(More than you may want to know about) Shoulder Instability
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1 (More than you may want to know about) Shoulder Instability Lindsey Dietrich MD Sports Medicine and Orthopedic Surgery
2 Lindsey Dietrich, MD Sports Medicine and Orthopedic Surgery Orthopedic Medicine Specialists 902 W. Randol Mill Rd. Ste 120 Arlington, TX Ph:
3 No Disclosures related to this talk. 3
4 Anatomy of the shoulder Osseous Ligamentous Muscular Shoulder Function Glenohumeral Shoulder Dysfunction Traumatic Instability Atraumatic Instability Management Options Case Reviews 4
5 Patients referring to shoulder often mean the Shoulder complex These articulations produce companion motions Shoulder motion 2/3 GH Scapulothoracic SC joint AC joint GH joint 5
6 Glenoid Pear, inverted comma, oval shaped Slightly larger ROC than humerus Avg 39mm x 29mm Cartilage Thickest ant-inf glenoid Glenoid version 0-2 retro 6
7 Humerus 25% articulates with glenoid Greater and lesser tuberosities Intertubercular (bicipital) Groove 30 retroversion Cartilage thickest central-superior Ideally Centered through arc of motion 7
8 Obligate Humeral Translation Capsular and soft tissue tightness Translation opposite direction Eg. Adhesive capsulitis Eg Capsulorrhaphy arthropathy 8
9 Capsular Laxity increases Humeral Translation Cannot redirect forces Snowball effect Increased translation = less centered humerus Less centered humerus = less force needed to overcome glenoid rim GH joint most stable when most centered This is why neuromuscular modification of scapular kinetics can be helpful 9
10 Adhesion-Cohesion Adhesion of synovial fluid to cartilage Synovial fluid HIGH tensile strength = hard to pull LOW shear strength = easy glide Cohesion of synovial surfaces (think of 2 wet microscope slides or coins) Effect is reduced Inflammatory synovial fluid Reduced contact area Glenoid rim (bony bankart) Irregularity of the cartilage sfc 10
11 Suction / vacuum effect Concavity-compression Cuff! Limited joint volume in normal shoulder Negative intraarticular pressure Disturbed by venting joint Disturbed by increasing capsule compliance Disturbed by labrum defects 11
12 These are why the shoulder doesn t just dislocate even when paralyzed Eg: during surgery 12
13 Glenoid Labrum Fibrocartilage ring attaching to articular glenoid and capsule Insertional and morphologic variants Peripheral blood supply (not from bone) Continuous with LHBT Static stabilizer 50% of glenoid depth Vacuum effect Anterior attachments Ant band IGHL MGHL 13
14 Glenoid Labrum 14
15 Glenoid Labrum 15
16 Glenohumeral Ligaments Check reigns to torque Limited stability when acting alone Eg: Torque of 10lb, 40 in from humeral head If IGHL acted alone- have to resist 400 lb of tension 16
17 Glenohumeral Ligaments Inferior Glenohumeral Ligament (IGHL) Anterior band Tensioned in abd/max ER Posterior band Stability in flexion/ir Axillary pouch 17
18 Glenohumeral Ligaments Superior Glenohumeral Ligament (SGHL) Blends with CHL In rotator interval Supraglenoid tubercle lesser tuberosity (fovea capitis) Bicipital sling/stability of LHBT Resists inferior translation in neutral/adduction 18
19 Glenohumeral Ligaments Middle Glenohumeral Ligament (MGHL) Most variable in size/morphology Resists translation in mid abduction 19
20 Rotator Cuff All origins on scapula insert humerus Supra, Subscap, Infra, Teres minor Dynamic stability Concavity compression 20
21 Rotator Cuff Dynamic stability MID range Supra Subscap ABER Infra, Teres Subscap Force Coupling Usually cuff and a power muscle 21
22 Muscular stability Scapular stabilizers Serratus anterior Trapezius Levator Scapulae Rhomboids Power MM Deltoid Latissimus Dorsi Pec Major In other words Proper Function requires Perfect Harmony! 22
23 Break. 23
24 Break down into 2 general categories Traumatic (TUBS = traumatic unilateral bankart surgery) Anterior >>Posterior > Luxatio Erecta Recurrence rate is age dependent 80%+ in teens Bankart Lesion: ant/inf glenoid Ant IGHL Soft tissue Bony 24
25 Traumatic Anterior: consideration Hill Sach s: posterior impaction Greater Tuberosity Fx Pts > 50 yo Axillary nn injury 5% Transient neurapraxia RTC tears 30% over 40yo 80% over 60yo 25
26 Traumatic Anterior Alphabet Soup GLAD Cartilage sheared with labrum ALPSA Labrum heals medially on glenoid HAGL Higher recurrence?open repair? 26
27 Traumatic Anterior History and Physical exam are paramount # of dislocations Provocative activities Apprehension exam Workup will include Xrays : 3 orthogonal views MRI or MR arthrogram (more sensitive) +/- CT scan Evaluate glenoid erosion Bone loss 27
28 Case 1: 40yo M, RHD came to clinic (at 430pm) 10 days post altercation. Eval in ER and dx with distal bicep tear and told to follow up with ortho. No xrays were taken at time of his evaluation. He has a physically demanding job, and c/o inability to use his arm. Exam: Muscular habitus, ecchymosis and deformity to arm. No active FF, abd. Hard block to IR/ER. 28
29 Case 1: 40yo M, RHD came to clinic (at 430pm) 10 days post altercation. Eval in ER and dx with distal bicep tear and told to follow up with ortho. No xrays were taken at time of his evaluation. He has a physically demanding job, and c/o inability to use his arm. 29
30 Case 1: YIKES! Missed Anterior inferior traumatic dislocation 10 days out So what is the best next step? A. MRI of the Shoulder B. Tell him sorry, this is what he has to work with C. Rehab to regain function D. Schedule reduction of the shoulder next avail E. Urgent reduction of the shoulder F. CT Scan 30
31 Case 1: Closed vs Open reduction that night 45 min of sweat required chemical paralysis Sling use ADDuction and IR? ER? Follow up 2 wk Feels better and wants clearance for work! Declines rehab or further imaging Ideal treatment Rehabilitate for 6+ weeks Avoid position of danger (ABER) MR Arthro to eval cuff, GH lig based on age and injury Torn cuff-> fix 31
32 Case 1: Ideal treatment Rehabilitate for 6+ weeks Avoid position of danger (ABER) MR Arthro to eval cuff, GH lig based on age and injury Torn cuff-> fix 32
33 Atraumatic instability Unidirectional (ant/post): see in kids MULTIDIRECTIONAL (MDI) Symptomatic instability in more than 1 plane Inferior instability is universal Anterior + Inferior +/- posterior Not all laxity is instability It is worth a mention to be weary of voluntary dislocators Historically do poorly (100% surg fail rate in some studies) Must differentiate AWARENESS of how to reproduce symptoms Habitual subluxation 33
34 Multidirectional instability AMBRI Atraumatic, multidirectional, bilateral, rehabilitation, inf capsular shift Seen in 2 nd /3 rd decades of life 34
35 Multidirectional instability Proposed mechanisms Microtrauma: overuse Overhead athletes» Swimmer» Gymnasts» Volleyball Generalized Ligamentous laxity Likely hereditary component Connective tissue disorders Patulous Capsule 35
36 Multidirectional instability (MDI) History and Physical exam Insidious onset Provoked by overuse OR Disuse Adolescent or early 20s Female athlete Reality Male = Female Contributing factors Compliant capsular tissues GHLs Rotator interval Neuromuscular weakness Scap stabilizers Cuff Lateral scapular droop Voluntary or involuntary 36
37 Multidirectional instability (MDI) MRI studies Show RI and Posterior inf capsule volume greater in pts with MDI 37
38 Multidirectional instability (MDI) Patulous capsule Voluminous axillary pouch 38
39 Multidirectional instability (MDI) Beighton Score Try to objectify generalized hyperlaxity Validated in kids 35% kids 6-12yo score of 5 or more Score 0-3 considered normal 39
40 Multidirectional instability (MDI) Takehome: largely based on hx/physical Diagnosis of exclusion ASSET? Vs PATHOLOGIC? 40
41 Treatment considerations Age Instability pattern Hand dominance Sport or activity level Prior treatment Expectation management Growing weary in our fitness-forward culture I don t need therapy bc I work out Concomitant injuries 41
42 Traumatic instability Do nothing Activity Modify Rehabilitate dynamic stabilizers and scapular coupling Bracing Surgical Management Primary dislocation 7-10days soft tissue rest Initiate rehab In-season athletes Situation dependent Let them play when pain free 42
43 Traumatic instability Instability Severity Index Score (ISIS) Balg and Boileau 2007 Score >6 = up to 70% Failure ATS repair 43
44 Traumatic Anterior instability Arthroscopic Bankart ant labrum repair 2 anterior portals Elevate labrum tissue Debride glenoid face Get low and place glenoid anchors Advance IGHL, labrum 44
45 Traumatic Anterior instability Arthroscopic Bankart ant labrum repair Create a bumper of capsulolabral tissue 45
46 Traumatic Anterior instability Arthroscopic Bankart ant labrum repair Recurrence rate 6-10% Thermal capsullorhaphy NO! Chondrolysis arthritis 46
47 Traumatic Anterior instability: other options Open Bankart labrum repair Similar recurrence rates on avg Add capsulorrhaphy Remplissage for large/engaging Hill sachs 47
48 Traumatic Anterior instability With Glenoid Bone loss Primary repair Coracoid transfer 48
49 Traumatic Anterior instability With Glenoid Bone loss Simple formula 49
50 Case 2: 26yo M former Div 1 Wide Receiver, RHD, now recreational FB and Baskeball athlete with R shoulder primary dislocation 2 yrs ago. He has had dislocations since, even in his sleep. He rehabbed the original injury. Exam significant apprehension/relocation 2+ anterior load and shift with guarding Next Step in workup? A. Physical therapy/rehabilitation B. Sully Brace and RTP as tolerated C. Imaging Workup D. Diagnostic Arthroscopy E. Send to Germany for stem cell injection 50
51 Case 2: XRAYS unrevealing MRI shows bony bankart with erosion CT shows chronic anterior glenoid insufficiency 20-30% Large Hill Sachs 51
52 Case 2: Reconstructive options High likelihood of failure with ats management Coracoid process transfer 52
53 Atraumatic or Multidirectional Instability Treatment options Rehabilitation Rehabilitation Rehabilitation Rehabilitation surgery 53
54 Atraumatic or Multidirectional Instability Avoiding Surgery 6-12 mos of compliant rehabilitation Successful in at least 80% of cases MANAGING expectations Recognized as a dx around 1982 Some patients just aren t surgical candidates Some pts may not return to sport 54
55 Surgical management of MDI Capsular shift/plication Arthroscopic Open +/- RI closure Swimmers 80% return to play But Only 20% return to pre injury training volume Overhead athletes 85% return to preinjury level Seems ambitious to me 55
56 Surgical management of MDI Capsular shift/plication Avoid overtightening Goal 30 ER at t.o.s RI closure Effect on volume Effect on Humeral translation Anterior Restricted ER We probably don t know 56
57 Surgical management of MDI 57
58 Post surgical rehabilitation Early 0-6 wk Activation of scapular stabilizers Passive active FF/IR/ABD (wk 5) Avoid ER past neutral Sling 4-6 wk Second six weeks Strengthening in protected abd (to 45 ) Gradual ER Avoid forceful PROM NM retraining of shoulder girdle Goal 5/5 cuff/scap (12 wk) Normalized scap-humeral coupling 58
59 Post surgical rehabilitation Week Strenghtening Low / medium velocity task Non provocative (ABER) Maintenance of strength with reps Wk 20 begin sport specifics 59
60 Take home points Traumatic Young = recurrence Older = eval for cuff tears Treatment Age/expectation/mechanism Bone involvement Atraumatic Takes many forms Rehabilitate! 60
61 61
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