Assessment of the unstable shoulder

Abbas Rashid FRCS (Tr&Orth) Wrightington Upper Limb Unit

Classification

Structural • traumatic - soft tissue (e.g. Capsulolabral injury) - bony (e.g. Glenoid bone loss or Hill Sachs defect)

• Atraumatic

- soft tissue ( e.g. Capsulolabral deficiency) - bony (e.g. Glenoid dysplasia)

Non-structural • Unbalanced muscle

recruitment

Instability Biomechanics

Static Stabilisers• Vacuum - negative intracapsular pressure - suction effect - adhesion cohesion

• Labrum - 9mm thick - 50% increase in glenoid depth - chock block strongest AI (Bankart) and PS (SLAP)

• Capsule - IGHL

• Bone geometry - glenoid 7o retro vs. scapula 30o ante - effective glenoid arc (balance stability angle)

Dynamic Stabilisers• Proprioception - mechanoreceptors in AI capsule - activated when capsule contact HH - feedback to muscles

• Muscles - force couples - subscap: ant stability when arm in neutral - ISS & Tm: reduce strain on ant IGHL in ABER - scapular muscles: stable base for shoulder movement

Assessment of Bony Anatomy

Bony Anatomy: Humeral Head

Bony Anatomy: Glenoid

Biomechanics

Static Stabilisers• Vacuum - negative intracapsular pressure - suction effect - adhesion cohesion

• Labrum - 9mm thick - 50% increase in glenoid depth - chock block strongest AI (Bankart) and PS (SLAP)

• Capsule - IGHL

• Bone geometry - glenoid 7o retro vs. scapula 30o ante - effective glenoid arc (balance stability angle)

Dynamic Stabilisers• Proprioception - mechanoreceptors in AI capsule - activated when capsule contact HH - feedback to muscles

• Muscles - force couples - subscap: ant stability when arm in neutral - ISS & Tm: reduce strain on ant IGHL in ABER - scapular muscles: stable base for shoulder movement

Assessment of Hypermobility

Beighton Score

>6/9 = hypermobility but NOT BJHS

joint finding

little finger DF beyond 90o

thumb PF to forearm

elbow HE beyond 10o

knee HE beyond 10o

FF trunk Palms on floor

Abnormal muscle patterning• Abnormal activation or suppression • De-stabilisation of force couples • Clinical exam wrong in 50% of cases • EMG quantifies muscle activity

• Jaggi et al. Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg. 2012. Vol 6.4:101-7

Anterior posterior MDI

overactivity PM (60%) LD (81%) AD (22%)

LD (80%) PM (37%) AD (18%)

PM LD

inactivity IS (2%) IS (25%) PM LD

Assessment of Muscle Patterning

Pec Major• stand or supine • 90 deg FF and IR • Palpate sup/med border • Test resisted AD

Lat Dorsi• Standing • Arm AB 90 deg elbow flexed • Palpate posterior pectoral fold • Test resisted AD

Assessment of Muscle Patterning

Anterior Deltoid• Arm FF 90 deg • Palpate between lat clavicle &

coracoid • Patient resists downward force

on above elbow

Infraspinatus• Elbow flexed 90 deg • Arm AD, neutral rotation • Palpate IS fossa • Push against patients wrist

Instability Biomechanics

Static Stabilisers• Vacuum - negative intracapsular pressure - suction effect - adhesion cohesion

• Labrum - 9mm thick - 50% increase in glenoid depth - chock block strongest AI (Bankart) and PS (SLAP)

• Capsule - IGHL

• Bone geometry - glenoid 7o retro vs. scapula 30o ante - effective glenoid arc (balance stability angle)

Dynamic Stabilisers• Proprioception - mechanoreceptors in AI capsule - activated when capsule contact HH - feedback to muscles

• Muscles - force couples - subscap: ant stability when arm in neutral - ISS & Tm: reduce strain on ant IGHL in ABER - scapular muscles: stable base for shoulder movement

Soft Tissue Anatomy

Which tests?• Capsulolabal restraints

• Eric J Hegedus. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med.2012;46:964-978

• Systematic review WITH meta-analysis • Nov 2006 – Feb 2012

• Exclusions: - non-English articles - cadaveric studies - EUA studies - use of equipment to readily available

• 32 studies

Anterior InstabilityTest Sensitivity

(%)Specificity

(%)Paper

Anterior load and shift 50 100 Tzannes & Morrell. Sports Med 2002

Anterior drawer test n/a n/a Gerber & Ganz. J Bone Joint Surg Br 1984

Anterior apprehension 52 99 Lo et al. Am J Sports Med 2004

Jobe relocation 79 97 Fowler et al. Sports med Arthrosc Rahabil Ther Technol 2010

Surprise test 82 86 Hegedus et al Br J Sport Med 2012

Anterior slide 43 82 Walsworth et al. Am J Sports Med 2008

Dynamic anterior jerk test 31 98 Lerat et al. Rev Chir Orthop Repatrtrice Appar Mot 1994

Crank 61 55 Walsworth et al. Am J Sports Med 2008

Modified Dynamic labral shear

72 98 Kibler et al. Am J Sports Med 2009

Bony apprehension test 100 86 Bushnell et al. Arthroscopy 2008

Kinetic medial rotation test

n/a n/a Comerford & Mottram. Manual Therapy 2001

Leffert n/a n/a

Rowe n/a n/a

Thrower n/a n/a

Clunk 1 & 2 n/a n/a

Anterior Load & Shift• Sillman & Hawkins 1993

• sitting

• arm in 20 deg AB & 20 deg FF

• concentrically load HH

• push anteriorly

• Assess traslation

• If +tive, LR >100

Anterior Apprehension• Rowe & Zarins 1981

• standing or supine

• arm in 90 deg AB & 90 deg ER

• ER force until apprehension/pain

• ?pain alone NOT predictive

• Apprehension alone ! specificity

• PPV 98% and NPV 73%

Jobe Relocation

• Jobe 1989

• Anterior apprehension

• Posterior directed force on HH

• Relief of apprehension

• Relief of apprehension alone ! specificity

• PPD 100%

Surprise Test• Lo 2004

• Apprehension & Jobe relocation

• No further ER

• Release pressure

• Apprehension or Pain = instability

• PPV 98%

• If all 3 tests +tive, then specificity and PPV = 100%

Surprise Test• Lo 2004

• Apprehension & Jobe relocation

• No further ER

• Release pressure

• Apprehension or Pain = instability

• PPV 98%

• If all 3 tests +tive, then specificity and PPV = 100%

Dynamic Labral Shear Test• O’Driscoll 2012

• Standing

• Arm AB in scapular plane to 120 deg

• Shear load applied by max ER

• Arm lowered from 120 to 60deg

• Pain, click or catch between 120 and 90 deg

• If +tive, LR=32

Bony Apprehension Test• Bushnell 2008

• Similar to ant apprehension

• Arm at 45deg Ab & 45 ER

• Apprehension +/- pain = bony instability

• PPV = 73%

• If +tive then LR=71

Posterior InstabilityTest Sensitivity

(%)Specificity

(%)Paper

Posterior apprehension 19 99 Jia et al. J bone Joint Surg Am 2009

Posterior load and shift 14 100 Tzannes & Morrell. Sports Med 2002

Posterior drawer n/a n/a Gerber & Ganz. J Bone Joint Surg Br 1984

Jerk test 73 98 Kim et al. Am J Sports Med 2005

Fukuda test n/a n/a Fukuda & Neer. Orthopaedics 1988

Kim Test 80 94 Kim et al. Am J Sports Med 2005

Posterior subluxation test n/a n/a Clarnette & Miniaci. Med Sco Sports Excec 1098

Posterior Apprehension• Kessel 1982

• FF & IR to 90 deg, posterior force

• Apprehension = instability

• Modified by O’Driscoll & Evans 1991

• Inject SAS & repeat test (RTC)

• pain = posterior instability

Posterior Load & Shift• Sillman & Hawkins 1993

• Sitting

• arm in 20 deg AB & 20 deg FF

• concentrically load HH

• push posteriorly

• If +tive then LR>100 • If –tive then LR<1

Jerk Test• Kim 2004

• AB to 90 deg and full IR

• Apply axial load through elbow

• Other hand stabilises scapula

• move arm horizontally across body

• Feel for sudden jerk

Kim Test• Kim 2005

• Seated

• Arm in 90 deg AB, 45 deg FF,

• posterior force through elbow

• Pain = posterior instability

Inferior laxityTest Sensitivity

(%)Specificity

(%)Paper

Gagey’s hyper abduction test

n/a n/a Gagey & Gagey. J Bone Joint Surg Br 2001

Sulcus sign at 0 degrees n/a n/a Neer. J Bone Joint Surg Am 1980

Inferior apprehension test n/a n/a Feagin. Personal communication 2004

Gagey’s Test• Gagey 2001

• Measure passive AB

• scapula stabilised

• >105o = IGHL laxity

Sulcus Sign• Neer 1980

• Seated

• Pull on AD arm (neutral)

• Assess acromio-humeral distance

• >2cm = capacious capsule

• Repeat with arm in ER

• If still >2cm, then RI deficiency (MGHL & CHL) 1cm 1+

2cm 2+

3cm 3+

Inferior Apprehension Test• Feagin 2004

• Standing

• Support arm on examiners shoulder

• Downward pressure on upper arm

• Apprehension/pain = IGHL laxity

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Shoulder Surg. 2012 Oct;6(4):101-7. 3. Hegedus E. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review

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