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Etiology of Shoulder Instability

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Title: Etiology of Shoulder Instability


1
Etiology of Shoulder Instability
  • Noel Goodstadt, MPT, OCS, CSCS
  • University of Delaware

2
Terminology
  • Translation
  • Laxity
  • Stability
  • Instability

3
Classification of Instability
  • Onset
  • Degree
  • Direction
  • Chronicity

4
  • Traumatic
  • Unilateral
  • Bankart Lesion
  • Surgery
  • Atraumatic
  • Multidirectional
  • Bilateral
  • Rehabilitation
  • Inferior Capsular Shift

Matsen
5
Spectrum of Instability
TUBS
AMBRI
6
Traumatic
  • Torn Loose
  • FOOSH
  • Contact Sports (Football, Wrestling, Boxing)
  • Bankart or SLAP Lesion
  • Concomitant pathology common

7
Incidence of Traumatic Dislocation
  • Young Athletes under 50
  • Males gt Females
  • Older individuals over 50
  • Females gt Males
  • Trend in the literature
  • equal number of dislocations above and below 45
    years of age
  • Seitz 2006

8
Degree of Instability
  • Subluxation - Pops out, but spontaneously
  • reduces
  • Dislocation - Pops out, Stays out, requires
  • manual reduction by MD

9
Direction of Instability
  • Anterior Dislocation
  • Most common
  • Subcorocoid
  • Subglenoid
  • Subclavicular
  • Posterior
  • Inferior
  • Multidirectional

10
Associated Complications
  • Ligamentous
  • Bankart Lesion
  • HAGL
  • Bone
  • Hill-Sachs Lesion
  • Glenoid Defect/Bony Bankart
  • Greater Tuberosity/Surgical Neck
  • Rotator Cuff Tears
  • Neurological
  • Axilary, Suprascapular, others
  • Seitz 2006

11
Nerve Injury
  • Visser et al. 1999
  • Most common nerves injured are the axillary nerve
    and the suprascapular nerve
  • EMG gt 3 weeks to detect motor lesion
  • NCV gt 7 days to detect a motor lesion
  • 85-100 recovery within 6-12 months
  • Will effect ER and elevation ROM
  • Suspicious
  • Older then 40, have hematoma, or associated
    fracture Seitz 2006

12
Initial Traumatic Dislocation
  • Immobilization
  • Best to immobilize 3 weeks for patients under 30
  • As needed for patients over 30
  • Seitz 2006

13
Circle Concept of Stability
14
Atraumatic
  • Born Loose
  • Overhead Athletes (Swimmers, Gymnasts)
  • Hyperflexible
  • Muscle Imbalances common
  • AMBRI tendency to improve with age
  • Shaffer 2006

15
History
  • Chronic
  • Easy reduction
  • Congenital
  • lt/ 20 years of age
  • most common for start of history
  • traumatic

16
Loose capsule
  • Repetitive strain
  • Rotator interval
  • May be a congenital defect
  • Histological differences
  • More collagen
  • Smaller collagen and less stiff
  • Shaffer 2006

17
Microtraumatic
  • Overhead Athletes
  • Repetitive Tension Overload
  • Stretch out Capsule / Ligaments (IGHL)
  • Erosion of Glenoid / Labrum

18
(No Transcript)
19
Other Causes of Instability
  • Poor Scapulohumeral Rhythm
  • Scapular Dumping

20
Imbalance of Forces
21
Neuromuscular Differences
  • Rotator Cuff
  • Timing Activation
  • Pectoralis Major new and not proven
  • Hyper-Active
  • Passive Tension
  • Shaffer 2006

22
Objective Exam Considerations
  • Fatigue/Endurance
  • Control
  • Macro-instability
  • TUBS do you need to test their laxity/instability?
  • Micro-instability
  • Translation with ER for anterior/inferior and IR
    for posterior
  • Does it decrease the translation
  • If not treatment success will be limited
  • Generalized Ligamentous Laxity

23
Chronicity of Instability
  • Acute vs. Chronic, Recurrent
  • First time vs. Recurrent
  • Frequency (Common vs. Rare)
  • Voluntary or Involuntary

24
Surgery vs. Conservative Treatment 1st time
dislocation
  • Edmonds et al, 2003 - RCT
  • Early arthroscopic stabilization no better than
    immobilization in proprioceptive response
    threshold to detection of passive motion (TTDPM)
    or reproduction of passive positioning (RPP)
  • Kirkly et al, 2005 RCT
  • Significant difference in rate of redislocation
  • No significant difference in shoulder function
  • Recommended early arthroscopic stabilization in
    young athletes, under 30 high level sports
  • Jakobsen et al, 2007
  • Concluded primary repair in active patients was
    indicated to reduce the risk of recurrence

25
Evaluation of Stability
  • A variety of tests that can be performed in
    several positions
  • Find a group of tests that you can perform
    consistently and reliably and use them as your
    core tests
  • Other tests for the suspected condition can be
    used to confirm the Dx if necessary

26
Tests for Inferior Stability
  • Sulcus Sign
  • Indicates MDI
  • SGHL, CHL
  • Inferior directed, long axis traction of the
    humerus
  • tests will display a sulcus sign

27
Tests for Anterior Instability
  • Anterior Apprehension Test
  • Aka Fulcrum test
  • Performed supine or seated
  • Maximum passive ER in the 90-90 position
  • Anterior band of the IGHL is directly anterior to
    the joint
  • Test is apprehension or pain Magee 4th ed.

28
Tests for Anterior Instability
Relocation Test Positive in patients with
congenital laxity or functional
instability/microlaxity
29
Tests for Anterior Instability
Load Shift in seated Supine
30
Load Shift / Drawer Grading
Minimal Translation
Translates to Rim
Perches on the Rim
Dislocates
31
Tests for Anterior Instability
Anterior Drawer in Supine
32
Tests for Posterior Instability
  • Posterior Apprehension
  • Horiz. Adduction 10
  • Posterior load through the elbow
  • Test is apprehension or pain
  • Posterior Load Shift
  • Posterior Glide
  • Test is grade 2 or higher and signs of
    apprehension

33
Tests for Posterior Instability
Posterior Drawer Test
34
Posterior Instability
  • Kim Test
  • Patient is seated with uninvolved side against
    the back of a chair or wall
  • Examiner holds the test arm at 90 applying an
    axial load through the elbow with simultaneous
    upward elevation of 45 at the distal arm.
  • At the proximal arm a inferior and posterior
    force is applied
  • Positive test is pain in the posterior shoulder,
    regardless if there is a clunk
  • Sensitivity 80
  • Specificity 94

Kim et al., AJSM 2005
35
Anterior Dislocations
  • 85 to 90 of all dislocations
  • Typical MOI - combined abduction, extension, and
    external rotation

36
Posterior Dislocations
  • Relatively uncommon - approximately 2
  • More common in impaired populations
  • Typical MOI - axial loading of the abducted,
    internally rotated arm

37
Inferior Dislocations
  • Generally subglenoid with humeral shaft pointing
    overhead
  • Very Rare
  • MOI - Hyperabduction force causes the neck of the
    humerus to impinge on the acromion driving the
    head inferiorly

38
Surgical Procedures
  • Over 150 procedures described
  • Two Major Categories
  • 1) Anatomic
  • 2) Non-anatomic

39
Decision-Making
  • Direction(s) of Instability
  • What degree of trauma lead to instability?
  • What pathology is responsible / involved?
  • Bankart lesion
  • Capsule / G-H ligament insufficiency
  • Large capsular redundancy
  • Bony problems (Hill Sachs or Rim Fx)
  • A combination of the above ...

40
Decision Making
  • Patients Hx (e.g. TUBS vs. AMBRI, recurrent,
    Voluntary Instability)
  • Functional goals (overhead athlete vs. general)
  • Timing of surgery its impact on patients
    quality of life

41
Anatomic Procedures
  • Attempt to restore anatomy to Normal
  • Bankart Repair
  • Capsular Shift
  • Tissue Shrinkage
  • Capsular Plication

42
Non-Anatomic Procedures
  • Designed to alter anatomy to limit translation
  • Shorten Subscapularis tendon
  • Putti-Platt, Magnusum-Stack
  • Osteotomy Procedures
  • Bristow, glenoid/humeral osteotomies

43
Structure Dictates Function
  • Capsular extracapsular contractures common
    (often intentional)
  • Alters normal mechanics / kinematics
  • Increases joint reaction forces
  • Rarely used today (last resort)
  • Function limited, but instability is too!

44
Perthes - Bankart Lesion
  • Detachment of the capsulolabral complex from the
    glenoid neck
  • May include a bony avulsion
  • Associated stretching of the capsule
  • Perthes, 1906 Bankart, 1938

45
Bankart Lesion
  • Increased laxity of the IGHL complex
  • Plastic deformation of the IGHL Bigliani, 1998
  • Positive Clunk test indicative of Bankart Lesion
  • Most common anterior inferior (3-7 PM)

46
Bony Bankart
  • With bony lesion the benefit of glenoid
    retroversion and the articular surface is reduced
  • Large defect - not repaired
  • significant increase in recurrence of instability
  • lose available ER ROM

Seitz, 2006
47
Procedure- Open Bankart Repair
  • Visualization
  • subscapularis is violated
  • Fixation
  • suture anchors (2 or 3) along the glenoid rim
  • reattach the soft tissue to glenoid

48
Open Bankart Repair
  • Methods of gaining exposure to capsule
  • 1) Subscapularis taken-down
  • 2) Proximal 2/3 of Subscapularis tendon
    divided vertically
  • 3) Subscapularis split and retracted

49
TAKEN
DOWN
50
SPLIT
51
Anterior-Inferior Capsular Shift
  • Indications
  • Chronic, recurrent instability
  • Multidirectional
  • Hx of voluntary instability
  • Unidirectional w/ clear capsular component
  • Revisions

52
Capsular Shift
  • Advantages
  • Addresses capsular laxity directly (MDI)
  • Get a good idea of your repair in OR
  • Effective

53
Capsular Shift
  • Disadvantages
  • Invasive (Increased pain inflammation)
  • Poorer cosmesis
  • More prone to motion loss (scarring)
  • Greater risk of complications
  • Subscapularis compromise

54
Capsular Shift
  • Visualization
  • Same as Open Bankart Repair
  • Fixation
  • Same as Open Bankart Repair

55
Hill-Sachs Lesion
  • Re-occurrence of dislocation is greater with a
    Hill-Sachs Lesion then without
  • Size of lesion increases risk with increased size

56
SLAP Lesions
  • Superior
  • Labrum
  • Anterior
  • Posterior

57
1000
Posterior
Anterior
200
58
SLAP Lesions
  • 4 Types
  • MOI
  • Repetitive biceps contraction
  • Compressed loading of the shoulder in flexion /
    abduction
  • Traction injury
  • Snyder et al, Arthroscopy, 1990
  • Peel Back
  • Tight Posterior Capsule/Muscle tightness
  • Shaffer, 2006

59
Type I SLAP
  • Marked fraying of the superior labrum, but rim
    is firmly attached (11)

60
Type II SLAP
  • Superior Labrum and attached Biceps tendon
    stripped off underlying glenoid (41)

61
Type III SLAP
  • Bucket-handle tear of the superior labrum
  • with displacement of central portion into joint
    (33)

62
Type IV SLAP
  • Bucket-handle tear of the superior labrum with
    extension into the biceps tendon (15)
  • -tendon splits

63
Tests for SLAP Lesions
  • OBriens Test
  • Differential Diagnosis
  • AC joint pathology
  • Rotator Cuff Pathology
  • SLAP lesion
  • Biceps Load Test II
  • Speeds Test
  • Differential Diagnosis
  • Biceps Tendonitis
  • Slap Lesion

64
OBriens Test
  • Part 1
  • Flexed 90 with elbow extended and horizontal
    adduction 10, maximum medial rotation
  • Examiner applies a downward force
  • Part 2
  • Same position with the forearm fully supinated
  • Positive if pain elicited in part 1 and reduced
    in part 2

65
Biceps Load Test II
  • Patient is supine
  • Arm elevated 120, maximal ER, elbow to 90
    flex., and forearm supinated
  • Perform resisted elbow flexion
  • for increased pain
  • Kim et al., 2001
  • On 127 patients, double blind
  • Confirmed arthroscopically
  • Sensitivity of 89.7
  • Specificity of 96.9

66
HAGL Lesion
  • Humeral
  • Attachment
  • Glenohumeral
  • Ligament

Midsubstance GHL tears are rare, but do occur
67
Rehabilitation post surgery
  • Judicious joint mobilization and PROM
  • Normal ROM?
  • Total Motion Concept
  • Pitchers shift in ROM
  • Greater ER and less IR than their other arm
  • Total arc from ER to IR is symmetrical
  • GIRD
  • Loss of 20 IR at risk of painful shoulder

68
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