The shoulder joint is one of the most mobile joints in the body, allowing for a wide range of movement. However, this mobility can come at the cost of stability. Some individuals, especially adolescents with naturally loose joints or genetic conditions like Ehlers-Danlos Syndrome (EDS), experience multidirectional instability (MDI) of the shoulder. This means the shoulder is prone to sliding partially or completely out of place in more than one direction.
When non-surgical treatments like physical therapy fail to control symptoms, open capsular shift surgery is often recommended to restore stability and function to the shoulder.
What Is Shoulder Multidirectional Instability?
Multidirectional instability occurs when the ligaments and capsule (a fibrous tissue envelope surrounding the joint) are too loose, allowing the shoulder to become unstable in multiple directions—usually downward (inferior), forward (anterior), and sometimes backward (posterior). For many young athletes or individuals with hyperlaxity (extremely flexible joints), this can cause pain, a sense of looseness, and repeated episodes of the shoulder slipping or dislocating.
Why Open Capsular Shift?
The open inferior capsular shift procedure is designed to tighten the overstretched capsule, thereby stabilizing the shoulder. While arthroscopic (minimally invasive) techniques are also available, open surgery may be preferred in certain cases—especially in patients with extreme laxity or genetic connective tissue disorders like EDS. These patients often require a more aggressive tightening of the capsule than can be achieved with arthroscopic methods.
Who Needs This Procedure?
This surgery is typically considered for:
- Adolescents or young adults with hypermobile shoulders
- Patients with Ehlers-Danlos Syndrome or other connective tissue disorders
- Individuals who have failed non-surgical treatment (at least 6 months of physical therapy)
- People with repeated shoulder subluxations or dislocations in more than one direction
The Surgical Technique
The procedure is performed under general anesthesia, typically with the patient sitting in a reclining (beach chair) position.
Step-by-Step Outline:
- Incision and Exposure: A small vertical incision is made along the front of the shoulder. The surgeon carefully separates the muscles (usually the deltoid and subscapularis) to reach the joint capsule.
- Capsular Opening: A “T-shaped” cut is made in the capsule to allow the surgeon to adjust the loose tissue.
- Capsule Tightening:
- The inferior (bottom) flap of the capsule is pulled up and stitched to the upper part of the capsule, eliminating excess looseness.
- The superior (top) flap is pulled downward and also stitched securely.
- This double-flap shift tightens the entire capsule, reducing joint volume and limiting unwanted motion.
- Closure: The capsule and muscles are repaired and the skin is closed in layers.
This method effectively “shrinks” the internal space of the shoulder joint, improving stability by limiting excessive movement.
Recovery and Rehabilitation
Recovery from open capsular shift is a structured process:
- First 4 weeks: The arm is kept in a sling. Only gentle pendulum exercises are allowed.
- Week 4 onwards: The sling is discontinued, and active range of motion exercises begin.
- Week 6: Strengthening exercises are introduced.
- Around 4 months: Return to sports or high-level activities may be permitted, depending on individual progress.
Rehabilitation focuses on strengthening the rotator cuff and shoulder blade muscles and improving joint proprioception (awareness of joint position).
What Results Can Patients Expect?
In a long-term study of adolescent patients with generalized hyperlaxity or EDS:
- 87% experienced improved pain and shoulder stability
- 64% returned to sports, with many resuming at or near their prior level
- 73% felt very satisfied with the outcome
Even in patients who reported some degree of recurring looseness, overall satisfaction remained high—suggesting that improved control and reduced pain made a meaningful difference in daily life.
Functional scores, like the ASES (American Shoulder and Elbow Surgeons) and QuickDASH (Disabilities of the Arm, Shoulder and Hand), showed substantial improvements. On average, patients scored 88/100 on the ASES scale at follow-up 7.5 years after surgery.
Risks and Considerations
Like any surgery, open capsular shift carries some risks. These include:
- Stiffness or limited motion, though loss of external rotation is typically minimal
- Recurrence of instability in a small percentage of patients
- Nerve injury or reflex sympathetic dystrophy (a rare pain condition), which are usually treatable
- Scarring from the open approach
Importantly, in this population of patients with generalized joint looseness, the recurrence of mild instability doesn’t necessarily mean failure. Many still report satisfaction and improved function.
How Does It Compare to Arthroscopic Surgery?
A systematic review comparing open capsular shift to arthroscopic plication found that:
- Both procedures are safe and effective
- No significant differences were found in long-term stability, return to sport, or complications
- Arthroscopic surgery has less scarring and avoids cutting through muscle, but may not reduce capsular volume as effectively as open surgery
- Open surgery may be preferred in patients with very loose joints or connective tissue disorders, where more substantial tightening is needed
Final Thoughts
Open capsular shift is a proven, time-tested surgical technique that restores stability to shoulders with multidirectional instability. For patients with hypermobility or genetic syndromes like EDS who don’t improve with physical therapy, this surgery can be life-changing—allowing them to return to normal function, reduce pain, and in many cases, return to sports.
As always, talk with your orthopedic surgeon about whether this procedure is right for you, and make sure to follow the rehabilitation plan closely for the best outcome.
Do you have more questions?
Q. What is a shoulder open capsular shift?
A. It is a surgical procedure used to tighten the shoulder joint capsule to reduce excessive looseness and instability.
Q. Why is a shoulder open capsular shift performed?
A. It is performed to treat shoulder instability, especially when the shoulder frequently dislocates or feels loose.
Q. Who might need a shoulder open capsular shift?
A. Patients with recurrent shoulder dislocations or instability that does not improve with non-surgical treatments.
Q. How is the procedure done?
A. The surgeon makes an incision to open the shoulder capsule and tightens it by overlapping and suturing the tissue to provide more stability.
Q. What are the expected benefits of a shoulder open capsular shift?
A. Improved shoulder stability and reduced risk of dislocations or subluxations.
Q. How long does recovery take after the surgery?
A. Recovery typically takes several months, including physical therapy for gradual return of motion and strength.
Q. What are the risks associated with the surgery?
A. Risks include infection, stiffness, nerve injury, and failure to fully resolve instability.
Q. Will physical therapy be required after surgery?
A. Yes, physical therapy is essential to regain shoulder strength and motion after the procedure.
Q. Can this surgery be done arthroscopically?
A. The open capsular shift is an open surgery, but similar tightening can sometimes be done with arthroscopic techniques depending on the case.
Q. What is the success rate of a shoulder open capsular shift?
A. It is generally successful in restoring stability for most patients with shoulder instability.
Q. How long will I be immobilized after surgery?
A. The shoulder is usually immobilized in a sling for several weeks before starting gentle movement exercises.
Q. What activities should be avoided after surgery initially?
A. Activities that stress or rotate the shoulder aggressively should be avoided during early recovery.
Q. When can I expect to return to sports or heavy activities?
A. Return to full sports or heavy activity may take 4 to 6 months depending on healing and physical therapy progress.
Q. What causes shoulder instability that requires this surgery?
A. Causes include injury, repetitive overuse, or congenital looseness of the shoulder capsule.
Q. How is shoulder instability diagnosed before surgery?
A. Diagnosis is made through physical examination, patient history, and imaging studies like MRI or X-rays.
Q. Is shoulder open capsular shift suitable for all types of shoulder instability?
A. It is mainly for patients with multidirectional instability or laxity not controlled by other means.
Q. What should I expect during the hospital stay?
A. The surgery is often outpatient, but some patients may stay overnight for monitoring.
Q. Will I have scars from the surgery?
A. Yes, as it is an open procedure, there will be a surgical scar on the shoulder.
Q. How is pain managed after the surgery?
A. Pain is managed with medications and ice therapy postoperatively.
Q. Are there alternatives to shoulder open capsular shift?
A. Alternatives include physical therapy, activity modification, or arthroscopic stabilization in some cases.
