Pediatric shoulder instability: epidemiology, etiology, diagnosis and treatment

TL;DR

This review discusses how shoulder instability in children and teens is influenced by age and activity, and outlines diagnosis and treatment strategies to avoid over- or undertreatment.

Contribution

The paper provides a structured, age-specific approach to diagnosing and managing pediatric shoulder instability.

Findings

Shoulder dislocations are rare in young children due to strong ligaments but more common in 14–18-year-olds.

Arthroscopic stabilization is preferred for adolescents with high recurrence risk, especially athletes.

Functional posterior instability is often misdiagnosed and responds well to neuromuscular electrical stimulation.

Abstract

Shoulder instability is increasingly prevalent among pediatric and adolescent populations due to growing participation in competitive sports at younger ages. However, the literature remains challenging to apply clinically, as it often fails to distinguish between different developmental stages, leading to potential overtreatment or undertreatment. This review aims to categorize types of shoulder instability in young patients, propose a diagnostic approach, and summarize current management strategies based on available evidence. Shoulder dislocations are rare in skeletally immature patients, with the highest risk observed in those aged 14–18 years. Younger children, particularly those under ten, are less prone to dislocations due to the relative strength of their ligaments compared to bone. Diagnosis relies on history, physical examination, and imaging modalities such as radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Special attention is required for functional posterior instability, which is frequently misdiagnosed. Treatment decisions—whether conservative or surgical—remain controversial. Conservative management, including immobilization and rehabilitation, is the first-line approach for primary anterior dislocations, particularly in children under 12. However, adolescents aged 12–16 face a high risk of recurrence, making early surgical stabilization a viable option. Arthroscopic stabilization is the preferred surgical technique, especially for athletes. In cases of recurrent instability with significant glenoid bone loss, the Latarjet procedure or iliac crest bone grafting may be indicated. Posterior instability, though rare, follows treatment principles similar to those in adults, with a primary emphasis on rehabilitation. Functional posterior instability responds well to neuromuscular electrical stimulation. Multidirectional instability, often associated with ligamentous laxity, is primarily managed nonoperatively, but surgical stabilization may be necessary if symptoms persist. In conclusion, pediatric shoulder instability is complex and requires an individualized approach. Understanding age-specific anatomical and physiological differences is crucial for optimizing treatment outcomes and preventing long-term complications.

Level 5.

Figures