Multidirectional Glenohumeral Instability Clinical Presentation

Updated: Jun 10, 2022
  • Author: Bradley S Raphael, MD; Chief Editor: Mohit N Gilotra, MD, MS, FAAOS, FAOA  more...
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A patient with multidirectional instability (MDI) most often presents with complaints of a generalized painful or sore shoulder, which is usually worse with activity or with certain arm positions. Instability symptoms perceived by the patient, such as dislocation, subluxation, or functional symptoms (eg, catching, locking), are less commonly reported than pain. [20] In fact, many patients may not appreciate or describe any actual sense of instability.

Symptoms may follow a roller-coaster pattern and may be aggravated by overhead activity, carrying objects at the side, overuse, or injury. These symptoms are relieved by rest and support of the arm. Nocturnal pain is variable.

The patient usually denies a history of frank traumatic dislocation but may describe subluxation or looseness, even with activities of daily living (ADLs). This history should provoke suspicion of and search for a multidirectional pattern of laxity, particularly if laxity is bilateral or posterior. The combination of posterior and inferior laxity is classic, according to Neer and Foster. [2]

An athletic history may be contributory. [21] Patients with a predisposition to MDI who are engaged in sports that are repetitively stressful to the shoulder girdle (eg, swimming, throwing, or racquet sports) may have a difficult time with consistent high activity levels. In many cases, the initial presentation is of an adolescent athlete who reports vague trauma, though it is the repetitive microtrauma combined with the capsular laxity that is the actual pain generator.

Perhaps one of the most confusing presentations is that of concomitant impingement. Not uncommonly, a patient with MDI may complain chiefly of pain with overhead use, especially if there is involvement with overhead athletics, such as throwing, volleyball, swimming, or racquet sports. Pain, in this case, may be minimal with the arm at the side. Tibone et al [22] showed that therapeutic management directed at the diagnosis of impingement and rotator-cuff pathology in patients participating in overhead activities may be unsuccessful.

Underlying instability always must be considered in those who report a painful shoulder, especially in the younger patient who is involved in vigorous activities above the shoulder.

Impingement symptoms (ie, pain with the arm at 90° or more) may be secondary to glenohumeral hypermobility and superior humeral head translation, regardless of acromial arch architecture.


Physical Examination

A notable highlight of MDI on examination is the bilaterality of physical findings. Although active range of motion (AROM) may be guarded, there are no passive limits.

A good stability examination yields underlying glenohumeral hyperlaxity if adequate relaxation can be achieved. The pathognomonic feature of MDI is demonstration of the sulcus sign—the hallmark of the inferior component of the capsular laxity. Again, with adequate relaxation, a patient examiner demonstrates laxity beyond the normal limits with anterior and posterior testing. Grade may be variable, and anterior and posterior components need not be symmetrical.

If the patient is unable to relax, an examination under anesthesia (EUA) may be required to demonstrate increased glenohumeral anterior and posterior translation, as well as inferior translation (ie, sulcus sign). More often than not, these findings are symmetrical.

Examination of the labrum (eg, labral grind test, superior labrum anterior and posterior lesion [SLAP] test) also may reveal positive findings, with or without true labral anatomic abnormalities. Furthermore, apprehension testing also may be positive, usually in the direction of the chief component of instability.

For example, anterior apprehension findings in the external rotation and abducted position may suggest a predominant anterior-inferior MDI pattern, with or without positive relocation, crank, or fulcrum tests. Alternatively, posterior apprehension signs or a positive jerk test may suggest a predominant posterior-inferior pattern.