Management of multidirectional instability of the shoulder

Glenohumeral Joint Volume Measurement in Patients with Shoulder Instability: A 3D Volumetric Magnetic Resonance Arthrographic Study

Background and Objectives: This study aimed to compare capsular volume in patients with shoulder instability to that in control subjects without instability using magnetic resonance (MR) arthrography. The objective was to develop a reliable screening method with which to assess shoulder volume. Materials and Methods: In 21 patients with atraumatic shoulder instability and 21 controls, thin-slice 3D volumetric MR arthrography sequences were obtained. MR arthrography images were uploaded to 3D reconstruction, and 3D images were generated. From the 3D reconstructed images, volumetric measurements of rotator interval (RI), anterior and posterior capsular (AC, PC) recesses, biceps tendon sheath (BS), axillary recess (AR), and total glenohumeral joint (TGJ) were performed. Individuals with any extra-articular contrast leakage were also recorded. Results: A retrospective study analyzed a patient group of 21 individuals with shoulder instability (mean age 29.52 ± 12.83 years) and a control group of 21 individuals without instability (mean age 35.71 ± 12.77 years). No statistically significant differences were identified between the groups with regard to age, gender, or side distribution. The mean total joint volume was significantly higher in the instability group (29.85 ± 6.40 cm3) compared to the control group (23.15 ± 3.48 cm3, p = 0.0001). Additionally, the mean volumes of the RI, AC, PC, BS, and AR were all significantly greater in the patient group compared to the control group. Conclusions: 3D volumetric MR arthrographic measurements of the shoulder joint capacity can provide valuable insights for clinical follow-up and guide surgical treatment decisions in cases of atraumatic shoulder instability.

Arthroscopic remplissage: history, indications, and clinical outcomes

Several surgical procedures have been proposed to address anterior glenohumeral instability, which is one of the most common complaints in the general population. The remplissage, first described in early 2000s, is a procedure performed simultaneously with the arthroscopic Bankart repair to correct large, engaging Hill-Sachs lesions (HSLs). This procedure stabilizes the joint by tenodesing the infraspinatus tendon into the HSL to fill and disengage the defect. This procedure gained popularity because it has relatively low risk and is able to improve shoulder stability while being less invasive than other bone-blocking procedures. The remplissage has become a valuable add-on technique that can substantially improve outcomes in unstable patients undergoing arthroscopic Bankart repair. Nevertheless, several studies in the literature have raised concerns regarding its efficacy in critically unstable patients and the potential range of motion limitations that can arise postoperatively. Additional comparative studies and trials should be conducted to appropriately establish the role of remplissage in treating anterior instability, especially in patients with critical bone loss.

Recurrent bilateral atraumatic shoulder dislocation in a young patient with bilateral shoulder multidirectional instability: Treatment consideration and description of a surgical technique

INTRODUCTION

Multidirectional instability is defined as symptomatic glenohumeral joint subluxation or dislocation occurring in more than one direction. Multidirectional shoulder instability with recurrent shoulder dislocation is a rare condition with controversies in the literature about the best treatment strategy. Physiotherapy remains the initial treatment of choice, and surgical intervention should be performed only if debilitating symptoms continue to be experienced.

CASE PRESENTATION

A young healthy male presented with bilateral shoulder multidirectional instability and recurrent shoulders atraumatic dislocation. The patient was treated with a supervised physiotherapy regimen, which succeeded on his non-dominant shoulder but failed on the contralateral dominant side. A surgical technique aimed at reducing the right shoulder capsule volume to gain stability was performed and described in detail in this paper. Patient was able to return to his normal daily activities, including sports, without new complaints.

DISCUSSION

The aim of surgery is to restore passive stability by reducing the shoulder capsular volume. Common surgical techniques for Multidirectional instability include an inferior capsular shift and open or arthroscopic capsular plication with variable outcomes have been proposed in the literature.

CONCLUSION

Surgical management should be individualized to address the anatomical cause of instability and should only be considered if conservative treatment with supervised physiotherapy fails. Using an arthroscopic grasper to apply appropriate capsule traction and tension while performing the plication and using an extra superior anchor contributed to attaining optimal capsular volume reduction.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

Dynamic pediatric shoulder instability: Etiology, pathogenesis and treatment

Dynamic shoulder instability in children or adolescents, whose glenohumeral growth plates are still open, is a rare condition with an etiology that is hard to decipher. Atraumatic and recurrent forms are most common, contrary to adults. Disruptions to capsule and ligament maturation, muscle balance or bone growth can lead to glenohumeral instability. The etiology assessment, which needs to be multidisciplinary in atraumatic forms, aims to collect the medical history, analyze the direction of the instability, determine whether it is voluntary or involuntary, and look for a history of trauma, connective tissue abnormality, psychological disorder, neuromuscular pathology or congenital malformation. The initial treatment is conservative. It requires a multidisciplinary team when the shoulder instability is voluntary. Surgical treatment is reserved for symptomatic forms that do not respond to conservative treatment and have an impact on daily life and/or sports participation after a minimum of 6 months of well-conducted rehabilitation. The results of surgical stabilization mainly depend on the features of the instability, the anatomical structures damaged and the etiology. Episodes of recurrent instability in children/adolescents with open glenohumeral growth plates can fade in adulthood or can get worse with the development of structural damage. Early detection of poor outcomes and suitable treatment will help to limit the occurrence of osteoarthritis in the medium and long term. LEVEL OF EVIDENCE: Expert opinion.

Rehabilitation after Shoulder Instability Surgery

Shoulder instability can occur in any direction and presents across a broad spectrum including traumatic dislocations, repetitive microinstability events or subluxations, and global joint laxity. The development of pain, functional decline, and articular pathologic condition is a multifaceted process that is influenced by the underlying bony morphology, biology of the surrounding soft tissue structures, dynamic coordination of the periscapular musculature, and patient factors such as age, activity level, and associated injuries. This article will focus on the younger, active patient with instability due to deficiencies in the capsulolabral complex and dynamic stabilizers.

Physical Therapy for the Treatment of Shoulder Instability

Shoulder instability is the separation of the humeral head from the glenoid. Injury to the static and dynamic stabilizers can result in instability. Anterior shoulder instability is the predominant form of instability. It is usually a result of trauma. Posterior shoulder instability often presents with an insidious onset of pain. Multidirectional instability of the shoulder is symptomatic laxity in more than one plane of motion. The primary goal of rehabilitation is to restore pain-free mobility, strength, and functioning. Rehabilitation implements range of motion and strengthening exercises to restore proprioceptive control and scapular kinematics.

Multidirectional instability of the shoulder: surgical techniques and clinical outcome

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume. Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis. Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation. In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered. Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients. In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Clinical Outcomes After Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Glenohumeral Instability at a Mean Follow-up of 9 Years

BACKGROUND

Arthroscopic treatment of multidirectional instability (MDI) of the shoulder is being increasingly performed, but there is a paucity of studies with minimum 5-year follow-up.

PURPOSE

To report on survivorship and patient-reported outcomes (PROs) after arthroscopic pancapsulorraphy (APC) for MDI with a minimum 5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Institutional review board approval was obtained before initiation of this retrospective review of prospectively collected data. Patients were included if they had a minimum of follow-up 5 years after APC for MDI. PROs included the 12-Item Short Form Health Survey Physical Component Summary; American Shoulder and Elbow Surgeons; Single Assessment Numeric Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; and patient satisfaction. Preoperative, short-term (1-2 years), and final follow-up PROs were compared. Recurrent instability, dislocation, and reoperation were collected, and survivorship analysis was performed.

RESULTS

A total of 49 shoulders in 44 patients (15 male, 29 female) treated between October 2005 and November 2015 were included in the study. MDI onset was atraumatic in 27 shoulders and traumatic in 22. Rotator interval closure was performed in 17 patients. Overall, 14 of 49 (29%) patients reported feelings of instability in the shoulder, of whom 5 (10.2%) underwent revision surgery at a mean of 1.5 years. Kaplan-Meier analysis demonstrated a survivorship rate of 88% at 5 years and 82% at 8 years, with failure defined as requiring revision surgery or postoperative feelings of instability with ASES score <65. Final outcome analysis was performed on 41 shoulders with a mean follow-up of 9.0 years (range, 5.1-14.6 years). All PROs demonstrated significant improvement from preoperative baseline (P < .05) and remained significantly improved at both short-term and long-term final follow-up. There was no difference in PROs based on \\ atraumatic versus traumatic onset, or patients treated with a rotator interval closure. There was a significant difference in PROs between patients who had continued instability.

CONCLUSION

APC for the treatment of MDI provided reasonable, durable long-term PROs that persisted from short-term follow-up. Although 29% of patients experienced feelings of instability at final follow-up, most of these patients still had high postoperative satisfaction and acceptable PROs.

Progress of Muscle Chain Theory in Shoulder Pain Rehabilitation: Potential Ideas for Pulmonary Rehabilitation

Pulmonary dysfunction is very common in stroke patients. A study has shown that acute stroke patients often cause a series of pulmonary dysfunction due to primary damage to the respiratory center, which is an important reason for hindering disease treatment and recovery. American Thoracic Society (ATS) and the European Respiratory Society (ERS) pointed out that pulmonary rehabilitation (PR) can be applied to the rehabilitation of stroke patients to improve their lung function. PR can improve the respiratory muscle strength of stroke patients, which is beneficial to improving the respiratory function of patients. At the same time, it can also significantly increase the maximum oxygen intake of patients, effectively improve the cardiopulmonary function of stroke patients, and reduce respiratory complications such as aspiration pneumonia. However, the common dysfunction of joints and muscles such as shoulder pain after stroke will affect the process of pulmonary rehabilitation. This is mainly because the changes in the position of the shoulder girdle, the decrease in the range of motion of the cervical and thoracic spine, and the changes in the cervical spondylolisthesis position caused by the elevation of the upper limbs will directly affect the breathing movement during the pulmonary rehabilitation process. The instability of the spine will weaken the deep abdominal muscles and reduce the function of the diaphragm; moreover, changes in the alignment and stability of the cervical and thoracic spine will also lead to wrong breathing methods. Therefore, it is of practical clinical significance to evaluate the functional rehabilitation of shoulder joint muscles and evaluate the efficacy of stroke patients to improve their respiratory function. This article through an extensive review of domestic and foreign literature in recent years, combined with clinical practice experience, summarizes the practical application of chain structure theory in the fields of rehabilitation training, postural adjustment, pain relief, etc., and further studies the functional exercise method based on muscle chain theory. The research on the muscle chain of shoulder pain rehabilitation as a model illustrates the positive effect of reconstructing neuroarticular muscle function on the respiratory system, hoping to provide new ideas for the treatment of respiratory diseases in stroke patients.

Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint

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.

Evaluation and Management of the Contact Athlete's Shoulder

Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.

High Rate of Return to Work by 3 Months Following Latarjet for Anterior Shoulder Instability

PURPOSE

To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss.

METHODS

Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey.

RESULTS

Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least "a little improvement" in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization.

CONCLUSIONS

Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

LEVEL OF EVIDENCE

IV, case series.

Atraumatic shoulder instability: patient characteristics, comorbidities, and disability

Background

Atraumatic shoulder instability of the shoulder is well described, and numerous extrinsic factors have been identified as having a negative influence on long-term shoulder function, including age, sex, smoking, and workers' compensation status. Furthermore, physical factors such as acute or chronic pain, as well as psychological comorbidities such as depression and suicidal thoughts, are common in shoulder-related conditions.

Methods

Patients with atraumatic shoulder instability were recruited from a review of outpatient logbook and inpatient rehabilitation center admission records. Average and worst pain visual analogue scale rates were recorded for acute and chronic shoulder pain. Disability was measured using the “Disability of the Arm and Hand” score, as well as the Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Depression was assessed using Becks Depression Inventory II, and further single psychological items were selected from other psychological assessment questionnaires.

Results

We included 64 patients, of which 51 (79.7%) were female. Mean visual analogue scale pain scores were in average 5.11 (standard deviation 2.24) and 5.58 (standard deviation 2.34) for acute and chronic shoulder pain, respectively. A stepwise, multiple linear regression revealed that only chronic shoulder pain remained significantly related to disability (F(1,61) = 46.13, P < .001). A second linear regression analysis was performed and showed a significant association between the overall Disability of the Arm, Shoulder and Hand score and overall Becks Depression Inventory score (F(1,62) = 12.78, P < .001). A further stepwise, multiple linear regression analysis indicated that chronic pain and depression remain independent variables in the prediction of disability.

Conclusion

In addition to sociodemographic factors, pain and psychological comorbidities were found to have a negative impact on patient's functional outcome. This study further supports the need for an multidisciplinary team, holistic approach in the management of atraumatic shoulder instability patients with particular emphasis on chronic pain management and psychological support.

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.

Muscle Contraction Has a Reduced Effect on Increasing Glenohumeral Stability in the Apprehension Position

PURPOSE

Glenohumeral instability accounts for 23% of all shoulder injuries among collegiate athletes. The apprehension position-combined shoulder abduction and external rotation-commonly reproduces symptoms in athletes with instability. Rehabilitation aims to increase glenohumeral stability by strengthening functional positions. However, it is unclear how much glenohumeral stability increases with muscle contraction in the apprehension position. The purpose of this study was to determine whether the ability to increase translational glenohumeral stiffness, a quantitative measure of glenohumeral stability, with muscle contraction is reduced in the apprehension position.

METHODS

Seventeen asymptomatic adults participated. A precision-instrumented robotic system applied pseudorandom, anterior-posterior displacements to translate the humeral head within the glenoid fossa and measured the resultant forces as participants produced isometric shoulder torques. Measurements were made in neutral abduction (90° abduction/0° external rotation) and apprehension (90° abduction/90° external rotation) positions. Glenohumeral stiffness was estimated from the relationship between applied displacements and resultant forces. The ability to increase glenohumeral stiffness with increasing torque magnitude was compared between positions.

RESULTS

On average, participants increased glenohumeral stiffness from passive levels by 91% in the neutral abduction position and only 64% in the apprehension position while producing 10% of maximum torque production. The biggest decrease in the ability to modulate glenohumeral stiffness in the apprehension position was observed for torques generated in abduction (49% lower, P < 0.001) and horizontal abduction (25% lower, P < 0.001).

CONCLUSION

Our results demonstrate that individuals are less able to increase glenohumeral stiffness with muscle contraction in the apprehension position compared with a neutral shoulder position. These results may help explain why individuals with shoulder instability more frequently experience symptoms in the apprehension position compared with neutral shoulder positions.

Medical Interactive Recovery Assistant: a useful clinical tool in paediatric shoulder rehabilitation?

Background/aims

Outpatient physical therapy is the mainstay of treatment in shoulder instability, but lack of motivation and intermittent monitoring of progress is associated with poor compliance. ‘Exergames’ (a combination of videogames and physical exercise) may provide an additional or alternative motivational factor. The aim of this study was to determine the applicability of the Medical Interactive Recovery Assistant Xbox Kinect gaming software in the management of adolescent atraumatic shoulder instability.

Methods

Patients completed six 30-minute sessions playing games using the Medical Interactive Recovery Assistant while participating in a therapy programme. Pain and fatigue questionnaires, functional assessments and a framework analysis of free-text comments were used.

Results

A total of 20 female patients (15 unilateral, five bilateral pathology, mean age 14.1 years) completed the sessions. An average session length was 10.8 mins (range 0–24 mins). After each session using the Medical Interactive Recovery Assistant, 80% were neither in pain, nor overly tired. At 2 weeks, the Stanmore Percentage of Normal Shoulder Assessment scores had improved by a mean 17.9% and 10 (50%) patients showed improvements in Oxford Shoulder Instability Scores. Overall, 15 participants (75%) liked the technology; however six (32%) preferred standard physiotherapy, because of software limitations and lack of personal interaction.

Conclusions

Medical Interactive Recovery Assistant gamification is applicable for this patient cohort and could be integrated into adolescent atraumatic shoulder instability rehabilitation programmes; however, results emphasise the importance of personal contact.

Interprofessional Inconsistencies in the Diagnosis of Shoulder Instability: Survey Results of Physicians and Rehabilitation Providers

BACKGROUND

Clinicians of many specialties within sports medicine care for athletes with shoulder instability, but successful outcomes are inconsistent. Consistency across specialties in the diagnosis of shoulder instability is critical for care of the athlete, yet the extent of divergence in its diagnosis is unknown.

HYPOTHESIS

Physicians differ from rehabilitation providers in which findings they deem clinically important to differentiate shoulder instability from impingement, and in how they diagnose athlete scenarios with atraumatic shoulder instability.

STUDY DESIGN

Cross-sectional study.

METHODS

Physicians (orthopaedic surgeons, primary care sports medicine physicians) and rehabilitation providers (physical therapists, athletic trainers) were asked via an online survey to rate clinical factors used to diagnose shoulder instability. Clinicians were also asked to diagnose two athlete scenarios with concurrent clinical findings of atraumatic shoulder instability and impingement, differentiated by the absence or presence of a positive sulcus sign.

RESULTS

Responses were recorded from 888 clinicians. Orthopaedic surgeons (N=170) and primary care sports medicine physicians (N=108) ranked physical examination factors as more important for the diagnosis of shoulder instability than patient history factors, whereas physical therapists (N=379) and athletic trainers (N=231) preferred patient history factors. Orthopaedic surgeons differed from physical therapists and athletic trainers in their clinical diagnoses for both scenarios (P≤0.001).

CONCLUSION

A lack of consistency exists among sports medicine clinicians in recognizing which clinical factors are important when used to diagnose shoulder instability and in diagnoses given with concurrent findings of impingement.

LEVEL OF EVIDENCE

Level 3.

Postoperative Rehabilitation of Multidirectional Instability Surgery: A Systematic Review

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.

Clinical Outcomes, Survivorship, and Return to Sport After Arthroscopic Capsular Repair With Suture Anchors for Adolescent Multidirectional Shoulder Instability: Results at 6-Year Follow-up

Background:

Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. To the best of our knowledge, no studies have reported on outcomes or examined the risk factors that contribute to poor outcomes in adolescent athletes.

Purpose:

To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent intervention for MDI.

Study Design:

Case series; Level of evidence, 4.

Methods:

All patients 20 years or younger who underwent arthroscopic shoulder surgery at a single institution between January 2009 and April 2017 were evaluated. MDI was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer tests while under anesthesia. A 2-year minimum follow-up was required, but those whose treatment failed earlier were also included. Demographic characteristics and intraoperative findings were recorded, as were scores on the Single Assessment Numeric Evaluation (SANE), Pediatric and Adolescent Shoulder Survey (PASS), and short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH).

Results:

Overall, 42 adolescents (50 shoulders; 31 female, 19 male) were identified as having undergone surgical treatment for MDI with minimum 2-year follow-up or failure. The mean follow-up period was 6.3 years (range, 2.8-10.2 years). Surgical failure, defined as recurrence of subluxation and instability, was noted in 13 (26.0%) shoulders; all underwent reoperation at a mean of 1.9 years (range, 0.8-3.2 years). None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, was associated with subjective outcomes or reoperation. Number of anchors used was not different between shoulders that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport occurred in 56% of patients.

Conclusion:

Adolescent MDI refractory to nonsurgical management appeared to have long-term outcomes after surgical intervention that were comparable with outcomes of adolescent patients with unidirectional instability. In patients who experienced failure of capsulorrhaphy, results showed that failure most likely occurred within 3 years of the index surgical treatment.

Mapping of the Inferior Glenohumeral Ligament for Suture Pullout Strength: A Biomechanical Analysis

Background

Suture pullout during rehabilitation may result in loss of tension in the inferior glenohumeral ligament (IGHL) and contribute to recurrent instability after capsular plication, performed with or without labral repair. To date, the suture pullout strength in the IGHL is not well-documented. This may contribute to recurrent instability.

Purpose/Hypothesis

A cadaveric biomechanical study was designed to investigate the suture pullout strength of sutures in the IGHL. We hypothesized that there would be no significant variability of suture pullout strength between specimens and zones. Additionally, we sought to determine the impact of early mobilization on sutures in the IGHL at time zero. We hypothesized that capsular plication sutures would fail under low load.

Study Design

Descriptive laboratory study.

Methods

Seven fresh-frozen cadaveric shoulders were dissected to isolate the IGHL complex, which was then divided into 18 zones. Sutures in these zones were attached to a linear actuator, and the resistance to suture pullout was recorded. A suture pullout strength map of the IGHL was constructed. These loads were used to calculate the load applied at the hand that would initiate suture pullout in the IGHL.

Results

Mean suture pullout strength for all specimens was 61.6 ± 26.1 N. The maximum load found to cause suture pullout through tissue was found to be low, regardless of zone of the IGHL. Calculations suggest that an external rotation force applied to the hand of only 9.6 N may be sufficient to tear capsular sutures at time zero.

Conclusion

This study did not provide clear evidence of desirable locations for fixation in the IGHL. However, given the low magnitude of failure loads, the results suggest the timetable for initiation of range-of-motion exercises should be reconsidered to prevent suture pullout through the IGHL.

Clinical Relevance

From this biomechanical study, the magnitude of force required to cause suture pullout through the IGHL is met or surpassed by normal postoperative early range-of-motion protocols.

The impact of age on 30-day complications following shoulder instability surgery

HYPOTHESIS

The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery.

METHODS

Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis.

RESULTS

Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for <25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P < .001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P < .001), and 30-day readmission (OR 3.39; P = .013).

CONCLUSION

This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Stress Distribution Patterns Across the Shoulder Joint in Gymnasts: A Computed Tomography Osteoabsorptiometry Study

Background:

The distribution pattern of subchondral bone density is an indicator of stress distribution over a joint surface under long-term physiologic loading. The biomechanical characteristics of the articular surfaces of the shoulder joint in gymnasts can be determined by measuring this distribution pattern.

Purpose:

To evaluate the distribution of subchondral bone density across the shoulder joint in male collegiate gymnasts and to determine the effects of gymnastic activities on its articular surfaces under long-term loading conditions using computed tomography osteoabsorptiometry (CTOAM).

Study Design:

Descriptive laboratory study.

Methods:

CT image data were obtained from both shoulders of 12 asymptomatic male collegiate gymnasts (gymnast group; mean age, 19.4 years; range, 18-22 years) and 10 male collegiate volunteers (control group; mean age, 20.2 years; range, 18-22 years). The distribution pattern of subchondral bone density across the articular surfaces of each shoulder joint was assessed by CTOAM. Quantitative analysis was performed of the locations and percentages of high-density areas on the articular surface.

Results:

Stress distribution patterns over the articular surfaces differed between the gymnasts and the controls. In the gymnasts, high-density areas were detected on the posterosuperior articular surface of the humeral head and the anterosuperior and/or posterosuperior articular surface of the glenoid. Mean bone density was greater in the gymnasts than in the controls (P < .0001).

Conclusion:

Stress distribution over the articular surfaces of the shoulder joint was affected by gymnastic activities. Stress was concentrated over the superior part of the glenohumeral joint in male collegiate gymnasts.

Clinical Relevance:

The present findings suggest that gymnastic activities increase stress to the articular surfaces of the superior glenohumeral joint. This supports the notion that mechanical conditions play a crucial role in the origin of disorders particular to gymnastic activities.

Muscle activity and scapular kinematics in individuals with multidirectional shoulder instability: A systematic review

BACKGROUND

Several studies reported the importance of glenohumeral and scapular muscle activity and scapular kinematics in multidirectional shoulder instability (MDI), yet a systematic overview is currently lacking.

OBJECTIVE

This systematic review evaluates and summarizes the evidence regarding muscle activity and shoulder kinematics in individuals with MDI compared to healthy controls.

METHOD

The electronic databases PubMed and Web of Science were searched in September 2020 with key words regarding MDI (population), muscle activity, and glenohumeral and scapular movement patterns (outcomes). All studies that compared muscle activity or scapular kinematics between shoulders with MDI and healthy shoulders were eligible for this review, except for case reports and case series. All articles were screened on the title and abstract, and remaining eligible articles were screened on full text. The risk of bias of included articles was assessed by a checklist for case-control data, as advised by the Cochrane collaboration.

RESULTS

After full text screening, 12 articles remained for inclusion and one study was obtained by hand search. According to the guidelines of the Dutch Institute for Healthcare Improvement, most studies were of moderate methodological quality. We found moderate evidence that MDI individuals show increased or prolonged activity of several rotator cuff muscles that control and centre the humeral head. Furthermore, we found evidence of decreased and/or shortened activity of muscles that move or accelerate the arm and shoulder girdle as well as increased and/or lengthened activity of muscles that decelerate the arm and shoulder girdle. The most consistent kinematic finding was that MDI individuals show significantly less upward rotation and more internal rotation of the scapula during elevation of the arm in the scapular plane as compared with controls. Finally, several studies also suggest that the humeral head demonstrates increased translations relative to the glenoid surface.

CONCLUSION

There is moderate evidence for altered muscle activity and altered humeral and scapular kinematics in MDI individuals as compared with controls.

[Short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity]

OBJECTIVE

To evaluate the short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity.

METHODS

A retrospective analysis was performed on 6 shoulder recurrent anterior dislocation patients combined with joint laxity treated with arthroscopically capsular vertical mattress suturing between January 2017 and December 2018. There were 5 males and 1 female with an average age of 20.8 years (range, 19-24 years). The number of shoulder dislocation was 3-18 times, with an average of 9.5 times. The disease duration ranged from 2 to 60 months, with an average of 25.3 months. The preoperative Beighton score was 4-7, with an average of 5.8; the Instability Severity Index Score (ISIS) was 2-5, with an average of 3.5. There were 5 cases of simple Bankart injury and 1 case of bony Bankart injury. The range of motion of shoulder joint (including active flexion and lifting, external rotation, abduction and external rotation, and internal ratation) was recorded before operation and at last follow-up; Oxford shoulder instability score, Rowe shoulder instability score, and Simple Shoulder Test (SST) score were used to evaluate shoulder joint function before operation, at 6 months after operation, and at last follow-up, and complications were recorded.

RESULTS

All patients were followed up 16-28 months (mean, 19.3 months). During the follow-up, all patients had satisfactory motor function, and no re-dislocation and postoperative neurovascular complications occurred. At last follow-up, the activities of active external rotation and abduction and external rotation were significantly improved when compared with those before operation ( P<0.05); the activities of active flexion and lifting and internal rotation were not limited before and after operation, and the difference was not significant ( P>0.05). The Oxford shoulder instability score, Rowe shoulder instability score, and SST score at 6 months after operation and at last follow-up were significantly improved when compared with those before operation ( P<0.05); there was no significant difference between at 6 months after operation and at last follow-up ( P>0.05).

CONCLUSION

The treatment of shoulder recurrent anterior dislocation combined with joint laxity by arthroscopically vertical matress suturing can achieve good short-term effectiveness.

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.

The role of structured physiotherapy in treating patients with atraumatic shoulder instability: Medium term results from a case series

BACKGROUND

Consensus favours conservative treatment for atraumatic shoulder instability, but literature is scarce on the topic. We therefore prospectively assessed the results of structured physiotherapy for these patients.

METHODS

Patient reported outcomes were recorded prior to physiotherapy and on discharge. Notes review identified patients re-referred for the same condition.

RESULTS

N = 85. Review range was 12-72 months post-treatment. Median Oxford Shoulder Instability Score (OSIS) improved from 21 (range: 2-47) to 39 (11-47). Median Western Ontario Shoulder Instability Index (WOSI) improved from 1117 (range: 306-2028) to 485 (0-1569). Patients with posterior instability demonstrated better results compared with other groups (OSIS change, p = 0.025; WOSI change, p = 0.060). Quicker referral to physiotherapy gave improved outcomes (OSIS change, p = 0.004, r_s  = -0.4; WOSI change, p = 0.047, r_s  = 0.24). Twenty-one patients (24.7%) were re-referred, seven of them for repeat physiotherapy and 14 of them for surgery. Previous surgery significantly affected the possibility of a further referral (p < 0.001), and initial diagnosis was significantly correlated with further surgery (p = 0.032).

DISCUSSION

Early referral to physiotherapy may produce better results. Patients with posterior instability responded better to physiotherapy. Previous surgery increased the risk of re-referral. Re-referred patients with posterior instability tended to be managed with further physiotherapy.

Comparison of clinical and patient-reported outcomes of three procedures for recurrent anterior shoulder instability: arthroscopic Bankart repair, capsular shift, and open Latarjet

Background

Best surgical of recurrent anterior shoulder instability remained controversial. We knew little about the superiority and choice between traditional open and modern arthroscopic techniques. We hypothesized that outcomes of all patients will be similar regardless of surgical technique.

Methods

A retrospective case-cohort analysis of 168 patients who had recurrent anterior shoulder instability was conducted from September 2010 to December 2013. All cases (mean age 30.8 [range 18–50] years) were performed with arthroscopic Bankart repair (33 males/20 females), open Latarjet (34 males/18 females), and capsular shift (31 males/14 females). The average follow-up was 67.6 months (range 60–72). The shoulder instability index score (ISIS) was more than 3 with an average of 6.4.

Results

All treatments proved to be effective in improving shoulder functional status and reducing symptoms, while Latarjet had an advantage over subjective perception. The Rowe scores in arthroscopic Bankart, open Latarjet, and capsular shift group were 92.3 ± 1.5, 96.2 ± 2.1, and 93.2 ± 2.3, respectively, with significant difference. There was no significant difference in other functional outcomes. However, the Latarjet group in subjective results (subjective shoulder value (SSV) and subjective shoulder value for sport practice (SSV Sport)) was superior to the others (P < 0.05). There were two relapsed cases in arthroscopic Bankart and capsular shift group, respectively, and no recurrence in open Latarjet group.

Conclusion

Arthroscopic Bankart repair has the advantage of mini-invasion and rapid recovery. Capsular shift offers stabilizing of inferior or multidirectional type, especially for little bone defect. Latarjet was more effective in reducing recurrence with higher stability.

Level of evidence

Therapeutic level III

Rotator Interval Plication: The "Seamster" Technique

The indications and best technique for plication of the rotator interval capsule, performed as a supplemental procedure at the time of arthroscopic shoulder stabilization, remain a controversial topic. There are currently no well-accepted surgical indication guidelines that have been established. Several biomechanical studies, however, have demonstrated the important contribution of the rotator interval capsule to stability of the glenohumeral joint, and the utilization of rotator interval plication in patients with glenohumeral instability has been supported in several publications. The indications for and surgical steps to accomplish the arthroscopic "seamster" technique for rotator interval plication, used by the authors for >20 years, is described.

Artistic Gymnastics Injuries; Epidemiology, Evaluation, and Treatment

Artistic gymnastics is a physically demanding sport that requires flexibility, agility, and extreme upper and lower body strength. The specific biomechanics of the sport leads to a unique injury profile. Gymnastic skills require intense upper body weight-bearing, placing unusual forces across the upper extremity joints and predisposing them to injury. In addition, the required body control during air aerobatics (tumbling, twisting, flipping) necessitates precise landing techniques to avoid spine and lower extremity injury. Common gymnastic injuries include those of the spine and upper extremity such as spondylolysis, shoulder instability, ulnar collateral ligament injuries, capitellar osteochondritis dissecans, and several wrist pathologies. Understanding the injury etiology, prevention, and treatment protocols is important for a successful recovery and return to sport.

Multidirectional Shoulder Instability With Bone Loss and Prior Failed Latarjet Procedure: Treatment With Fresh Distal Tibial Allograft and Modified T-Plasty Open Capsular Shift

Recurrent multidirectional shoulder instability (MDI) is a challenging clinical problem, particularly in the setting of connective tissue diseases, and there is a distinct lack of literature discussing strategies for operative management of this unique patient group. These patients frequently present with significant glenoid bone loss, patulous and abnormal capsulolabral structures, and a history of multiple failed arthroscopic or open instability procedures. Although the precise treatment algorithm requires tailoring to the individual patient, we have shown successful outcomes in correcting recurrent MDI in the setting of underlying connective tissue disorders by means of a modified T-plasty capsular shift and rotator interval closure in conjunction with distal tibial allograft bony augmentation. The purpose of this Technical Note was to describe a technique that combines a fresh distal tibial allograft for glenoid bony augmentation with a modified T-plasty capsular shift and rotator interval closure for the management of recurrent shoulder MDI in patients presenting with Ehlers-Danlos syndrome or other connective tissue disorders after failed Latarjet stabilization.

Multidirectional Instability of the Shoulder: Treatment Options and Considerations

Multidirectional instability (MDI) is a debilitating condition that involves chronic subluxation or dislocation of the shoulder in >1 direction. Numerous proposed mechanisms of MDI exist, which occurs in the setting of redundant capsular tissue. Symptoms can range from recurrent dislocations or subluxations to vague aching pain that disrupts activities of daily living. Magnetic resonance imaging is often performed during evaluation of this condition, although magnetic resonance arthrography may provide more detailed images of the patulous capsule. In the absence of a well-defined traumatic cause, such as a labral tear, initial treatment for MDI is a structured rehabilitation program with exercises aimed at strengthening the rotator cuff and periscapular muscles to improve scapular kinematics. Patients with recalcitrant symptoms may benefit from surgical stabilization, including open capsular shift or arthroscopic capsular plication, aimed at decreasing capsular volume and improving stability.

Glenohumeral Instability Related to Special Conditions: SLAP Tears, Pan-labral Tears, and Multidirectional Instability

Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.

Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management

Multidirectional instability of the shoulder is a type of glenohumeral joint shoulder instability. There are discrepancies in the definition and classification of this condition, which can make diagnosis and treatment selection challenging. Knowledge of contributing factors, the typical clinical presentation, and current best evidence for treatment options can assist in the diagnosis and appropriate treatment selection for this pathology. The purpose of this article is to present an overview of the current literature regarding the etiology, classification, assessment, and management of multidirectional instability of the glenohumeral joint.

Mapping glenohumeral laxity: effect of capsule tension and abduction in cadaveric shoulders

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.

Pitch-side management of acute shoulder dislocations: a conceptual review

The shoulder, specifically the glenohumeral joint, by virtue of its anatomical characteristics and biomechanics confers a large range of movement, which ultimately results in a joint that is inherently prone to becoming unstable. The incidence of acute traumatic shoulder dislocation varies within the sporting environment, commonly occurring following direct trauma. Anterior dislocations account for nearly 90% of all dislocations. While most are referred and managed in the emergency department, pitch-side relocation by experienced clinicians does occur prior to referral. The aim of this study was to delineate a guideline specifically for the pitch-side management of this common injury. A literature search of PubMed and Medline using the keywords ‘prehospital’, ‘pitch-side’, ‘shoulder dislocation’ and ‘reduction’ or ‘relocation technique’ was performed, and the available literature was reviewed and collated. Articles focusing on reduction techniques were then reviewed, with particular consideration on their applicability to a pitch-side setting. While studies exist that compare and contrast examination and reduction techniques, most are based in a hospital setting. To date, there is no standardised management protocol published for the initial management of an anterior dislocated shoulder in a pitch-side setting. This article addresses this discrepancy and proposes a structured, algorithmic approach to the pitch-side management of a shoulder dislocation. The article addresses factors to consider in a pitch-side setting, suitable techniques and postreduction care. While a systematic approach has been delineated in this article, we recommend those pitch-side medical practitioners who provide this form of support should have attended appropriate training and ensure adequate malpractice cover.

Multidirectional Shoulder Instability: Treatment

Background:

The treatment of multidirectional instability of the shoulder is complex. The surgeon should have a clear understanding of the role of hiperlaxity, anatomical variations, muscle misbalance and possible traumatic incidents in each patient.

Methods:

A review of the relevant literature was performed including indexed journals in English and Spanish. The review was focused in both surgical and conservative management of multidirectional shoulder instability.

Results:

Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder. The presence of a significant traumatic incident, anatomic alterations and psychological problems are widely considered to be poor prognostic factors for conservative treatment. Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.

When conservative treatment fails, a surgical intervention is warranted. Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes. Thermal or laser capsuloraphy is no longer recommended.

Conclusion:

Multidirectional instability is a complex problem. Conservative management with focus on strengthening and balancing of the dynamic shoulder stabilizers is the first alternative. Some patients will fare poorly and require either open or arthroscopic capsular plication.

Multidirectional Instability: Natural History and Evaluation

Background:

Multidirectional instability (MDI) represents a great challenge to the orthopedic surgeon. When treating these patients we must be aware that instability refers to a symptomatic situation, thus multidirectional instability is defined as symptomatic involuntary instability in two or more directions, and should be clearly differentiated from asymptomatic hyperlaxity.

It may be associated with hyperlaxity, either congenital or acquired following repetitive stress, but also may be present without hyperlaxity, which is rare.

Methods:

We searched in the online data bases and reviewed the relevant published literature available.

Results:

Many differences can be seen in the current literature when identifying these patients, unclear definitions and criteria to be included in this patient group are common.

Conclusion:

Understanding the complex shoulder biomechanics as well as being aware of the typical clinical features and the key examination signs, which we review in this article, is of paramount importance in order to identify and classify these patients, allowing the best treatment option to be offered to each patient.

Arthroscopic treatment of the atraumatic shoulder instability: a case series with two-year follow-up evaluation

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.

Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation

Capsulolabral augmentation is one of the most used arthroscopic techniques to address multidirectional instability of the shoulder. Given the thin and weak capsule seen in the affected patients, reconstruction in this subset of patients can be particularly challenging. This arthroscopic technique aims to reduce the capsular volume and deepen the glenoid socket through the creation of a particularly voluminous "bumper" along the glenoid bone. Increasing the depth of the glenoid facilitates a concavity-compression stabilizing effect and, therefore, shoulder stability, especially midrange stability. This technique aims to augment the bump of the standard capsulolabral reconstruction by using a resorbable surgical mesh derived from porcine skin.

Outcomes After Arthroscopic Pancapsular Capsulorrhaphy With Suture Anchors for the Treatment of Multidirectional Glenohumeral Instability in Athletes

BACKGROUND

Outcomes after arthroscopic pancapsular capsulorrhaphy (APC) with suture anchors for multidirectional instability (MDI) of the shoulder are not widely reported.

PURPOSE

To compare intraoperative findings and midterm outcomes of APC with suture anchors for MDI between female and male athletes and between a classic, atraumatic onset versus clinical onset of MDI after a traumatic event.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent APC with suture anchors for MDI and were at least 2 years out from surgery were included. Data were prospectively collected and retrospectively reviewed and included the onset of MDI, intraoperative pathoanatomic findings, level of sports participation, and patient satisfaction as well as the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Information regarding shoulder instability and return to sport was collected, and Kaplan-Meier survivorship analysis was performed.

RESULTS

Forty-one patients (45 shoulders; 25 male, 20 female), consecutively treated between October 2006 and January 2013, were included. The onset of MDI was atraumatic in 22 shoulders and traumatic in 23 shoulders. At surgery, 29 of 45 (64.4%) had labral detachment. Seven shoulders (16.7%) experienced instability episodes postoperatively, and 3 of these underwent revision surgery. The mean follow-up was 3.3 years (range, 2.0-6.6 years). All subjective outcome scores improved significantly from preoperative levels (P < .005). At final follow-up, the mean ASES score was 92.0, and 76.7% (23/30) indicated that they had returned to sports participation equal to or slightly below their preinjury level. Kaplan-Meier analysis showed a survivorship rate of 87% at 3 years. Male patients were 2.3 times more likely to have a traumatic onset of instability (68% vs 30%, respectively; P = .017) and were 2.1 times more likely to have concomitant lesions (84% vs 40%, respectively; P = .004) than female patients. Furthermore, male patients demonstrated a higher mean postoperative ASES score than female patients (97.0 ± 4.7 vs 85.5 ± 16.4, respectively; P = .023). Female patients were 6.9 times more likely to undergo an additional rotator interval closure (RIC) procedure (58% vs 4.7%, respectively; P < .001) and to experience postoperative subluxations (40% vs 22%, respectively; P = .035) than male patients. A traumatic onset of MDI was associated with a higher mean postoperative ASES score (96.4 ± 6.9 vs 87.0 ± 15.7, respectively; P = .048), higher median satisfaction score (10 vs 9, respectively; P = .029), and higher return-to-sport rate (83% vs 44%, respectively; P = .030) than an atraumatic onset.

CONCLUSION

APC with suture anchors can be an effective and safe treatment for patients with MDI. Labral tears were commonly found, even in patients with a classic, atraumatic onset. Male patients and patients with a traumatic onset of MDI had more favorable outcomes. Female patients may be more challenging to treat as they were more likely to undergo an additional RIC procedure and experience postoperative subluxations.

Arthroscopic treatment of glenoid bone loss

Recurrent anterior instability of the glenohumeral joint has long been an arduous problem to solve surgically, owing to its difficulty to the need to restore both osseous and dynamic constraints in the unstable shoulder. Biomechanical studies have indicated that glenoid bone loss shortens the safe arc through which the glenoid can resist axial forces; in these cases, a soft tissue repair alone may be insufficient to maintain stability. Clinical studies have confirmed that major bone loss is associated with an unfavourable outcome. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions and less soft tissue dissection, better access for repair and, potentially, the maximum respect for the undamaged anatomical structures. The biggest disadvantage of arthroscopic procedures until recently was the inability to successfully treat a significant bone defect. Over the last 10 years, several new arthroscopic techniques have been developed, providing new surgical options for successfully treating soft tissues and bony lesions in anterior-inferior glenohumeral instability. Level of evidence V.

History of shoulder instability surgery

PURPOSE

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

METHODS

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

RESULTS

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

CONCLUSIONS

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

LEVEL OF EVIDENCE

IV.

The Rotator Interval of the Shoulder: Implications in the Treatment of Shoulder Instability

Biomechanical studies have shown that repair or plication of rotator interval (RI) ligamentous and capsular structures decreases glenohumeral joint laxity in various directions. Clinical outcomes studies have reported successful outcomes after repair or plication of these structures in patients undergoing shoulder stabilization procedures. Recent studies describing arthroscopic techniques to address these structures have intensified the debate over the potential benefit of these procedures as well as highlighted the differences between open and arthroscopic RI procedures. The purposes of this study were to review the structures of the RI and their contribution to shoulder instability, to discuss the biomechanical and clinical effects of repair or plication of rotator interval structures, and to describe the various surgical techniques used for these procedures and outcomes.

Multidirectional Instability of the Shoulder: A Systematic Review

PURPOSE

To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI).

METHODS

A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed.

RESULTS

Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy.

CONCLUSIONS

Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Posteroinferior shoulder instability: clinical outcome of arthroscopic stabilization in 32 shoulders and categorization based on labral mapping

INTRODUCTION

Posterior shoulder instability is rare, appears in varying clinical patterns and can be the main symptom in patients with instability in more than one direction. The purpose was to analyze and categorize our patients and to report on the results of operative treatment by arthroscopy.

MATERIALS AND METHODS

A consecutive series of 32 shoulders in 31 patients from a 7-year period was chosen for retrospective clinical evaluation with VAS for pain, Rowe Score, Constant Score and Simple Shoulder Test. Follow-up rate was 100 %, the mean FU period was 28 months (range 13-58). Allocation based on clinical and intraoperative criteria resulted in the 4 groups A to D characterized by an increasing traumatic impact. Patients received a posterior Bankart repair with bone anchors in 21 or capsular plication to the intact labrum in 11 cases.

RESULTS

The clinical outcome scores were generally good and all showed a trend towards better results from A to D, but without significance. Pain on VAS pre- and postoperatively showed a significant (p < 0.0001) overall decline from 7.4 to 1.8. The Rowe Score increased significantly (p < 0.0001) from a mean value of 41.4 to 89.5 points. Three patients were reoperated and satisfied, four patients (12.5 %) not satisfied at follow-up. The drive-through sign was significantly (p = 0.003) more distinct in the less traumatic groups A and B than groups C and D. Subgroup allocation resulted in the following distribution: 7 patients qualified for group A (PPM = predominantly posterior multidirectional), 13 for B (RPS = recurrent posterior subluxation), 7 for C (unidirectional) and 5 patients for group D (bi-directional). Graphic display of labral lesions, called "labral mapping", revealed typical patterns for the groups.

CONCLUSION

In patients with posteroinferior shoulder instability, good results can be obtained with the arthroscopic treatment of all identified pathologies. Categorization into one of four subgroups might be a valuable tool regarding the choice of the operative treatment options.

Upper limb kinematics after arthroscopic and open shoulder stabilization

BACKGROUND

Shoulder joint stability mediated by proprioception is often quantified by arm repositioning tests (i.e., static end-position accuracy), overlooking ongoing movement quality. This study assessed movement quality by adopting smoothness-related kinematic descriptors. We compared performance of healthy controls with that of patients in arthroscopic shoulder stabilization and open shoulder stabilization groups. We hypothesized that arm kinematics after arthroscopic intervention would more closely resemble healthy movements compared with patients after open shoulder stabilization surgery.

METHODS

Healthy controls (N = 14) were compared with patients after arthroscopic shoulder stabilization (N = 10) and open shoulder stabilization (N = 12). Right-hand dominant subjects (the affected side in patients) performed 135 unconstrained 3-dimensional pointing movements toward visual targets (seen through pinhole goggles; i.e., no arm vision). Arm kinematic data were recorded and offline analyzed to obtain hand tangential velocity profiles further used to compute the acceleration-to-movement time ratio, peak-to-mean velocity ratio, and number of velocity peaks ("symmetry," "proportion," and "fragmentation" features, respectively). Parametric and nonparametric statistics were used for comparisons (P ≤ .05).

RESULTS

Control and arthroscopic shoulder stabilization groups presented similar acceleration-to-movement time ratio and peak-to-mean velocity ratio. Both groups differed from the open shoulder stabilization group (P = .001). Distributions of velocity peaks for control and arthroscopic shoulder stabilization groups were similar, whereas open shoulder stabilization and control subjects differed significantly (P = .028).

CONCLUSIONS

Movement quality mediated by proprioception in arthroscopic shoulder stabilization patients matches that of healthy controls, whereas performance in open shoulder stabilization patients seems inferior compared with that in healthy controls, as assessed by smoothness-related measures (less symmetrical, more fragmented movements).

Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies

Multidirectional instability (MDI) of the shoulder is a condition where the dislocation occurs in more than one direction with minimal or no causative trauma. Its pathoanatomy is complex and characterized by a redundant capsule, resulting in increased glenohumeral joint volume. The fact that several further factors may contribute to symptom onset complicates the diagnosis and hampers the identification of a therapeutic approach suitable for all cases. There is general agreement that the initial treatment should be conservative and that surgery should be reserved for patients who have not responded to an ad hoc rehabilitation program. We review the biomechanics, clinical presentation, and treatment strategies of shoulder MDI.