of the plica-
First described in 1993,57 arthroscopic capsular plication tion (Fig. 7). Anchor fixation may be used or suture may be
for MDI has several advantages versus the open technique. passed through the capsule and into the labrum for plica-
Arthroscopy allows the surgeon to fully evaluate the gleno- tion. The decrease in capsular volume is proportional to the
humeral joint at the time of the capsular procedure, which amount and size of plication. Flanigan et al62 showed that
can allow treatment of multiple intra-articular abnormalities increasing plication from 5 to 10 mm led to a decrease in
if present. The arthroscopic technique can also avoid com- capsular volume from 16% to 34%.
plications associated with the open procedure, including Both open and arthroscopic techniques are used for the
postoperative subscapularis failure (Table 1).60 treatment of MDI without consensus on the superiority of either
The procedure can be performed in beach-chair or approach. A comparison of both techniques showed that
lateral-decubitus position. Arthroscopic portals can be made
according to surgeon preference and on the basis of the
location of abnormalities. Common portals used are the
posterior portal with anterosuperior and anteroinferior
portals for cannula insertion. Comprehensive diagnostic
arthroscopy should always be performed to assess for con-
comitant abnormalities. A “drive-through” sign occurs
when the arthroscope is passed easily between the humeral
head and the glenoid at the level of the anterior band of the
inferior glenohumeral ligament and may be present in the
setting of a patulous inferior capsule. The “drive-through”
sign may be seen in patients with ligamentous laxity; how-
ever, it is not specific for clinical instability.61 Capsular
abrasion may be performed with a rasp. It is important to
perform the plication from inferior to superior along the

TABLE 1. Open Inferior Capsular Shift Versus Arthroscopic

Capsular Plication for Multidirectional Instability of the Shoulder
Arthroscopic Capsular
Open Inferior Capsular Shift Plication
Traditionally regarded as “gold Allows full evaluation of
standard” glenohumeral joint at time of
surgery
Lower rates of recurrent May treat concomitant
instability in some studies intracapsular abnormality at
compared with arthroscopic time of surgery
stabilization5,17
May be advantageous in revision May avoid postoperative
surgery or in patients with subscapularis deficiency
bone loss FIGURE 7. Illustration of arthroscopic capsular plication. Suture
No difference in complication Fewer postoperative anchors are used to perform the plication and reduce capsular
rates in some studies complications and stiffness volume. Anchors are first placed inferiorly, and then subsequent
compared with arthroscopic compared with open anchors are placed more superiorly. This pattern of anchor
stabilization56,58 stabilization59 placement, from inferior to superior, aids in visualization during
the arthroscopic procedure.

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Best and Tanaka
arthroscopic capsular plication with 3 sutures decreased capsular
volume by 22% compared with open capsular shift using the
method of Neer and Foster,5 which decreased capsular volume
by almost 50%.63 Another study evaluating the arthroscopic
technique showed that increasing the amount of arthroscopic
capsular plication sutures to 5 decreased capsular volume by
49% to 52%.64 Jacobson et al58 compared arthroscopic capsular
plication with open capsular shift for patients with MDI in a
systematic review of 7 studies with 219 shoulders. Both proce-
dures resulted in similar rates of recurrent instability, overall
complications, return to sport, postoperative range of motion,
and loss of shoulder external rotation. Importantly, the authors
noted that their review contained nearly 3 times as many patients
undergoing open versus arthroscopic stabilization, which may
have influenced their results. Another systematic review by
Longo et al56 analyzed 861 shoulders with MDI undergoing
open capsular shift, arthroscopic capsular plication, or non-
operative treatment. They found similar rates of redislocation,
postoperative loss of external rotation, return to sport, and
overall complications in the open and arthroscopic groups.
Chen et al59 conducted a meta-analysis to evaluate
arthroscopic and open stabilization in patients with MDI and
hypothesized that arthroscopic stabilization would be associated
with less postoperative stiffness and fewer complications than
open stabilization. They included patients with MDI and min-
imum 2-year follow-up for whom rehabilitation programs had
failed; patients who were able to perform voluntary dislocation
and who also had osseous defects were excluded. The authors
found no difference in the rates of recurrent instability or
reoperation between the 2 groups; however, they noted that
patients who underwent arthroscopic stabilization lost less range
of external motion than did patients who underwent open
surgery. The study had several weaknesses that may limit its
clinical use. Of the 36 studies included, 35 provided level-IV
evidence and only 1 provided level-II evidence. The authors
acknowledge that the lack of randomized controlled trials is a
major limitation in performing any comparison of these 2
procedures. Furthermore, there was heterogeneity in the
arthroscopic group with respect to surgical technique; some
patients were treated with sutures and some with suture anchors.
CONCLUSIONS
The diagnosis and treatment of patients with MDI presents
multiple challenges to the orthopedic surgeon. A thorough
patient history is necessary for evaluating traumatic injury or
generalized ligamentous laxity because these factors can influence
outcomes. Many physical examination and imaging findings can
be nonspecific and may provide only moderate diagnostic benefit.
Initial treatment involves a comprehensive physical therapy
program to strengthen the periscapular muscles and rotator cuff,
which can improve shoulder kinematics. Patients for whom
extensive nonoperative treatment has failed may benefit from
surgical stabilization. Open capsular shift and arthroscopic sta-
bilization have been compared in several large reviews and nei-
ther has shown clear superiority. Larger studies to address the
heterogeneous patient samples can help better determine out-
comes and dictate optimal treatments for MDI in the future.
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