Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, symptomatic multidirectional instability of the left shoulder. Reports recurrent episodes of subluxation, generalized shoulder pain, and a sensation of the joint "giving way" during overhead activities or reaching. Denies acute traumatic event; symptoms exacerbated by repetitive motion and relieved by rest.
Clinical Examination Findings
Left shoulder examination reveals positive Sulcus sign (grade II+), indicating inferior laxity. Anterior and posterior drawer tests demonstrate increased translation compared to the contralateral side. Generalized ligamentous laxity noted. Rotator cuff strength is 5/5, though limited by apprehension. No neurovascular deficits noted in the distal extremity.
Treatment Protocol
Conservative management initiated, including physical therapy focused on scapular stabilization, rotator cuff strengthening, and proprioceptive neuromuscular facilitation. Activity modification advised to avoid provocative overhead positions. NSAIDs prescribed for pain management. Follow-up in 6 weeks to assess progress for potential surgical stabilization (capsular shift).