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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 ?
Providing)the)best)possible)care!@shoulderpedia
Defining Instability
Providing)the)best)possible)care!@shoulderpedia
Instability
• “Symptomatic” “abnormal translation” of humeral head
• Important to differentiate from hyperlaxity
Providing)the)best)possible)care!@shoulderpedia
Understanding Instability
Providing)the)best)possible)care!@shoulderpedia
Understanding StabilityStatic Stabilisers
Bone
Providing)the)best)possible)care!@shoulderpedia
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
Hill Sach’s lesion
Bony Bankart’s
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
ReverseHill Sach’s lesion
Reverse Bony Banakart’s
Anterior Posterior
Providing)the)best)possible)care!@shoulderpedia
Providing)the)best)possible)care!@shoulderpedia
Understanding StabilityStatic Stabilisers
BoneLabrum
Providing)the)best)possible)care!@shoulderpedia
Wheel Chocks
Providing)the)best)possible)care!@shoulderpedia
Providing)the)best)possible)care!@shoulderpedia
Understanding StabilityStatic Stabilisers
BoneLabrumGH ligaments
Providing)the)best)possible)care!@shoulderpedia
Attachments
Image courtesy: www.pitt.edu
Providing)the)best)possible)care!@shoulderpedia
Understanding Instability
Providing)the)best)possible)care!@shoulderpedia
MR Arthrogram
Providing)the)best)possible)care!@shoulderpedia
Instability Arthroscopy
Providing)the)best)possible)care!@shoulderpedia
Understanding Instability
Providing)the)best)possible)care!@shoulderpedia
HAGL
Humeral Avulsion Gleno humeral ligament
Providing)the)best)possible)care!@shoulderpedia
Understanding StabilityStatic Stabilisers
BoneLabrumGH ligaments
Dynamic Stabilisers
Rotator CuffPeriscapular muscles+ +
Providing)the)best)possible)care!@shoulderpedia
Concavity compression
Lippitt, Matsen; CORR
“Lad Hugging a Ball”
Providing)the)best)possible)care!@shoulderpedia
Scapulo-humeral balance
+ +
Providing)the)best)possible)care!@shoulderpedia
Atraumatic Instability
Providing)the)best)possible)care!@shoulderpedia
Atraumatic Instability
Providing)the)best)possible)care!@shoulderpedia
Atraumatic Instability
Providing)the)best)possible)care!@shoulderpedia
Atraumatic Instability
• Disruption of dynamic stabilisers.
• Weak Muscles
• Muscle incoordination
• In a predisposed shoulder i.e.
• Lax capsule
• Shallow Glenoid
Providing)the)best)possible)care!@shoulderpedia
Atraumatic instability
Providing)the)best)possible)care!@shoulderpedia
Understanding StabilityStatic Stabilisers
BoneLabrumGH ligaments
Dynamic Stabilisers
Rotator CuffPeriscapular muscles+ +
Proprioceptors
Providing)the)best)possible)care!@shoulderpedia
Classification
Providing)the)best)possible)care!@shoulderpedia
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
Providing)the)best)possible)care!@shoulderpedia
Classification
• Thomas and Matsen
• TUBS; Traumatic Unidirectional Bankart’s Surgery
• AMBRII; Atraumatic Multidirectional Bilateral Rehab Inferior Capsular shift
Providing)the)best)possible)care!@shoulderpedia
Classification
• Gerber
• Static
• Dynamic
• Voluntary
Providing)the)best)possible)care!@shoulderpedia
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
Providing)the)best)possible)care!@shoulderpedia
Clinical Assessment
Providing)the)best)possible)care!@shoulderpedia
Age at Presentation
Ref; Matsen et al
Providing)the)best)possible)care!@shoulderpedia
History
• Usually begins with a minor injury/innocuous event/s.
• Tilts a compensated “at risk” shoulder towards symptomatic instability.
• Ask about position of instability
Providing)the)best)possible)care!@shoulderpedia
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
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