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shoulder instability types

 

28/02/2021

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Numerous clinical tests described for shoulder examination. In athletes, shoulder instability is caused by activities, such as tackling or pitching, that put extreme force on the shoulder. When these classifications are followed it has, and does often, lead to failures in surgery and management and can make matters worse for patients with unstable shoulders. Rehabilitation aims to enhance the dynamic muscular and proprioceptive restraints to shoulder instability. Finally we have the muscles and tendons of shoulder, first the rotator cuff group, made up of the supraspinatus superiorly, the subscapularis anteriorly and the infraspinatus and teres minor posteriorly, these are responsible for holding the HoH snug against the Glenoid when at rest, this is termed passive stability and helps contribute with all the other passive structures just mentioned ie the labrum, capsule and ligaments. THE CLASSIFICATION OF SHOULDER INSTABILITY - NEW LIGHT THROUGH OLD WINDOWS, Courtesy of: I. L. Bayley, Royal National Orthopaedic Hospital. Hippocrates, in 460 BC, described the reduction of a dislocated shoulder using the heel in the axilla and application of traction to the affected arm. I love the shoulder joint, its a marvellous unique structure within the human body, it is the most mobile joint we have, no other joint can match it in the degrees of freedom it has. Traumatic (Subluxation or Dislocation) Due to repetitive micro-instability; Multidirectional instability; Traumatic instability is initially caused by a single traumatic injury. A shoulder subluxation occurs when the humerus partially slides in and out of place quickly (Figure 2). Or perhaps a Type III/II shoulder which are those with muscle patterning issues, but have had over time multiple episodes of dislocations leading to structural changes over time or visa verse those with a structural defect but have developed adverse muscle patterning as a consequence, these are called Type II/III. a) acute Shoulder Instability . Margie Olds, Specialist Shoulder Physiotherapist explains the difference between anterior, posterior and multi-directional shoulder instability. The Stanmore triangle uses three classifications of shoulder instability based around if a shoulder has some structural traumatic or non traumatic defects that are contributing to instability, with a third classification for the non structural but adverse muscle patterning shoulders, they are as follows The diagnosis of each type is made on the basis of a careful history and clinical examination followed by arthroscopy and, when necessary, functional electro-myography. Depending on the cause, shoulder instability can be placed into one of three different categories: Traumatic Dislocation – a traumatic dislocation is the result of …  • no trauma c) recurrent. The system works well for posterior and anterior dislocations and also for subluxations, and complete dislocations. For example, some patients in polar groups III do give a history of injury of varying degrees of severity.   If the joint is too loose, is may slide partially out of place, a condition called shoulder subluxation. There are two different types of instability that can be classified as: 1. The following are types of shoulder instability: Shoulder Dislocation and Subluxation. This is often what prompts the athlete to seek medical attention. Treatment may include rest, physical therapy or … The HoH can also be varied in shape and angled differently from person to person read here for more info, and finally the labrum can be thicker or thinner in various areas, again read this if you really want to bore yourself silly.  • no abnormal muscle patterning Similarities between polar groups II and III will be self-evident. This site complies with the HONcode standard for trustworthy health information: verify here. Images from his MRI are shown in Figures B and C.  • usually unilateral Shoulder instability classification differentiates 1 the involuntary instability that can occur in one (anterior or posterior) or more than one direction (multidirectional instability [MDI]; anterior, posterior, inferior) from voluntary instability. One could perhaps characterise this situation by drawing three overlapping circles. (Cave et al, 1974) Subcoracoid dislocation is the most common type of anterior dislocation. Next is the joint capsule, the fibrous 'bag' that surrounds the whole joint, its primary role is to contain the synovial fluid which nourishes the joint surfaces, but it also helps a bit with the joints stability as it produces a negative pressure within the joint, which through hydrostatic pressure helps suck the joint surfaces together, think of when you try and get a glass slide off a wet table. Stanmore Classification of Shoulder Instability, The Stanmore triangle uses three classifications of shoulder instability based around if a shoulder has some structural traumatic or non traumatic defects that are contributing to instability, with a third classification for the non structural but adverse muscle patterning shoulders, they are as follows, TYPE I Traumatic structural • significant trauma • often a Bankart’s defect • usually unilateral • no abnormal muscle patterning, (ie: your classic sporting injury), TYPE II Atraumatic structural • no trauma • structural damage to the articular surfaces • capsular dysfunction • no abnormal muscle patterning • not uncommonly bilateral, (ie the classic recurrent dislocators when doing normal or sporting activities), TYPE III Habitual non-structural (muscle patterning) • no trauma • no structural damage to the articular surfaces • capsular dysfunction • abnormal muscle patterning • often bilateral, (ie the rarer more complex shoulder with multiple factors). May be seen after surgery for shoulder dislocation, due to glenoid rim lesions. Posititional non-traumatic: This condition refers to the ability to dislocate your shoulder without any form of trauma. Shoulder instability is a long recognised problem. But, this mobility comes at a price, a reduction in its stability. The shoulder joint has to constantly maintain a balancing act between mobility and stability and sometimes this balancing act can go wrong, in both directions, with shoulders either losing their mobility and becoming too stiff and restricted, but what we are going to look at is when they go the other way and lose their stability. (Kazar and Relovszky, 1969) Of these, almost 85% are anterior glenohumeral dislocations. Neither do existing classifications recognise two fundamental issues, namely that a combination of pathologies may exist and also that cases may move from one group to another over time.  • no abnormal muscle patterning, II Atraumatic 3 Causes of Shoulder Instability. There are several types of shoulder operations that stabilize the shoulder. Full Disclaimer. It is possible to fit patients into the three polar groups or somewhere along the lines which join them. We can see that using the Stanmore Classification of shoulder instability we can cover all types of shoulder instabilities and it gives us flexibility when co concurrent pathologies and causes of instability exist, which they often do, and helps us plan our management much more effectively. Furthermore, a careful doctor when examining patient’s in clinic and investigating them by arthroscopy will soon discover that there can be much overlap between groups.  • often a Bankart’s defect III      Habitual non-structural (muscle patterning). So in conclusion for this brief introduction into shoulder instability we can see that there is wide variation in shoulder structural anatomy. Risk factors in this situation include being on the phone for extended … ): A dislocation occurs when the long bone of the upper arm (humerus bone) slides outside of its socket (glenoid cavity) and remains there. Stanmore Classification (Bayley Triangle). Traumatic anterior events account for 80% of all instability and result in a predictable pattern of pathologic changes. When a shoulder is unstable it can dislocate, this is the complete separation of the ball of the shoulder, called the head of the Humerus (HOH) from the socket, called the Glenoid. The material on this website is designed to support, not replace, the relationship that exists between ourselves and our patients. b) persistent However this model tends to compress the interlocking parts of the circles and might compound rather than relieve confusion. Shoulder Instability Types. The Postero-Lateral Corner, the "Dark side of the Knee"… A guest article by Richard Norris, Bankart and Hill-Sachs Lesions (bony injuries that I will discuss later), Multidirectional (loose in various planes). (OBQ10.264) Open anterior shoulder stabilization procedures have failed twice for an active 22-year-old patient. So I, and all those who I work with, use the Stanmore Triangle Classification System when describing shoulder instability, and I highly recommend you do too, this is an excellent way of diagnosing unstable shoulders and planning their management.  • no structural damage to the articular surfaces 2. Shoulder arthroscopy is a minimally invasive surgical technique that allows your surgeon to evaluate your shoulder and in some … We have preferred to use the model of a triangle since it better highlights the continuum of presentation which can occur in between the three polar groups. The classification suggests that for the symptoms to occur there has to be a disturbance of one or more of the following factors, in isolation or together: 1. the capsulolabral complex and its proprioceptive mechanism 2. the rotator cuff 3. the surface arc or area of contact between the glenoid and humeral head 4. the central/peripheral nervous system. The first factor to consider in the rehabilitation of a patient with shoulder instability is the mechanism and chronicity of the injury. Within the orthopaedic surgical world the terms TUBS and AMBRIs have been widely used, and still are, when diagnosing unstable shoulders. The term “shoulder instability” constitutes a spectrum of disorders that includes dislocation, subluxation and laxity.  • no trauma Symptoms of shoulder instability are pain that comes on either suddenly or gradually, a feeling that the shoulder is loose, or a weakness in the arm. As I mentioned at the beginning the structure of the shoulder has a balancing act to maintain between the roles of mobility and stability, first lets talk about the bony shapes and alignment of the shoulder joint and how these help or don't in shoulder stability. What is shoulder instability? Chronic, atraumatic instability Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability.  • abnormal muscle patterning Many similar tests have been described by different people and given different names. ShoulderDoc.co.uk satisfies the INTUTE criteria for quality and has been awarded 'editor's choice'.  • often bilateral. Yet again the capsule has vast anatomical differences with some capsules being much more baggy or capacious than others, some thinner and some that have holes in. Other patients will have a clear cut muscle patterning problem and will also demonstrate clear cut articular surface damage at arthroscopy. When the other muscles of shoulder ie the Deltoid, Pecs and Latissmus Dorsi etc move the arm around, the rotator cuff work to compress and hold the HoH centred on the Glenoid, this is termed active or dynamic stability, again some vast variations can be found in the rotator cuffs strength, timing and synchronicity leading to shoulder instability issues for some, and even adverse muscle patterning with any of the other muscles that act on the shoulder also creating shoulder instability, but more on this in later posts.

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