1. Shoulder
Instability
DR MANDEEP SINGH
Moderators
Dr. A Pathak
Dr. A Ganvir

2. WHAT IS INSTABILITY?
During the use of normal shoulder,humeral head is
centered within the glenoid and coracoacromial arch
When the shoulder cannot maintain this centered
position it is said to be unstable
It is not the same as joint laxity allows the shoulder to
attain its full range of functional positions while an
unstable shoulder prevents normal function of that
upper extremity

4. Factors contributing to shoulder
stability
1. STATIC FACTORS
2. DYNAMIC FACTORS

5. STATIC FACTORS
Normal glenoid is about 7 degrees retroverted
If the retroversion is excessive, it leads to posterior
instability of shoulder

6. The labrum increases the superoinferior diameter of
the glenoid by 75% and the anteroposterior (AP)
diameter by 50%

7. The bony conformity of the glenoid and humeral head
articular surfaces provides some of the stability of the
shoulder.
Frequently, patients with recurrent dislocations have
bony deficits in one or both of these surfaces.

8. LIGAMENTS

9. • Superior Glenohumeral ligament : Most important
check at zero degrees of abduction
• Middle Glenohumeral Ligament : Most important
check at middle ranges of abduction
•Inferior Glenohumeral ligament : Most important
check at more than 45 degrees of abduction

10. DYNAMIC FACTORS
1. The movement of rotator cuff muscles help to contribute to
the negative intra - articular pressure.
2. The rotator cuff muscles themselves make a protective cuff
all around the shoulder except inferiorly where shoulder
capsule is the weakest.

11. Other factors :
1.Muscles around the shoulder
- Levator scapulae
- Rhomboids
-Trapezius
2. Biceps Brachii
3. Proprioceptors

12. PATHOLOGICAL
ANATOMY
LABRAL LESIONS :
1.Bankart lesion
2.Reverse Bankart
lesion
3.SLAP Lesion


13. BANKART LESION-labral tear at
anterior half of glenoid rim

14. Reverse Bankart lesion

15. SLAP Lesion

16. CAPSULAR LESIONS:
1. Intra Substance Tear
2. HAGL Lesion
3. Repetitive Micro Trauma
4. Excessive capsular laxity

17. HAGL Lesion(Humeral
avulsion of the inferior
glenohumeral ligament)

18. Repetitive Micro trauma

19. Glenoid Bone loss

20. Hill Sach Lesion

21. Classification of instability

22. MATSEN’S CLASSIFICATION
T Traumatic
U Unilateral
B Bankart lesion
S Surgery is often necessary
A Atraumatic
M Multidirectional
B Bilateral
R Rehabilitation is the treatment
I If surgery is needed inferior capsular shift is performed

23. History
Define mechanism
 Position of arm
 Point of force
 Amount of force
Electric Shock /Seizure

24. CLINICAL EXAMINATION
LOOK
FEEL
MOVE
SPECIAL TESTS

26. LOOK
- Generalized joint laxity
- Muscle wasting
- Asymmetry
- Previous operative
scars
- Ecchymosis

27. FEEL
Local temperature
Tenderness
Any palpable mass
Bony defect
Muscular weakness
Nerve injury

28. CLINICAL TESTS
The sulcus test.

29. Shift and Load Test

30. The anterior apprehension test

31. The anterior drawer test

32. RADIOGRAPHIC EVALUATION
A routine AP shoulder radiograph shows overlap of the
anterior and the posterior glenoid rims. A true AP
radiograph demonstrates superimposition of the anterior
and the posterior glenoid rims, producing an excellent
view of the glenohumeral joint.

33. Normal Shoulder AP view

34. Transcapular Y-view of the glenohumeral joint allows assessment of humeral head
location in relation to the Glenoid cavity

37. Axillary view represents the “gold standard” in
radiographic assessment of location of the humeral
head relative to the glenoid cavity.

39. The stryker notch view

41. The west point view

42. QUESTIONS TO BE ANSWERED WHILE
EVALUATING A PATIENT
 Is the problem in the glenohumeral joint ?
 Is the problem one of failure to maintain the humeral head in its
centered position ?
 What mechanical factors are contributing to the instability ?
 Are these factors amenable to surgical repair or reconstruction ?

43. McLaughlin & Cavallaro
 After acute dislocations, development of
recurrence

44. Rowe and Sakellarides
 Frequent dislocations in young athletes
 Duration of immobilization does not affect
recurrence rates

45. Burkhart and Debeer;
Sugaya et al; Itoi et al
 Glenoid bone loss more than 20% leads to shoulder
instability

46. RATIONALE FOR TREATMENT
2 important factors favoring surgical treatment
YOUNG AGE
HIGH ACTIVITY LEVEL

47. EMERGENT MANAGEMENT OF
ACUTE DISLOCATIONS

48. NON-OPEREATIVE TREATMENT
 A trial of non-operative treatment is recommended for the following
group of patients-a)
All patients who sustained a traumatic first time dislocation regardless
of age
b) Patients > 40 yrs with recurrent instability
c) All patients with atraumatic instability

49. NON-OPERATIVE TREATMENT PROTOCOL
 All patients< 30 yrs shoulder immobilized for 3 wks
 Patients 30-40yrs shoulder immobilized for 1-2 wks
 Patients >40 yrs the shoulder immobilized for 1
wks
 Atraumatic instability- immobilization not
required
 Patients with anterior instability-limit ext. rotation
to 30 deg. and abd. to < 60 deg.
Patients with posterior instability- avoid flex.>60
deg. and int. rotation > 30 deg.

50. INDICATIONS FOR OPERATIVE TREATMENT IN
INSTABILITY
 Failure of non operative therapy
 Young adult with high functional demands
 Irreducible dislocation
 Open dislocation

51. TREATMENT OPTIONS TYPE OF INSTABILITY PREFERRED SURGERY
Traumatic anterior, with Bankart Lesion Open / arthroscopic Bankart repair
Traumatic anterior , with no labral
lesion, just capsular laxity
Open / arthroscopic capsular
imbrication
AMBRI lesions Lateral capsular shift( modified Neer
and Foster ) with closure of rotator
interval
Recurrent posterior dislocation in
association with a reverse Hill-Sachs
lesion
modified McLaughlin procedure
Head defect > 30 – 45 %
> 45 %
Acute disimpaction / Weber
osteotomy
Prosthetic replacement
Glenoid defect Bristow – Latarjet coracoid transfer
Structural bone graft

52. OPEN SOFT TISSUE PROCEDURES FOR
ANTERIOR INSTABILITY
 Open Bankart procedure
 Arthroscopic Bankart procedure
 Arthroscopic Thermal capsulorraphy
 Arthroscopic capsular imbrication
 Putti-Platt procedure
Only 3 – 10 % failure
rate by various studies
10 – 15 % failure rate by
various studies
Long term follow up
shows high incidence of
OA, about 30 %

54. Anchor used for repair

55. Modified bankart repair

56. OPEN BONY PROCEDURES FOR ANTERIOR
INSTABILITY
Bristow procedure
Latarjet procedure

57. Latarjet procedure

59. AMBRII Lesions-Idea of
management
 Primary treatment nonoperative
 Operative management recommended for
patients who have continued pain or
disability despite an adequate rehabilitation
 The gold standard is open stabilization

60. Capsular shift( modified Neer and
Foster )

61. POSTERIOR INSTABILITY-A
general overview
 Rare
 Often missed
 Often has a component of muscle
imbalance
 Indication for operative treatment is
generally continued problems despite
rehab.

62. Procedures
Procedure Description Results
Neer’s Capsulorrraphy Posterior capsular
tightening
Generally unsatisfactory,
upto 50 % recurrence
Staple capsulorraphy Tightening done with
staples
Small study group
Tieborne and bradley
procedure
Capsular Imbrication with
a horizontal T approach
Upto 20 % recurrence
Hawkins and Janda
procedure
Subscapularis
advancement and
shortening
0 – 5 % recurrence
Rockwood Glenloid
Plasty with Biceps
Tenodesis to the posterior
capsule
Combined bony and soft
tissue procedure
Not often done

63. ARTHROSCOPIC PROCEDURES FOR
POSTERIOR INSTABILITY
 Posterior capsulolabral
reattachment with the help of
suture anchors
 Arthroscopic posterior
capsulorrhaphy

64. OPEN ANTERIOR PROCEDURES FOR
POSTERIOR INSTABILITY
McLaughlin procedure
 Neers modification of McLaughlin procedure

65. McLaughlin technique
 subscapularis

66. Neer’s modification

67. Some procedures of
historic interest
Weber osteotomy

68. Putty Platt Operation
Surgical procedure for stabilizing the
glenohumeral joint after recurrent anterior
shoulder dislocations. The subscapularis tendon
is detached near its insertion on the humerus,
the joint opened, and the stump of the tendon on
the lesser tuberosity is sutured to the glenoid
labrum.
Sometimes the procedure is combined with
reattachment of the glenoid labrum.
Technically an easy procedure
Disadvantages:
The Putti-Platt procedure is not to be performed
on throwers because it can reduce the range of
movement in the shoulder.
30 – 35 % incidence of late OA

69. Magnuson Stack
procedure

70. ADVANTAGES AND DISADVANTAGES OF
ARTHROSCOPIC STABILIZATION
 ADVANTAGES DISADVANTAGES
-Improved cosmesis -Technically demanding
-Shorter operative time -Difficult in revision case
-Short hospital stay -Difficult in altered anatomy
-Decreased morbidity -Cannot address bony
defect
-Decreased complication
-Lower cost

71. PHASES OF REHABILITATION
 Phase I Rest and immobilization. Pain control with
nonsteroidal anti-inflammatory drugs and ice
applied to the shoulder
 Phase II Isometric strengthening Isotonic
strengthening. Begin exercises with shoulder in
adducted, forward- flexed position, progressing to
abducted position
 Phase III Endurance building along with
strengthening exercises. Goal: the patient reaches
90% strength in the injured shoulder compared
with the uninjured shoulder
 Phase IV Increase activity to sport- or job-specific
activities

72. THANK YOU