An overview of shoulder instability and its management

Recurrent Anterior Shoulder Dislocation with Coracoid Fracture in an Old Age Male: A Rare Case Report

Introduction

Anterior shoulder dislocation is a common pathology in young males with less prevalence in other age groups. Anterior shoulder dislocation being the most common variety of dislocation among the shoulder dislocation can be managed both conservatively and surgically. Recurrent anterior dislocation in middle-aged males with a coracoid fracture is a rare entity and should be managed with proper pre-operative planning including computed tomography (CT) scan, magnetic resonance imaging (MRI), and surgery.

Case Report

A 65-year-old male is a known case of recurrent anterior dislocation presented with anterior shoulder dislocation 1½ years back. Closed reduction was done. Radiological evaluations such as CT scan and MRI were done which were suggestive of bony Bankart and coracoid fracture which was managed with open Latarjet procedure.

Conclusion

Recurrent anterior shoulder dislocation with a concomitant coracoid fracture is a rare entity in old age, which can be managed with a Latarjet procedure and has a good post-operative outcome.

Source-Dependent Quality Variation in Shoulder Dislocation Videos on YouTube

Purpose

To assess the quality of YouTube videos for patient education on shoulder dislocation.

Methods

A standard YouTube search was performed in March 2023 using the terms "shoulder dislocation," "dislocated shoulder," and "glenohumeral joint dislocation" to identify eligible videos. Multiple scoring systems, including DISCERN (a validated tool for analyzing the quality of health information in consumer-targeted videos), Journal of the American Medical Association (JAMA) Benchmark Criteria, and the Global Quality Score (GQS) were used to evaluate the videos. Video quality scores from various sources were compared using the Kruskal-Wallis test for initial analysis, followed by Dunn's post-hoc test with Bonferroni correction, and the strength of relationship between variables was assessed using Spearman's rank correlation coefficient.

Results

A total of 162 eligible videos were identified. The mean video duration was 11.38 ± 3.01 minutes, the median number of views was 653. Median number of days since upload was 1,972, the median view rate was 0.343, and median number of likes was 66.12. Based on the DISCERN classification, a substantial proportion of videos were classified as insufficient quality, with 19.4% as "very insufficient" and 42.1% as "insufficient"; 24.1% were classified as "average" quality, whereas only 13.1% were classified as "good" and 1.2% were "excellent." Videos from academic and professional sources showed a significant positive correlation with DISCERN scores (rho: +0.784, P < .001) and greater scores on all 4 scoring systems compared to health information websites.

Conclusions

This study reveals that the majority of YouTube videos on shoulder dislocation lack sufficient quality for patient education, with content quality significantly influenced by the source.

Clinical Relevance

Examining the accuracy of information that patients encounter on YouTube is essential for health care providers to direct individuals toward more reliable sources of information.

Anatomy features of the shoulder joint in asymptomatic chinese Han adults

BACKGROUND

To evaluate the shoulder anatomical characteristics in asymptomatic Chinese adults.

METHODS

The prospective study enrolled individuals without shoulder pain at Beijing Tiantan Hospital Affiliated to Capital Medical University between January 2019 and January 2020. Six radiographic parameters were measured and analyzed, including glenoid plane to the acromion (GA), glenoid plane to the lateral aspect of the humeral head (GH), acromion index (AI), lateral acromial angle (LAA), acromion-humeral interval (AHI), and critical shoulder angle (CSA).

RESULTS

103 participants (51 males and 52 females) were enrolled. The mean values of GA, GH, AI, CSA, LAA, and AHI were 32.88 ± 5.68 mm, 47.16 ± 4.82 mm, 0.70 ± 0.11, 37.45 ± 6.00°, 6.32 ± 3.99°, and 9.611.86 mm, respectively. Females had lower GA (30.78 ± 5.06 vs. 35.01 ± 5.51 mm, P < 0.001) and GH (44.28 ± 3.67 vs. 50.11 ± 4.02 mm, P < 0.001) than males and LAA was significantly smaller in the Bigliani flat type compared with the curved type and the hooked type (5.07 ± 2.31° vs 12.33 ± 5.46°vs 10.00 ± 3.37, P = 0.001).

CONCLUSIONS

Females had lower GA and GH than males in asymptomatic Chinese Han adults. Asymptomatic Chinese Han subjects with Bigliani flat type had lower LAA. CSA appears lager in Chinese Han individuals. Curve type of acromion performed lager LAA. The results may help establish an anatomical model of the shoulder joint and elucidate the anatomy features of the shoulder joint in asymptomatic Chinese Han adults.

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

Management of atraumatic shoulder instability in physiotherapy (MASIP): a survey of physiotherapy practice

BACKGROUND

The impact of atraumatic shoulder instability (ASI) on patients can be extensive, its management complex, with a biopsychosocial approach recommended. Currently how physiotherapists manage ASI is unknown or the extent to which current clinical practice aligns with existing evidence. At the time of this study no national guidelines or consensus to direct practice existed.

METHODS

A cross-sectional electronic survey was distributed between July-September 2018, targeting UK-based physiotherapists managing shoulder pathology. Respondents were invited to describe their management of ASI, and rate their awareness and utilisation of various treatment techniques on a Likert-scale; median and interquartile ranges were calculated. Free text survey items were analysed using quantitative content analysis (QCA) to identify codes and categories. Means and percentages were calculated to summarise QCA and descriptive data.

RESULTS

Valid survey responses were analysed (n = 135). Respondents had between 2 and 39 years of physiotherapy experience (mean = 13.9 years); the majority (71.1 %) reported that ASI made up < 10 % of their caseload. Only 22.9 % (n = 31/135) of respondents reported feeling 'very confident' in managing ASI; the majority feeling 'somewhat confident' (70.4 %, n = 95/135) or 'not confident' (6.7 %, n = 9/135). The majority of respondents (59.3 %) used an ASI classification system, > 90 % citing the Stanmore Classification. Physiotherapists adapted their management according to clinical presentation, responding to differing biopsychosocial needs of the patient scenario. Most respondents (> 80 %) did not use a protocol to guide their management. Exercise was the most utilised management approach for ASI, followed by education; novel treatment strategies, including cortical rehabilitation, were also reported.

CONCLUSION

Findings indicate physiotherapists utilise a wide range of treatment strategies and respond to biopsychosocial cues when managing patients with ASI. The majority reported not being very confident in managing this condition, however only a minority use rehabilitation protocols to support their management. Some interventions that respondents reported using lacked evidence to support their use in ASI management and further research regarding effectiveness is required. Guidelines have been published since this survey; the impact of these will need evaluating to determine their effectiveness in the future.

Glenohumeral Joint Instability: A Review of Anatomy, Clinical Presentation, and Imaging

The glenohumeral joint is intrinsically predisposed to instability because of the bony anatomy but maintained in alignment by many important structures, including the glenoid labrum, glenohumeral ligaments (GHLs), and muscles and tendons. Trauma and overuse can damage these stabilizers, which may then lead to subluxation or dislocation and eventually recurrent instability. This is most common in the anterior direction, which has several recognizable patterns of injury on advanced imaging, including humeral Hill Sachs deformities, bony Bankart lesion of the anteroinferior glenoid, soft tissue Bankart lesions, Bankart variant lesions (Perthes and ALPSA lesions), and HAGL/GAGL lesions. Similar reverse lesions are seen, as well as unique posterior lesions, such as Bennett and Kim's lesions. When symptoms of apprehension and instability in more than one direction are seen, one should consider multidirectional instability, which often presents with a patulous joint capsule. Finally, owing to significant impacts of daily activities and quality of life, surgical correction of labral tears, bony Bankart defects, Hill Sachs defects, and capsular laxity, may be considered.

Thread-Embedding Acupuncture for the Treatment of Shoulder Instability: Protocol for a Randomized, Controlled, Patient-Assessor Blinded Pilot Study

PURPOSE

This study aims to determine the feasibility of thread-embedding acupuncture (TEA) for the treatment of shoulder instability.

PATIENTS AND METHODS

This is a patient-assessor blinded, randomized, sham-controlled trial with two parallel arms. A total of 40 patients with shoulder instability aged between 13 and 43 years will be recruited and screened using set inclusion and exclusion criteria. After screening, they will be randomly allocated to the TEA or sham TEA group. Patients in both groups will then receive TEA or sham TEA treatment on six acupoints once a week for 8 weeks, which will be followed by additional follow-up assessments at 4 and 8 weeks after the end of treatment. Changes in shoulder pain and disability will be assessed as the primary outcome, whereas 100-mm pain visual analogue scale, shoulder range of motion, rotator cuff quality of life index, EuroQol 5-dimension 5-levels, treatment satisfaction, economic evaluation, and safety will all be measured as secondary outcomes of the study. Outcome assessment will be conducted at baseline and at 4, 8, and 16 weeks after screening.

CONCLUSION

The results from this trial will help to design further clinical trials on the efficacy, safety, and cost-effectiveness of performing TEA for shoulder instability.

TRIAL REGISTRATION NUMBER

KCT0005921 (Clinical Research Information Service of the Republic of Korea).

[Shoulder instability: review of current concepts of diagnosis and treatment]

OBJECTIVE

To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability.

MATERIAL AND METHODS

Searching for literature data was performed using the Pubmed and Google Scholar databases.

RESULTS

The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed.

The approaches to diagnosis and treatment of shoulder instability have been updated.

CONCLUSION

Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.

The efficacy of a phone assistance nursing program for functional outcomes in patients after shoulder instability surgery: A protocol for randomized controlled trial

OBJECTIVE

We conduct this research protocol for the assessment of the effect of phone-assisted care programs on functional outcomes in patients receiving shoulder instability surgery.

METHODS

This is a randomized controlled, single center trial which will be implemented from October 2020 to December 2021. This trial is conducted according to the SPIRIT Checklist of randomized researches. It was authorized via the Ethics Committee of the First People's Hospital of Xiangyang city affiliated to Hubei Medical College (XY234-026). Ninety participants who undergo shoulder instability surgery are analyzed. Patients are randomly divided into control group (standard management group, with 45 patients) and study group (the phone program group, with 45 patients). In control group, the exercises at home are not monitored. Whereas in study group, patients are asked about their at-home activities, and the extra coaching sessions are provided to patients on self-care, exercise guidance, and the importance of exercise at home, and then answers to their questions. The primary outcome is the range of motion of the shoulder joint, and the pain arcs are determined through the range of motion. The extra assessments include the shoulder functional outcome, pain, and the quality of life. All the analysis needed in this study is implemented with SPSS (IBM, Chicago, USA) for Windows Version 19.0.

RESULTS

The clinical outcome variables between groups are shown in Table.

CONCLUSION

This investigation can offer a reliable basis for the effectiveness of phone assistance nursing program in patients after shoulder instability surgery.

TRIAL REGISTRATION NUMBER

researchregistry6010.

Imaging of shoulder instability

The shoulder enjoys the widest range of motion of all the joints in the human body, therefore requires a delicate balance between stability and motility. The glenohumeral joint is inclined to fall into two main instability categories: macro and micro. Macroinstability can be traumatic or atraumatic, with anterior or posterior dislocation of the humeral head. Microinstability falls within the broader section of acquired instability in overstressed shoulder caused by repeated joint stress. Anterior traumatic instability is the most frequent entity and a relatively common injury in young and athletic population. While shoulder instability is a clinical diagnosis, imaging impacts the patient management by detailing the extent of injury, such as capsulo-labral-ligamentous tears, fracture, and/or dislocation, describing the predisposing anatomic conditions and guide the therapetic choice. The aim of this comprehensive review is to cover the imaging findings of shoulder instability by different imaging techniques.

Global Perspectives on Management of Shoulder Instability: Decision Making and Treatment

The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy.

Reliability of high-resolution ultrasound and magnetic resonance arthrography of the shoulder in patients with sports-related shoulder injuries

Introduction

The shoulder, a very complex joint, offers a wide range of pathologies. Intraarticular abnormalities and rotator cuff injuries are mainly assessed and diagnosed by magnetic resonance arthrography (MRA). In contrast to this well-established gold standard, high-resolution ultrasound (US) offers an additional easy and excellent modality to assess the shoulder joint. Therefore, the purpose of this study was to evaluate in which anatomic structures and pathologies comparable results of US and MRA could be achieved.

Materials and methods

In this IRB-approved prospective study 67 patients with clinically suspected labral lesions, rotator cuff rupture, or injury of the long head of the biceps (LHB) tendon were enrolled. Each participant was examined with high resolution US, and directly followed by MRA at 3 Tesla with a standard sequence protocol. To evaluate the agreement of the diagnostic performance between US and MRA a weighted kappa statistic was used.

Results

Both of the investigated modalities yielded a moderate to almost perfect agreement in assessing a wide range of shoulder joint pathologies. For the rotator cuff, consistency was found in 71.64% for the supraspinatus tendon, in 95.52% for the infraspinatus tendon, in 83.58% for the subscapularis tendon, and in 98.51% for the teres minor tendon.

The diagnostic accuracy between both modalities was 80.60% for the LHB tendon, 77.61% for the posterior labroligamentous complex, 83.58% for the acromioclavicular joint, and 91.04% for the assessment of osseous irregularities and impaction fractures.

Conclusions

High resolution US is a reliable imaging modality for the rotator cuff, the LHB tendon, and the acromioclavicular joint, so for these structures we recommend a preference for US over MRA based on its diagnostic accuracy, comfortability, cost effectiveness, and availability. If the diagnosis remains elusive, for all other intraarticular structures we recommend MRA for further diagnostic assessment.

Our First experience of Using Biodegradable Implants in Latarjet – Bristow Surgical Procedure at Chronic Posttraumatic Anterior Shoulder Insta

Background. Multi-layer spiral computed tomography shows that the main cause of shoulder instability is glenoid cavity bone defect. The aim of our research was to assess the effectiveness and safety of biodegradable implants in the treatment of patients with chronic posttraumatic anterior shoulder instability under conditions of bone defect of glenoid cavity margin by the restoration of anatomic shape and structure of scapula articular surface.

Materials and methods. We performed a pilot study based on the results of surgical treatment of 7 patients using 4.5 mm biodegradable compressing screws. In preoperative period, all patients had standard two-dimensional X-rays and MSCT with 3D-reconstruction. In postoperative period, all patients had check-up X-ray right after the surgery and MRI in 3 months after the surgery.

Results. The results of the treatment were assessed by common clinical criteria, functional criteria, X-ray evidence and intraand postoperative complications. We registered strong functioning of an arm and an increase in the range of motions. Data from Rowe/Zarins and DASH questionnaires showed that the patients totally recovered. X-ray evidence showed consolidation of non-free autograft to the zone of scapula bone defect without osteolysis or widening of a drilled hole. We did not observe either a failure of union, or any formation of false joint, or any screw fractures in bone tissue. Beyond that, we did not observe any complication in postoperative period and early postoperative complications in particular.

Conclusion. Pilot study with use of modern biodegradable implants in osteoplastic stabilization of shoulder joint at recurring instability showed their effectiveness and safety in patients of young and active working age. However, considering small number of patients in pilot study we cannot extrapolate our results to all similar and analogue cases of using biodegradable implants. In this regard, it is necessary to perform major multicenter clinical randomized study for further long-term observation and detection of possible unwanted side effects.

Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability

HYPOTHESIS

The purpose of this multicenter epidemiologic study was to determine the distribution of patients within the Frequency, Etiology, Direction, and Severity (FEDS) classification system to determine which categories are of clinical importance.

METHODS

Shoulder instability patients were identified using International Classification of Diseases, Ninth Revision coding data from 3 separate institutions from 2005-2010. Data were collected retrospectively. Details of instability were recorded in accordance with the FEDS classification system. Each patient was assigned a classification within the FEDS system. After all patients were assigned to a group, each group was individually analyzed and compared with the other groups.

RESULTS

There are a total of 36 possible combinations within the FEDS system. Only 16 categories were represented by at least 1% of our patient population. Six categories captured at least 5% of all patients with shoulder instability. Only 2 categories represented greater than 10% of the population: solitary, traumatic, anterior dislocation, with 95 patients (24.8%), and occasional, traumatic, anterior dislocation, with 63 patients (16.4%).

CONCLUSIONS

There are 16 categories within the FEDS classification that are clinically significant. Solitary, traumatic, anterior dislocation and occasional, traumatic, anterior dislocation were the most frequently observed in our cohort.

Intertester reliability of clinical shoulder instability and laxity tests in subjects with and without self-reported shoulder problems

OBJECTIVE

First, to investigate the intertester reliability of clinical shoulder instability and laxity tests, and second, to describe the mutual dependency of each test evaluated by each tester for identifying self-reported shoulder instability and laxity.

METHODS

A standardised protocol for conducting reliability studies was used to test the intertester reliability of the six clinical shoulder instability and laxity tests: apprehension, relocation, surprise, load-and-shift, sulcus sign and Gagey. Cohen's kappa (κ) with 95% CIs besides prevalence-adjusted and bias-adjusted kappa (PABAK), accounting for insufficient prevalence and bias, were computed to establish the intertester reliability and mutual dependency.

RESULTS

Forty individuals (13 with self-reported shoulder instability and laxity-related shoulder problems and 27 normal shoulder individuals) aged 18-60 were included. Fair (relocation), moderate (load-and-shift, sulcus sign) and substantial (apprehension, surprise, Gagey) intertester reliability were observed across tests (κ 0.39-0.73; 95% CI 0.00 to 1.00). PABAK improved reliability across tests, resulting in substantial to almost perfect intertester reliability for the apprehension, surprise, load-and-shift and Gagey tests (κ 0.65-0.90). Mutual dependencies between each test and self-reported shoulder problem showed apprehension, relocation and surprise to be the most often used tests to characterise self-reported shoulder instability and laxity conditions.

CONCLUSIONS

Four tests (apprehension, surprise, load-and-shift and Gagey) out of six were considered intertester reliable for clinical use, while relocation and sulcus sign tests need further standardisation before acceptable evidence. Furthermore, the validity of the tests for shoulder instability and laxity needs to be studied.

Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability

PURPOSE OF REVIEW

The goal of this paper is to provide an overview in evaluating the patient with suspected or known anteroinferior glenohumeral instability.

RECENT FINDINGS

There is a high rate of recurrent subluxations or dislocations in young patients with history of anterior shoulder dislocation, and recurrent instability will increase likelihood of further damage to the glenohumeral joint. Proper identification and treatment of anterior shoulder instability can dramatically reduce the rate of recurrent dislocation and prevent subsequent complications. Overall, the anterior release or surprise test demonstrates the best sensitivity and specificity for clinically diagnosing anterior shoulder instability, although other tests also have favorable sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and inter-rater reliabilities. Anterior shoulder instability is a relatively common injury in the young and athletic population. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers will optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice.

Current Concepts in the Diagnosis and Management of Traumatic, Anterior Glenohumeral Subluxations

Traumatic anterior glenohumeral subluxations comprise the majority of glenohumeral instability events and are endemic in young athletes. Unlike the definitive complete dislocation event, subluxation events may often be more subtle in presentation and, therefore, may be overlooked by clinicians. Glenohumeral subluxation events are associated with a high rate of labral tears as well as humeral head defects. While less is known of the natural history of these injuries, young athletes are at risk for recurrent instability events if not properly diagnosed and treated. While reports of surgical treatment outcomes isolated to subluxation events are limited, arthroscopic and open Bankart repair have been shown to result in excellent outcomes. The purpose of this paper is to review the etiology and pathoanatomy of traumatic anterior glenohumeral subluxations as well as to review the appropriate evaluation and management of patients with this injury.

Beyond the Cuff: MR Imaging of Labroligamentous Injuries in the Athletic Shoulder

Shoulder disease is common in the athletic population and may arise as a consequence of a single traumatic episode or multiple repeated events. Associated labroligamentous injuries can result in substantial disability. Specific athletic and occupational activities result in predictable injury patterns. Imaging in general and magnetic resonance (MR) imaging, in particular, are vital in establishing the correct diagnosis and excluding common mimicking conditions, to ensure timely and appropriate management. In this review, the utility of MR imaging and MR arthrography will be explored in evaluation of shoulder disease, taking into account normal variants of the labroligamentous complex. Subsequently, broad categories of labral lesions and instability, external and internal impingement, as well as nerve entrapment syndromes, will be discussed, while emphasizing their imaging findings in the clinical context and illustrating key features. More recent concepts of internal impingement and secondary subacromial impingement will also be clarified.

Irreducible superolateral dislocation of the glenohumeral joint

The overwhelming majority of glenohumeral dislocations are anterior dislocations that either spontaneously reduce or are reduced at the point of care without significant complications. Posterior dislocations are uncommon, and superior and inferior dislocations are even rarer. We present a case of "superolateral" shoulder dislocation in which the entire rotator cuff was torn either off its insertion or at the musculotendinous junction in combination with a large longitudinal split tear of the deltoid muscle. This allowed the humeral head to dislocate both superiorly and laterally into a subcutaneous position through the tear of the anterolateral deltoid muscle with an associated de-gloving soft tissue lesion. Buttonholing of the humeral head through the deltoid and interposition of the dislocated long head of the biceps tendon and macerated rotator cuff prevented closed reduction of the glenohumeral joint. The resultant radiographic appearance and treatment of this dislocation is unique. To our knowledge, this is the first reported case of this dislocation in the literature.