Purpose: Shoulder pain in the young athlete is often a diagnostic challenge. It is our experience that this pain can be related to a so-called “unstable painful shoulder” (UPS), defined as instability presenting in a purely painful form, without any history of instability but with anatomical (soft tissue or bony) ‘roll-over’ lesions. The objectives are to describe the epidemiology and diagnostic criteria and to report the results of surgical treatment.

Method: A prospective review was performed of 20 patients (mean age 22 ± 8 years). Inclusion criteria: a painful shoulder and “roll-over lesions” on imaging or at surgery. Exclusion criteria: a dislocation/subluxation; associated pathology; previous shoulder surgery.

Results: Most patients were male (60%), athletes (85%) and involved the dominant arm (80%). All patients denied a feeling of instability and only complained of deep, anterior pain. Most had a history of trauma (80%). All patients had rehabilitation without success and 30% had subacromial injections. All had to stop sports. Most (85%) had anterior or inferior hyperlaxity. All had pain with an anterior apprehension test and relieved by relocation test. ‘Roll-over’ lesions included: labrum detachment (90%), capsular distension (75%), HAGL lesion (10%), glenoid fracture (20%) or Hill-Sachs (40%). Time from symptoms to surgery was 25 ± 23 months. All patients had arthroscopic treatment. Mean follow-up was 38 ± 14 months. Eighteen patients (90%) were very satisfied/satisfied. None had pain at rest, but one (5%) had pain with apprehension test. There was no change in elevation, external or internal rotation (p> 0.05). There were no cases of instability. Rowe and Duplay scores improved (p< 0.05).

Conclusion: Instability of the shoulder can present in a purely painful form, without any history of dislocations or subluxations. Diagnosis can be difficult, and should be suspected in young patients and athletes. Most patients have deep anterior pain and pain with apprehension test. ‘Roll-over’ lesions are necessary to confirm the diagnosis. Arthroscopic repair is effective.