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Multidirectional Glenohumeral Instability Workup

  • Author: Daniel C Wnorowski, MD, MBA; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Jan 15, 2016
 

Imaging Studies

Most often, plain radiographs are negative in patients with multidirectional instability (MDI) of the shoulder. Findings of an osseous glenoid rim fracture or a Hill-Sachs humeral head impression defect are usually not seen unless concomitant traumatic instability exists.

Results of noncontrast magnetic resonance imaging (MRI) are the same as those described for plain radiography—that is, benign and negative, unless MRI is performed with contrast (gadolinium).[23, 24]

Magnetic resonance (MR) arthrography may be helpful in identifying patients with atraumatic MDI of the shoulder.[25] Typically, MR arthrography may demonstrate blunting of the labrum, diffuse capsular laxity, and increased capsular volume. Labral and capsular tears, such as those seen with traumatic instability, are unusual in classic MDI, and rotator-cuff tears and superior labral anterior and posterior (SLAP) lesions are only rarely seen in association with MDI of the shoulder.

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Diagnostic Procedures

Examination under anesthesia (EUA) and diagnostic arthroscopy are indicated.

Diagnostic arthroscopy must always be preceded by a thorough EUA. In an EUA, it is important to examine both shoulders, comparing the symptomatic side with the asymptomatic side. Typically, with relaxation afforded by general anesthesia, the clinical diagnosis is obvious, even if it was unsuspected preoperatively. Again, increased anterior and posterior laxity that exceeds the normal range combined with a positive sulcus sign is easily demonstrated.

Arthroscopy can be performed with the patient in either the beach-chair or the lateral decubitus position. Surgeon preference may dictate the choice of patient position. However, if open anterior capsular shift is planned, an upright or semiupright beach-chair position allows for ease of transition to open surgery without significant modification of position. If arthroscopic management of capsular patholaxity is planned, there is little difference between these variations.

To facilitate a complete and systematic glenohumeral joint (GHJ) evaluation, views from both anterior and posterior portals are necessary. This approach allows more thorough labral and capsular visualization. Moreover, it is essential to evaluate for concomitant pathology, including articular surface rotator-cuff pathology, SLAP lesion, labral tears, Bankart lesion and Hill-Sachs defect, and humeral avulsion[26] of the glenohumeral ligament (HAGL). All of these are atypical in straightforward MDI.

Typical characteristics of MDI are a loose capsule with poor development of the glenohumeral ligaments and a normal, attenuated, or unimpressive labrum. Capsular tissues typically are thin. The axillary recess or pouch and the rotator-cuff interval are spacious and patulous. The articular surfaces most often are normal or show minimal chondromalacia. A Hill-Sachs lesion is absent. (See the images below.)

Labral features characteristic of multidirectional Labral features characteristic of multidirectional instability; normal appearing. Note: Although there is only 2 lb of traction, it is very easy to push arthroscope between humeral head and glenoid surfaces (ie, drive-through sign). Photo courtesy of Daniel C Wnorowski, MD.
Hypoplastic labrum. Photo courtesy of Daniel C Wno Hypoplastic labrum. Photo courtesy of Daniel C Wnorowski, MD.
Posterior and superior aspects of humeral head of Posterior and superior aspects of humeral head of shoulder with multidirectional instability are pristine. Typically, there is no Hill-Sachs lesion, even if there has been subluxation. Photo courtesy of Daniel C Wnorowski, MD.
Posterior aspect of humeral head of shoulder with Posterior aspect of humeral head of shoulder with multidirectional instability is without Hill-Sachs lesion. Also note patulous capsule. Photo courtesy of Daniel C Wnorowski, MD.
Multidirectional instability of right shoulder, fr Multidirectional instability of right shoulder, from posterior portal. Patient is in lateral position with minimal arm traction (2 lb). Note glenohumeral inferior subluxation, with humeral head perched on normal-appearing anterior-inferior labrum. Photo courtesy of Daniel C Wnorowski, MD.
Normal subacromial space in patient with multidire Normal subacromial space in patient with multidirectional instability and history of secondary impingement. Photo courtesy of Daniel C Wnorowski, MD.

Moving the arthroscope within the shoulder of an individual with MDI is easy, even without traction in the beach-chair position. A "positive drive-through sign" is typical. This means that it is very easy to move the arthroscope across the GHJ between the humeral head and the glenoid fossa without axial arm traction or distraction. Subluxation of the humeral head on the glenoid is obvious, even without supplemental traction.

Finally, assessment of the subacromial space also is important, especially in the patient with suggestive impingement history and findings. Evaluation in this location includes scrutiny of the bursal cuff surface, as well as the coracoacromial arch, for signs of cuff and subacromial abrasion.

A patient with secondary impingement from an underlying glenohumeral instability may demonstrate impressive subacromial findings that are suggestive of impingement. These findings should provoke consideration of primary versus secondary impingement and review of the clinical presentation, EUA, and glenohumeral arthroscopic findings so that appropriate management can be selected.

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Contributor Information and Disclosures
Author

Daniel C Wnorowski, MD, MBA Consulting Surgeon, Department of Orthopedic Surgery, Syracuse Orthopedic Specialists, PC

Daniel C Wnorowski, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

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Labral features characteristic of multidirectional instability; normal appearing. Note: Although there is only 2 lb of traction, it is very easy to push arthroscope between humeral head and glenoid surfaces (ie, drive-through sign). Photo courtesy of Daniel C Wnorowski, MD.
Hypoplastic labrum. Photo courtesy of Daniel C Wnorowski, MD.
Posterior and superior aspects of humeral head of shoulder with multidirectional instability are pristine. Typically, there is no Hill-Sachs lesion, even if there has been subluxation. Photo courtesy of Daniel C Wnorowski, MD.
Posterior aspect of humeral head of shoulder with multidirectional instability is without Hill-Sachs lesion. Also note patulous capsule. Photo courtesy of Daniel C Wnorowski, MD.
Multidirectional instability of right shoulder, from posterior portal. Patient is in lateral position with minimal arm traction (2 lb). Note glenohumeral inferior subluxation, with humeral head perched on normal-appearing anterior-inferior labrum. Photo courtesy of Daniel C Wnorowski, MD.
Normal subacromial space in patient with multidirectional instability and history of secondary impingement. Photo courtesy of Daniel C Wnorowski, MD.
Cosmetically ideal modified axillary incision for open inferior capsular shift. Incision will be made in apex of axillary crease. Photo courtesy of Daniel C Wnorowski, MD.
Open approach via axillary incision. Self-retaining retractor is shifted cephalad after mobilization of skin flaps. Photo courtesy of Daniel C Wnorowski, MD.
Rotator-cuff interval is closed with nonabsorbable suture. T-capsulotomy incision is planned with dotted lines.
Superomedial (SM) and inferomedial (IM) flaps created by T-capsulotomy incision. First, IM flap will be advanced superiorly and laterally; then, SM flap will be advanced inferiorly over top of IM flap.
Finished repair with superomedial (SM) flap advanced inferiorly, overlapping previous inferomedial (IM) flap advancement. Note how axillary pouch has been eliminated.
Suture passer device (Spectrum; ConMed Linvatec, Largo, FL) is placed through working cannula, then through "pinch" of posterior capsule, and also through posterior labrum. Photo courtesy of Daniel C Wnorowski, MD.
Next, with monofilament suture and all-arthroscopic knot-tying technique, knot is tied, thus plicating capsular "pinch" to labrum. Photo courtesy of Daniel C Wnorowski, MD.
Process in image above is repeated to place second, slightly more superior suture and knot. Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third "pinch." Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third labral pass. Photo courtesy of Daniel C Wnorowski, MD.
Third suture is placed. Photo courtesy of Daniel C Wnorowski, MD.
Completed third knot. Photo courtesy of Daniel C Wnorowski, MD.
Depending on degree of capsular laxity, one may take "double tuck" to achieve additional plication and tightening, at risk of added range of motion restriction. Photo courtesy of Daniel C Wnorowski, MD.
View from posterior portal of "interval closure"; with suture passer device, monofilament suture is placed at margins of cuff interval. Photo courtesy of Daniel C Wnorowski, MD.
Knot is tied through anterosuperior portal, thus closing rotator-cuff interval. Photo courtesy of Daniel C Wnorowski, MD.
Second of two anchors placed for posterior plication, given hypoplastic posterior labrum, prior to suture passage. Note anchor placement on posterior margin of articular surface, not on neck of glenoid. This allows for "capsulolabral reconstruction". See next image. Photo courtesy of Daniel C Wnorowski, MD.
After passage of anchor-based suture and completion of plication and "capsulolabral reconstruction," augmenting hypoplastic labrum with capsular fold. Note that these are permanent sutures and therefore are tied off glenoid to avoid knot-articular surface impingement. Photo courtesy of Daniel C Wnorowski, MD.
Monopolar radiofrequency probe applied to posterior capsule with grid technique after treatment to 65°C. Ellipses indicate areas of linear application (grid lines). Rectangle indicates untreated island between lines. Photo courtesy of Daniel C Wnorowski, MD.
Table 1: Postoperative Multidirectional Instability (MDI) Rehabilitation Protocol
ANTERIOR CAPSULAR SHIFT (S-3)



Daniel Wnorowski MD



For open surgery, follow protocol as is!!!



For arthroscopic plication surgery, defer all events by two weeks!!!



Patient:_______________________________________



Date of Surgical Procedure:_______________________



Physical Therapist:______________________________



PHASE I - IMMOBILITY
  • Postoperative sling/immobilizer: Immobility ends on POW * 6
  • Active and passive ROM : Elbow and wrist allowed
  • Sling: Wear day/night through POW 3; night only POW 4-5
  • Immobilizer: Wear all times except shower/bath through POW 5
PHASE II - MOTION



  • Begin ROM on POW 2 (start supine): Start with Codman pendulum exercises, followed by wand exercises as tolerated.
  • ROM (active and passive)
  • Flexion/internal rotation: Increase as tolerated starting POW 2.
  • External rotation: To neutral external rotation ASAP ("shooter position"), then increase 10°/wk
  • Abduction: To 45° abduction ASAP, then increase 10°/wk
*** After 6 weeks, increase all ranges as tolerated.***



PHASE III - ISOMETRIC
  • Isometrics: All muscles; can use spectrum isometrics, except subscapularis muscle restricted through POW 3
  • Neuromuscular stimulator optional
PHASE IV - ISOTONIC



  • Start PREs on POW 5; begin supine position; progress to standing as tolerated (hand weights or stretch cords).
  • Rotator cuff program: Avoid impingement positions early; elbow and wrist PREs as tolerated
***These are all individualized, as tolerated; progress from submaximal midrange isometrics to short arc isotonics.***



PHASE V - ISOKINETIC
  • Begin with concentrics.
  • Can start on POW 10
  • Body position: Sitting or standing
  • High speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Low speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Eccentric work and PNF § program at 12-14 weeks
PHASE VI - ENDURANCE
  • May start swimming on POW 12-16. (Restrictions: Do not perform overhead strokes until POW 16.)
  • Start short toss program POW 12.
  • Restrictions:_________________________________________________.
PHASE VII - SPORTS
  • Begin participation on POW 24 (for contact/collision and throwing sports).
  • Restrictions: Must have strength test and authorization from physician prior to return to activity
  • Lifting activities restricted to 10-15 lb for 2 months; then increase as tolerated.
  • Delay return to activity (sports) until after 4 months and with physician clearance.
  • Full-functional activities (except lifting and sports); ADLs || permitted at 8 weeks postsurgery
* POW - Postoperative week



ROM - Range of motion



PREs - Progressive-resistive exercises



§ PNF - Proprioceptive neuromuscular facilitation



|| ADLs - Activities of daily living



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