atraumatic shoulder instability principles and assessment

Providing)the)best)possible)care!@shoulderpedia

Atraumatic Instability-Principles and assessment

Puneet MongaConsultant Orthopaedic Shoulder Surgeon

Providing)the)best)possible)care!@shoulderpedia

Scenario 116 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and can demonstrate shoulder dislocation in clinic…..but has no pain or other symptoms.

• Hyperlax?

• Unstable?

• Management?

Providing)the)best)possible)care!@shoulderpedia

Scenario 216 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and dislocates her shoulder when swimming. It is very painful and she has been to Casualty 5 times.

• Hyperlax?

• Unstable?

• Management ?

Providing)the)best)possible)care!@shoulderpedia

Scenario 316 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and dislocates her shoulder every morning. Mum feels “queasy” and daughter has missed school for weeks.

• Hyperlax?

• Unstable?

• Management ?

Providing)the)best)possible)care!@shoulderpedia

Scenario 416 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and injured her shoulder when fell off a horse 3 months ago. Since then it keeps coming out of the joint on relatively minor tasks.

• Hyperlax?

• Unstable?

• Management ?

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Defining Instability

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Instability

• “Symptomatic” “abnormal translation” of humeral head

• Important to differentiate from hyperlaxity

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Understanding Instability

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Understanding StabilityStatic Stabilisers

Bone

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Anterior Posterior

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Anterior Posterior

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Anterior Posterior

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Anterior Posterior

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Hill Sach’s lesion

Bony Bankart’s

Anterior Posterior

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ReverseHill Sach’s lesion

Reverse Bony Banakart’s

Anterior Posterior

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Understanding StabilityStatic Stabilisers

BoneLabrum

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Wheel Chocks

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Understanding StabilityStatic Stabilisers

BoneLabrumGH ligaments

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Attachments

Image courtesy: www.pitt.edu

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Understanding Instability

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MR Arthrogram

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Instability Arthroscopy

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Understanding Instability

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HAGL

Humeral Avulsion Gleno humeral ligament

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Understanding StabilityStatic Stabilisers

BoneLabrumGH ligaments

Dynamic Stabilisers

Rotator CuffPeriscapular muscles+ +

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Concavity compression

Lippitt, Matsen; CORR

“Lad Hugging a Ball”

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Scapulo-humeral balance

+ +

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Atraumatic Instability

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Atraumatic Instability

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Atraumatic Instability

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Atraumatic Instability

• Disruption of dynamic stabilisers.

• Weak Muscles

• Muscle incoordination

• In a predisposed shoulder i.e.

• Lax capsule

• Shallow Glenoid

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Atraumatic instability

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Understanding StabilityStatic Stabilisers

BoneLabrumGH ligaments

Dynamic Stabilisers

Rotator CuffPeriscapular muscles+ +

Proprioceptors

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Classification

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Classification

• Rockwood

• Type I; traumatic. h/o prior dislocation

• Type II; traumatic. no prior dislocation

• Type III; atraumatic. a) with, b) without psychiatric issues

• Type IV; involuntary

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Classification

• Thomas and Matsen

• TUBS; Traumatic Unidirectional Bankart’s Surgery

• AMBRII; Atraumatic Multidirectional Bilateral Rehab Inferior Capsular shift

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Classification

• Gerber

• Static

• Dynamic

• Voluntary

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Classification

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Stanmore triangle

Providing)the)best)possible)care!@shoulderpedia@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16

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Clinical Assessment

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Age at Presentation

Ref; Matsen et al

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History

• Usually begins with a minor injury/innocuous event/s.

• Tilts a compensated “at risk” shoulder towards symptomatic instability.

• Ask about position of instability

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Assessment

Assess contributions from the three poles@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16

Providing)the)best)possible)care!@shoulderpedia

Assessment

• Traumatic

• History of Trauma

• Positive apprehension / Jerk test / load and shift

• MR Arthrogram

@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16

Providing)the)best)possible)care!@shoulderpedia

Assessment

• Atraumatic structural

• Brighton Score

• Sulcus Sign (graded / >2cm +)

• Gagey sign (GH passive abduction >105)

@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16

Providing)the)best)possible)care!@shoulderpedia

Assessment

• Muscle Patterning

• Scapular Dyskinesia

• Pec Major deactivation

• Latt dorsi deacivation

@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16

Providing)the)best)possible)care!@shoulderpedia

Scenario 116 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and can demonstrate shoulder dislocation in clinic…..but has no pain or other symptoms.

• Hyperlax

• Instability?

• Management?

Providing)the)best)possible)care!@shoulderpedia

Scenario 216 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and dislocates her shoulder when swimming. It is very painful and she has been to Casualty 5 times.

• Hyperlax?

• Instability

• Management ?

Providing)the)best)possible)care!@shoulderpedia

Scenario 316 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and dislocates her shoulder when every morning. Mum feels “queasy” and daughter has has missed school for weeks.

• Hyperlax?

• Unstable- Consider the other Issues

• Management ?

Providing)the)best)possible)care!@shoulderpedia

Scenario 416 year old girl. Comes with her Mum, who is very concerned. Mum says her daughter is “double-jointed” and injured her shoulder when fell off a horse 3 months ago. Since then it keeps coming out of the joint on relatively minor tasks.

• Hyperlax?

• Instability - consider traumatic lesions

• Management ?

Providing)the)best)possible)care!@shoulderpedia

Questions and comments….

@shoulderpedia Puneet Monga

Understanding Instability

Tuesday, 24 May 16

Atraumatic Instability

Tuesday, 24 May 16

+++ +

Tuesday, 24 May 16

! "$!

Figure 5: The Stanmore classification of instability

It is apparent from the above discussion that the presentation of patients with instability

can vary significantly and hence for the purposes of this study only patients with

recurrent anterior glenohumeral dislocations following a traumatic episode were

included.

Treatment of traumatic anterior shoulder dislocation may range from initial

immobilization followed by rehabilitation to early operative stabilization. The patient’s

age, previous dislocations, joint laxity, co-morbidities, compliance and activity level

guide the choice of treatment. It is common practice to reserve surgical treatment for

patients having recurrent dislocations. Non-operative management generally involves an

initial reduction of the dislocation followed by immobilization of the shoulder for a

period of three to six weeks. This is followed by physiotherapy focusing initially on

regaining the range of motion and then subscapularis strengthening exercises {O'Brien

et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence

of dislocation {Hovelius et al., 1996}.

In the past, tendon or muscle units were shortened to stabilize the shoulder. For

example, the Putti-Platt procedure involved surgical shortening of the subscapularis to

achieve stability. This however led to a loss of movement, especially external rotation,

Tuesday, 24 May 16

Tuesday, 24 May 16