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Evidence on which to base decision-making in the management of atraumatic shoulder instability is limited. This is due to the lack of a universal definition for the condition, small cohort studies and multiple outcome scores being used to evaluate treatment.  Despite these limitations it is evident that the vast majority of patients with atraumatic shoulder instability (with or without structural pathology) seem to improve with physiotherapy.   Physiotherapy should always be the first line (and second line) of management for such patients.   Patients that do not improve should be referred to a specialist orthopaedic shoulder surgeon and shoulder physiotherapist for careful assessment.   If necessary, patients with certain indications may be referred directly to tertiary centres early   ○ Frequent attendance at A&E for relocation   ○ Persistent displacement or shoulder dislocation/subluxation   ○ Absence from school (>20%) or work (>3 months)       A multidisciplinary team approach is essential in complex cases.   Evidence for operative intervention is poor and inconsistently reported in the literature. If surgery is to be undertaken then arthroscopic capsulorrhaphy is not recommended for the treatment of atraumatic shoulder instability.   Inappropriate or incorrect surgery is to be avoided as this has been shown to be associated with poor outcomes.      We propose a treatment algorithm as shown in Figure 3 to guide the management of patients with atraumatic shoulder instability based on the limited available evidence and expert consensus opinion.       Open in a separate window   Figure 3.   Proposed algorithm for the management of atraumatic shoulder dislocation. EMG: electromyography; MDT: multidisciplinary team.

BESS/BOA patient care pathways: Atraumatic shoulder instability