atraumatic shoulder instability principles and assessment
TRANSCRIPT
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Atraumatic Instability-Principles and assessment
Puneet MongaConsultant Orthopaedic Shoulder Surgeon
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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