Functional outcome and quality of life after rehabilitation for voluntary posterior shoulder dislocation: a prospective blinded cohort study

  • Giovanni Merolla
  • Elisa De Santis
  • Ann M. J. Cools
  • Giuseppe Porcellini
Original Article



Voluntary posterior instability of the shoulder is a rare condition in which the patient is able to cause a subluxation by voluntary muscle activation. A shoulder rehabilitation program aimed to correct abnormal muscle patterns and restore correct scapular motion may provide good results and improve the quality of life of these patients.


Fifteen subjects (six males, nine females; mean age 19 years) underwent physical examination and clinical tests [Disability of the Arm, Shoulder and Hand (DASH) score, Shoulder Pain and Disability Index (SPADI), and modified Rowe score] and compiled the patient global assessment (PGA). Articular or rotator cuff lesions were excluded by X-rays and MRI. The rehabilitation program included three phases: (1) assessment and correction of abnormal muscle patterns, (2) restoration of correct scapular motion, and (3) strengthening of scapular and posterior glenohumeral muscles. Follow-up was at 3, 6, 12, and 24 months.


DASH and SPADI scores improved significantly at 3 (p < 0.01), 6 (p < 0.009), 12 (p < 0.001), and 24 months (p < 0.001). The Rowe score was fair at 3 months and good at 6, 12, and 24 months. Active flexion, abduction, and external rotation increased at all follow-up points (p < 0.01), whereas internal rotation remained unchanged (p > 0.05). PGA values were high. Compliance was good without serious adverse events reported during the treatment. A correlation was found between age and DASH changes (Spearman’s ρ −0.56; p = 0.0455).


Our findings stress the value of a rehabilitation program that teaches subjects with voluntary instability how to correct abnormal muscle patterns to restore scapular motion, and the importance of adopting home rehabilitation exercises as a part of the normal lifestyle.


Shoulder Voluntary instability Rehabilitation Scapula 



We are grateful to Dr. Silvia Modena for the language revision ( We are also grateful to Dr. Elisabetta Fabbri (U.O. Ricerca ed Innovazione, AUSL della Romagna Ambito Territoriale di Rimini, Italy) for the precious professional support in the statistical analysis.

Conflict of interest



  1. 1.
    Genovesi A (1962) Contributo alla conoscenza della lussazione volontaria della spalla. Arch Putt 17:268–275Google Scholar
  2. 2.
    Rowe CR, Pierce DS, Clark IC (1973) Voluntary dislocation of the shoulder. J Bone Joint Surg 55:445–460PubMedGoogle Scholar
  3. 3.
    Schwartz E, Warren RF, O’Brien SI, Fronek I (1987) Posterior shoulder instability. Orthop clin N Am 18:409–419Google Scholar
  4. 4.
    Alexander CM (2007) Altered control of the trapezius muscle in subjects with non-traumatic shoulder instability. Clin Neurophysiol 118:2664–2671PubMedCrossRefGoogle Scholar
  5. 5.
    Pollock RG, Bigliani LU (1993) Recurrent posterior shoulder instability. Diagn Treat Clin Orthop 291:85–96Google Scholar
  6. 6.
    Fuchs B, Jost B, Gerber C (2000) Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 82:16–25PubMedGoogle Scholar
  7. 7.
    Merolla G, De Santis E, Sperling JW, Campi F, Paladini P, Porcellini G (2010) Infraspinatus strength assessment before and after scapular muscles rehabilitation in professional volleyball players with scapular dyskinesis. J Shoulder Elbow Surg 19:1256–1264PubMedCrossRefGoogle Scholar
  8. 8.
    Huber H, Gerber C (1994) Voluntary subluxation of the shoulder in children: a long-term follow-up study of 36 shoulders. J Bone Joint Surg Br 76:118–122PubMedGoogle Scholar
  9. 9.
    Keiser RP, Wilson CL (1961) Bilateral recurrent dislocation of the shoulder (atraumatic) in a thirteen-year-old girl. Report of an unusual case. J Bone Joint Surg 43:553–554PubMedGoogle Scholar
  10. 10.
    Devgan LL, Gill HS, Faustin C, Park HB, McFarland EG (2006) Posterior dislocation in a voluntary subluxator: a case report. Med Sci Sports Exerc 38:613–617PubMedCrossRefGoogle Scholar
  11. 11.
    Neer CS, Foster CR (1980) Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am 62A:897–908Google Scholar
  12. 12.
    Gagey J, Gagey N (2001) The hyperabduction test. J Bone Joint Surg Br 83-B:69–74CrossRefGoogle Scholar
  13. 13.
    Silliman JF, Hawkins RJ (1993) Classification and physical diagnosis of instability of the shoulder. Clin Orthop Relat Res 291:7–19PubMedGoogle Scholar
  14. 14.
    Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J (2002) Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg 11:550–556PubMedCrossRefGoogle Scholar
  15. 15.
    Jaggi A, Lambert S (2010) Rehabilitation for shoulder instability. Br J Sports Med 44:333–340PubMedCrossRefGoogle Scholar
  16. 16.
    Jaggi A, Noorani A, Malone A, Cowan J, Lambert S, Bayley I (2012) Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg 6:101–117PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Morris AD, Kemp GJ, Frostick SP (2004) Shoulder electromyography in multidirectional instability. J Shoulder Elbow Surg 13:24–29PubMedCrossRefGoogle Scholar
  18. 18.
    Barden JM, Balyk R, Raso VJ, Moreau M, Bagnali K (2005) Atypical shoulder muscle activation in multidirectional instability. Clin Neurophysiol 116:1846–1857PubMedCrossRefGoogle Scholar
  19. 19.
    Takwale VJ, Calvert P, Rattue H (2000) Involuntary positional instability of the shoulder in adolescents and young adults. Is there any benefit from treatment? J Bone Joint Surg Br 82:719–723PubMedCrossRefGoogle Scholar
  20. 20.
    Holmgren T, Bjornsson Hallgren H, Oberg B, Adolfsson L, Johansson K (2012) Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomized controlled study. BMJ 344:e787PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Cools AM, Dewitte V, Lanszweert F et al (2007) Rehabilitation of scapular muscle balance: which exercise to prescribe? Am J Sports Med 35:1744–1751PubMedCrossRefGoogle Scholar
  22. 22.
    Wilk KE, Macrina LC, Reinold MM (2006) Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther 1:16–31PubMedCentralPubMedGoogle Scholar
  23. 23.
    Reinold MM, Escamilla RF, Wilk KE (2009) Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 39:105–117PubMedCrossRefGoogle Scholar
  24. 24.
    Merolla G, De Santis E, Campi F, Paladini P, Porcellini G (2010) Supraspinatus and infraspinatus weakness in overhead athletes with scapular dyskinesis: strength assessment before and after restoration of scapular musculature balance. Musculoskelet Surg 94:119–125PubMedCrossRefGoogle Scholar
  25. 25.
    Hudak PL, Amadio PC, Bombardier C (1996) Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The upper extremity collaborative group (UECG). Am J Ind Med 29:602–608PubMedCrossRefGoogle Scholar
  26. 26.
    Roach KE, Budiman-Mak E, Songsiridej N, Lertrantanakul Y (1991) Development of a shoulder and pain disability index. Arthritis Care Res 4:143–149PubMedCrossRefGoogle Scholar
  27. 27.
    Rowe CR (1998) Evaluation of the shoulder. In: The shoulder. Churchill Livingstone, New York, NY, pp 631–617Google Scholar
  28. 28.
    Rothman M, Vallow S, Damaraju CV, Hewitt DJ (2009) Using the patient global assessment of the method of pain control to assess new analgesic modalities in clinical trials. Curr Med Res Opin 25:1433–1443PubMedCrossRefGoogle Scholar
  29. 29.
    Padua R, Padua L, Ceccarelli E et al (2003) Italian version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Cross-cultural adaptation and validation. J Hand Surg Br 28:179–186PubMedCrossRefGoogle Scholar
  30. 30.
    Marchese C, Cristalli G, Pichi B et al (2012) Italian cross-cultural adaptation and validation of three different scales for the evaluation of shoulder pain and dysfunction after neck dissection: University of California, Los Angeles (UCLA) shoulder scale, shoulder pain and siability index (SPADI) and simple shoulder test (SST). Acta Othorhinolaryngol Ital 32:12–17Google Scholar
  31. 31.
    Jensen KU, Bongaerts G, Bruhn R, Schneider S (2009) Not all Rowe score are the same! which Rowe score do you use? J Shoulder Elbow Surg 18:511–514PubMedCrossRefGoogle Scholar
  32. 32.
    Skare O, Schroder CP, Mowinckel P, Reikeras O, Brox JI (2011) Reliability, agreement and validity of the 1988 version of Rowe score. J Shoulder Elbow Surg 20:1041–1049PubMedCrossRefGoogle Scholar
  33. 33.
    Maruyama K, Sano S, Saito K, Yamaguchi Y (1995) Trauma-instability-voluntarism classification for glenohumeral instability. J Shoulder Elbow Surg 4:194–198PubMedCrossRefGoogle Scholar
  34. 34.
    Kuroda S, Sumiyoshi T, Moriishi J, Maruta K, Ishige N (2001) The natural course of atraumatic shoulder instability. J Shoulder Elbow Surg 10:100–104PubMedCrossRefGoogle Scholar
  35. 35.
    Young MS (1994) Electromyographic biofeedback use in the treatment of voluntary posterior dislocation of the shoulder: a case study. J Orthop Sports Phys Ther 20:171–175PubMedCrossRefGoogle Scholar
  36. 36.
    Greiwe RM, Galano G, Grantham J, Ahmad CS (2012) Arthroscopic stabilization for voluntary shoulder instability. J Pediatr Orthop 32:781–786PubMedCrossRefGoogle Scholar
  37. 37.
    Bahu MJ, Trentacosta N, Vorys GC, Covey AS, Ahmad CS (2008) Multidirectional instability: evaluation and treatment options. Clin Sports Med 27:671–689PubMedCrossRefGoogle Scholar
  38. 38.
    Carter C, Sweetnam R (1960) Recurrent dislocation of the patella and of the shoulder: their association with familial joint laxity. J Bone Joint Surg Br 42:721–727PubMedGoogle Scholar
  39. 39.
    Finsterbush A, Pogrund H (1982) The hypermobility syndrome: musculoskeletal complaints in 100 consecutive cases of joint hypermobility. Clin Orthop 168:124–127PubMedGoogle Scholar
  40. 40.
    Beall MS Jr, Diefenbach G, Allen A (1987) Electromyographic biofeedback in the treatment of voluntary posterior instability of the shoulder. Am J Sports Med 15:175–178PubMedCrossRefGoogle Scholar
  41. 41.
    Lefort G, Pfliger F, Mal-Lawane M, Belouadah M, Daoud S (2004) Capsular shift for voluntary dislocation of the shoulder: results in children. Rev Chir Orthop Reparatrice Appar Mot 90:607–612PubMedCrossRefGoogle Scholar
  42. 42.
    Massoud SN, Levy O, Copeland SA (2007) Radiofrequency capsular shrinkage for voluntary shoulder instability. J Shoulder Elbow Surg 16:43–48PubMedCrossRefGoogle Scholar
  43. 43.
    Papavasileiou A, Kitsis C (2003) Multidirectional voluntary glenohumeral dislocation in a 7-year-old patient: a case report. Acta Orthop Belg 69:558–561PubMedGoogle Scholar
  44. 44.
    Patralekh MK, Maini L, Kalra M (2012) Voluntary anterior dislocation of the shoulder in a 10-year-old child treated surgically. J Hand Microsurg 4:32–33PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Rosaaen BJ, DeLisa JA (1983) Voluntary anterior dislocation of the shoulder: case study. Voluntary anterior dislocation of the shoulder: case study. Arch Phys Med Rehabil 64:326–328PubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

  • Giovanni Merolla
    • 1
    • 2
  • Elisa De Santis
    • 2
  • Ann M. J. Cools
    • 3
  • Giuseppe Porcellini
    • 1
  1. 1.Unit of Shoulder and Elbow SurgeryD. Cervesi HospitalCattolicaItaly
  2. 2.Biomechanics Laboratory “Marco Simoncelli”D. Cervesi HospitalCattolicaItaly
  3. 3.Department of Rehabilitation Sciences and PhysiotherapyGhent UniversityGhentBelgium

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