Systematic Review

Open Capsular Shift and Arthroscopic Capsular Plication for

Treatment of Multidirectional Instability

Mark E. Jacobson, M.D., Michael Riggenbach, M.D., Adam N. Wooldridge, B.A., B.S., and
Julie Y. Bishop, M.D.

Purpose: To compare the results of open inferior capsular shift with arthroscopic capsular plication
for multidirectional instability in patients without a Bankart lesion. We hypothesized that there is no
difference with regard to the specific clinical outcomes evaluated, including recurrent instability,
range of motion, return to sport, and complications. Methods: We conducted a comprehensive
literature search. Databases searched included PubMed from 1966 to 2010, the Cochrane Database
of Systematic Reviews and Controlled Trials, CINAHL (Cumulative Index to Nursing and Allied
Health Literature) from 1982 to 2010, and SPORTDiscus from 1975 to 2010. Limits included English
language, human subjects, and title. Results: We found 7 articles with a total of 197 patients (219
shoulders) that met our inclusion criteria. The data did not clearly show open treatment to be superior
to arthroscopic treatment. No study reported a consistent loss of greater than 40° of external rotation.
No technique showed significantly less external rotation loss over the other. Whereas there was a
slight trend toward increased return to sport for patients treated arthroscopically, no clear conclusion
can be drawn given the variability of reporting in the reviewed studies. Analysis of complications
shows that both procedures are reliably safe with minimal complications. Conclusions: When one is
evaluating patients with traumatic or atraumatic onset of shoulder instability in 2 directions and no
structural lesions, arthroscopic capsular plication yields comparable results to open capsular shift
with regard to recurrent instability, return to sport, loss of external rotation, and overall complica-
tions. Level of Evidence: Level IV, systematic review of Level IV studies.

I n 1980, Neer and Foster1 coined the term “mul-

tidirectional instability” (MDI) and proposed
specific surgical treatment to patients in whom con-
servative management has failed. In this classic
article they report preliminary results of the inferior
capsular shift as a means to address the patulous
From the Division of Shoulder Surgery, Department of Ortho-
paedics, The Ohio State University, Columbus, Ohio, U.S.A.
The authors report that they have no conflicts of interest in the
authorship and publication of this article.
Received September 30, 2011; accepted December 6, 2011.
Address correspondence to Julie Y. Bishop, M.D., Department of
Orthopaedics, The Ohio State University Medical Center, 2050
Kenny Rd, Ste 3300, Columbus, OH 43221, U.S.A. E-mail: julie
.bishop@osumc.edu
© 2012 by the Arthroscopy Association of North America
0749-8063/11627/$36.00
doi:10.1016/j.arthro.2011.12.006
inferior capsule that they believed to be the respon-
sible pathology. Although open inferior capsular
shift remains the standard in surgical treatment of
MDI, multiple alternative procedures have been de-
veloped. In 1993, Duncan and Savoie2 first reported
preliminary results of arthroscopic capsular plica-
tion.
In all patients presenting with MDI, a regimented
course of physical therapy directed at strengthening
of scapular stabilizers, the rotator cuff, and the
deltoid is warranted.1,3,4 Burkhead and Rockwood4
reported good or excellent results in 88% of patients
with atraumatic instability treated with an exercise
program; however, more recent results have been
less encouraging, at 30% to 61%.3,5 If these recent
reports more adequately represent our current pa-
tient population and its expectations, it is reason-

1010 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 7 (July), 2012: pp 1010-1017
 MULTIDIRECTIONAL INSTABILITY
able to expect that surgical management of MDI
will increase.
The definition of MDI has been somewhat conflict-
ing over the years, making interpretation of surgical
outcomes articles somewhat difficult. Several ar-
throscopic outcomes articles6-11 and a recent review of
treatment options12 have not differentiated patients
with and without focal structural pathology, such as
the Bankart lesion.
The purpose of this study is to review the literature
systematically and compare the results of open infe-
rior capsular shift with arthroscopic capsular plication
for MDI in patients without a Bankart lesion; thus
surgical intervention was purely aimed at capsular
plication. We hypothesize that there is no difference
with regard to the specific clinical outcomes evalu-
ated, including recurrent instability, range of motion,
return to sport, and complications.
METHODS
In October 2010, a comprehensive literature search
was conducted. Databases searched included PubMed
from 1966 to 2010, the Cochrane Database of Sys-
tematic Reviews and Controlled Trials, CINAHL (Cu-
mulative Index to Nursing and Allied Health Litera-
ture) from 1982 to 2010, and SPORTDiscus from
1975 to 2010. Limits to this search included English
language, human subjects, and title. Each database
was searched for the terms “multidirectional instabil-
ity,” “inferior instability,” “capsular shift,” “capsular
plication,” and “capsulorrhaphy.” Abstracts from each
search “hit” relevant to this systematic review were
identified, and these articles were reviewed in their
entirety by a senior attending fellowship trained in
shoulder surgery and assisted by a resident. Inclusion
criteria consisted of the following: MDI defined as
instability in at least 2 directions, results with a min-
imum of 2-year follow up, and surgical treatment
consisting of either open inferior capsular shift or
arthroscopic capsular plication. We excluded review
TABLE 1. Literature Search Results
PubMed Medline
MDI 103 (21) 95 (20)
Capsular plication 18 (0) 14 (0)
Capsular shift 69 (18) 69 (19)
Inferior instability 46 (11) 44 (15)
Capsulorrhaphy 109 (2) 108 (2)
NOTE. The number of articles for each search term relevant to this review is shown in parentheses.
1011
articles, articles reporting results of patients with Ban-
kart lesions, and articles including patients in whom
dislocation occurred voluntarily.
After thorough review of each article, the following
data were extracted: patient demographics, definition
of MDI, surgical technique, failure rate, change in
range of motion from preoperatively to postopera-
tively, return to sport, and complications. Patient de-
mographics included gender, age, and arm dominance.
Surgical technique was classified as open or ar-
throscopic, with an anterior or posterior approach,
with a medial- or lateral-based capsular shift. Treat-
ment failure was determined in those patients who did
not achieve satisfactory results as defined by the Neer
criteria: no recurrence of dislocation or subluxation,
no significant pain, full activities, normal strength, and
within 10° of full elevation and 40° of rotation com-
pared with the contralateral shoulder.1 Range of mo-
tion was determined as the mean postoperative change
in external rotation with the arm in 90° of abduction.
RESULTS
Search Results
The number of hits for each search term for a given
database is shown in Table 1. After reviewing the
abstracts of all search results, we identified 33 articles
with relevance to this review. After application of our
inclusion and exclusion criteria, 7 articles remained
(Fig 1). Two of these studies included patient popu-
lations with and without Bankart lesions; however, the
results of these groups could be interpreted indepen-
dently and therefore met our inclusion criteria.30,31 In
these 2 articles we were able to cleanly dissect the
failure data for patients who did not have Bankart
lesions and thus had purely capsular-based surgery.
We did not include articles in which we could not
clearly differentiate this population.
Cochrane CINAHL SPORTDiscus
0 42 (11) 46 (12)
1 (0) 7 (0) 6 (1)
2 (0) 27 (8) 29 (10)
2 (0) 16 (7) 16 (8)
5 (0) 32 (0) 32 (1)
1012 M. E. JACOBSON ET AL.
FIGURE 1. Article exclusion flowchart. Exclusion criteria in-
cluded review articles,13-16 less than 2 years’ follow-up,1-3,17-24
inclusion of Bankart or bony lesions,6-11 wrong procedures,25-27
and inclusion of voluntary dislocators.28,29
Characteristics of Included Studies
No study with a level of evidence higher than Level
IV was identified, and all studies consisted of case
series, 5 of which were retrospective. There were 197
patients included in all studies, of whom 22 underwent
bilateral procedures. Of the shoulders, 137 were
treated with open capsular shift whereas 92 were
treated arthroscopically. All patients were included in
analysis of patient demographics, range of motion,
complication, and return to sport. A total of 37 pa-
tients from 2 studies30,31 in the arthroscopic group
were excluded from the failure analysis because of the
presence of a Bankart lesion. The mean age was 25.6
years in the open treatment group and 23.2 years in the
arthroscopic group. Whereas all patients were fol-
lowed up for a minimum of 2 years, mean follow-up
of the open treatment group was longer (57 months v
44 months).
MDI was defined as instability in at least 2 direc-
tions in all studies. Four studies specified that inferior
instability must be present with instability in at least 1
other direction.30-33 Two studies only specified that 2
directions of instability be present.34,35 One study
specified that all cases must be atraumatic with infe-
rior instability and positive anterior apprehension.36
Two studies reported patients with prior shoulder
surgeries. The cohort of Baker et al.30 included 3
patients with a prior thermal capsulorrhaphy and 1
patient with a prior open anterior capsulorrhaphy. The
cohort of Treacy et al.31 included 1 patient with a prior
distal clavicle excision and 2 patients with prior open
acromioplasty.
There was an even distribution of male and female
patients in the included studies (106 and 111, respec-
tively); however, a significantly greater proportion of
female patients were treated with open surgery, and
more male patients were treated with arthroscopic
surgery. Of the studies reporting hand dominance,
both arthroscopic and open procedures were more
commonly performed on the dominant extremity. Pa-
tient characteristics are summarized in Table 2.
Procedure
Four of seven studies used open capsular shift pro-
cedures.32,34-36 Bak et al.34 and Choi and Ogilvie-
Harris35 preferred the method described by Neer. An-
terior or posterior capsular shift was performed
depending on the predominant direction of instability
as determined by the history and examination of the
patient in the office and under anesthesia. Whereas
Bak et al. performed all anterior inferior shift proce-
dures (N ⫽ 26), Choi and Ogilvie-Harris included 37
anterior and 16 posterior procedures. A standard del-
topectoral approach was used in the anterior approach.
Whereas Bak et al. preserved the insertion of the
subscapularis tendon, Choi and Ogilvie-Harris split it
obliquely. The subscapularis was dissected from the
capsule, and a T capsulotomy was performed with the
short arm of the T based laterally and longitudinally.
With the arm in 45° of abduction and neutral rotation,
the inferior flap was rotated anteriorly and superiorly
and sutured in a position such that the inferior pouch
was obliterated. With the arm in adduction, the supe-
rior flap was rotated anteriorly and inferiorly. When
the posterior shift was used, the infraspinatus was split
obliquely and the capsular shift was performed in an
identical manner as the anterior shift. Although the
subscapularis tendon was not shortened in the anterior
approach, the infraspinatus was shortened in the pos-
 MULTIDIRECTIONAL INSTABILITY 1013

TABLE 2. Patient Characteristics of Individual Studies

Age Gender Follow-Up Shoulder Dominance
Shoulders Patients (Mean) (Mean)
Procedure Study (N) (N) (yr) Male Female (mo) Dominant Nondominant

Open capsular shift Bak et al.34 26 25 23 18 17 NR 14 12

Choi and Ogilvie- 53 47 NR 18 29 42 NR NR
Harris35
Marquardt et al.36 38 35 25.4 9 26 89 NR NR
Steinbeck and 20 20 26 3 17 38 18 2
Jerosch32
Arthroscopic capsular Baker et al.30 43 (23 with 40 (20 with 19.1 24 16 33.5 23 20
plication Bankart) Bankart)
Treacy et al.31 25 (14 with 11 (14 with 26.4 21 5 60 14 11
Bankart) Bankart)
Wichman and 24 24 26.6 13 11 NR NR NR
Snyder33

Abbreviation: NR, not reported.

terior approach because of the relative thinness of the
posterior capsule. Marquardt et al.36 (N ⫽ 38) and
Steinbeck and Jerosch32 (N ⫽ 20) modified the ante-
rior inferior shift in that the short arm of the T was
medially based. The inferior flap shift was performed
first with the arm in 20° of abduction and 20° of
external rotation. The inferior capsular flap was se-
cured to the decorticated rim of the glenoid by use of
2 suture anchors.
There was slight variation in technique for perform-
ing arthroscopic capsular plication. Wichman and
Snyder33 (N ⫽ 24) used an anterior inferior capsular
pinch stitch that was then passed through the labrum
to create a 1-cm capsular fold in a horizontal mattress
fashion. Additional sutures were placed anterior, pos-
terior, or inferior as deemed necessary by the history,
examination, and arthroscopic findings. They did note
that after plication, the humeral head sat concentri-
cally within the glenoid as opposed to the anterior
inferior position seen on diagnostic arthroscopy.
Treacy et al.31 preferred a capsular plication using a
transglenoid approach. Three O polydioxanone su-
tures were placed into the inferior glenohumeral lig-
ament at the anterior band, at the posterior band, and
centrally 1 cm from the glenoid rim. After abrasion of
the inferior glenoid rim, these sutures were then
passed through the glenoid neck in an anterior-to-
posterior direction with a Beath pin. As multiple
sutures in the capsule were tightened and sutured
posteriorly, the capsule tightened and advanced
superiorly. Baker et al.30 used 4 nonabsorbable cap-
sular-labral plication stitches starting at the 5:30 clock
positioning in the capsule 1 cm off the glenoid and
advancing this to the 4:30 clock position of the
labrum. A similar technique was used for posterior
predominant instability shoulders starting at the 6:30
clock position. Suture anchors were used where the
labrum was deficient (but not torn or detached). For
open and arthroscopic procedures, closure of the ro-
tator interval was variable and not clearly docu-
mented.
Recurrent Instability
The procedure-specific recurrent instability results
are summarized in Table 3. A lower rate of recurrent
instability in the studies using an open technique as
compared with an arthroscopic technique was repor-
ted: 11.7% (16 of 137) versus 20% (11 of 55). This
difference was not statistically significant. Failure in
patients treated by open means was equally associated
with spontaneous (5 patients) and traumatic (5 pa-
tients) recurrent instability.32,34,36 A history of prior
surgery was associated with half of the cases of re-
current instability after arthroscopic repair.30,31 The
cohort of arthroscopically treated patients reported by
Wichman and Snyder33 had the highest failure rate
(21%). Patient involvement with Workers’ Compen-
sation claims or litigation accounted for 4 of 5 of their
reported failures.
Return to Sport
There was a trend toward increased return to pre-
operative level of sports participation for patients
treated arthroscopically versus those treated with open
capsular shift (86% v 80%) (Table 4). No study re-
ported the preoperative level of play or specific sport
for all patients; thus no clear conclusions can be drawn
1014 M. E. JACOBSON ET AL.

TABLE 3. Study- and Procedure-Specific Failures and Suspected Cause

Overall Procedure
Procedure Author Failure Rate Association With Failures Failure Rate

Open capsular shift Bak et al.34
Choi and Ogilvie-Harris35
Marquardt et al.36
Steinbeck and Jerosch32
Arthroscopic capsular Baker et al.30
plication
Treacy et al.31
Wichman and Snyder33
19% (5/26) 3 traumatic, 2 spontaneous 11.7% (16/137)
9% (5/53) Mechanism not reported
11% (4/38) 2 traumatic, 1 who had prior
surgery, 1 spontaneous
10% (2/20) 2 spontaneous
20% (4/20) 1 traumatic, 1 spontaneous, 2 with 20% (11/55)
history of thermal capsulorrhaphy
18% (2/11) 1 spontaneous, 1 prior surgery
21% (5/24) Mechanism not reported (3 involved
in BWC claims, 1 involved in
litigation for MVA)

Abbreviations: BWC, Bureau of Workers’ Compensation; MVA, motor vehicle accident.

from these data. In addition, patients with Bankart
lesions in the cohorts of Baker et al.30 and Treacy et
al.31 could not be excluded from these results.
Both Choi and Ogilvie-Harris35 and Bak et al.34
specifically focused on open capsular shift in athletes.
Choi and Ogilvie-Harris noted that of the 6 patients
who underwent bilateral procedures in their cohort,
only 1 returned to sport. The authors concluded that
the outcome for patients with bilateral instability is
poor. The overall rate of return to sport in the patient
population of Bak et al. was 84%; however, this was
reduced (76%) in overhead athletes. In the cohort
reported by Marquardt et al.,36 the 72% rate of return
to sport decreased to 50% (3 of 6) when only “elite”
athletes were included.
The rate of return to sport after arthroscopic capsu-
lar plication in the cohorts of Baker et al.30 and Treacy
et al.31 was 86%. Of these athletes, swimmers were
least likely to return to the level of prior participa-
tion.30
Loss of External Rotation
Reporting of preoperative and postoperative range
of motion was highly variable among included stud-
ies, making interpretation of this outcome difficult.
Postoperative external rotation with the arm in abduc-
tion is shown in Table 5. In no study was a failure of
either open or arthroscopic repair attributed to limited
range of motion according to the Neer criteria. With
respect to the open capsular shift procedure, Choi and
Ogilvie-Harris35 did note a greater loss of external
rotation after anterior capsular shift as opposed to a
posterior shift (71° v 82°). Wichman and Snyder33
reported mean postoperative external rotation of
80.4°; however, no preoperative data were reported. In
addition, they noted that the largest loss of external
rotation was found in patients involved in Workers’
Compensation claims or litigation.
Complications
Complications from MDI repair (outside of recur-
rent instability) were infrequent in the included stud-
ies. Choi and Ogilvie-Harris35 had 2 superficial wound
infections and 1 musculocutaneous nerve injury that
resolved with observation. Marquardt et al.36 had 1
superficial wound infection in a patient who was lost
to follow-up. Treacy et al.31 reported 2 patients in

TABLE 4. Study- and Procedure-Specific Return to Preoperative Level of Sport

Study-Specific Return to Overall Return to Preoperative
Procedure Author Preoperative Level of Sport Level of Sport

Open capsular shift Bak et al.34 84% (21/25) 80% (101/127)

Choi and Ogilvie-Harris35 81% (44/53)
Marquardt et al.36 72% (21/29)
Steinbeck and Jerosch32 75% (15/20)
Arthroscopic capsular plication Baker et al.30 86% (31/36) 86% (37/43)
Treacy et al.31 86% (6/7)
Wichman and Snyder33 Not reported
 MULTIDIRECTIONAL INSTABILITY
TABLE 5. Range of Motion After Open Capsular Shift and Arthroscopic Plication
Procedure Author
Open capsular shift Bak et al.34
Choi and Ogilvie-Harris35
Marquardt et al.36
Steinbeck and Jerosch32
Arthroscopic capsular plication Baker et al.30
Treacy et al.31
Wichman and Snyder33
NOTE. Mean range of motion and loss of motion represent external rotation with the arm in 90° of abduction.
Abbreviations: ER, external rotation; ROM, range of motion.
whom persistent pain developed over the posterior
suture knot, requiring removal.
DISCUSSION
MDI presents a complex problem to manage for the
treating surgeon. Previously reported success rates of
nonoperative management have recently been chal-
lenged as patient expectations increase.5,37 Frequently,
patients present with long-term disability and have not
uncommonly undergone a prior surgical procedure on
the symptomatic shoulder. Prior surgical dissection
and capsular manipulation such as thermal capsu-
lorrhaphy may compromise the soft tissues and
complicate a revision stabilization procedure.38,39
Patients are typically young and involved in sport-
ing activities, which increase the demand on any
planned procedure.
Further complicating matters is the inconsistent def-
inition of MDI, which has led to difficulty interpreting
the available literature. McFarland et al.40 showed that
variability in the definition of MDI led to a statistically
significant difference in the number of patients as-
signed this diagnosis. Thomas and Matsen41 classified
the etiology of recurrent shoulder instability as trau-
matic in origin, resulting in unidirectional instability,
or atraumatic in origin, resulting in MDI. Neer and
Foster1 and other authors42 have cautioned against a
strictly atraumatic definition of MDI because this may
lead to misdiagnosis and failure to address the offend-
ing pathology. More recently, a classification system
incorporating frequency, etiology, direction, and se-
verity (FEDS) was introduced.43 Interestingly, the au-
thors purposefully avoided the concept of MDI, opting
instead to rely on the history and physical examination
to determine a single primary direction of instability.
For the purposes of this review, we chose an inclusive
1015
Range of Motion Reported
Mean, 90°
Anterior shift: mean, 71°
Posterior shift: mean, 82°
3.4° mean loss of ER, no patient lost ⬎10°
Rowe score improvement from 17 to 19 for ROM
91% satisfactory ROM, 9% limited ROM
No loss of ER
Mean, 80.4°; loss of ⬎10° in 2/24
definition of MDI as the traumatic or atraumatic onset
of involuntary symptomatic shoulder instability in
more than 1 direction without a structural lesion such
as a Bankart lesion.
The procedures pertinent to this review were de-
signed to address the patulous capsule present in pa-
tients with MDI rather than the labrum. Whereas both
labral pathology and ligamentous laxity may be seen
in concert in a patient with MDI, we elected to elim-
inate patients with labral pathology in an effort to
reduce confounding factors. Our goal was to evaluate
the surgical outcomes of procedures aimed at elimi-
nating shoulder instability that were purely capsular
based. To our knowledge, this is the first comparison
of procedures to address MDI as a distinct entity from
labral pathology.
A patulous inferior capsule and laxity of the inferior
glenohumeral ligaments are agreed on in the literature
as the responsible pathologies in MDI.1,2,11,44 Since
Neer and Foster1 proposed the open capsular shift,
multiple procedures have been developed to both
tighten the inferior capsule and reduce total joint vol-
ume. In an in vitro study comparing volume reduction
of the glenohumeral joint using 2 techniques, Cohen et
al.45 found that arthroscopic capsular plication using
three 1-cm capsulolabral plication sutures resulted in a
volume reduction of 22% whereas open capsular shift
as described by Neer and Foster reduced joint volume
by nearly 50%. Ponce et al.46 noted that the addition of
five 1-cm capsular plication stitches was shown to
reduce capsular volume by 49% with a suture-only
technique and by 52% with suture anchors. Flanigan
et al.47 found that volume reduction increased from
16% to 34% when the arthroscopic capsulolabral pli-
cation was increased from 5 to 10 mm. Miller et
al.48 compared volume reduction of the glenohu-
meral joint using 3 different open capsular shift
techniques: the humeral- or lateral-based shift as
1016 M. E. JACOBSON ET AL.
described by Neer and Foster, the glenoid- or me-
dial-based shift as used by Marquardt et al.36 and
Steinbeck and Jerosch,32 and a centrally based shift.
The humeral-based shift reduced glenohumeral
joint volume by a statistically significant amount
greater than the glenoid-based shift (49% v 37%).48
Although these studies suggest that open capsular
shift and the sequential capsular plication stitches
can achieve a 50% joint volume reduction, the
clinical significance of this is unknown.
This review shows that arthroscopic capsular plica-
tion is a reasonable alternative to open capsular shift
to reliably decrease the incidence of recurrent insta-
bility in patients with MDI. Whereas the gold standard
for this pathology has classically been thought to be an
open capsular shift, this review does not clearly show
open treatment to be superior to arthroscopic treat-
ment. Loss of range of motion is a concern in any
capsular tightening procedure; however, no study re-
ported a consistent loss of greater than 40° of external
rotation (which was defined as a failure according to
the early Neer criteria). Neither technique was shown
to be superior with respect to postoperative range of
motion. Although there was a slight trend toward
increased return to sport for patients treated ar-
throscopically, no clear conclusion can be drawn
given the variability of reporting in the reviewed stud-
ies. Analysis of complications shows that both proce-
dures are reliably safe with minimal complications.
Although this report does show a similar efficacy
with regard to the reported outcomes, the potential
benefits of an all-arthroscopic approach that have not
been addressed should not be ignored. These include
avoidance of subscapular or infraspinatus takedown
and the associated complications, limited scarring, and
ability to address associated pathology, which may be
inaccessible with an open approach.49
There are several limitations to this systematic re-
view. First, there is a large discrepancy between the
number of patients treated arthroscopically (n ⫽ 55)
and those treated with an open procedure (n ⫽ 137).
This is not surprising, given that open capsular shift
was introduced more than 10 years before ar-
throscopic treatment methods. In addition, there was
variability in the method used to report loss of external
rotation, which makes drawing conclusions between
the 2 groups difficult. Finally, there was inconsistent
reporting of patients having undergone prior proce-
dures, which could directly influence recurrent insta-
bility.
CONCLUSIONS
When one is evaluating patients with traumatic or
atraumatic onset of shoulder instability in 2 directions
and no structural lesions, arthroscopic capsular plica-
tion yields comparable results to open capsular shift
with regard to recurrent instability, return to sport, loss
of external rotation, and overall complications.
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