Glenohumeral Joint Instability: An Athlete s Perspective

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Anatomic Considerations Glenohumeral Joint Instability: An Athlete s Perspective Michael D. Loeb, MD Texas Orthopedics, Sports Medicine, and Rehabilitation Associates Austin, Texas Static Stabilizers Osseous Capsuloligamentous Negative intra-articular pressure Dynamic Stabilizers Rotator cuff Periscapular musculature Osseous Anatomy Glenoid Labrum Humeral Head 45mm diameter 30 degrees retroversion 130-140 neck shaft angle Glenoid 35 mm cephalad/caudad 25 mm anterior/posterior +5/-20 degrees version Labrum Fibrocartilage ring attached peripherally to glenoid Deepens socket by 50% Provides attachment site for glenohumeral ligaments Commonly injured with traumatic glenohumeral dislocation (Bankart Lesion)

Capsuloligamentous Complex Negative Intra-Articular pressure Identifiable thickenings of the glenohumeral joint capsule Superior Glenohumeral Ligament Middle Glenohumeral Ligament Inferior Glenohumeral Ligament Complex (Ant/Post) High osmotic pressure of interstitial tissues Water and synovial fluid are drawn out of joint Leading to vacuum type effect Adhesion/cohesion at articular interface Help provide stability to joint at end range of motion Injury to complex leads to predictable patterns of glenohumeral instability Rotator Cuff Periscapular Musculature Four muscles Originate from body of scapula Provide dynamic stability to glenohumeral joint through concavity-compression Are responsible for stability through midrange of motion (along with long head of biceps) Position glenoid relative to humeral head to provide stable platform Postural Scapular dyskinesia Scapular winging neuromuscular Rehabilitation following instability largely focused on rotator cuff strengthening

Laxity vs. Instability Evaluation Laxity Physiologic spectrum Objective, increased glenohumeral joint motion Instability Pathologic Traumatic vs. Atraumatic Acquired Congenital Neuromuscular Subjective Voluntary or involuntary TUBS vs. AMBRI Traumatic Unidirectional Bankart Surgery Atraumatic Multidirectional Bilateral Rehabilitation History Mechanism of injury Contact vs. non-contact Position of extremity Abduction/external rotation Adduction/internal rotation Subsequent episodes Pattern of pain referral Locking/catching/ popping sensation May indicate articular fracture or loose body Physical Examination Anterior Glenohumeral Instability Inspection/Palpation Range of Motion Passive Active Muscle Strength Testing Neurologic assessment Instability testing Anterior Posterior Multidirectional Most common Forced abduction and external rotation Injury to: a. Anterior/inferior labrum and Inferior Glenohumeral Ligament Complex (Bankart Lesions) b. Anterior/inferior glenoid articular surface (Bony Bankart) c. Perthes lesion d. ALPSA (Anterior Labrum Periosteal Sleeve Avulsion) e. GLAD (Glenolabral articular disruption) f. HAGL (Humeral Avulsion of Glenohumeral Ligament) Humeral Head (Hill-Sachs lesions) Reverse HAGL

Posterior Glenohumeral Instability Less Common Adduction/Forward Flexion/Internal Rotation Offensive Lineman Posterior Labrum (Reverse Bankart) Voluntary (psychiatric??) vs. Involuntary Glenoid Dysplasia Congenital retroversion Non-surgical (Rehab) vs. Surgical Multidirectional Glenohumeral Instability Posterior Instability Rare Swimmers Primary Direction of instability May be exacerbated by acute injury Thumb MCP hypertextension, elbow hyperextension, genu recurvatum Inherent (genetic) ligamentous laxity Collagen disease (Ehlers-Danlos) REHAB, REHAB, REHAB!!!! Inferior capsular shift (open vs arthroscopic) Jerk Test

Elbow Hyperextension Thumb Metacarpophalangeal Hyperextension

Sulcus Sign Goals of Treatment Restore Stability Restore full active/passive ROM Full Strength Eliminate pain Eliminate apprehension Return to Competition Immobilization Physical Therapy Sling immobilization No clear time recommendations based on literature 1-3 weeks depending on severity of injury Internal versus external rotation Traditionally placed in internal rotation Some evidence to suggest external rotation may better approximate anterior structures to glenoid rim (must be initiated within 24 hrs of reduction) Passive>>>>>Active ROM/Strengthening Rotator Cuff Scapular Stabilizers Therapeutic modalities Electrical Stimulation www.asmi.org/sportsmed/throwing/thrower10.pdf

Surgical Treatment Surgical Treatment Restore normal anatomy Arthroscopic vs. Open stabilization Early vs. Delayed Repair Surgical repair must take into consideration: Age of patient Activity level Concomitant pathology (Bony injury) Arthroscopic vs. Open procedure (Bankart lesions) Results of arthroscopic stabilization equivalent to traditional techniques for anterior instability Allows for simultaneous treatment of concomitant pathology SLAP Hill-Sachs (Remplissage) Surgical Treatment Open procedures may be necessary for more extensive injuries and instability patterns Articular fracture (Bony Bankart) Recurrent instability Multidirectional Instability (MDI) Recovery and Rehabilitation 6 weeks of immobilization Encourage Elbow/wrist/hand ROM Passive>>>>Active ROM/Strengthening Return to Contact 5-6 months Use of external bracing devices (Sully strap, etc.)?

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