SHOULDER INSTABILITY Flashcards
Other names for shoulder instability
(a) Dislocation
(b) Multidirectional instability
(c) Recurrent dislocation
(d) Subluxation
(Instability, Subluxation, or Dislocation)
anterior, posterior, inferior or multidirectional glenohumeral
laxity due to traumatic or atraumatic pathology
Instability
(Instability, Subluxation, or Dislocation)
humeral completely slips out of glenoid fossa with spontaneous
reduction or sometimes requiring manual manipulation
Dislocation
(Instability, Subluxation, or Dislocation)
humeral head partially slips out of socket with spontaneous
reduction
Subluxation
What are the two specific instability patterns have been described for Shoulder Instability.
(a) TUBS - Traumatic unilateral dislocations with a Bankart lesion that can be
successfully treated with surgery
(b) AMBRI - Atraumatic multidirectional instability that is commonly bilateral
and is often successfully treated with rehabilitation and occasionally an
inferior capsular shift (surgery)
Clinical Symptoms of a patient with Shoulder Instability
(1) Patient with anterior instability will describe the sensation of the shoulder slipping
out of joint when arm is abducted and externally rotated
(2) Initial anterior dislocation is associated with trauma from a fall or forceful throwing
motion
(3) Recurrent dislocations may occur simply by positioning arm overhead
(4) Patient with posterior dislocation will describe a force that is posteriorly directed
(5) Patient with multidirectional instability may have vague symptoms but usually
related to activity
(a) Ability to voluntarily dislocate shoulder is frequently associated with
multidirectional instability and has a poor prognosis for surgical treatment
Physical Exam of a patient with Shoulder Instability
(1) Visual
(a) Joint disfigurement noted if arm is currently dislocated
(b) Anterior dislocation- most common direction
1) Patient supports arm in neutral position
(c) Posterior dislocation- patient holds arm in adduction and internal rotation
(2) Palpation
(a) General tenderness noted throughout shoulder
(3) ROM
(a) Limited to no AROM or PROM if currently dislocated
(b) Multidirectional instability will not limit ROM but humeral “clucking” is
noted with flexion and abduction/adduction
(c) If multidirectional instability is suspected patient should be checked for
generalized ligamentous laxity
(4) Muscle Tests
(a) Typically limited by pain or lack of joint motion
(5) Neurovascular Tests
(a) Assess axillary, musculocutaneous, median, ulnar and radial nerve function
(b) Assess radial pulse and capillary refill
(6) Special Tests
(a) Positive Sulcus test with inferior laxity
(b) Positive Apprehension test with anterior instability
(c) Anterior/Posterior Drawer test - anterior/posterior laxity
(d) Jerk test- posterior instability
Diagnostic Test of a patient with Shoulder Instability
(1) Radiographs to include AP and axillary views- Rule out Hill-Sachs lesion with
anterior dislocations
(2) AP and axillary radiographs needed if posterior dislocation is suspected
(3) MRI- needed to evaluate health or rotator cuff tendons, labrum (Bankart lesion)
and other soft tissue structures
Treatment of a patient with Shoulder Instability
(1) Reduce acute dislocations
(a) Stimson technique- gravity assisted with patient lying on stomach
(b) Longitudinal traction- elbow at 90 degrees flexion while longitudinal
traction is applied to the humerus. Gently rotate arm.
(c) Valium maybe be required to relax muscle structures to allow for reduction
(d) Re-evaluate axillary nerve function after reduction
(2) Immobilize arm in a sling in neutral rotation
(3) Light duty to include no active use of arm for 2-3 weeks
(4) Begin rotator cuff strengthening 2-3 weeks post reduction
(5) Physical therapy consult
(6) Orthopedic consult
Referral Decisions/Red Flags of a patient with Shoulder Instability
(1) First time dislocations or evidence of neurovascular compromise require
orthopedic evaluation for possible surgery – MEDEVAC
