The Unstable Shoulder

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Shoulder hypermobility and hyperlaxity role and
risks in sports
Mr Roger G Hackney FRCS (Orth) Dip Sports
Med Consultant Upper Limb Surgeon Honorary
Senior Lecturer Chapel Allerton Hospital Leeds
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What is hypermobility?

• Spectrum
• Benign hypermobility
• Ehlers Danlos
• Several genes
• Close locus but can have very lax shoulder
  without other upper limb signs
• Laxity vs instability

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Terminology

• Instability is symptomatic laxity
• Multi-directional instability is instability in 2
  or more directions
• Termed coined by Neer and Foster 1980
• Multidirectional laxity is not multi-directional
  instability unless symptomatic
• Common in asymptomatic children, Roger Emery
  found evidence of instability in 57 of male
  schoolchildren, JBJS 1991

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Beighton score total of 9 points Thumb to
forearm Little finger to 90 degrees Recurvatum of
knee and elbow Hand to floor with legs straight
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Terminology

• Voluntary dislocators
• Able to sublux shoulder by voluntary contraction
  and relaxation of muscle agonist/antagonist
• Habitual dislocator
• Unable to maintain the position of the humeral
  head in the glenoid whilst moving the shoulder

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Voluntary Subluxation
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Involuntary positional instability

• Takwale VJ Calvert P Rattue H
• Make the diagnosis
• only 19/50 referred with correct diagnosis
• Is symptomatic
• Careful explanation
• Analysis of abnormal muscle couples
• Muscle retraining with specialist physios
• Botox, biofeedback etc

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Terminology

• Mc Farland JBJS A 2003
• Different systems used to classify MDI in the
  same group of patients undergoing surgery for
  instability
• Number with MDI varied from 1.2 to 8.3
• Implications for comparing apples with pears

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Shoulder instability
Trauma
Muscle patterning
Laxity
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Is hypermobility helpful in sport?

• YES
• Sports requiring huge range of motion
• Advantaged gymnastics, butterfly swimming,
  overhead throwers, dancers
• NO
• Increases risk of instability
• Contact sports
• Rugby players!

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What goes wrong?

• Over stretching in training
• Traumatic episode
• need only be minor, eg swimmer misjudging pool
  edge
• Chronic repetitive minor trauma
• Throwing injury flattens labrum stretches IGHL
• Present with PAIN, may not be aware of instability

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Examination

• Posture
• Rhythm and range of movement
• ER, in neutral and at 90 of abduction
• Scapula
• Voluntary or habitual dislocation
• Stress tests, sulcus sign, A-P glide
• Apprehension
• Slide and glide
• Jobes relocation test

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Anterior and posterior glide/draw signs
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Investigation

• Radiography for bony defect
• CT scan if suspicious
• MRI, arthrography
• Flattened inferior labrum (Kim)?
• SLAP lesion, bony defect, HAGL

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Management

• Team
• Surgeon
• Specialist physiotherapist
• Psychologist
• Nursing staff
• Conservative
• Surgical

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Physiotherapy

• Core stabiliity, pelvis, trunk, scapula
• Proprioceptive exercises
• Rotator cuff strengthening
• Biofeedback
• Botox injections
• Time
• More time
• Yet more time

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Surgical options

• Arthroscopic
• Mechanical lesions, Bankart/SLAP/tear of capsule
• Capsular plication
• Closure of rotator interval
• Kims procedure
• Thermal capsular shrinkage
• Open
• Posterior-inferior capsular shift

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Kims procedure

• AJSM 2004 Arthroscopic capsulolabroplasty
• Flattened inferior labrum
• Extensive capsular plication from inferior
  including both anterior and posterior labrum
• Difficult access
• Long term results? Only 39 month follow up

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Arthroscopic repair

• Alpert, J N Wysocki, R Yanke, A Romeo A.
• Arthroscopy 2008 June
• 270 degree labral tearing
• Not atraumatic MDI
• 85 satisfaction rates
• BUT included MDI defined intra-operative as well
  as pre-op including findings on EUA.
• Only 2 of 15 patients complained of instability,
  the rest pain
• NO patients has gross instability pre-operatively

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Thermal Capsular Shrinkage Biomechanics and
Biology

• Reduced stiffness
• More soluble
• Scar formation
• At 6 weeks, synovitis, fibrosis
• and neovascularisation
• Remodeling from fibroblasts
• Normal fibres at around a year

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Thermal Capsular Shrinkage

• Hawkins R AJSM Sep 07 60 failure rate with TCS
• Now augment with capsular plication and rotator
  interval closure
• Miniaci JBJS 2003 High failure rate
• Now rarely used
• May have an indication for short term gain of
  stability in severe control problems
• Beware of reports of capsule disappearing with
  excess use

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Open surgery

• AMBRI
• Posterior inferior capsular shift
• Hamada et al JBJS 1999
• 85 satisfactory outcome
• maintained at 11 years
• 50 failure rate for voluntary instability

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Summary

• Difficult patients
• Present with pain less so instability
• Classification still a problem
• Conservative treatment first
• Arthroscopic surgery for recalcitrant patients
• Capsular plication, correct labral pathology
• TCS to augment only
• Open capsular shift

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World Sports Trauma Congress

• 2012 Olympic Games
• London
• United Kingdom
• November
• Combined with EFOST 2012