Shoulder Instability

The Ultimate Rotator Cuff Training Guide

Herbal Treatments for Rotator Cuff Injury

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Bony anatomy provides minimal stability to the gleno-humeral joint; therefore the primary stability depends on both static and dynamic soft tissue structures. The static soft tissue structures include the fibrocartilaginous labrum,

Figure 30-10 Lift-off test is used to assess subscapularis muscle function. Patients are asked to lift their hand off their back against resistance. Weakness or pain indicates subscapularis pathology.

(CourtesyMark R. Hutchinson, MD.)

Figure 30-10 Lift-off test is used to assess subscapularis muscle function. Patients are asked to lift their hand off their back against resistance. Weakness or pain indicates subscapularis pathology.

(CourtesyMark R. Hutchinson, MD.)

Shoulder Maneuver Family Medicine

Figure 30-11 "Napoleon" or "tummy pat" test is a modified lift-off test to evaluate subscapularis function. Patients are asked to maintain their elbow laterally while pressing into their belly. (Ensure that patients do not drop their arm and use their humerus extensors to mimic subscapularis function.)

(CourtesyMark R Hutchinson, MD.)

Figure 30-11 "Napoleon" or "tummy pat" test is a modified lift-off test to evaluate subscapularis function. Patients are asked to maintain their elbow laterally while pressing into their belly. (Ensure that patients do not drop their arm and use their humerus extensors to mimic subscapularis function.)

(CourtesyMark R Hutchinson, MD.)

glenohumeral ligaments, and capsule. The labrum attaches to the periphery of the glenoid and serves to deepen the socket, reducing translation out of the socket. The gleno-humeral ligaments attach to the labrum, are thickenings in the capsule, and connect to the humeral head. The intrinsic dynamic stabilizers are the rotator cuff and biceps, which help to maintain the humeral head in the glenoid socket. The extrinsic dynamic stabilizers include the rhomboid, levator scapulae, serratus, and trapezius muscles, which position the glenoid beneath the humeral head.

The diagnosis of shoulder instability begins with the patient's history and mechanism of injury, which often include episodes of subluxation, dislocation, or apprehension. Classically, anterior instability is appreciated when the arm is placed in abduction and external rotation (Tennent et al., 2003a, 2003b) (Fig. 30-12). Inferior instability is appreciated

Figure 30-12 Apprehension test is performed with the arm in full abduction and external rotation. Sensation of impending subluxation is a positive finding.

( Courtesy Mark R Hutchinson, MD.)

Figure 30-12 Apprehension test is performed with the arm in full abduction and external rotation. Sensation of impending subluxation is a positive finding.

( Courtesy Mark R Hutchinson, MD.)

when the patient tries to hold a heavy object and the shoulder subluxes inferiorly. Posterior instability is frequently associated with a fall on an outstretched arm, or occasionally with weightlifters who lock out their arms in extension while bench pressing. The clinical examination targets these specific pathologies with the classic apprehension test for anterior instability, performed with the arm in abduction and external rotation, and the patient having the sensation of the arm going out of place. In the relocation test the examiner then presses the humeral head back into a reduced position, thus eliminating the sensation of apprehension. Posterior instability is assessed in a supine position with the arm forward-flexed 90 degrees with a posteriorly directed force. Inferior instability is assessed by pulling inferiorly on the arm and looking for or feeling the humerus come out the socket and looking for a concavity just below the acromion, called the "sulcus sign" (Fig. 30-13).

Some patients may have generalized ligamentous laxity, but laxity itself is not a painful process and is therefore not pathologic. However, some patients with generalized liga-mentous laxity do have symptoms of instability and pathology that can be assessed by comparison to the opposite side or looking at the elbows, fingers/thumb, or knees for excessive recurvatum, In general, patients with generalized ligamentous laxity should undergo an extensive course of conservative treatment because of the increased risk of failure associated with most surgical interventions compared to simple unidirectional instability.

The conservative treatment of shoulder instability is targeted at balancing the flexibility, optimizing the motor strength, and optimizing the function of the kinetic chain. The core component is rotator cuff-strengthening exercises as well as scapular stabilizer exercises. Controversy surrounds the ideal treatment for a first-time shoulder anterior dislocation. In young athletes or military populations, the risk of recurrence and future shoulder problems approaches 90%. Surgical treatment with repair of labral detachments has led to a high rate of return to play and return to performance, with a low risk (<10%) of recurrent instability for a first dislocation. Older nonath-letic patients (>40) with first-time dislocation have a reduced risk of recurrent instability (<50%), so surgical treatment is unnecessary. However, if any patient has recurrent instability

Figure 30-13 Presence or absence of a sulcus sign is evaluated by distracting the arm inferiorly to sublux the humeral head out of the socket. If a sulcus is appreciated as the glenoid is emptied of the humeral head, the clinician should suspect multidirectional instability.

(CourtesyMark R. Hutchinson, MD.)

Figure 30-13 Presence or absence of a sulcus sign is evaluated by distracting the arm inferiorly to sublux the humeral head out of the socket. If a sulcus is appreciated as the glenoid is emptied of the humeral head, the clinician should suspect multidirectional instability.

(CourtesyMark R. Hutchinson, MD.)

or pain, surgery to repair the torn capsule or labral lesions is strongly recommended, with outcomes ranging from 75% to 95% good to excellent results. The Bankart procedure is most often performed and involves direct repair of the torn labrum back to the glenoid from which it was detached (Fig. 30-14). Classically, this procedure was performed open, although the current trend is toward arthroscopic assistance.

Posterior instability accounts for only 10% to 15% of isolated instability of the shoulder. The classic treatment for posterior instability is to initiate a course of conservative treatment focused on strengthening the posterior capsular muscles, including infraspinatus and teres minor. If a conservative course fails, surgical treatment can once again address either capsular laxity or posterior labral injuries.

Multidirectional instability is usually not secondary to a single acute traumatic event. More frequently, the patient will have underlying generalized ligamentous laxity that may or may not be exacerbated by a single traumatic event. These patients are generally loose jointed in all directions and in other joints. Initially, treatment is conservative, although in resistant cases, surgical capsular tightening can be successful in improving symptoms. A thorough history is necessary to rule out psychologic factors (e.g., voluntary dislocation for attention or party trick). These patients have an extremely high failure rate with surgical intervention.

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