summary Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased external rotation. Treatment is a trial of prolonged physical therapy focusing on dynamic stabilization and periscapular muscle training. Arthroscopic stabilization with capsular shift is indicated for patients with persistent instability who fail an extensive course of physical therapy. Epidemiology Incidence peaks in second and third decades of life Etiology 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 Imaging findings: patulous inferior capsule on MRI (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 MDI is also referred to as AMBRI Atraumatic Multidirectional Bilateral (frequently) Rehabilitation (often responds to) Inferior capsular shift (best alternative to nonop) Anatomy Glenohumeral stability static restraints glenohumeral ligaments (below) glenoid labrum (below) articular congruity and version negative intraarticular pressure if release head will sublux inferiorly dynamic restraints rotator cuff muscles the primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by compressing the humeral head against the glenoid biceps periscapular muscles Complete Glenohumeral anatomy Presentation Symptoms pain instability weakness paresthesias crepitus shoulder instability during sleep Physical exam Tests - must have instability in 2 or more planes (anterior, posterior, or inferior) to be defined as MDI sulcus sign (2+ or more) assesses rotator interval laxity of rotator interval presents as increased external rotation with the arm fully adducted and at 90 degrees abduction apprehension/relocation test anterior and posterior load and shift test (2+ or more) Neer and Hawkins test impingement or rotator cuff tendonitis in <20 year old signals possible MDI signs of generalized hypermobility - generalized ligamentous laxity = Beighton's criteria >4/9 able to touch palms to floor while bending at waist (1 point) genu recurvatum (2 points) elbow hyperextension (2 points) MCP hyperextension (2 points) thumb abduction to the ipsilateral forearm (2 points) 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 indications to fully evaluate shoulder anatomy arthrogram needed to assess volume of capsule findings patulous inferior capsule (IGHL anterior and posterior bands) Bankart lesion - may occur in conjunction with traumatic anterior instability Kim lesion - may occur in conjunction with traumatic posterior instability bony erosion of glenoid - following chronic anterior instability Arthroscopy drive-through sign may be present a positive drive-through sign is considered the ability to pass an arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the IGHL also associated with shoulder laxity Differential Diagnosis Anterior shoulder instability Posterior shoulder instability Cervical spine 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 capsular reconstruction (allograft) rare, described in refractory cases and patients with collagen disorders Techniques Capsular shift / stabilization procedure (open or arthroscopic) approach arthroscopic approach to shoulder deltopectoral approach for open subscapularis tenotomy versus subscapularis split 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 capsular thinning/insufficiency and attenuation, and chondrolysis 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 only 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 test and excessive external rotation late finding - humeral head anterior sublaxation on axillary radiograph 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 (abduction and ER moves axillary nerve away from glenoid) usually a neuropraxia that can be observed postoperatively can occur with anterior dislocation of shoulder Late arthritis (capsulorraphy induced arthritis) usually wear of posterior glenoid with posterior humeral head subluxation and significant retroversion of the glenoid may have internal rotation contracture (severe lack of external rotation on exam) historically seen with Putti-Platt and Magnuson-Stack (non-anatomic, historical) procedures Recurrence most common complication following arthroscopic or open capsulorraphy high rate following thermal capsulorrhaphy (historical) due to capsular insufficiency open revision indicated (not arthroscopic)
QUESTIONS 1 of 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Previous Next (OBQ18.164) A 13-year-old baseball pitcher presents with persistent pain of the right shoulder over the last 2 years. He denies any antecedent trauma or dislocations. They report sensations of instability when performing activities with external rotation and abduction. Physical examination reveals an internal rotation deficit of 10 degrees on the right shoulder. The patient is able to hyperextend the elbows and knees to 12 degrees, can place both palms on the floor with knees fully extended, and hyperextend the small finger MCP joint past 90 degrees. There is a positive anterior and posterior load and shift test with a positive sulcus sign. What is the likely diagnosis and next best step in management? QID: 213060 Type & Select Correct Answer 1 Labral tear; MRI of the shoulder 1% (18/1857) 2 Glenohumeral internal rotation deficit; sleeper stretches 8% (141/1857) 3 Multidirectional instability; periscapular muscle training 85% (1579/1857) 4 SLAP tear; MRI arthrogram of the shoulder 2% (36/1857) 5 Little leauger's shoulder; refrain from pitching for 3 months 4% (67/1857) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.105) A 17-year-old gymnast comes to your clinic reporting multiple atraumatic shoulder dislocation events. She has been able to reduce her shoulder on her own without a single trip to the emergency department. Radiographs are normal and an MRI arthrogram is seen in Figure A. Which of the following physical exam findings is most likely to be present? QID: 213001 FIGURES: A Type & Select Correct Answer 1 Cross-body adduction test 4% (62/1651) 2 O'Brien's Test 14% (237/1651) 3 Axillary Webbing 8% (125/1651) 4 Jobe’s Test 6% (100/1651) 5 Increased external rotation in adduction 68% (1115/1651) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.10) 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? QID: 4370 FIGURES: A B Type & Select Correct Answer 1 Physical therapy 89% (5551/6212) 2 Bilateral glenohumeral corticosteriod injections and physical therapy 2% (108/6212) 3 Bilateral subacromial corticosteriod injections and physical therapy 2% (130/6212) 4 Bilateral staged arthroscopic labral repair and capsulorrhaphies 4% (269/6212) 5 Bilateral staged open capsular shifts 2% (97/6212) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.137) Which of the following is true regarding closure of the rotator interval in patients undergoing arthroscopic shoulder stabilization? QID: 3188 Type & Select Correct Answer 1 It can lead to recurrent instability 1% (54/5031) 2 It restricts external rotation predominately in the "arm cocking" phase of throwing 26% (1292/5031) 3 It restricts combined flexion and cross-body adduction 3% (128/5031) 4 It restricts external rotation predominately with the arm at 0 degrees of shoulder abduction 64% (3206/5031) 5 It restricts internal rotation predominately with the arm at 90 degrees of shoulder abduction 6% (321/5031) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.150) 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? QID: 2963 Type & Select Correct Answer 1 Arthroscopic anterior and posterior labral repair 3% (88/2581) 2 Arthroscopic anterior and posterior labral repair with rotator interval closure 6% (163/2581) 3 Home stretching program with emphasis on posterior capsular stretching 8% (200/2581) 4 Dynamic stabilization therapy 81% (2096/2581) 5 Sport specific bracing 1% (16/2581) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.97) What procedure can eliminate a sulcus sign? QID: 8759 Type & Select Correct Answer 1 Rotator interval closure 61% (305/502) 2 SLAP repair 9% (44/502) 3 Bankart repair 19% (96/502) 4 Supraspinatus repair 10% (52/502) 5 Subacromial decompression 1% (5/502) L 4 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 180 FIGURES: A B Type & Select Correct Answer 1 Shoulder range of motion program with emphasis on posterior capsular stretching 4% (120/3420) 2 Shoulder arthroscopy with anterior and posterior capsulolabral plication with superior shift 7% (240/3420) 3 Shoulder arthroscopy with thermal capsulorrhaphy and rotator interval closure 1% (51/3420) 4 Shoulder arthroscopy with repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion 7% (241/3420) 5 Rotator cuff and peri-scapular muscular strengthening program 80% (2750/3420) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.51) A 20-year-old girl reports a shoulder dislocation while reaching for a high shelf. Her history reveals multiple past dislocations with spontaneous reduction and no obvious traumatic event at onset. A photograph of her hand is shown in figure A. What is the most likely etiology of her shoulder instability? QID: 937 FIGURES: A Type & Select Correct Answer 1 inverted pear glenoid with bone deficiency 3% (96/3705) 2 long thoracic nerve palsy 0% (7/3705) 3 Bankart lesion 2% (67/3705) 4 capsular redundancy 93% (3445/3705) 5 Buford complex 2% (63/3705) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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: QID: 1381 Type & Select Correct Answer 1 Elbow hyperextension of the left arm 2% (35/1873) 2 Left 5th finger passive extension beyond 90° 3% (59/1873) 3 Genu recurvatum of the bilateral knees 8% (149/1873) 4 Excessive supination of the left forearm 86% (1609/1873) 5 Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand 1% (12/1873) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (4) Podcasts (1) Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery Complex Posterior and MDI: All My Tricks - Scott W. Trenhaile, MD (CSMS #9, 2018) Scott Trenhaile Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) E 11/11/2018 314 views 4.0 (1) Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Video Spotlight: Arthroscopic Treatment of Multidirectional Instability - Felix Savoie, III, MD (1.16, 2018 Winter SKS) Felix H. "Buddy" Savoie III Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) B 7/9/2018 349 views 3.7 (3) Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Multidirectional Instability - Does it Exist? - Evan Lederman, MD (1.13, 2018 Winter SKS) Evan Lederman Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) A 7/6/2018 400 views 4.3 (3) Shoulder & Elbow⎪Multidirectional Shoulder Instability (MDI) Shoulder & Elbow - Multidirectional Shoulder Instability (MDI) Listen Now 20:0 min 10/15/2019 431 plays 4.8 (4) See More See Less