New York State Medical Treatment Guidelines for
Shoulder Instability in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Shoulder Instability.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders. The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Shoulder Instability of Shoulder Injury

The glenohumeral joint subluxation (partial dislocating), dislocating (in an anterior, interior, posterior, or multidirectional position).

History and Mechanism of Injury for Shoulder Instability

Mechanism of Injury: Instability should become evident after a direct traumatic blow to the shoulder, or indirectly by falling on an extended arm, or when providing heavy traction to the arm, or it may also appear after a series of traumatic blows to the shoulder.

Work should aggravate or trigger symptoms, which are then initially relieved by relaxation. Other activities that aren’t necessarily work-related can make symptoms worse (e.g., driving a car).

History may include:

  • A feeling of slipping in the arm;
  • Severe discomfort that prevents the arm from being moved;
  • Outward rotation and abduction provide the impression that the shoulder might “pull out”; or
  • Weakness in the shoulders.

Age of onset of instability is crucial to the history of subacute and/or chronic instabilities. The older age group (those over 30) tends not to re-dislocate. Treatment strategies should be more vigorous for younger age groups.

Patients with a history of voluntary subluxation or dislocation should not receive any harsh therapy. These patients could require a mental health assessment.

Physical Findings of Shoulder Instability

Loss of the usual shoulder shape, a fullness in the axilla, pain over the shoulder with motion, and frequently the patient holding the extremity in a very still position are all indicators of anterior dislocation.

In most cases, posteriorly directed stresses to the humeral head cause posterior dislocations after a direct fall on the shoulder or outstretched arm. These individuals exhibit a shoulder inability to externally rotate.

Axillary nerve injuries are most frequently discovered during a neurologic examination, however musculocutaneous nerve injuries can also occur.

For those with anterior instability, positioning in abduction and external rotation will hurt. Those with posterior instability will experience pain from direct posterior tension in the supine position. When there is inferior instability, longitudinal traction will result in a “sulcus sign” (a huge dimple on the lateral side of the shoulder).

Laboratory Tests

Laboratory Tests of Shoulder Instability

Laboratory Tests of Shoulder Instability are recommended when a systemic illness or disease is suspected in a subset of patients.

Testing Procedures

Testing Procedures of Shoulder Instability X-Ray

Testing Procedures of Shoulder Instability X-Ray is recommended clinically appropriate in a subset of patients.

Indications: AP, axillary, lateral in the plane of the scapula, and potentially the West Point view on plain x-rays to rule out bone deficit on the glenoid. The bigger Hill-Sachs lesion of the humeral head can be seen in the axillary view.

MRI/CT of Shoulder Instability

Indications: After four to eight weeks of therapy, an MRI, CT-assisted arthrogram, or MRI-assisted arthrogram may be ordered for lateral detachment in more challenging diagnostic cases with mild history and physical symptoms suggesting instability. (This is only attempted if more conventional treatments have failed.)

Non-Operative Treatment Procedures

  • First-Time Acute Severe Bony Involvement: :
    Therapeutic Procedures:
    • Stabilisation
    • Physical Therapy
    • Surface Cold and Heat
    • Ultrasound
    • TENS is not advised.
    • Changes to Workstation and Occupation
    • Prior to receiving a doctor’s approval for heavier activities, one may not return to work performing overhead tasks or lifting with the injured arm.
  • Additional therapies may include:
    • Physical Medicine and Rehabilitation
      • Teaching therapeutic exercise and appropriate work methods
      • Occupational Therapy Methods
    •  Medications
      • Analgesics
      • Anti-inflammatories
  • Biofeedback
    Biofeedback is not recommended for first, severe, acute bone involvement.Acute or persistent dislocations with significant fracture fragments that cause instability:
    • If necessary, try to immobilise the patient. position; otherwise, have surgery to fix.
    • The time it takes for the fracture to heal may directly affect when you can go back to work.
    • Subacute and/or chronic instability:
    • Acute dislocation should be managed similarly to provocative dislocation at first.
    • Consider surgical correction if immediate treatment is ineffective and instability is still present.

Operative Procedures of Shoulder Instability is Recommended – clinically appropriate in a subset of patients.

Determine whether a bone lesion, labral separation, or multidirectional instability is to blame for the instability, and then carry out the following steps:

  • Block transfer of bone;
  • Capsular constriction; or
  • Correction of a bankart lesion.

Post-Operative Procedures of Shoulder Instability

Depending on the patient’s age, the arm is immobilised in a sling for one to twelve weeks after the injury. While wearing a sling, the patient is shown isometric exercises for the deltoid, internal and external rotators.

A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be a part of post-operative procedures. The patient will require three to six weeks of immobilisation following surgery, depending on the procedure.

Progressive therapy with consultation from an occupational and/or physical therapist should start with therapeutic exercise, physical therapy, and rehabilitation as soon as it is safe to do so without endangering the repair. The patient could return to work during this time if:

  • Drugs that could increase the risk of damage are no longer prescribed or used; and
  • The patient is now authorised to engage in the specific occupational activities by the treating physician.

What our office can do if you have Shoulder Instability

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.


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Dr. Nakul Karkare

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.