American Shoulder and Elbow Surgeons
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Average 4.1 of 36 Ratings
A 19-year-old female presents with bilateral shoulder pain and instability during volleyball practice. She denies any injuries. Physical exam elicits pain when her arm is internally rotated with her shoulder forward flexed to 90 degrees. In the seated position there is a 2cm sulcus present with inferior traction on each arm. Radiographs are unremarkable. Her representative MRI images from her right shoulder are seen in figures A and B, which are identical to her other side. What is the most appropriate initial treatment?
Bilateral glenohumeral corticosteriod injections and physical therapy
Bilateral subacromial corticosteriod injections and physical therapy
Bilateral staged arthroscopic labral repair and capsulorrhaphies
Bilateral staged open capsular shifts
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The clinical presentation is consistent with symptomatic bilateral multidirectional shoulder instability (MDI). The most appropriate treatment is a shoulder physical therapy program focusing on rotator cuff and periscapular conditioning.
MDI is a common condition that peaks in the second and third decades of life. The underlying mechanism includes microtrauma from overuse and/or generalized ligamentous laxity. This is commonly seen with overhead throwing, volleyball players, swimmers, and gymnasts. Physical exam findings can include positive bilateral sulcus sign, apprehension/relocation tests, and bilateral positive impingement signs.
Provencher et al. looked at the challenges in diagnosis and treatment of MDI. With an improved understanding of pertinent clinical symptoms and physical examination findings, a successful strategy for nonsurgical and surgical management can be developed. Initial treatment includes physical therapy.
Forsythe et al. highlight the common presentation, physical findings, and radiographic workup in a patient that presents after failed posterior instability of MDI repair and offer strategies for revision surgical repair. They recommend careful understanding of potential pitfalls of MDI including errors in history and physical examination, failure to recognize concomitant pathology, and problems with the surgical technique or implant failure.
Figures A and B show T2 MRI axial and coronal cuts demonstrating capacious capsule without the presence of any labral tears. Illustration A shows a T2 axial image of a patient with multidirectional instability. The image demonstrates a capacious and redundant posterior capsule.
Answers 2-5: Although invasive measures are sometimes needed in the management of MDI, the first line treatement for patients with MDI is a physical therapy program focused on rotator cuff and periscapular conditioning.
Provencher MT, Romeo AA.
Instr Course Lect. 2008;57:133-52. PMID: 18399576 (Link to Abstract)
Forsythe B, Ghodadra N, Romeo AA, Provencher MT.
Sports Med Arthrosc. 2010 Sep;18(3):149-61. PMID: 20711046 (Link to Abstract)
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Average 4.0 of 18 Ratings
Which of the following is true regarding closure of the rotator interval in patients undergoing arthroscopic shoulder stabilization?
It can lead to recurrent instability
It restricts external rotation predominately in the "arm cocking" phase of throwing
It restricts combined flexion and cross-body adduction
It restricts external rotation predominately with the arm at 0 degrees of shoulder abduction
It restricts internal rotation predominately with the arm at 90 degrees of shoulder abduction
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 at the patient's side (0 degrees of abduction). 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.
Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM
Am J Sports Med. 2006 Oct;34(10):1656-61. PMID: 16832127 (Link to Abstract)
Plausinis, AJSM 2006
Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW
J Bone Joint Surg Am. 2003 Jan;85-A(1):48-55. PMID: 12533571 (Link to Abstract)
Gerber, JBJS 2003
Average 3.0 of 23 Ratings
A 16-year-old swimmer has pain and weakness in her dominant shoulder with overhead use. Her physical examination demonstrates a +2 anterior and posterior load and shift test. There is 1.5cm of sulcus sign evident with the arm at adduction and 30 degrees of external rotation. Her radiographs are normal. What is the most appropriate next step in management?
Arthroscopic anterior and posterior labral repair
Arthroscopic anterior and posterior labral repair with rotator interval closure
Home stretching program with emphasis on posterior capsular stretching
Dynamic stabilization therapy
Sport specific bracing
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.
Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN
J Bone Joint Surg Am. 2000 Jun;82(6):849-57. PMID: 10859105 (Link to Abstract)
Lee, JBJS 2000
Schenk TJ, Brems JJ.
J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):65-72. PMID: 9692942 (Link to Abstract)
Schenk, JAAOS 1998
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?
Shoulder range of motion program with emphasis on posterior capsular stretching
Shoulder arthroscopy with anterior and posterior capsulolabral plication with superior shift
Shoulder arthroscopy with thermal capsulorrhaphy and rotator interval closure
Shoulder arthroscopy with repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion
Rotator cuff and peri-scapular muscular strengthening program
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.
Robinson CM, Aderinto J.
J Bone Joint Surg Am. 2005 Apr;87(4):883-92. PMID: 15805222 (Link to Abstract)
Robinson, JBJS 2005
Levine WN, Prickett WD, Prymka M, Yamaguchi K.
Orthop Clin North Am. 2001 Jul;32(3):475-84. PMID: 11888142 (Link to Abstract)
Average 3.0 of 18 Ratings
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:
Elbow hyperextension of the left arm
Left 5th finger passive extension beyond 90°
Genu recurvatum of the bilateral knees
Excessive supination of the left forearm
Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand
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.
Average 3.0 of 21 Ratings
Multi-directional shoulder instability refers to instability that occurs in 2 or...