Chronic shoulder instability – Non-surgical approach to dislocation, subluxation and shoulder instability
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Chronic shoulder instability – Non-surgical approach to dislocation, subluxation and shoulder instability
If you are reading this article, you are probably wrestling with a decision to have a surgery. While the surgical option is something that is not first choice in your mind, you may be thinking anything has got to be better than my shoulder popping out all the time.
So you went to the surgeons office. There you may have been told that the conservative care, non-surgical option of exercise and physical therapy has at best a 50% chance of helping you and this is a long-term treatment set. If you are active in sports or do physically demanding work, long-term PT may not be the best option for you. On the other hand, surgery may not be the answer you are looking for either. Six month recovery time, possibility of the need for revision or secondary surgery, muscle atrophy on the surgical side, all have their concerns to you. If you are self-employed, keeping your arm in a sling 4 – 8 weeks in not an option for you, nor is three months before you can swing a hammer. But anything has to be better than a chronically dislocating shoulder, even surgery. There may be an option for you.
In this article we will explore non-surgical tissue building injections in the form of Prolotherapy combined with Platelet Rich Plasma Therapy as well as exploring different treatment options. In discussing the surgical options, we will rely on the surgeons to explain procedures and success rates.
Shoulder dislocations or subluxations management that typically does NOT provide long-term relief or shoulder stability
There is a new wave of research bringing attention to possible risk and complication in surgeries performed for chronic shoulder dislocations.
If you look at your guidelines sheet that you may have been given at your orthopedist center or physical therapists’s office of how to manage your shoulder after it fell out of the socket, you start to understand that nothing in the guidelines suggests any long-term resolution of your problem possibly with the exception of how to prevent this from happening again.
Is this the information you are reading or getting? Does it make sense to you?
If you feel that your shoulder is out of place, and you went to the doctors, or this is happening so often that most times you do not go to the doctors unless the pain is severe and you have more numbness than usual. You know that you will go through the “my shoulder is out of place protocol of treatments.”
- ICE – carefully, so you do not give yourself ICE BURNS, apply ice for 20 minutes at a time for every 3 to 4 hours until the pain goes away.
- Ibuprofen – take anti-inflammatory medicine, as directed. We have written extensively on the problems of taking Nonsteroidal anti-inflammatory medicines (NSAIDs) may cause. For many patients prolonged use of NSAIDs can make your problem worse.
- Avoid activities that cause pain – If it hurts to move your shoulder a certain way don’t move your shoulder that way – avoid activities that cause pain.
Once you are through the immediate reaction to your shoulder popping out of place, then the long-term answers are suggested:
- The best treatment for the loose, wobbly, unstable shoulder prone to subluxation and dislocation is shoulder strengthening exercises. If exercises does not work, then surgery may be needed.
At the orthopedist or the physical therapists, there is brief talk about repairing the shoulder ligaments that cause this problem in your shoulder. Yet they will acknowledge that the ligaments are the big problem. Unfortunately surgery or physical therapy does not have a good remedy for this problem. We believe we do, Prolotherapy injections.
Let’s get to the research and clinical observations on treatments
The main cause of chronic shoulder dislocations are chronic shoulder dislocations. This is not a play on words, treat and cure the chronic shoulder dislocation and you prevent future dislocations.
Your shoulder has been dislocating. These are questions we may ask new patients about their previous visits to the orthopedist to help us and them understand what is going on in his/her shoulder:
Was your past dislocation(s) a shoulder subluxation?
In a shoulder dislocation, the ball of the shoulder pops completely out of the shoulder socket. In a shoulder subluxation, the ball of the shoulder does not come completely out of the shoulder joint capsule. It can be also called a partial shoulder dislocation.
Are your dislocations the result of a traumatic injury?
Patients need to be made aware that in first time dislocations there is usually enough trauma and significant soft tissue damage that future and chronic instability and dislocations and a long medical history of shoulder problems will occur. This is because the shoulder ligaments, tendons and cartilage are usually significantly damaged in traumatic shoulder dislocation.
Are your dislocations the result of overuse, repetitive strain injuries?
For some people chronic shoulder dislocation and subluxation just happen without there being an initial traumatic injury. These are typical laborers with physically demanding jobs like landscapers, machinery operators, firefighters and construction workers to name but a few. It can also happen in musicians, especially drummers. Many of the patients we see are athletes or people who work out a lot. Shoulder wear and tear instability that can lead to chronic dislocations are typically seen in volleyball players, tennis players, swimmers, workout enthusiasts and weight trainers.
Are your dislocations the result of past arthroscopic surgeries to fix your shoulder?
For someone who has not had a surgery for their shoulder instability, this last question will certainly cause concern? How does the surgery that was suppose to fix the problem, make the problem worse?
Chronic shoulder instability caused by anterior shoulder dislocation treatment
This is how treatment of dislocations can cause future dislocations. Many readers will probably recognize their own story here:
Initial traumatic shoulder dislocation are almost always seen in an emergency room because of the almost immediate recognition by sight of some type of clear and gross anatomical defect. This portion of our article focuses on the aftermath and treatment recommendations for someone treated in the emergency room or urgent care center after they had their first dislocation.
Anterior simply means the front. Anterior shoulder dislocation occurs in approximately 95 percent of all shoulder dislocation cases. In this dislocation, the anterior static shoulder stabilizers the soft tissue and muscles of the shoulder are injured and sometimes torn away from the bone. Your doctor may have talked to you about these structures.
They are the:
- inferior glenohumeral ligament process, three ligaments who’s main job is to prevent Anterior shoulder dislocation
- The shoulder or glenoid labrum
- The shoulder or glenohumeral capsular (inside the joint) ligaments
- The rotator cuff complex which hold the scapular muscles.
- In some cases a chip of bone or a gouge of the posterolateral (the back and side) of the humeral head (ball) occurs as the soft head of the shoulder crashes into the shoulder socket.
- This impact may also cause a Bankart lesion. This is damage to the shoulder labrum which causing problems of future dislocations.
- Exercise and rehabilitation usually follow a period of immobilization after an anterior dislocation and, if this fails to restore strength and stability to the shoulder, surgery is usually recommended.
- In one definitive 10-year prospective study published in The Journal of bone and joint surgery, it was found that half of those treated with immobilization had recurrent dislocations and, of these, half had surgical treatment. This study included 247 patients with first-time dislocations.(1)
- It demonstrates an alarming number of athletes who are unable to continue their sport without further dislocation or the need for surgery. This also does not address the percentage of athletes who do have surgery and return to their sport. Please see Doctors question effectiveness of glenoid labrum surgery look for alternatives to surgery.
Chronic shoulder instability caused by ALPSA Lesions – A Type of Anterior Shoulder Dislocation
Recurrent anterior shoulder dislocation and instability is sometimes associated with an ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion or labral tear.
The difference between a Bankart lesion and ALPSA lesion is that both have labrum displacement, in the ALPSA lesion the anterior scapular periosteum (the membrane covering the bones which contain fibroblasts and osteoblasts – healing and building cells of cartilage and bone) tears off as well allowing the labroligamentous (the labrum, ligaments and connective tissue) structures to also be displaced.
People with ALPSA tears tend to have a high number of recurrent dislocations, because of the instability and weakness of the anterior inferior glenohumeral ligament. ALPSA tears are also associated with larger sized Hill-Sachs lesions.
Those with ALPSA tears not only suffer from recurrent dislocations, but high surgical failure rates.
Arthroscopic ALPSA repair failure is quite high compared to repair of Bankart lesions. In a study comparing ALPSA lesions with Bankart lesions and postoperative recurrence rates after arthroscopic capsulolabral repair- the ALPSA group had more than double the recurrence rate. In addition, according to a study from researchers in South Korea, the ALPSA group presented significant postoperative loss of external rotation after capsulolabral repair.(2) The obvious choice for ALPSA lesion treatment and repair of the tears is Prolotherapy rather than surgery.
While surgery can treat the anterior dislocation effectively in certain types of lesions, post-operative pain, lengthy rehabilitation, and a chance of not returning to a previous level of activity, work or sports participation are reasons to consider Prolotherapy as an alternative to standard treatment approaches.
Option: Prolotherapy injections
Prolotherapy injections directed at the anterior shoulder capsule and the insertions of the middle and inferior glenohumeral ligaments will increase joint strength and allow pain-free motion through the wide range of movement in overhead throwing sports.
Once pain has been reduced, a gradual return to one’s previous level of activity can be expected. Substantial improvement may be noted in as few as one to two Prolotherapy treatments, and the scar tissue from surgery can be avoided. There are other advantages to Prolotherapy over surgery for shoulder instability.
- Prolotherapy is the only treatment that is designed to help repair the painful area. It involves no cutting, suturing, sewing, or stapling. The patient is also encouraged to exercise while undergoing Prolotherapy, whereas after surgery there are careful limits to activity.
Chronic shoulder instability caused by Acromioclavicular joint instability, osteoarthritis, and chronic dislocation
Acromioclavicular joint osteoarthritis is a degenerative disease where the articular cartilage lining of the Acromioclavicular joint bones wears out over time. In this condition, there is shoulder instability causing grinding and pain.
The shoulder joint is a juncture of three bones, the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The scapula and the clavicle meet to form the top or roof of the shoulder and is called the acromion. The joint where the acromion and the clavicle join is the Acromioclavicular joint or AC joint. Acromioclavicular (AC) joint osteoarthritis can develop as a result of chronic shoulder dislocation or normal wear and tear in the aging patient with heavy shoulder rotational loads in sports or work.
The acromioclavicular joint contribution to your shoulder’s range of motion is to get your arm above your head. It also distributes the weight of the arm to the rest of the body. It is therefore not surprising that weight lifters and wrestlers who frequently lift large amounts of weights have significant incidences of AC joint sprains.
Tremendous forces not only injure the AC joint, but are transmitted down the clavicle to the sternoclavicular (SC) joint, which can also be sprained or dislocated. There is a direct correlation between the amount of weight lifted and the weight that is transmitted throughout the AC and SC joints. The greater the weight lifted, the greater the impact throughout the AC joint and, ultimately, the SC joint.
During the early stages, AC joint arthrosis usually manifests itself with tenderness and pain in the front of the shoulder around the joint. The pain gets worse when the arm is extended across the chest as this motion compresses the joint, or when lifting. A vague pain may be felt in the shoulder, the neck and the front of the chest. The affected joint may also be disproportionate to the uninjured joint, and may snap or click when used.
Typically, surgery is not required in acromioclavicular joint dislocation, however, there is a debate as to the best method of treatment.
Doctors at the University of Michigan describe the problem in their review published in Current reviews in musculoskeletal medicine:
“In high-grade injuries, acromioclavicular joint reconstruction procedures may be indicated for functional improvement. There is currently no gold standard for the surgical management of these injuries.
Multiple reconstructive options exist, including coracoclavicular screws, hook plates, endobutton coracoclavicular fixation, and anatomic ligament reconstruction with tendon grafts”(3)
The acromioclavicular (AC) joint is one of the unsung heroes of the body. It is formed by the distal clavicle and medial facet of the acromion. (The end of the collar bone and that portion of the shoulder blade that meets to form the point of the shoulder). Interposed in the joint is a fibrocartilaginous disc, and the joint is covered by a capsule.
The acromioclavicular joint becomes injured or dislocated when a large force is applied to the acromion when the arm is in an adducted position, for example, during a wrestling takedown or a tackle in football.
The acromioclavicular joint is stabilized by three ligaments:
- Acromioclavicular ligament,
- Inferior Acromioclavicular Ligament
- Superior Acromioclavicular Ligament.
- A fourth ligament – the Coracoacromial Ligament is a strong triangular band which serves to prevent the upward dislocation of the shoulder (glenohumeral) joint.
Chronic shoulder instability caused by Acromioclavicular joint dislocation treatments
Treating the patient with chronic shoulder dislocation with the “gold” standard of treatments, physical therapy, activity modification, anti-inflammatory medications or cortisone shots has not shown successful. Furthermore, the surgery following the failed conservative treatments fairs no better. This is pointed out by Finnish researchers in the journal Springerplus.
- “Conservative treatment of acromioclavicular joint dislocation is not always successful. A consequence of persistent cromioclavicular joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant cromioclavicular joint instability and impaired shoulder function.”(4)
- In this cited research from doctors at the University of Rome examined 39 patients who underwent coracoclavicular (CC) ligament reconstruction. After surgery, almost half the AC joints failed to stabilize. In chronic and acute cases of shoulder dislocation management remains controversial, and the debate about whether patients should be conservatively or surgically treated continues.(5)
- In a seeming contradiction, a study from the University of Missouri says the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency.(6)
Lastly, the more surgery – the more bone loss
- The more shoulder dislocations you have, the more bone breakdown and the more difficult the surgery, because now bone repair is involved.(7)
Conservative management and surgery for acromioclavicular joint osteoarthritis
- The usual treatment for this injury is a figure-eight splint to keep the joint immobile while the healing process occurs. While the initial immobilization may relieve pain, weakening of the ligaments will occur if the immobilization continues indefinitely.
- Physical therapy and an exercise program may restore strength and function to the shoulder, but the injured ligaments may continue to grind, pop, click and cause pain, especially with overhead activities and when reaching across the chest.
Because these activities put a strain on the ligaments, the surrounding muscles may go into spasm and become chronically painful, inhibiting the ability of the patient, often an athlete, from using the shoulder normally.
Another standard practice is to inject steroids into the shoulder or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.
This is often the case in patients who have had numerous cortisone shots and are eventually recommended to shoulder replacement surgery. However, in our experience, this type of surgery is avoidable. For patients who have already been through any type of shoulder surgery and still having pain or instability symptoms, a consultation outside of a surgeon’s office needs to be considered, particularly with a Prolotherapy specialist to determine instability from ligament failure or laxity.
Doctors need to pay attention to the shoulder ligaments
Doctors at the Autonomous University of Barcelona writing in the Journal of Orthopaedics and Traumatology examined the use of surgery for acromioclavicular joint instability. What they found was a very strong need to pay attention to the shoulder ligaments.
“Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts, (for ligament reconstruction).
Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential.”(7)
Over 160 different surgical techniques described in the literature for acromioclavicular joint injury. Do any of them work? Ask the surgeons.
In the May 2019 edition of the medical journal Arthroscopy (8) researchers from the University Hospital Regensburg and Technical University of Munich in Germany made these observations regarding the confusion that surgery brings to acute acromioclavicular joint injury and the importance of treating and repairing ligaments.
“Over the past decade, the interest in acromioclavicular (AC) joint research has experienced a revolutionary increase. Biomechanical and anatomic studies have been carried out to investigate and obtain a better understanding of the function of this joint. The reason for this huge investigational effort is the fact that we do not have any gold standard for the treatment, diagnosis, or follow-up of patients with acute or chronic AC joint injuries.
“This is reflected by the huge number of over 160 different surgical techniques described in the literature. . . Because of this wide variety, it is hard and nearly impossible to compare clinical data.
Within the past 5 years, we have focused not only on the vertical instability but also, more and more, on the horizontal instability and tried to understand the rotational component of this joint with the importance of scapulothoracic motion (very simply the ability to raise your shoulders as in shrugging your shoulders or the ability to reach out with your arm and pull something back or away from you).”
The researchers of this editorial concluded that: “we have changed our practice in the past few years in line with the newly derived data, by addressing the coracoclavicular ligaments as well as the AC capsule to restore horizontal and vertical stability but also allow for physiological rotation and movement.”
Simply, whatever repair you decide on, it is best to try to achieve nature’s original design. Something that many surgeries cannot do.
Prolotherapy treatment pays attention to shoulder ligaments and restores shoulder stability
Comprehensive H3 Prolotherapy and a rehabilitation program can strengthen the ligaments and dynamic shoulder stabilizers (rotator cuff muscles). Chronic pain is most commonly due to tendon and ligament weakness or cartilage deterioration, as is the case in acromioclavicular joint syndrome.
Prolotherapy is a regenerative injection treatment, which is what degenerated structures need. In our office, the shoulder is one of the most common areas we treat.
In addition, we have published scientific articles and studies on our results, this includes shoulder pain, glenoid labrum tears, arthritis and more.
RESEARCH: A Journal of Ultrasound in Medicine (9)
The aim of this study was to evaluate the therapeutic efficacy of ultrasound-guided prolotherapy in the treatment of acromial (inflammation of the enthesis) enthesopathy and acromioclavicular joint degeneration.
- Thirty-one patients with chronic moderate-to-severe shoulder pain
- Ultrasound-guided prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule.
- Prolotherapy was given in 2 sessions separated by a 1-month interval.
- Average follow up 62 days
- Conclusion: Ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint damage.
Comparisons in shoulder instability treatment | Physical therapy and surgery
Research hospital doctors in Spain publishing in The Open Orthopaedics Journal, write of the complexities in treating a patient who has multidirectional instability of the shoulder. (10)
Complexities include hyperlaxity (very to extremely loose shoulder), anatomical problems, muscle imbalance and possible traumatic incidents in each patient.
First treatment: Physical therapy
- “Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder.” However, they go on, “significant traumatic incident (an injury), anatomic alterations (degenerative – osteoarthritic or genetic problems), and psychological problems (depression and anxiety, et al), are widely considered to be poor prognostic factors for conservative treatment.”
Next treatment after three months: Surgery
- Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.
- When conservative treatment fails, surgical intervention is warranted.
- Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes.
A discussion of the surgeries are included here in the second paper we are looking at:
In the August 2017 edition of The Open Orthopaedics Journal, researchers from Spain published these observations:
- Due to the complex anatomy of the shoulder and the large range of movement of this joint, a wide variety of anatomic injuries and conditions can lead to shoulder instability, especially present in the young population.
- Recognizing and treating all of them including Bankart repair (see below) and capsule-labral plicatures (this is a condition where the soft tissue that lines and holds the shoulder in place becomes excessively loose).
- SLAP repair, circumferential approach to pan-labral lesions (a 360 degree tear), rotator interval closure (in simple terms, suturing to hold the rotator cuff together), rotator cuff injuries and HAGL lesion repair (humeral avulsion of the glenohumeral ligament tears) is crucial to achieve the goal of a stable, full range of movement and not painful joint. (If they work)
While looking at all these possible candidates for shoulder instability, the Spanish team wrote of the difficulties in making these surgeries work.
- The glenohumeral joint is a ball-and-socket joint that is inherently unstable and thus, susceptible to dislocation. The traditional and most common anatomic finding is the Bankart lesion (anterior-inferior capsule labral complex avulsion), but there is a wide variety of anatomic alterations that can cause shoulder instability or may be present as a concomitant injury or in combination, including bone loss (glenoid or humeral head), complex capsule-labral tears, rotator cuff tears, Kim´s lesions (injuries to the posterior-inferior labrum) and rotator interval pathology.
Comment: The warning is that all these things may be happening at once. Below the research finishes with the recognition that if you fix one thing, you may make one of the other problems worse.
- In The Open Orthopaedics Journal, (11) surgeons wrote: “Physicians must be familiarized with all the lesions involved in shoulder instability, and should be able to recognize and subsequently treat them to achieve the goal of a stable non-painful shoulder. Unrecognized or not treated lesions may result in recurrence of instability episodes and pain while overuse of some of the techniques previously described can lead to stiffness, thus the importance of an accurate diagnosis and treatment when facing a shoulder instability.”
Caring Medical Research
In published research from Caring Medical doctors, The optimal long-term, symptomatic therapy for chronic shoulder pain has not been established. Accordingly, we investigated the outcomes of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved shoulder pain at a charity clinic in rural Illinois.
- We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy.
- An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation). Prolotherapy, PRP, and Stem Cell Therapy have been used successfully in patients seeking alternatives to rotator cuff surgery. as well as patients with SLAP Lesions and Glenoid Labral Tears.
If you have a question about shoulder instability treatment, you can get help and information from our Caring Medical staff.
1. Hovelius, L. Anterior dislocations of the shoulder in teen-agers and young adults. Journal of Bone and Joint SurgeryùAmerican. 1987; 69 (3):393-9) [Google Scholar]
2. Lee BG, Cho NS, Rhee YG. Anterior labroligamentous periosteal sleeve avulsion lesion in arthroscopic capsulolabral repair for anterior shoulder instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2011; 19(9): 1563-1569. [Google Scholar]
3. Lee S, Bedi A. Shoulder acromioclavicular joint reconstruction options and outcomes. Curr Rev Musculoskelet Med. 2016 Dec;9(4):368-377. [Google Scholar]
4. Virtanen KJ, Savolainen V, Tulikoura I, et al. Surgical treatment of chronic acromioclavicular joint dislocation with autogenous tendon grafts. Springerplus. 2014 Aug 10;3:420. [Google Scholar]
5. De Carli A, Lanzetti R, Ciompi A, Lupariello D, Rota P, Ferretti A. Acromioclavicular third degree dislocation: surgical treatment in acute cases. J Orthop Surg Res. 2015 Jan 28;10(1):13. [Google Scholar]
6. Ma R, Smith PA, Smith MJ, Sherman SL, Flood D, Li X. Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction. Curr Rev Musculoskelet Med. 2015 Feb 8. [Google Scholar]
7. Denard PJ, Dai X, Burkhart SS. Increasing preoperative dislocations and total time of dislocation affect surgical management of anterior shoulder instability. Int J Shoulder Surg. 2015 Jan-Mar;9(1):1-5. [Google Scholar]
7. Cisneros LN, Reiriz JS, Management of chronic unstable acromioclavicular joint injuries. J Orthop Traumatol. 2017 Mar 8. doi: 10.1007/s10195-017-0452-0. [Google Scholar]
8 Voss A, Imhoff AB. Editorial Commentary: Why We Have To Respect The Anatomy In Acromioclavicular Joint Surgery And Why Clinical Shoulder Scores Might Not Give Us The Information We Need!. [Google Scholar]
9 Hsieh PC, Chiou HJ, Wang HK, Lai YC, Lin YH. Ultrasound‐Guided Prolotherapy for Acromial Enthesopathy and Acromioclavicular Joint Arthropathy: A Single‐Arm Prospective Study. Journal of Ultrasound in Medicine. 2019 Mar;38(3):605-12. [Google Scholar]
10 Ibán MA, Heredia JD, Navlet MG, Serrano F, Oliete MS. Suppl-6, M2: Multidirectional Shoulder Instability: Treatment. The Open Orthopaedics Journal. 2017;11:812. [Google Scholar]
11 Marco SM, Lafuente JL, Ibán MA, Heredia JD. Suppl-6, M16: Controversies In The Surgical Management Of Shoulder Instability: Associated Soft Tissue Procedures. The Open Orthopaedics Journal. 2017;11:989. [Google Scholar]