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Rawal A, Eckers F, Lee OSH, Hochreiter B, Wang KK, Ek ET. Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population. J Clin Med 2024; 13:724. [PMID: 38337418 PMCID: PMC10856087 DOI: 10.3390/jcm13030724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.
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Affiliation(s)
- Aziz Rawal
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
| | - Franziska Eckers
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Olivia S. H. Lee
- Victorian Paediatric Rehabilitation Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, 8006 Zürich, Switzerland
| | - Kemble K. Wang
- Department of Orthopaedic Surgery, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Surgery, Monash University, Melbourne, VIC 3800, Australia
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2
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Wilk KE, Thomas ZM, Mangine RE, Fuller P, Davies GJ. Neurocognitive and Reactive Return to Play Testing Protocol in Overhead Athletes Following Upper Extremity Injury. Int J Sports Phys Ther 2023; 18:1364-1375. [PMID: 38050554 PMCID: PMC10693490 DOI: 10.26603/001c.89926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023] Open
Abstract
The incidence of upper extremity (UE) injuries in sport, particularly with the shoulder and elbow in baseball/softball players, appears to be increasing yearly, especially in younger age athletes. Improving the objective criteria and testing methods used to determine return to play (RTP) readiness following non-operative or post-operative management of UE injuries is one aspect of the rehabilitation process that may significantly help in reducing reinjury rates. Currently, the majority of clinicians are still using post operative time frame and/or strength/range of motion as their main criteria for clearance to RTP following UE injury. This demonstrates an inadequate reflection of the actual unpredictable, dynamic environment athletes are returning to participate in. In our clinical experiences, objective testing to allow for clearance to sport participation should incorporate neurocognitive and reactive testing to promote improvements in the athlete's ability to dual task and focus/concentrate on the multi-dimensional tasks at hand. We know that neuroplastic changes occur following UE injury resulting in decreased proprioception and increased motor activation with simple UE tasks. Currently the research on UE return to play testing is limited. The purpose of this clinical commentary was to describe the utilization and provide reference values for a series of reactive neurocognitive UE tests, to assist with RTP, in high school and collegiate overhead athletes (baseball and softball) utilizing the Blaze Pod light system. The use of a more dynamic reactive testing battery may decrease the reinjury rates when an athlete is cleared for participation by measuring readiness in chaotic circumstances that are more reflective of the sporting environment the athlete is working to return to resulting in a greater sense of confidence, performance and prevention of reinjuries.
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Affiliation(s)
- Kevin E Wilk
- Champion Sports Medicine
- American Sports Medicine Institute
| | | | | | | | - George J Davies
- Georgia Southern University
- Coastal Therapy & Sports Rehab
- Gundersen Health System Sports Medicine
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Watson L, Pizzari T, Balster S, Lenssen R, Warby SA. Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint. J Clin Med 2022; 11:5140. [PMID: 36079068 PMCID: PMC9456769 DOI: 10.3390/jcm11175140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 08/28/2022] [Indexed: 11/16/2022] Open
Abstract
Multidirectional instability (MDI) of the glenohumeral joint refers to symptomatic subluxations or dislocations in more than one direction. The aetiology of MDI is multifactorial, which makes the classification of this condition challenging. A shoulder rehabilitation program is the initial recommended treatment for MDI, however available rehabilitation programs have varying levels of evidence to support their effectiveness. In 2016, we published the details of an evidence-based program for MDI that has been evaluated for efficacy in two single-group studies and a randomised controlled trial. In 2017, we published a clinical commentary on the aetiology, classification, and treatment of this condition. The aim of this paper is to provide an update on the components of these publications with a particular focus on new advances in the non-operative management of this condition.
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Affiliation(s)
- Lyn Watson
- Melbourne Shoulder Group, 305 High Street, Prahran, VIC 3181, Australia
| | - Tania Pizzari
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, La Trobe University, Corner of Kingsbury Drive and Plenty Road Bundoora, Bundoora, VIC 2080, Australia
- Mill Park Physiotherapy, 22/1 Danaher Dr, South Morang, VIC 3752, Australia
| | - Simon Balster
- Melbourne Shoulder Group, 305 High Street, Prahran, VIC 3181, Australia
| | - Ross Lenssen
- Melbourne Shoulder Group, 305 High Street, Prahran, VIC 3181, Australia
| | - Sarah Ann Warby
- Melbourne Shoulder Group, 305 High Street, Prahran, VIC 3181, Australia
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, La Trobe University, Corner of Kingsbury Drive and Plenty Road Bundoora, Bundoora, VIC 2080, Australia
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Housset V, Nourissat G. Arthroscopic Capsular Plication for Multidirectional Shoulder Instability in Hypermobile Ehlers-Danlos Syndrome Patients. Arthrosc Tech 2021; 10:e2767-e2773. [PMID: 35004159 PMCID: PMC8719266 DOI: 10.1016/j.eats.2021.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/13/2021] [Indexed: 02/03/2023] Open
Abstract
Patients with hypermobile Ehlers-Danlos syndrome commonly present with painful shoulder disorders mostly represented by a multidirectional instability and with often painless episode of atraumatic shoulder dislocation and/or subluxation. Because of the generalized soft tissue fragility, most of the surgical treatments of shoulder instability, as the Bankart repair or the Latarjet procedure becomes not effective, exposing a risk of failure. Then, capsular plication has to be considered in order to reduce the articular joint volume and to diminish the mobility of the joint. Two main benefits of this surgical procedure are that it doesn't modify the anatomy or damage the labrum or cartilage that is healthy. The purpose of this Technical Note is to present the arthroscopic capsular plication for the treatment of patient with hypermobile Ehlers-Danlos syndrome, which is associated with a multidirectional shoulder instability.
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Affiliation(s)
- Victor Housset
- Clinique Maussins-Nollet, Sorbonne Université, Paris, France,Address correspondence to Victor Housset, M.D., Clinique Maussins-Nollet, Sorbonne Université, Paris, France.
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Postoperative Rehabilitation of Multidirectional Instability Surgery: A Systematic Review. Sports Med Arthrosc Rev 2021; 29:88-93. [PMID: 33972485 DOI: 10.1097/jsa.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multidirectional instability (MDI) of the shoulder is managed with surgery when conservative rehabilitation fails. The optimal postsurgical management of MDI is not well understood. The purpose of this study is to create a systematic review evaluating postsurgical rehabilitation protocols treating MDI. Articles were included if a postsurgical rehabilitation protocol was described following surgical treatment for MDI. Identified articles underwent 2 phases of screening by blinded team members. Remaining articles had their level of evidence determined by a predefined grading system, ranging from levels I to V. Articles with evidence levels I to IV were included in analysis. Of the 163 articles identified in the literature, 9 were included in this study. Surgical techniques examined in these articles include capsular plication, rotator interval closure, and capsular shift. Rehabilitation protocols were evaluated for duration of treatment and physical therapy modalities. Article results were evaluated for subjective and objective measures of protocol success. Overall, there is a lack of evidence to indicate the optimal rehabilitation protocol post-MDI surgery. Further research is needed to compare rehabilitation protocols following specific surgical procedures to determine their effect on postsurgical patient outcomes.
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Frank RM, Romeo AA, Bush-Joseph CA, Bach BR. Injuries to the Female Athlete in 2017: Part II: Upper and Lower-Extremity Injuries. JBJS Rev 2019; 5:e5. [PMID: 29028751 DOI: 10.2106/jbjs.rvw.17.00031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Rachel M Frank
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Charles A Bush-Joseph
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Bernard R Bach
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Kraeutler MJ, Aberle NS, Brown CC, Ptasinski JJ, McCarty EC. Clinical Outcomes and Return to Sport After Arthroscopic Anterior, Posterior, and Combined Shoulder Stabilization. Orthop J Sports Med 2018; 6:2325967118763754. [PMID: 29637085 PMCID: PMC5888826 DOI: 10.1177/2325967118763754] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Glenohumeral instability is a common abnormality, especially among athletes. Previous studies have evaluated outcomes after arthroscopic stabilization in patients with anterior or posterior shoulder instability but have not compared outcomes between groups. Purpose: To compare return-to-sport and other patient-reported outcomes in patients after primary arthroscopic anterior, posterior, and combined anterior and posterior shoulder stabilization. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary arthroscopic anterior, posterior, or combined anterior and posterior shoulder stabilization were contacted at a minimum 2-year follow-up. Patients completed a survey that consisted of return-to-sport outcomes as well as the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Sur’geons (ASES) score, and Shoulder Activity Scale. Results: A total of 151 patients were successfully contacted (anterior: n = 81; posterior: n = 22; combined: n = 48) at a mean follow-up of 3.6 years. No significant differences were found between the groups with regard to age at the time of surgery or time to follow-up. No significant differences were found between the groups in terms of WOSI (anterior: 76; posterior: 70; combined: 78; P = .28), SANE (anterior: 87; posterior: 85; combined: 87; P = .79), ASES (anterior: 88; posterior: 83; combined: 91; P = .083), or Shoulder Activity Scale (anterior: 12.0; posterior: 12.5; combined: 12.5; P = .74) scores. No significant difference was found between the groups in terms of the rate of return to sport (anterior: 73%; posterior: 68%; combined: 75%; P = .84). Conclusion: Athletes undergoing arthroscopic stabilization of anterior, posterior, or combined shoulder instability can be expected to share a similar prognosis. High patient-reported outcome scores and moderate to high rates of return to sport were achieved by all groups.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, Seton Hall-Hackensack Meridian School of Medicine, South Orange, New Jersey, USA
| | | | - Colin C Brown
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joseph J Ptasinski
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Mapping glenohumeral laxity: effect of capsule tension and abduction in cadaveric shoulders. J Shoulder Elbow Surg 2018; 27:624-634. [PMID: 29269137 DOI: 10.1016/j.jse.2017.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/04/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder capsular plication aims to restore the passive stabilization of the glenohumeral capsule; however, high reported recurrence rates warrant concern. Improving our understanding of the clinical laxity assessment across 2 dimensions, capsular integrity and shoulder position, can help toward the standardization of clinical tools. Our objectives were to test and describe glenohumeral laxity across 5 capsular tension levels and 4 humeral position levels and describe tension-position interplay. METHODS We tested 14 dissected cadavers for glenohumeral laxity in 5 directions: anterior, posterior, and inferior translation, and internal and external axial rotation. Laxity was recorded across capsule tension (baseline, stretched, 5 mm, 10 mm, and 15 mm of plication) and position (0°, 20°, 40°, 60° of scapular abduction). Repeated-measures analysis of variance with post hoc contrasts tested the effect of tension, position, and composite tension × position on laxity. RESULTS Capsule tension, position, and composite interplay had a statistically significant, although unequal, effect on laxity in each direction. Laxity was consistently overconstrained in 15-mm plication and was overall greatest in 20° and lowest in 60°. Restoration occurred most in 10 mm, but this depended on the position. The composite effect was significant for external and internal rotation and inferior laxity, but laxity at the middle range (20° or 40°) was different than at the end range (0° or 60°) for all directions. CONCLUSIONS On average, laxity was restored to baseline tension after 10-mm plication, but this determination varied depending on shoulder position. Middle-range laxity behaved differently than end-range laxity across plication tensions. This information is useful in understanding the unstable shoulder as well as for standardizing clinical laxity assessment.
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Frangiamore SJ, Mannava S, Godin JA, Anavian J, Fritz EM, Millett PJ. Arthroscopic Pancapsular Shift With Labral Repair for Multidirectional Instability of the Shoulder. Arthrosc Tech 2017; 6:e1113-e1117. [PMID: 29354405 PMCID: PMC5621849 DOI: 10.1016/j.eats.2017.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/30/2017] [Indexed: 02/03/2023] Open
Abstract
Initial treatment of shoulder multidirectional instability (MDI) consists of nonoperative modalities of physical therapy and rehabilitation; if this fails, surgical treatment can become necessary. MDI of the shoulder can be challenging to manage in individuals who fail conservative management. Historically, surgical treatment for MDI has been open capsular plication; however, arthroscopic capsular plication has now become the standard of care, with outcomes similar to the open procedure. The purpose of this article and Video 1 is to describe our arthroscopic technique for pancapsular shift with labral repair.
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Affiliation(s)
- Salvatore J. Frangiamore
- Steadman Clinic, Vail, Colorado, U.S.A.,Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Sandeep Mannava
- Steadman Clinic, Vail, Colorado, U.S.A.,Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jonathan A. Godin
- Steadman Clinic, Vail, Colorado, U.S.A.,Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jack Anavian
- Steadman Clinic, Vail, Colorado, U.S.A.,Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Erik M. Fritz
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Peter J. Millett
- Steadman Clinic, Vail, Colorado, U.S.A.,Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Address correspondence to Peter J. Millett, M.D., M.Sc., The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, U.S.A.The Steadman ClinicSteadman Philippon Research Institute181 West Meadow DriveSuite 400VailCO81657U.S.A.
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Gervasi E, Sebastiani E, Cautero E, Spicuzza A. Arthroscopic treatment of the atraumatic shoulder instability: a case series with two-year follow-up evaluation. Muscles Ligaments Tendons J 2017; 6:433-439. [PMID: 28217563 DOI: 10.11138/mltj/2016.6.4.433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this work is to evaluate the results of arthroscopic capsulolabroplasty in patients affected by atraumatic shoulder instability (ASI). METHODS A retrospective review was performed of 10 patients (7 women and 3 men) who underwent arthroscopic treatment of symptomatic ASI. Mean age at evaluation was 27.9 (19-35) years and the mean follow-up was 23.3 (12-37) months. We evaluated recurrence rate, range of movement, apprehension and relocation tests, hyperlaxity, and sport activity. The ASES score, the Rowe score, the Simple Shoulder Test (SST) and Visual Analogue Scale (VAS) were also used as outcomes measure. RESULTS None of the patients experienced episodes of dislocation or subluxation after surgery. The apprehension and relocation tests produced positive results in 2 patients. Six out of 10 patients reported apprehension with the arm in specific positions. The ASES mean score was 93.4 (55-100); the Rowe mean score was 85.5 (70-100); the SST mean score was 9.1 (5.8-10). On average, external rotation is reduced by 10° in adduction, and by 8° in abduction in 6 out of 10 patients; internal rotation is reduced on average by 6.6° in abduction with the arm abducted, and was overall limited in 6 out of 10 patients. CONCLUSIONS Arthroscopic capsulolabroplasty ensures excellent results in patients showing atraumatic shoulder instability in terms of recurrence. Still, an underlying insecurity persists and the risk of residual stiffness is tangible. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Enrico Gervasi
- Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (UD), Italy
| | - Enrico Sebastiani
- Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (UD), Italy
| | - Enrico Cautero
- Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (UD), Italy
| | - Alessandro Spicuzza
- Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (UD), Italy
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