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Shoulder Instability
From WikiSM
(Redirected from Glenohumeral Instability)
Contents
Other Names
- Glenohumeral Instability
- Anterior Shoulder Instability
- Multidirectional Instability
- MDI
- Unidirectional Shoulder Instability
- Traumatic Shoulder Instability
- Atraumatic Shoulder Instability
Background
- This page refers to multidirectional instability (MDI), chronic subluxation and recurrent dislocations of the Glenohumeral Joint
- Acute shoulder dislocation is discussed elsewhere
- There is no clear definition of MDI, glenohumeral instability and shoulder instability is variable in the literature
- For MDI, sometimes the sensation of instability occuring in more than one direction is sufficient
- This is not commonly agreed upon by experts
History
- MDI first described by Neer and Foster in 1980[1]
Epidemiology
- General
- Prevalence of non-pathologic hyperlaxity in the general population is estimated to be between 5 and 15%[2]
- MDI
- Incidence, prevalence largely unknown
- 2008: 7% of shoulder operations in Norway due to MDI[3]
- Most commonly seen in patients in their 2nd and 3rd decade (need citation)
- Traumatic instability
Pathophysiology
- There is no clear definition of MDI, glenohumeral instability and shoulder instability in the literature
- No pathognomonic finding or widely standardized diagnostic criteria
- Some literature references the Del Mar and Beighton scoring systems (see below), but these are not universally adopted
- For MDI, some cite instability in two directions
- Subsequently diagnosis, research, practice guidelines are lacking
- In general, shoulder instability is pathological condition characterized by increased length and elasticity of normal glenohumeral joint restraints
- Indicates deficiency in static or dynamic stabilizers of the glenohumeral joint
- Subsequently, there is increased translation of the articular surface
- In MDI, this can be from repetative microtrauma or overall joint hyperlaxity
- This can also occur due to primary trauma from shoulder dislocation
- Hyperlaxity by itself is not pathologic
- May be present in asymptomatic patients or asymptomatic translation of the glenohumeral joint
- Patients with anterior traumatic shoulder instability without true hyperlaxity
- Can experience recurrent dislocations and subluxations due to primary injury to the capsulolabral complex, glenoid or humeral head
- Patients with shoulder instability and hyperlaxity are more likely to experience recurrent subluxations than frank dislocations[6]
- Due to microtrauma from overuse
Etiology
- Typical etiology includes repetitive microtrauma imposed on a congenitally lax joint[7]
- Some degree of imbalance in muscle strength, neuromuscular control and dysfunction scapular biomechanics
- Most common mechanism for initial anterior dislocation is fall onto outstretched arm with abducted, externally rotated arm
Pathoanatomy
- Glenohumeral Joint
- Static stabilizers
- Bony structures
- Ligaments
- Negative intra-articular pressure
- Dynamic Stabilizers
- Rotator Cuff
- Long head of the Biceps Brachii
- Periscapular muscles
Associated Injuries
- Glenohumeral Dislocation
- Scapular Dyskinesis
- Bankart Lesion
- Kim Lesion
- Rotator Cuff Tendonitis (compensatory)
Risk Factors
- Prior Injury (greatest risk)[8]
- Age of first dislocation
- Congenital Hyperlaxity/ Ligamentous laxity including
- Ehler's Danlos Syndrome
- Marphan Syndrome
- Osteogenesis Imperfecta
- Benign Hypermobility Syndrome
- Age
- Labral hypoplasia[9]
- Glenoid size
- Modifiable
- Rotator cuff strength
- Muscular imbalance
- Activity level
- Acquired hyperlaxity from Sports
- Volleyball
- Swimming
- Gymnastics
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
- History
- Important to clarify history of dislocations, subluxations or sensation of laxity
- Any history of developmental delay, seizure disorder, collagen disorder, congenital problems
- Clarify if the patient can volitionally dislocate their shoulder
- Symptoms may include vague shoulder pain with sports or demanding activities
- May endorse recurrent dislocations and/or subluxations
- In atraumatic cases, pain is usually insidious in onset
- Patients may endorse declining athletic performance
- Less commonly parasthesias, weakness
- Symptoms may occur while sleeping
- Physical Exam: Physical Exam Shoulder
- Important to compare to contralateral arm
- Examination is best performed through provocative testing
- Special Tests
- Internal Rotation Resistance Test: Arm abducted to 90°, internally and externally rotate against resistance
- Crank Test: Hyper-abducted shoulder, axial load on humerus with internal and external rotation
- OBriens Test: Shoulder flex to 90°, upward force against resistance in supination and pronation
- Passive Compression Test: Arm abducted to 30°, externally rotated, axial load into joint with extension
- Dynamic Labral Shear Test: Externally rotate arm and abduct to 90°, bring form 90-120° to reproduce symptoms
- Anterior Instability/ Laxity
- Apprehension Test: Flexes elbow to 90°, abduct shoulder to 90°, slowly externally rotate shoulder
- Jobe Relocation Test: Supine with abducted, externally rotated shoulder and a posterior force
- Load and Shift Test: Arm slightly abducted, apply anterior-posterior force to humeral head assessing translation
- Anterior Shoulder Drawer Test: Arm abducted and externally rotated, try to pull humeral head anterior
- Shoulder Fulcrum Test: Fist under shoulder, passively rotate arm and fatigue subscapularis
- Anterior Release Test: similar to apprehension, provide a relocation force to humeral head
- Posterior Instability/ Laxity
- Kim Test: Arm abducted to 90°, apply axial load and elevate arm cranial and anterior
- Jerk Test: Arm abducted to 90°, internally rotated with axial load and arm is abducted anteriorly in same plane
- Posterior Apprehension Test: Apply a posterior force through flexed, adducted shoulder
- Posterior Shoulder Drawer Test: with arm flexed and in partial traction, apply a posterior directed force
- Inferior laxity Instability/ Laxity
- Sulcus Sign: Place axial traction on affected limb with arm resting at side
- Gagey Test: Hyperabduct arm to barrier or as patient tolerates
Evaluation
Radiographs
- Start with Standard Radiographs Shoulder
- Frequently normal
- May show Hill Sachs Lesion
- May show Bankart Lesion
CT
- Helpful to better evaluate bone abnormalities
MRI
- Best imaging modality for soft tissue pathology
- Can add arthrogram to better evaluate labrum and capsule
- MDI: Hallmark finding is pathologic inferior capsule (IGHL, anterior and posterior bands)
- May also show Bankart Lesion, Kim Lesion
Classification
Hospital Del Mar Score
- Can be used to assess, quantify hyperlaxity[10]
- Score ranges from 0-10
- Score of 4/10 (men) or 5/10 (women) or higher suggests generalized joint laxity
- Criteria
- Passive hyperextension of the metacarpophalangeal joint of the little finger of 90° or more
- Passive apposition of the thumb to the flexor aspect of the forearm at less than 21 mm
- Passive elbow hyperextension of 10° or more
- Passive shoulder external rotation of 85° or more
- Passive hip abduction of 85° or more
- Hyperextension of the first metatarsophalangeal joint beyond 90°
- Patellar hypermobility, defined as excessive passive displacement medially and laterally as assessed by three or more quadrants of displacement
- Excessive range of passive ankle dorsiflexion and eversion of the foot with the knee flexed to 90°
- Passive knee hyperflexion, defined as ‘knee makes contact with the buttock’
- Appearance of ecchymoses after hardly noticed, minimal trauma (historical datum)
Beighton Criteria
- Scoring system for hyperlaxity and shoulder instability[11]
- Score ranges from 0-9
- Score of 2+ increases likelihood of future instability
- Ranallette et al: Score of 6 or greater indicative of hyperlaxity[12]
- Criteria
- Passive dorsiflexion of the fifth finger beyond 90°
- Passive thumb opposition to the forearm
- Active elbow hyperextension beyond 10°
- Active knee hyperextension beyond 10°
- Forward flexion of the trunk with knees fully extended so that the palms of the hands rest flat on the floor.
Management
Prognosis
- Age of first dislocation is important prognostic indicator[13]
- Dislocation under 20 years of age, 90% recurrence rate
- Dislocation over 40, 10% recurrence rate
- MDI
- Conservative management strategies have had inconsistent results, some positive and some negative.
Nonoperative
- Indications:
- First line therapy in most cases
- Activity modification
- Physical Therapy
- Strengthening dynamic stabilizers compensates for lack of stability in passive stabilizers[14]
- Emphasis on strengthening Rotator Cuff, functional reduction of instability
- Scapulothoracic training, core stability, proprioceptice exercise programs
- Equipment: Shoulder Harness
Operative
- Indications
- Failure of conservative therapy
- Unidirectional instability
- Technique
- MDI: inferior capsular shift, arthroscopic plication, thermal capsulorrphaphy
- Others: glenoid osteotomy, labral augmentation, capsuloligamentous reconstruction
- Surgical management should be individualized to address underlying cause of instability
- In 98% of MDI cases, there are no pathognomonic findings on arthroscopy[15]
Rehab and Return to Play
Rehabilitation
- Strengthening dynamic stabilizers compensates for lack of stability in passive stabilizers[16]
- Emphasis on strengthening Rotator Cuff, functional reduction of instability
- Scapulothoracic training, core stability, proprioceptice exercise programs
Return to Play
- Systematic review: 60% of athletes returned to sport at the same level, 34% to a lower level and 2% did not return to sport[17]
Complications
- Athletes with pathologic hyperlaxity or hypermobility are at risk of injury to other joints[18]
- Including knee, ankle injuries
- Surgical
- Iatrogenic hyperlaxity after surgical procedures is high, ranging from 61-100%[19]
- Recurrent instability
- Subscapularis Deficiency
- Loss of range of motion (overtightening of capsule)
- Axillery Nerve Injury
- Glenohumeral Arthritis
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Alpert, Joshua M., et al. "Arthroscopic treatment of multidirectional shoulder instability with minimum 270 labral repair: Minimum 2-year follow-up." Arthroscopy: The Journal of Arthroscopic & Related Surgery 24.6 (2008): 704-711.
- ↑ Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature. J Rheumatol. 2007;34:804–809.
- ↑ Blomquist, Jesper, et al. "Shoulder instability surgery in Norway: the first report from a multicenter register, with 1-year follow-up." Acta orthopaedica 83.2 (2012): 165-170.
- ↑ Owens, BD, Duffey, ML, Nelson, BJ, DeBerardino, TM, Taylor, DC, Mountcastle, SB. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007;35(7):1168-1173.
- ↑ Simonet WT, Melton LJ, Cofield RH, Ilstrup DM. Incidence of anterior shoulder dislocation in Olmsted County, Minnesota. Clin Orthop Relat Res. 1984;186:186–91.
- ↑ An YH, Friedman RJ. Multidirectional instability of the glenohumeral joint. Orthop Clin North Am. 2000;31:275–285.
- ↑ Warby, Sarah A., et al. "The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review." Journal of shoulder and elbow surgery 23.1 (2014): 128-142.
- ↑ Cameron, KL, Mountcastle, SB, Nelson, BJ. History of shoulder instability and subsequent injury during four years of follow-up: a survival analysis. J Bone Joint Surg Am. 2013;95(5):439-445
- ↑ Doukas, William C., and Kevin P. Speer. "Anatomy, pathophysiology, and biomechanics of shoulder instability." Orthopedic Clinics 32.3 (2001): 381-391.
- ↑ Bulbena A, Duró JC, Porta M, et al. Clinical assessment of hypermobility of joints: assembling criteria. J Rheumatol. 1992;19:115–122
- ↑ Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51:444–453.
- ↑ Ranalletta M, Bongiovanni S, Suarez F, et al. Do patients with traumatic recurrent anterior shoulder instability have generalized joint laxity? Clin Orthop Relat Res. 2012;470:957–960
- ↑ c LH, Cavallaro WU. Primary anterior dislocation of the shoulder. Am J Surg. 1950;80(6):615–21. passim.
- ↑ Beasley L, Faryniarz DA, Hannafin JA. Multidirectional instability of the shoulder in the female athlete. Clin Sports Med 2000;19:331–49
- ↑ Choi, C. H., and D. J. Ogilvie-Harris. "Inferior capsular shift operation for multidirectional instability of the shoulder in players of contact sports." British journal of Sports medicine 36.4 (2002): 290-294.
- ↑ Beasley L, Faryniarz DA, Hannafin JA. Multidirectional instability of the shoulder in the female athlete. Clin Sports Med 2000;19:331–49
- ↑ Longo, Umile Giuseppe, et al. "Multidirectional instability of the shoulder: a systematic review." Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.12 (2015): 2431-2443.
- ↑ Decoster LC, Bernier JN, Lindsay RH, et al. Generalized joint hypermobility and its relationship to injury patterns among NCAA lacrosse players. J Athl Train. 1999;34:99–105
- ↑ Boileau P, Richou J, Lisai A, et al. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy. 2009;25:1075–1084.
Created by:
John Kiel on 17 June 2019 19:16:59
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Last edited:
1 October 2022 19:06:12
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