Multidirectional Shoulder Instability (MDI)

Author: Jason McKean

Topic updated on 04/20/13 9:56am

Introduction

Also referred to as AMBRI
- Atraumatic
- Multidirectional
- Bilateral (frequently)
- Rehabilitation (often responds to)
- Inferior capsular shift (best alternative to nonop)
Epidemiology
- incidence
  - peaks in second and third decades of life
Pathophysiology
- mechanisms
  - underlying mechanism includes
    - microtrauma from overuse
      - seen with overhead throwing, volleyball players , swimmers, gymnasts
    - generalized ligamentous laxity
      - associated with connective tissue disorders Ehlers-Danlos and Marfan's
- pathoanatomy
  - hallmark findings of MDI
    - patulous inferior capsule (IGHL anterior and posterior bands)
    - rotator interval deficiency
  - labral lesions or glenoid erosion can still occur from traumatic events
    - Bankart lesion is anteroinferior labral tear
    - Kim lesion is posteroinferior labral avulsion

Anatomy

Glenohumeral anatomy

Presentation

Symptoms
- pain
- weakness
- paresthesia
- crepitus
- shoulder instability during sleep
Physical exam
- tests
  - sulcus sign
    - assesses rotator interval
  - apprehension/relocation test
  - load and shift test
  - Neer and Hawkins test
    - impingement or rotator cuff tendonitis in <20 year old signals possible MDI
- signs of generalized hypermobility
  - patella hypermobility
  - genu recurvatum
  - elbow hyperextension
  - MCP hyperextension
  - thumb abduction to the ipsilateral forearm

Imaging

Radiographs
- recommended views
  - a complete trauma series needed for evaluation (AP-IR, AP-ER, AP-True, Axillary, Scapular Y)
- findings
  - may be normal in multidirectional instability
MRI
- indcations
  - to fully evaluate shoulder anatomy
- findings
  - patulous inferior capsule (IGHL anterior and posterior bands)
  - Bankart lesion
  - Kim lesion
  - bony erosion of glenoid
Arthroscopy
- drive through sign may be present

Differential Diagnosis

Unidirectional instability
Cervical disease
Brachial plexitis
Thoracic outlet syndrome

Treatment

Nonoperative
- dynamic stabilization physical therapy
  - indications
    - first line of treatment
    - vast majority of patients
  - technique
    - 3-6 month regimen needed
    - strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
    - closed kinetic chain exercises are used early in the rehabilitation process to safely stimulate co-contraction of the scapular and rotator cuff muscles
Operative
- capsular shift / stabilization procedure (open or arthroscopic)
  - indications
    - failure of extensive nonoperative management
    - pain and instability that interferes with ADLs of sports activities
  - contraindications
    - voluntary dislocators

Techniques

Capsular shift / stabilization procedure (open or arthroscopic)
- approach
  - arthroscopic approach to shoulder
- stabilization
  - must address capsule +/- rotator interval
  - inferior capsular shift (capsule shifted superiorly)
  - plication of redundant capsule in a balanced fashion
  - rotator interval closure (open or arthroscopic)
    - produces the most significant decrease in range of motion in external rotation with the arm at the side
  - address any anterior or posterior labral pathology if present
  - thermal capsulorrhaphy (historical)
    - is contraindicated because of complications including capsule ablation
- post-operative rehabilitation
  - 4-6 weeks: shoulder immobilizer or sling
  - 6-10 weeks: ADL's with 45 degree limit on abduction and external rotation
  - 10-16 weeks: gradual range of motion
  - >16 weeks: strengthening
  - >10 months: contact sports
  - patient should resume sports activities after normal strength and motion have returned

Complications

Subscapularis deficiency
- more common after open anterior-inferior capsular shift
- may be caused by injury or failed repair
- postop physical exam will show a positive lift off and excessive external rotation
Loss of motion
- may be due to asymmetric tightening or overtightening of capsule
- leads to loss of ER
- treat with Z-lengthening of subscapularis
- rare
Axillary nerve injury
- iatrogenic injury with surgery (avoid by adduction and ER of arm during procedure)
- usually a neuropraxia that can be observed postoperatively
- can occur with anterior dislocation of shoulder
Late arthritis
- usually wear of posterior glenoid
- may have internal rotation contracture
- seen with Putti-Platt and Magnuson-Stack procedures
Recurrence

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Qbank (6 Questions)

TAG

(OBQ10.137) Which of the following is true regarding closure of the rotator interval in patients undergoing arthroscopic shoulder stabilization? Topic

Review Topic

1. It can lead to recurrent instability.
2. It may cause multi-directional instability.
3. It restricts internal rotation more than external.
4. It restricts external rotation more than internal.
5. It restricts flexion more than rotation.

PREFERRED RESPONSE ▶

DISCUSSION: Rotator interval closure involves plicating the anterior-superior region of the capsule by suturing the superior and middle glenohumeral ligaments together. This has been advocated as a treatment for certain recurrent instability patterns such as multi-directional instability (MDI). It was felt to address inferior subluxation in patients with a sulcus sign, however, the greatest effect is a decrease in external rotation. In general, a tighter anterior capsule tends to decrease external rotation most, and a tighter posterior capsule causes a decrease in internal rotation. The study by Gerber et al performed selective capsular plications around the shoulder in cadavers and measured the resulting changes in motion. Anterosuperior capsular plication, the area where a rotator interval closure is performed, most markedly affected external rotation of the adducted arm, decreasing it by a mean of 30.1 degrees. The study by Plausinis measured the effects of different interval closure suture patterns in 12 cadavers and found the greatest decrease was in external rotation (10 degs) compared to flexion.

REFERENCES:

1. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J Sports Med. 2006 Oct;34(10):1656-61. PMID:16832127 (Link to Abstract)

2. Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003 Jan;85-A(1):48-55. PMID:12533571 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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TAG

(OBQ09.150) What is the preferred initial treatment for atraumatic multidirectional shoulder instability in athletes? Topic

Review Topic

1. Arthroscopic bankhart repair
2. Thermal capsulorrhaphy
3. Home stretching program
4. Dynamic stabilization therapy
5. Sport specific bracing

PREFERRED RESPONSE ▶

DISCUSSION: Multidirectional instability (MDI) is defined by symptomatic global laxity of the glenohumeral joint with increased translation in multiple planes (ie. anterior, inferior, and posterior directions). It is usually an atraumatic patholaxity and should be initially treated by physical therapy to strengthen and retrain the proprioreceptive response of the muscular stabilizers of the shoulder. Lee et al performed a cadaveric study and each rotator cuff muscle contributed to dynamic stabilization of the glenohumeral joint in various arm positions. Schenk and Brems reviewed MDI and noted that shoulder laxity was typically bilateral but the symptomatic shoulder usually correlates with loss of strength, poor neuromotor coordination of the rotator cuff and scapular stabilizing muscles, and defective proprioceptive responses. If a 6-month trial of nonoperative management fails, the patient is a candidate for surgical stabilization.

REFERENCES:

1. Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion: A study of cadavera. J Bone Joint Surg Am 2000;82:849-857. PMID:10859105 (Link to Abstract)

2. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998;6:65-72. PMID:9692942 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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TAG

(OBQ06.69) A freshman collegiate swimmer complains of right shoulder pain after increasing his workout duration and intensity. He denies trauma and admits to popping his shoulders in and out voluntarily since the age of 8. Exam reveals bilateral anterior shoulder apprehension and relocation, positive jerk test, and a 2cm sulcus bilaterally. O’Brien active compression tests are negative bilaterally. Radiographs are normal and MR arthrogram of his right shoulder is shown in Figures A and B. What is the best initial treatment? Topic

Review Topic

FIGURES: A

1. Posterior labral repair
2. Arthroscopic anterior and posterior capsulolabral plication with superior shift
3. Thermal capsulorrhaphy with rotator interval closure
4. Open repair of HAGL lesion
5. Rotator cuff and peri-scapular muscular strengthening

PREFERRED RESPONSE ▶

DISCUSSION: This patient has multidirectional shoulder instability a(MDI) and the initial treatment strategy is physical therapy to strengthen the rotator cuff and peri-scapular muscles to actively compress the humeral head into the glenoid cavity and support the shoulder girdle. The MRI demonstrates posterior capsular redundancy and an intact anterior and posterior labrum. Any patient with history and exam findings of MDI should initially undergo physical therapy. The reference by Levine et al. reviews the treatment strategy of MDI and discusses the potential need for operative intervention which include open capsular shifts in non-overhead contact athletes or for revision surgery. The Robinson et al article reviews posterior instability and the multi-factorial nature and various treatments for this problem.

REFERENCES:

1. Robinson CM, Aderinto J. Recurrent posterior shoulder instability. J Bone Joint Surg Am. 2005 Apr;87(4):883-92. PMID:15805222 (Link to Abstract)

2. Levine WN, Prickett WD, Prymka M, Yamaguchi K. Treatment of the athlete with multidirectional shoulder instability. Orthop Clin North Am. 2001 Jul;32(3):475-84. PMID:11888142 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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TAG

(OBQ04.51) An 18-year-old high school volleyball player is being treated for multidirectional instability of the right shoulder with a physical therapy program. She has intermittent pain and instability and episodic numbness and weakness in the ipsilateral hand. All of the following are characteristic features of a generalized connective tissue disorder EXCEPT: Topic

Review Topic

1. Elbow hyperextension of the left arm
2. Left 5th finger passive dorsiflexion beyond 90°
3. Genu recurvatum of the bilateral knees
4. Excessive supination of the left arm
5. Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand

PREFERRED RESPONSE ▶

DISCUSSION: Excessive supination of the left arm is not listed as part of the Beighton 9-point scoring system for hypermobility. All of the other options are part of this scoring system, and a score of >6 is associated with connective tissue disorders such as Marfan's and Ehlers-Danlos Syndrome.

The Level 5 review article by Schenk and Brems notes that generalized ligamentous laxity has been reported in 45% to 75% of patients who have undergone surgery for multidirectional (MDI) shoulder instability. Patients with MDI have pathologic laxity of the glenohumeral joint in more than one direction with at least one of those being inferior. The onset of symptoms is frequently atraumatic, and the chief complaint is often pain more than instability. Patients can experience concomitant recurrent, transient episodes of numbness, tingling, and weakness in the affected extremity. Most patients can be successfully treated nonoperatively with a specific exercise program. If a 6-month trial of nonoperative management fails, then surgical intervention with an inferior capsular shift can be performed.

REFERENCES:

1. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):65-72. Review PMID:9692942 (Link to Abstract)

Question Authors:

Michael Hughes MD, Eric Shirley MD, Patrick McCulloch MD,

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Robinson CM, Aderinto J. Recurrent posterior shoulder instability. J Bone Joint Surg Am. 2005 Apr;87(4):883-92. PMID:15805222 (Link to Abstract)
Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):65-72. Review PMID:9692942 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Provencher MT, Romeo AA. Posterior and multidirectional instability of the shoulder: challenges associated with diagnosis and management. Instr Course Lect. 2008;57:133-52. PMID:18399576 (Link to Abstract)
Forsythe B, Ghodadra N, Romeo AA, Provencher MT. Management of the failed posterior/ multidirectional instability patient. Sports Med Arthrosc. 2010 Sep;18(3):149-61. PMID:20711046 (Link to Abstract)
Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J Sports Med. 2006 Oct;34(10):1656-61. PMID:16832127 (Link to Abstract)
Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003 Jan;85-A(1):48-55. PMID:12533571 (Link to Abstract)
Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion: A study of cadavera. J Bone Joint Surg Am 2000;82:849-857. PMID:10859105 (Link to Abstract)
Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998;6:65-72. PMID:9692942 (Link to Abstract)
Levine WN, Prickett WD, Prymka M, Yamaguchi K. Treatment of the athlete with multidirectional shoulder instability. Orthop Clin North Am. 2001 Jul;32(3):475-84. PMID:11888142 (Link to Abstract)
Ide J, Maeda S, Yamaga M, et al: Shoulder-strengthening exercise with an orthosis for multidirectional instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program. J shoulder Elbow Surg 2003;12:342-345. PMID:12934027 (Link to Abstract)
Levine WN, Prickett WD, Prymka M, et al: Treatment of the athlete with multidirectional shoulder instability. Orthop Clin North Am 2001;32:475-484. PMID:11888142 (Link to Abstract)
Beasley L, Fayniarz DA, Hannafin JA: Multidirectional instability of the shoulder in the female athlete. Clin Sports Med 2000;19:331-349. PMID:10740763 (Link to Abstract)

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