Phys Med Rehabil Clin N Am 15 (2004) 575–605Glenohumeral instability and dislocation Jonathan T. Finnoff, DOa,b,*, Susan Doucette, PT,MSc, Gregory Hicken, MDb Department of Health, Physical Education and Recreation, Utah State University, Logan, UT 84341, USA b Alpine Orthopedic Specialists, 2380 North 400 East, Suite A, North Logan, UT 84341, USA c Logan Physical Therapy, 550 East 1400 North, Suite M, Logan, UT 84341, USA a Glenohumeral joint instability is a common disorder of the shoulder. The glenohumeral joint is the most mobile joint in the body, and by design, it has gained the extra mobility at the expense of stability. Instability may present in a variety of ways. Pain may be the only symptom experienced by some patients, whereas others may present with a frank dislocation. A thorough understanding of the regional anatomy and biomechanics, the pathophysiology of glenohumeral joint instability, and the performance of an appropriate history and physical examination should lead the examiner to the correct diagnosis. This article reviews the anatomy of the shoulder joint complex; discusses the complex interplay of static and dynamic structures that provide glenohumeral joint stability; presents a classification system for glenohumeral joint instability; discusses the pathophysiology of glenohumeral joint instability; presents a logical approach to the history, physical examination, and radiologic examination for glenohumeral joint instability; and discusses the current nonoperative and operative treatment options for this disorder. Anatomy and biomechanics The shoulder complex is composed of the sternoclavicular joint, acromioclavicular joint, scapulothoracic articulation, and glenohumeral joint [1]. The glenohumeral joint, which is considered an enarthrodial joint * Alpine Orthopedic Specialists, 2380 North 400 East, Suite A, North Logan, UT 84341, USA. E-mail address: finnoff@msn.com (J.T. Finnoff ). 1047-9651/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2003.12.004 576 J.T. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 (ball and socket), depends on static and dynamic factors for joint stability. A more detailed description of shoulder anatomy is presented in another article elsewhere in this issue. Static stabilizers The static stabilizers of the glenohumeral joint include the bony congruence of the joint surfaces, the geometry of the glenohumeral joint, the glenoid labrum, the joint capsule and ligaments, and the negative intraarticular pressure [2]. The humeral head to shaft angle is 130 to 140 , and the humeral head is retroverted 30 relative to the elbow’s transepicondylar axis [3]. The humeral head composes approximately one third of a sphere on the proximal humerus, which equates to an arc of 120 [3]. The glenoid fossa is the articular surface on the scapula where the humeral head articulates. The scapula rests in a position of 30 to 45 anterior to the coronal plane, and the glenoid fossa is approximately 7 retroverted relative to the scapula with a 5 cephalad tilt [3]. The orientation of the glenoid fossa relative to the humeral head provides a barrier to posterior and inferior glenohumeral joint instability [4]. Proper scapulothoracic movement is required to maintain the appropriate glenohumeral joint orientation for static glenohumeral joint stability. The glenoid fossa is relatively shallow and covers only about 25% of the humeral head surface [3]. This percentage is increased to approximately 35% with the addition of the glenoid labrum [3]. The glenoid labrum is a fibrocartilaginous structure that is attached firmly to the rim of the glenoid in all regions except for the superior area, where it is attached loosely. The glenoid labrum increases the glenoid fossa depth by 50% and provides an attachment point for the glenohumeral ligaments. The forces required to dislocate the humeral head are decreased by 20% after removal of the glenoid labrum, indicating that this structure has an important role as a static stabilizer of the glenohumeral joint [5]. The glenohumeral joint capsule attaches proximally to the glenoid labrum and distally to the surgical neck of the humerus [6]. The capsule is lax in the mid ranges of glenohumeral joint motion and becomes taut at the extremes of motion. The glenohumeral joint capsule acts as a static stabilizer at end ranges of glenohumeral joint motion [6]. The glenohumeral ligaments are thickenings of the glenohumeral joint capsule and include the superior, middle, and inferior glenohumeral ligaments. Another ligament involved in the static stability of the glenohumeral joint is the coracohumeral ligament. Dempster [7] hypothesized that the capsuloligamentous restraints of the glenohumeral joint acted in a global or ring fashion. Any translation of the humerus on the glenoid would result in tension of the capsuloligamentous structures on the same and opposite sides of the translation. This theory has been supported by research designed to identify the stabilizing role of the glenohumeral ligaments. J.T. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 577 The superior glenohumeral ligament is the most constant of the three glenohumeral ligaments and provides resistance to inferior and posterior glenohumeral instability [4,8]. The superior glenohumeral ligament resists posterior and inferior instability most efficiently when the humerus is in adduction and external rotation [9]. The coracohumeral ligament seems to have a similar role to the superior glenohumeral ligament in preventing posterior and inferior glenohumeral joint instability [4,9,10]. The superior glenohumeral ligament, coracohumeral ligament, and long head of the biceps tendon all are located within the rotator interval, an area between the supraspinatus and subscapularis tendons [11]. The middle glenohumeral ligament is the least consistent of the glenohumeral ligaments and is the primary restraint to anterior glenohumeral joint instability when the humerus is abducted to 45 [12]. The inferior glenohumeral ligament includes an anterior band and a posterior band, which are divided by a loose area of capsule referred to as the axillary pouch [13]. With the humerus in 90 of abduction, the anterior band of the inferior glenohumeral ligament becomes the primary restraint to anterior glenohumeral instability [13]. Selective incision of the posterior capsule and posterior band of the inferior glenohumeral ligament results in posterior subluxation of the glenohumeral joint, but an incision of the rotator interval is required before full dislocation can occur [14,15]. The posterior stabilizing effect of the inferior glenohumeral ligament’s posterior band is most effective at 90 of humeral abduction [16]. The requirement of pathology to the anterior and the posterior static stabilizers of the glenohumeral joint before full posterior dislocation serves to reinforce further the circle theory of capsuloligamentous glenohumeral stability. The intact glenohumeral joint has a negative intra-articular pressure creating a vacuum effect across the glenohumeral joint [17]. Loss of this intraarticular pressure results in inferior subluxation of the glenohumeral joint [17]. Although the vacuum-stabilizing effect of the negative intra-articular pressure is primarily a stabilizer against inferior instability, it also serves to prevent instability in all other directions [18]. Dynamic stabilizers The dynamic stabilizers of the glenohumeral joint include the scapular stabilizing and rotator cuff muscles and the long head of the biceps [19]. Dynamic stability not only depends on the sufficient strength, flexibility, and endurance of these muscles, but also appropriate proprioceptive input and neuromuscular control [20]. The importance of optimal scapular function for glenohumeral joint stability cannot be overemphasized. The scapular stabilizing muscles orient the scapula properly in relation to the humerus for optimal static and dynamic stability of the glenohumeral joint and stabilize the scapula during glenohumeral joint movements [21]. The scapular stabilizing muscles include In particular. beyond normal physiologic limits.24]. Acute instability involves an acute injury resulting in subluxation or dislocation of the glenohumeral joint. pectoralis minor. and help resist glenohumeral translation. subscapularis. coordinated rotator cuff muscle contraction and concavity compression are particularly important mechanisms for glenohumeral joint stability in these ranges [19]. Classification of glenohumeral joint instability The classification of glenohumeral joint instability includes the degree. The degree includes dislocation. These forces press the humeral head into the glenoid fossa.T. latissimus dorsi. rhomboideus minor and major. subluxation. and microinstability. the subscapularis seems to be an important stabilizer of anterior and posterior glenohumeral joint stability [14. With rotator cuff muscle contraction. is multidirectional. and levator scapulae [21].578 J. are processed.25]. Chronic instability refers to repetitive instability episodes. it is possible that the glenohumeral joint capsule develops tension and increases in stiffness. The abnormal proprioception is restored after surgical correction of the joint instability. and direction of instability [6]. first described by Lippitt et al [22]. The rotator cuff muscles include the supraspinatus. there is an intertwining of the joint capsule with the rotator cuff tendons. frequency. Because the glenohumeral ligaments are lax in the mid ranges of glenohumeral joint motion. A subluxation occurs when the humeral head translates to the edge of the glenoid. At the distal insertion of the rotator cuff muscles on the humerus. followed by selfreduction. etiology. The frequency of instability can be acute or chronic [6]. Microinstability is due to excessive capsular laxity. Proprioception and neuromuscular control refer to the mechanism by which the position and movements of the shoulder girdle are sensed (proprioception). Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 the serratus anterior. infraspinatus. . refers to the compressive forces placed on the glenohumeral joint during rotator cuff muscle cocontractions. These muscles contribute to dynamic glenohumeral joint stability through many mechanisms. suggesting that the mechanism of proprioceptive deficits in unstable glenohumeral joints is a lack of appropriate capsuloligamentous tension [27]. and is associated frequently with internal impingement of the rotator cuff [6]. center the humeral head within the glenoid fossa. and result in an appropriate motor response (neuromuscular control) [20]. trapezius. A dislocation implies that the humeral head is disassociated from the glenoid fossa and often requires manual reduction. Glenohumeral joint instability often is associated with a concomitant decrement in proprioception [26]. The rotator cuff muscles also provide glenohumeral joint stability through passive muscle tension and act as barriers to glenohumeral joint translation during active motion [23. acting as a dynamic musculoligamentous stabilizing system [19]. Concavity compression. and teres minor. Multidirectional instability is instability in two or more directions and is usually due to congenital capsular laxity or chronic repetitive microtrauma [6]. Unidirectional instability frequently is caused by a traumatic event resulting in disruption of the glenohumeral joint. Glenohumeral joint instability can be unidirectional or multidirectional. injury to the rotator interval. or congenital abnormalities [10]. Atraumatic instability can be subclassified into voluntary and involuntary categories. Unidirectional instability refers to instability only in one direction. Causes of inferior glenohumeral joint instability include . Anterior instability Anterior instability is caused most frequently by a tear in the anteriorinferior glenohumeral joint capsule (involving the middle glenohumeral ligament or anterior band of the inferior glenohumeral ligament) or detachment of the anterior-inferior glenoid labrum from the glenoid rim [19].T. chronic repetitive microtrauma. The most frequently occurring type of unidirectional instability is traumatic anterior instability [6]. Bankart lesions also can involve a fracture of the anterior-inferior glenoid rim. Pathophysiology of glenohumeral joint instability Glenohumeral joint instability may result from three primary etiologies: acute major trauma. superior labral anterior posterior lesions. This section discusses common pathologic lesions associated with glenohumeral joint instability. referred to as a Hill-Sachs defect [30]. whereas an individual who cannot do so has involuntary instability. and rotator cuff tear (particularly to the subscapularis muscle) [19]. which portends a poor outcome if surgical stabilization is performed [28]. Acute anterior glenohumeral joint dislocations also frequently are associated with a compression fracture of the posterolateral aspect of the humeral head. Inferior instability Inferior glenohumeral joint instability typically does not occur in isolation. commonly referred to as a bony Bankart lesion [30].J. Atraumatic instability refers to glenohumeral joint instability due to congenital capsular laxity or repetitive microtrauma. Other anatomic lesions that contribute to anterior glenohumeral joint instability include humeral avulsion of the glenohumeral ligament. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 579 The etiology of glenohumeral joint instability can be traumatic or atraumatic [6]. Some patients with voluntary instability have associated psychological pathology. The latter of these two entities frequently is referred to as a Bankart lesion [29]. Variations of the Bankart lesion include the Perthes lesion and the anterior labroligamentous periosteal sleeve avulsion lesion [30]. An individual who can sublux or dislocate the glenohumeral joint volitionally has voluntary instability. 31]. It also is important to determine when the symptoms first were noticed. absence of the glenoid fossa upward tilt. posterior band of the inferior glenohumeral ligament. Another possible cause for secondary multidirectional instability is the presence of an underlying connective tissue disorder. Although many patients with glenohumeral joint instability have vague symptoms. or subscapularis muscle [10].580 J. .31]. such as Marfan’s or Ehlers-Danlos syndromes [6]. When the patient reports pain. recurrent unilateral joint instability stretches the glenohumeral capsuloligamentous structures to the point where multidirectional instability develops secondarily [6]. Multidirectional instability Multidirectional instability may be due to primary or secondary capsuloligamentous laxity. Posterior instability Congenital glenoid hypoplasia or excessive glenoid or humeral retroversion has been reported to contribute to posterior glenohumeral joint instability. A history of acute trauma or chronic. superior glenohumeral ligament. quality. and swelling [32]. often referred to as a reverse Bankart lesion. Some patients may have a history of glenohumeral joint dislocation. intensity. and vocational and avocational activities. catching. More common lesions that lead to posterior glenohumeral joint instability include excessive capsuloligamentous laxity and injury to the rotator interval. popping. locking. common complaints of patients with shoulder instability include pain. and inferior glenoid labrum. inferior glenohumeral ligament. and lesions to the rotator interval. hand dominance. and the examiner should determine the direction of dislocation. Occasionally. A tear of the posterior-inferior glenoid labrum causing separation from the glenoid fossa rim. or a fracture of the posterior inferior glenoid fossa rim also may cause posterior glenohumeral joint instability [10. coracohumeral ligament. The patient should be asked about exacerbating and alleviating factors. superior glenohumeral ligament. coracohumeral ligament. repetitive microtrauma should be obtained. A reverse Hill-Sachs defect also may be present. and positions or activities that result in instability episodes. an unstable sensation. and any radiation of the pain should be determined. the location. It frequently is seen bilaterally and may be accompanied by generalized joint laxity [6]. the frequency of symptoms. age. stiffness. representing an impaction fracture of the anterior humeral head [10. History The history should include the patient’s chief complaint.T. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 capsuloligamentous laxity. Adjacent joints should be evaluated to rule out referred pain or concomitant pathology. Palpation should begin at the sternoclavicular joint and progressive laterally to encompass the anterior. The lateral scapular slide measurement can be used as an objective test for scapulothoracic movement symmetry. reflex evaluations. and weakness while carrying heavy objects may indicate inferior instability [32]. and special tests for glenohumeral joint instability. paresthesias. posterior. The patient’s shoulder girdle should be inspected for posture. Scars that are thin or spreading may suggest an underlying connective tissue disorder [32]. such as baseball pitching. Posterior instability is suggested by instability that occurs when the patient’s shoulder is forward flexed and internally rotated [32]. Areas of deformity or tenderness should be noted. muscle atrophy. The distance from the inferior . glenohumeral joint range of motion (ROM). scapulothoracic motion should be assessed for the presence of winging and abnormalities in the scapulothoracic rhythm.T. and whether it required manual reduction or reduced spontaneously. muscle imbalance or fatigue. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 581 the duration of the dislocation. During the concentric and eccentric phases of active shoulder abduction and forward flexion. Scapular position should be noted. A kinetic chain evaluation also should be performed to ensure that deficits in distant regions are not contributing to the glenohumeral joint instability. scars. indicating scapulothoracic dyskinesis or weakness of the scapular stabilizers. The patient should be asked whether he or she or any family members have a history of generalized ligamentous laxity or connective tissue disorder. and lateral aspects of the shoulder. abduction. Winging of the scapula may be associated with scapulothoracic dyskinesis. The direction of instability may be elicited through historical information. or an injury to the spinal accessory nerve or long thoracic nerve [1]. and deformity.J. extension. whether it has reoccurred. superior. may cause enough microtrauma to lead to symptomatic laxity [32]. discoloration. Internal and external rotation should be assessed with the arm at the side and with the shoulder abducted 90 . including flexion. Instability that occurs with the patient’s shoulder in the abducted and externally rotated position suggests anterior instability [32]. palpation. ROM should be assessed actively and passively. Repetitive overhead activities. and internal and external rotation. Patients with multidirectional instability may report symptoms of two or more instability patterns. upper extremity strength. adduction. Physical examination The physical examination should include inspection. inferior. Pain. sensation (including proprioception). swelling. Subluxation episodes commonly are associated with a burning or aching dead feeling in the arm. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 angle of the scapula to the nearest spinous process is measured in three positions: arms at the side. The patient is placed in the supine position. Sensation should be assessed in the C5 through T1 dermatomes and in the cutaneous nerve distributions of the upper extremities. and triceps reflex (C7-8) [34]. The test is considered positive if the patient indicates a feeling of impending anterior dislocation [37]. The patient is placed supine on the examination table. whereas the posterior drawer test (Fig. 2B) is used to evaluate posterior glenohumeral joint instability. The hand of the patient’s affected shoulder is placed in the examiner’s axilla and grasped by the examiner’s arm. brachioradialis or pronator reflex (C5-6). The patient’s shoulder is abducted 80 to 120 and flexed 0 to 20 . Functional testing procedures. The examiner grasps the patient’s proximal humerus with the remaining hand and exerts an anteriorly directed force on the humeral head. 1) are for anterior glenohumeral joint instability. . The examiner abducts the patient’s shoulder 90 and flexes the elbow 90 .582 J. The examiner uses the other hand to stabilize the scapula and monitor for anterior translation of the shoulder. and arms abducted 90 . with an emphasis on the rotator cuff and scapular stabilizing muscles. hands on the hips. The examiner uses one hand slowly to externally rotate the patient’s humerus using the patient’s forearm as the lever. The relocation test is positive if the examiner removes the hand from behind the proximal humerus. Clinical tests used to measure the proprioceptive and kinesthetic abilities of the shoulder commonly consist of angular reproduction and threshold to sensation of movement maneuvers. also can provide reliable information. A positive test is indicated by excessive anterior translation of the humerus relative to the glenoid. while the other hand is placed posterior to the patient’s proximal humerus and exerts an anteriorly directed force on the humeral head. Special tests for instability Anterior apprehension (crank) and relocation tests The anterior apprehension (crank) and relocation tests (Fig. such as the closed kinetic chain upper extremity stability test [35] and functional throwing performance index [36]. Reflex testing should include the biceps reflex (C5-6). This test may be accompanied by apprehension or a click [38]. and exerts a posteriorly directed force. Strength testing should include all of the upper extremity muscles. and the patient reports a reduction in the apprehension [37]. A side-to-side difference of 2 or more cm is considered significant [33].T. Anterior and posterior drawer tests The anterior drawer test (Fig. places it over the anterior proximal humerus. 2A) is used to evaluate anterior glenohumeral joint instability. T. 1. (B) Relocation test. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 583 Fig. (A) Anterior apprehension test. flexing the patient’s elbow to 120 .J. which indicates a positive test [38]. and flexing the shoulder 20 to 30 . The same hand that is exerting the posteriorly directed force on the humeral head also monitors the humeral head for posterior translation. The test occurs when the examiner forward flexes the shoulder 60 to 80 while placing a posteriorly directed force against the patient’s humeral head with the thumb of the other hand. abducting the shoulder to 80 to 120 . The examiner’s other hand stabilizes the scapula with the thumb over the anterior aspect of the shoulder just lateral to the coracoid process and the remaining fingers along the posterior shoulder. The posterior drawer test begins with the patient in a supine position. . The examiner grasps the patient’s proximal forearm with one hand. The patient’s affected shoulder is forward flexed to 90 . (A) Anterior drawer test. the patient is in a seated position with the arms at the sides. Load and shift test For the load and shift test (Fig. 3). while pressing the humeral head into the glenoid fossa with the other hand. Posterior apprehension test The posterior apprehension test (Fig. and the amount of humeral anterior and posterior translation is assessed [39]. 4) evaluates posterior glenohumeral joint stability. 2.584 J.T. An anterior and posterior force is placed on the proximal humerus. (B) Posterior drawer test. The examiner stabilizes the patient’s affected shoulder with one hand. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Fig. then . J. The patient’s elbow is grasped by the examiner.T. Jerk test The jerk test is another test to evaluate posterior glenohumeral joint stability. (B) Posterior load and shift test. and an axial load is placed through the humerus. The patient’s arm is adducted horizontally across the body while maintaining the axial load. A posteriorly directed force is placed on the patient’s elbow by the examiner. A positive test causes a 50% or greater posterior translation of the humeral head or a feeling of apprehension in the patient [40]. The patient is seated. and the shoulder is abducted 90 and maximally internally rotated. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 585 Fig. A . (A) Anterior load and shift test. maximally internally rotated. 3. Sulcus sign The sulcus sign (Fig. Posterior apprehension test. 5. It may relocate with another jerk as the arm is returned back to an abducted position [40]. 5) is used to evaluate inferior glenohumeral joint instability.T. Sulcus sign. and a distal traction force Fig. 4.586 J. . The patient is seated or standing with the arm relaxed at the side. positive test is indicated by a posterior ‘‘jerk’’ of the humeral head as it displaces posteriorly. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Fig. The patient’s forearm is grasped by the examiner. a sulcus develops between the humeral head and the acromion [40]. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 587 is placed through the patient’s arm. and scapular ‘‘Y’’ view [6]. The most common initial radiographic views for the evaluation of glenohumeral joint instability include the anteroposterior shoulder view. clavicle. Feagin test The Feagin test (Fig. With internal rotation.T. The scapular Y view can help to assess glenohumeral joint alignment after acute dislocations [30]. Feagin test. the elbow extended. The examiner clasps the hands together over the patient’s proximal humerus and exerts a downward force. and glenoid rim [30]. including the scapula. axillary lateral view. . and the forearm resting on the examiner’s shoulder. humeral head. Radiologic evaluation The various lesions commonly seen with glenohumeral joint instability were discussed earlier. both of which are useful in the detection of Bankart fractures. The axillary lateral view can assess anterior or posterior subluxation or dislocation and fractures of the anterior or posterior glenoid rim [30]. The patient is seated or standing with the arm abducted 90 . the anteroposterior view also may allow visualization of a Hill-Sachs defect [30]. Other specialized views include the Garth view and the West Point view. 6) also is used to assess inferior glenohumeral joint stability.J. In the presence of inferior instability. The anteroposterior view allows visualization of the osseous structures of the shoulder. The test is considered positive if the patient feels apprehension [40]. upper ribs. 6. the Stryker Notch view for the evaluation Fig. obtaining full function of the dynamic . MRI and magnetic resonance arthrography provide superior visualization of the labrum. Sensory testing over the deltoid muscle is important because the axillary nerve is the most commonly injured nerve after shoulder dislocation [6]. flexibility. and joint capsule without the ionizing radiation of CT. monitoring and restoring shoulder girdle ROM. an individualized rehabilitation program based on the specific deficits identified is developed. Regardless of whether a patient chooses early surgical intervention. however. anteroposterior with the humerus in internal rotation and axillary lateral views) to confirm relocation and exclude an associated fracture [30]. CT was previously the gold standard for glenoid labral evaluation. Treatment The treatment options for glenohumeral joint instability and dislocation include nonoperative and operative approaches. Radiologic studies should be performed in two planes (eg. the decision between trials of nonoperative treatment versus immediate surgical stabilization is more controversial. CT now has a limited role. The nonoperative treatment of glenohumeral joint instability should include pain and edema control.588 J. Medications such as nonsteroidal anti-inflammatory drugs and mild narcotics may be considered for initial pain control.T. Immobilization of the glenohumeral joint after relocation does not seem to affect the rate of glenohumeral joint redislocation and should be considered only a comfort measure [41–43]. For patients who have a first-time anterior glenohumeral joint dislocation. and shoulder girdle strength. closed reduction confirmed by radiologic examination should be performed on all patients who sustain an acute glenohumeral joint dislocation that does not reduce spontaneously. the controversy between surgical and nonsurgical treatment is addressed in the surgical section. Such a program is discussed in the nonoperative treatment section. With the advent of MRI and magnetic resonance arthrography. Although the rehabilitation of acute anterior glenohumeral joint dislocation is addressed in the nonoperative treatment section. a comprehensive rehabilitation program that addresses kinetic chain deficits. cartilage. protection of the static glenohumeral joint stabilizers. and stress views for the documentation of the degree of glenohumeral joint instability [30]. Specific surgical and rehabilitative treatments are discussed in subsequent sections. Nonoperative treatment After a thorough examination. Visualization of nondisplaced injuries to the inferior glenohumeral ligament or anterior-inferior glenoid labrum is improved by placing the arm in an abducted and externally rotated position. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 of Hill-Sachs defects. scapulothoracic mechanics. After glenohumeral joint subluxation episodes and in patients with multidirectional instability. and neuromuscular control is appropriate. 50]. and decreasing the deleterious effects of immobilization. patients with anterior instability display posterior glenohumeral joint capsular tightness. such as shoulder abduction and external rotation in patients who have sustained an anterior dislocation. Initially. 7). it is important to remember Dempster’s ring concept . soft tissue mobilization. This positioning maintains proper shoulder girdle alignment during neuromuscular reeducation training [44]. Exercising in the plane of the scapula also is functional because most shoulder activities occur in this plane. improve joint biomechanics. Reestablishing appropriate force couples about the glenohumeral and scapulothoracic joints is important during rehabilitation. One significant force couple involves the synergistic contraction of the deltoid. Exercising in the plane of the scapula often is recommended because it optimizes rotator cuff length-tension relationships. Strategies include keeping the humerus at less than 90 of elevation and at or anterior to the plane of the scapula and using a low-resistance. Mobilizing the glenohumeral joint using a posterior glide technique and horizontally adducting the internally rotated arm are useful techniques for stretching the posterior capsule (Fig. The principles of glenohumeral joint tissue protection include avoiding impingement positions. This tightness can cause an increase in anterior glenohumeral joint capsular stress.J. and preventing tendon overload. and subscapularis to allow glenohumeral joint abduction. infraspinatus. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 589 stabilizers. Posterior glenohumeral joint capsular tightness frequently is found in throwing athletes [48].47]. and correcting associated kinetic chain deficits. After acute dislocation. protecting healing tissues. and cryotherapy may be beneficial for reduction of pain and edema and promotion of tissue healing.T. Another force couple involves the coordinated contraction of the serratus anterior and upper and lower trapezius to facilitate upward rotation of the scapula during shoulder elevation. The ultimate goal of this program should be the unrestricted return of the patient to preinjury activities. teres minor. Occasionally. supraspinatus. and provides maximal glenohumeral joint surface conformity [46. particularly in the scapular stabilizers [49. 8). positions of tissue stress should be avoided. Patients with glenohumeral joint instabilities frequently have abnormalities in these force couples. reduces stress on capsuloligamentous structures. treatment of the unstable shoulder emphasizes controlling pain and edema. and enhance neuromuscular reeducation of the shoulder complex musculature. Taping the unstable shoulder can help to decrease pain. When strengthening the rotator cuff for the treatment of specific instability patterns. ultrasound. decreasing capsular stress. restoring joint proprioception. highrepetition exercise format [45]. Modalities such as interferential electrical stimulation. Taping can reduce anterior humeral head translation in patients with anterior instability and can be used to elevate and center the humeral head in the glenoid fossa for patients with multidirectional instability (Fig. The humeral head is placed manually in neutral position. This finding suggests that the reciprocal also is true—that strengthening the stabilizers on either side of the glenohumeral joint helps prevent unidirectional instability. 7. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Fig. as mentioned earlier [7]. Tape is used to elevate the humeral head and center it in the glenoid. The second piece begins anteriorly on the humerus. ending just medial to the inferior border of the scapula. The first piece of tape is anchored over the middle deltoid and pulled superiorly to attach over the acromion. .590 J. and is anchored on the spine of the scapula. The patient rests the arm in 45 of abduction. (A) Anterior instability taping. (B) Multidirectional instability taping. passes diagonally over the clavicle. The third piece of tape is placed along the posterior deltoid and is anchored along the upper trapezius.T. Tape is used to lift the head of the humerus superiorly and posteriorly so that the head of the humerus is slightly externally rotated. It has been found that any stress on the stabilizers of one side of the glenohumeral joint also places stress on the stabilizers of the opposite side of the joint. The tape is pulled diagonally across the scapula. of glenohumeral joint instability. and the deltoid. it is important to strengthen the anterior and posterior cuff and scapular muscles for the treatment of anterior and posterior unidirectional glenohumeral joint instability [51. For inferior glenohumeral joint instability. and neuromuscular control of the rotator cuff and . Multidirectional instability requires strengthening of all of the rotator cuff muscles.T. the rehabilitation program needs to address the strength.52]. Because the rotator cuff muscles provide dynamic stability for the glenohumeral joint. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 591 Fig. strengthening the deltoid and supraspinatus helps prevent inferior migration of the humerus. endurance. 7 (continued ) Using this rationale. the long head of the biceps. and the length-tension relationship of the rotator cuff depends on scapular position.J. Initial scapular neuromuscular control training may begin with manually assisted or resisted protraction and retraction in sitting or side-lying position using a lowresistance. and rowing [55–57]. Exercises that commonly are used to produce increased levels of posterior rotator cuff electromyographic activation include resisted prone external rotation with the shoulder abducted 90 . Strengthening of the supraspinatus involves humeral elevation in the plane of the scapula. high-repetition format. and improve local blood flow [53]. however. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Fig. This exercise can be performed with the humerus in an externally rather than internally rotated position because . resisted side-lying external shoulder rotation. whereas a tennis player should train in an upright position.592 J. because many activities. This program progresses to isotonic exercises within a limited ROM using manual resistance. submaximal isometric muscular contractions to begin neuromuscular reeducation. Plyometric exercises are the last to be added because they generate the most force through the shoulder girdle. Posterior glide in the loose pack position. and isodynamic resistance at submaximal and maximal levels. and the exercise movements should simulate those of a swimming or tennis stroke. These exercises are an important component of the rehabilitation program. require explosive movements that can be mimicked only through plyometric exercises. particularly sports. 8. light weights. scapular stabilizing muscles. Initial strengthening exercises should include multiple angle. or resistance cords. and resisted prone shoulder extension. Strength training should be activity specific so that exercises are performed in a functional position and proper muscle synergies are used [54]. incorporating isotonic. A swimmer should be trained in a prone or supine position (depending on his or her stroke). Rehabilitation exercises eventually should progress to multiplanar activities in the full range of shoulder motion.T. isokinetic. develop strength. abduction with external rotation. Rotator cuff strengthening can be done with resisted internal and external rotation of the shoulder with the arm in the scapular plane [55]. shoulder shrugs. (B) Prone rowing. 9) [58]. Commonly used exercises include rowing. and posterior deltoid muscles eccentrically. (A) Push-up with a plus. Strengthening exercises for the scapular stabilizers need to address the superior.T. 9. levator scapula. which is important because these muscles frequently are called on to decelerate the shoulder. Elastic tubing or pulleys can be used to strengthen the infraspinatus. The scapula is protracted at the end of a push-up to increase serratus anterior activation. teres minor. and seated press-ups (Fig. Biceps strengthening is important and may include exercises such as resisted elbow flexion at multiple angles of shoulder flexion and scapular plane elevation. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 593 this reduces subacromial impingement and does not appear to alter electromyographic activity in the supraspinatus muscle [55]. and pectoralis minor muscles. serratus anterior. push-ups with a plus. and inferior aspects of the trapezius muscle and the rhomboideus major and minor. Fig. middle. .J. As discussed earlier.594 J. Patients with glenohumeral joint instability also frequently have postural abnormalities. The use of the closed kinetic chain exercise also is important for strengthening the unstable shoulder. iliotibial band. diagnostic imaging. TUBS stands for traumatic instability that is unidirectional and has an associated Bankart lesion. which may cause articular damage. Finally. Surgical treatment Surgical treatment options for shoulder instability are based on the information gathered during the history. inflexible quadriceps. rhythmic stabilization activities in biped. such as a head-forward position and protracted scapula with rounded shoulders. These complications need to be explained to the patient in detail before any surgical intervention so that the patient can make an informed decision regarding treatment. hip flexors. Examples of closed kinetic chain exercise include hand step-ups. the pathology indicated by imaging studies or findings at the time of surgery dictates the appropriate surgical interventions. and injury to the axillary or suprascapular nerves [63]. and its direction all are important determinants of appropriate treatment. triped. migration of suture anchors or suture tacks. In addition to the standard risks of surgery. The age of the patient. and external rotation. 12) [49]. AMBRI . physical examination. 10) [49]. and restricted hip internal rotation and thoracic rotation. and multijoint training [59]. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Exercises with combined movement patterns also are used to reestablish function. which consists of abduction. weak hip girdle musculature. flexion.T. and quadruped positions. activity level. complications unique to shoulder stabilization surgery include recurrent instability. latissimus dorsi. can be used during functional neuromuscular reeducation (Fig. which responds best to surgical treatment. and seated press-ups (Fig. Rehabilitative exercises to enhance proprioception include rhythmic stabilization and ball tossing activities in varying degrees of abduction and external rotation and proprioceptive neuromuscular facilitation drills using exercise tubing and manual resistance concomitantly (Fig. traumatic versus atraumatic origin. such as the proprioceptive neuromuscular facilitation D2 flexion pattern for the upper extremities. postural and kinetic chain deficits need to be identified and corrected. One classification system that frequently is used to divide patients into nonoperative and surgical categories is the TUBS and AMBRI mnemonics. push-ups with additional scapular protraction. The benefits of closed chain exercise include muscular cocontraction. 11). cohesion of joint surfaces. Combined movement patterns. Throughout the rehabilitation program. Kinetic chain deficits frequently present in patients with shoulder instability and include dynamic pes planus. degree of instability. extremity dominance. patients with shoulder instability frequently experience proprioceptive deficits [60–62]. and pectoralis major and minor muscles. and examination under anesthesia. 10. Proprioceptive neuromuscular facilitation D2 flexion pattern. These areas are addressed in subsequent sections. stands for atraumatic instability that is multidirectional and bilateral.T. does not address patients with unidirectional instability patterns that are not just anterior. and does not address patients who sustain recurrent dislocations. including elevation. surgical treatment involves an inferior capsular shift. This is a diagonal pattern consisting of shoulder abduction. This classification is oversimplified. and if this fails.J. and flexion. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 595 Fig. external rotation. The treatment begins with rehabilitation. . Passive shoulder ranges of motion. Examination under anesthesia A meticulous examination under anesthesia must be performed before shoulder surgery. external rotation. Examples of closed chain shoulder exercises to facilitate cocontraction and enhance neuromuscular control.T. 3—moderate translation with progression to the rim of the glenoid. The arm is tested in 90 of external rotation and 45 of internal rotation to assess the anterior-inferior and anterior-posterior capsules. (A) Hand step-ups. (B) Rhythmic stabilization.596 J. 4—dislocation of the glenohumeral joint. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 Fig. Application of axial pressure during this maneuver is crucial. 11. Studies comparing the . 2—mild translation. Translation is graded as follows: 1—no translation. Perturbation of a patient in the biped position. Stepping on and off of a step with the scapula in a protracted position. are recorded. Anterior and posterior stability is assessed with the arm abducted 90 and in neutral rotation with anterior and posterior forces applied. and internal rotation with the arm at the side and at 90 of abduction. Physiologic translation is usually a grade 2. The examination should be performed with the patient supine or in the beach-chair position with both arms available for comparison. In younger. thermal probes. treatment options include nonoperative and surgical interventions. while the clinician places perturbations against the patient’s arm.70]. Open and arthroscopic techniques can be used.T. Early procedures created soft tissue contracture and bony block to prevent further dislocation. Open stabilization of anterior glenohumeral instability has been used frequently in the athletic population. Indications for surgery in first-time traumatic anterior glenohumeral joint dislocation patients include patients who have failed conservative management and young patients who are involved in contact sports or other highdemand occupations [65. and modalities such as laser.69]. Rhythmic stabilization exercise in which the patient tries to hold the shoulder in a static position against stretch cord resistance. examination under anesthesia with eventual findings observed at surgery show sensitivity of 100% and specificity of 93% [63]. 12. surgical intervention was limited to scarification of the anterior capsule for dislocations.68. with one study reporting that 96% of professional athletes treated with this technique were able to return to their sport [68]. In older. Open stabilization is done best with the patient in the beach-chair .65–67]. less active patients. The increased pathoanatomic understanding of shoulder instability has allowed significant improvements in surgical techniques and their subsequent outcomes [68. nonoperative management frequently is successful [64]. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 597 Fig. studies have shown a high redislocation rate in patients treated nonoperatively compared with patients receiving early operative intervention [63.J. Historically. more active patients involved in contact sports. Surgical treatment of anterior instability After a traumatic anterior glenohumeral joint dislocation. or traditional suturing may be indicated based on the pathoanatomy. The size of the tucks determines the degree of capsular and ligamentous shortening. however. This technique has the advantage of not altering the inherent anatomy. The sutures are tied resulting in a tightening of the joint capsule and glenohumeral ligaments. Bioabsorbable suture anchors have become popular. narcotic use. The most difficult portion of this technique is tensioning the capsule appropriately [84]. and humeral avulsion of the glenohumeral ligament lesions. and the capsular redundancy is eliminated with a superior shift. more recent literature indicates that the redislocation rate after arthroscopy is now only 15%. and the capsule is separated from its undersurface. all have been compared with open techniques. More recent advances in the treatment of multidirectional . and the redislocation rate after open repair is approximately 10% [71–76]. Neer and Foster [83] first described the open capsular shift for multidirectional instability in 1980. and it is not technically demanding. The first arthroscopic shoulder stabilization procedure using a capsular staple was done in 1982 [63]. The Bankart lesion is repaired using direct suture to the glenoid or with suture anchors. An anterior axillary approach allows separation of the deltopectoral interval. Capsular tucks are made inferiorly and progressing superiorly to the rotator interval. thermal capsulorrhaphy. These tissues are at risk for recurrent stretching. The subscapularis tendon is repaired and the skin approximated. the most common bioabsorbable material used today in the shoulder is poly-L-lactic acid. time lost from work. including decreased operating room time. Postoperative rehabilitation needs to allow the repaired tissue adequate time to heal. and it continues to be the gold standard today with reported success rates of 92% to 94% [85–90]. Contraindications to arthroscopic techniques include patients with glenoid bone loss.71–76]. Arthroscopic capsular plication or capsular tucks have been performed to avoid using the thermal energy on capsular tissue.T. and laser. blood loss. Arthroscopic stabilization procedures seem to have many benefits over open procedures. suture anchors. engaging Hill-Sachs lesions. and long-term success with this treatment is questionable [77–83]. suture tacks. The subscapularis tendon is incised 1 cm medial to its insertion. Thermal or laser shrinkage of the capsule addresses capsular stretching that may occur with instability events [77]. Although early studies revealed relatively high redislocation rates after arthroscopic repair. including transglenoid suture repair.598 J. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 position. Surgical treatment of multidirectional instability Multidirectional instability is a difficult problem and should be treated surgically only if conservative measures fail. hospital stay. attenuated capsulolabral tissue. Capsular plication involves roughening the capsule using a shaver. preservation of the cephalic vein. and complications compared with open procedures [68. Arthroscopic techniques. and adequate visualization of the damaged tissue. followed by the passage of a suture through the capsule and the labrum. followed by thermal capsulorrhaphy for any further redundancy. however.T. to name a few. Evaluation of tissue readiness. such as superior labral anterior posterior lesions and posterior impingement lesions resulting from this instability. two posterior portals also are required to place sutures and use the electrothermal device to tension this tissue appropriately. Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 599 instability have been accomplished using the arthroscope with success rates of 70% to 90% [91–96]. Capsular tension can be addressed with plication sutures in the anterior and the posterior capsule. type of surgical procedure. Many of the exercises used postoperatively are similar to the exercises used for the standard nonoperative treatment of shoulder instabilities. Frequently a short period of shoulder immobilization is required after shoulder stabilization surgery. open or arthroscopic posterior Bankart repair with appropriate capsular plication is effective in 80% to 90% of these patients [10. such as collagen malalignment and articular cartilage degeneration. If this treatment fails.97–100]. Full ROM is allowed by 8 weeks postoperatively. Postoperative rehabilitation Although the specific postsurgical rehabilitation protocol varies according to the surgeon and type of surgery performed. however. resistive internal rotation should be limited initially. and method of fixation should be considered before performing ROM and strengthening activities [49]. Thermal capsulorrhaphy now is used primarily for augmentation of capsular plication rather than as a primary form of treatment for global instability [93–96]. Postoperative ROM considerations are crucial in these patients. Surgical treatment of posterior instability Treatment of posterior instability is initially nonoperative. external rotation is limited to 40 in the plane of the scapula for the first 4 weeks and is progressed to 90 of external rotation in the abducted position 6 weeks postoperatively. Early protected ROM activities are important to institute as soon as possible. . the goal of rehabilitation is the same—to obtain full static and dynamic function of the shoulder.J. to prevent the adverse effects of immobilization. If the subscapularis muscle is detached then reattached during open reconstruction. type of instability. Additional pathology. Rotator interval closure has been advocated to assist in capsular tensioning. also need to be addressed at the time of surgery. Specific postoperative rehabilitation protocols Bankart procedure Frequently after open anterior stabilization surgery. however. tissue status. Two anterior portals are required to allow access to appropriate areas of the capsule. For posterior plication. 13). Finnoff et al / Phys Med Rehabil Clin N Am 15 (2004) 575–605 After arthroscopic surgery. internal rotation. If the patient exhibits a soft end feel and motion is greater than guidelines. The ROM is usually restored within 8 weeks. particularly external rotation. Thermal capsulorrhaphy Rehabilitation for thermal capsulorrhaphy involves a period of immobilization before beginning ROM activities. . The ROM exercises are progressed based on end feel. conversely. motion is slowed. Capsular-shift procedures (anterior or inferior) Postoperative rehabilitation for multidirectional instability is treated with a more conservative program than used for anterior instability.T. Fig. Anterior glide mobilization of the shoulder for anterior capsular tightness. joint mobilization and stretching may be performed to stretch the anterior shoulder capsule to increase shoulder external rotation (Fig. The combined movement of flexion. External rotation usually is limited to 25 in the plane of the scapula for the first 6 weeks and progressed to full ROM at 10 weeks. The goal is to restore shoulder motion to approximately 10 to 15 less than the preoperative level by 10 to 12 weeks postoperatively [50]. Posterior instability procedures There is usually a period of immobilization after posterior stabilization due to the thin posterior capsule. motion is accelerated [50]. and horizontal adduction is avoided for 6 weeks postoperatively. 13. Should this loss of motion occur. if the patient exhibits a hard or firm end feel and less motion than the guideline.600 J. Patients with congenital instability are progressed more slowly than patients with acquired instability. 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