Shoulder Instability

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Definition 
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The term ‘shoulder instability’ is used to refer to the inability to maintain the humeral head in the glenoid fossa.(1)The ligamentous and muscle structures around the glenohumeral joint, under non-pathological conditions, create a balanced net joint reaction force. The relevant structures are listed below. If the integrity of any of these structures is disrupted it can lead to atraumatic or traumatic instability. Atraumatic instability commonly results from repetitive overhead movements or congenital joint features. Traumatic mechanisms of injury may result in frank dislocations where there is a loss of joint integrity. Instability can occur anteriorly, posteriorly, or in multiple directions regardless of mechanism of injury.

Mechanism of Injury / Pathological Process
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Clinical Presentation[edit | edit source]

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Diagnostic Procedures[edit | edit source]


Tests used for detecting shoulder instability:
→ laxity examinations

→ provocative tests


Laxity examinations


Load and shift test:

  • Application: The patient lies on his back with the scapula on the table but the caput free. Load the caput humerus into the glenoid and then translate the caput in the anterior and posterior directions.
  • Conclusion: The test aims to evaluate the amount of translation of the caput humerus on the glenoid. There are many methodes to grade the test but the most common one is the Hawkins grading. This method is considered to be the best one because it has a clinical basis. Hawkins divided the movement in four grades: Grade 0 = little to no movement; grade 1 = the humeral head rises up onto the glenoid rim; grade 2 = when the caput humerus can be dislocate but relocate spontaneously; grade 3 = when the head does not relocate after the pressure.
  • Clinical obviousness: Tzannes and Murell[1] have concluded that this test is entirely reliable (p<0,0001) and a LR > 80 for instability.


Drawer test:

  • Application: The patient is positioned supine. The examiner holds the patients scapula with his left hand while grasping the patient’s upper arm and drawing the humeral anterior head with his right hand. You can hold the shoulder in a different position.
  • Conclusion: The test tells you more about the laxity. The test is positive when the thumb was felt to slide past the coracoid.
  • Clinical obviousness: Tzannes and Murell[2] have concluded that this test is still to be assessed as to its validity and reliability.


Sulcus sign:

  • Application: The patient’s elbow is pulled inferiorly while the patient is relaxed
  • Conclusion: This manoeuvre tests the superior glenohumeral ligament. The test is positive when there is a sulcus of more than 2 cm between the acromion and caput humerus.
  • Clinical obviousness: Tzannes and Murell[3] also evaluate this test as being completely reliable (p<0,0001).

Provocative tests [edit | edit source]

Anterior release test:

  • Application: In this test, the examiner applies posteriorly directed force to the humeral head, with the patient being in abduction and external rotation.
  • Conclusion: The test is positive in case of pain or apprehension when easing the pressure.
  • Clinical obviousness: In the light of the results of Tzannes and Murell[4](p<0,0001) and Ian et al[5] we can conclude that it is a reliable test for the detection of the unstable shoulder.


Apprehension/augmentation test:

  • Application: The apprehension test is being applied when the patient is lying or sitting with the shoulder in a neutral position (90° abduction). The examiner holds the patient’s wrist with one hand and with the other hand he applies anteriorly directed force to the humeral head.
  • Conclusion: Signs of glenohumeral anterior instability are: pain, a feeling of subluxation or clear defence. If a relocation test is being applied almost immediately after the apprehension test and if this relocation test results to be negative, than we can decide that there is anterior instability.
  • Clinical obviousness: Based on the results of Levy et al.[6]; Ian et al.[7](sensitivity = 53 & specificity = 99), Tzannes and Murell[8] (p= 0,0004 pain and/or apprehension and a LR 8-100 for anterior instability) and Marx et al.[9], we are able to conclude that there is not sufficient clinical proof to detect or exclude instability.


Relocationtest

  • Application: The patient is in the starting position of the apprehension test and the examiner now applies posteriorly directed force to the humeral head.
  • Conclusion: When this test results to be negative, there is glenohumeral anterior instability.
  • Clinical obviousness: The article by Ian et al. [10] (sensitivity = 45 & specificity = 54) states that the relocation test is not clinically evident. However, other articles by Tzannes and Murell[11] (p= 0,0003 pain and/or apprehension) and Liu et al.[12] provide evidence to the contrary.

Outcome Measures[edit | edit source]

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Management / Interventions
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Differential Diagnosis
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Key Evidence[edit | edit source]

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Resources
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Case Studies[edit | edit source]

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References[edit | edit source]

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  1. ↑ Tzannes A, Murrel, GAC. An assessment of the interexaminar reliability of tests for shoulder instability. The journal of Shoulder and Elbow Surgery 2004; 13:18-23.
  2. ↑ Tzannes A, Murell GAC. Clinical examination of the unstable shoulder. Sports Medicine 2002; 32: 447-457.
  3. ↑ Tzannes et al. 2004
  4. ↑ Tzannes et al. 2002
  5. ↑ Ian KY, Lo IKY, Nonweiler B, et al. An evaluation of the apprehension, relocation, and surprise test for anterior shoulder instability. American Journal of Sports Medicine 2004; 32:301-307.
  6. ↑ Levy AS, Lintner S, Kenter K, et al: intra- and interobserver reproducibility of the shoulder laxity examination. The American Journal of Sports medicine 1999; 4: 460-463.
  7. ↑ Ian et al.
  8. ↑ Tzannes A, Murrel, GAC. An assessment of the interexaminar reliability of tests for shoulder instability. The journal of Shoulder and Elbow Surgery 2004; 13:18-23.
  9. ↑ Marx RG, Bombardier C, Wright JG. What do we know about the reliability and validity of physical examination tests used to examine the upper extremity? Journal of Hand Surgery 1999; 24A:185-193.
  10. ↑ Ian et al.
  11. ↑ Tzannes et al. 2004
  12. ↑ Liu SH, Henry MH, Nuccion S, et al. Diagnosis of glenoid labral tears. A comparison between magnetic resonance imaging and clinical examinations. The American Journal of Sports Medicine 1996; 2:149-154.
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