Shoulder Hypermobility "Unstable Shoulder"

Treatment for Hypermobility of the Shoulder: Symptom Modulation

anti-inflammatory

modalities

gentle ROM exercise (within available ROM)

isometrics

strengthening in protected ranges

Treatment for Hypermobility of the Shoulder: Motor Control

ROM and gentle strengthening/stabilization exercises (just prior to end-range but not at end-range)

strengthening in positions closer to position of instability

Treatment for Hypermobility of the Shoulder: Functional Optimization

strengthening

proprioceptive exercises

CKC exercises

plyometrics

sports/work specific (at position of prior instability or position of work or sport)

How is a dislocation relocated?

requires manual relocation unlike a subluxation

Dislocations of shoulder

anterior - sits anterior infeior

posterior - sits posterior superior

Bony Geometry of GH joint

not a lot of stability - large humeral head articulates with smaller glenoid fossa

golf ball on tee

Areas of weakness of GH joint not reinforced by passive restraints

ant/inf GHL

rotator interval

Based on areas of weakness what extreme motion yields dislocations or instability events the most?

ER in abd

Stability Ratio

displacing force/compressive load

What maximizes the stability ratio?

humeral head centered on glenoid fossa - when net compressive forces maximized between passive and active structures

RC Function as a group

approximate humeral head to glenoid

Supraspinatus function alone

assists deltoid in abd

provide compressive force through humeral head into the glenoid

subscapularis, infraspinatus, teres minor function

depress humeral head (controls superior migration)

scapular influence on GH stability: glenoid center line

approx. 10 degrees posterior to scapular plane

what causes misalignment of the glenoid center line?

any amount of anteversion, retroversion, upward/downward rotation --> misalignment --> net compressive force

scapular plane orientation

30 degrees anterior to frontal plane

how to assess scapular control?

scapular assistance test

how to complete scapular assistance test?

1. assess sx (pain) in unassisted scapular plan elevation

2. repeat with therapist-assisted upward rotation and posterior tilt

+ scapular assistance test

reduction of pain (2 or more points on 0-10 scale)

what is scapular assistance test used for?

identify pt who may benefit from interventions to address scapular control

onset of GH instability

traumatic in specific direction

repetitive microtrauma/overuse

atraumatic (multidirectional) - often some amount of hyperlaxity

voluntary GH instability

individual can willingly demonstrate the instability

involuntary GH instability

traumatic onset, related to the position to the arm

subluxation

dislocates but spontaneously reduces

frank dislocation

dislocates and needs reduction by medical professionl

unidirectional GH instability classification

anterior (80-95%)

posterior

inferior - rare

multidirectional GH instability classification

anterior and inferior

posterior and inferior

anterior and posterior and inferior

TUBS

traumatic

unidirectional

bankart lesion

surgical repair required

AMBRI

atraumatic

multidirectional

bilateral

rehabilitation

inferior capsular shift (if surgery required)

issues with historical classification : TUBS and AMBRI

oversimplified

does not account for overlapping presentation

does not account for neuromuscular contributors

more contemporary classification

more individualized and evidence-based approach

integrates mechanical, structural, neuromuscular factors

Rule in GH instability

Younger (< 40); males > females - Second peak in incidence: Females > 70 years

Reports of instability/pain/apprehension with specific shoulder positions

History of subluxation / dislocation

(+) Apprehension/Relocation or Hyperabduction tests

Possibly (+) SLAP lesion tests

Generalized joint laxity/hypermobility (atraumatic)

Rule out GH instability

No history of subluxation or dislocation

(-) Apprehension / Relocation

(-) Hyperabduction tests

what type of imaging does everyone get?

plain radiograph

if fx present on xray what is the next imaging step?

CT

if xray negative but that history is screaming dislocation or presence of Bankart/Hill-Sachs lesion what imaging do you get?

MRI or MRA

if MRI/MRA finds elements that suggest bone loss or fracture, what happens next?

CT scan

what to palpate for shoulder exam?

AC joint

clavicle

LHBT

SST

INF

Subscap

assess pulses and reperfusion (Red flag related - esp. for acute phase)

what part of exam is contraindicated with hypermobility?

mobility assessment

special tests for hypermobility

translational tests:

1. anterior/posterior drawer test

2. sulcus sign (0 degree and 90 degrees)

steps of anterior drawer

Patient is in supine

Arm is abducted to 70-80 degrees

Slight flexion and ER (resting position)

Stabilize scapula with grip, attempt to put thumb on coracoid

Grasp proximal humerus with other hand

Passively translate anteriorly

positive anterior drawer test

increased translation relative to contralateral side

steps of posterior drawer

Patient is in supine

Arm is in 90 degrees of abduction

Stabilize scapula with grip, attempt to put thumb on coracoid

Grasp proximal humerus with other hand

Passively translate humeral head posteriorly (downward pressure)

positive posterior drawer test

increased translation relative to contralateral side

laxity vs instability

instability = dysfunction

(patient has symptoms, uni or multidirectional, traumatic or nontraumatic)

laxity does not equal dysfunction

(patient is symptom free, inc. connective tissue mobility through jt mobility testing)

steps of sulcus sign

Patient is sitting

3a. Sulcus at 0° - infraspinatus

• Arm at side

3b. Sulcus at 90° - teres minor

• Arm at 90 abduction

Passively translate the humeral head inferiorly

positive sulcus test

excessive inferior translation or Step off / sulcus inferior to the acromion

usual HPI of anterior instability

Younger (ages 15 - 29 years) (related to high-risk activities)

History of trauma (or recurrence)

Especially in athletes

Apprehension and/or pain with arm in ABD/ER or overhead

Possible report of 'click' or mechanical symptoms in shoulder

traumatic mechanism for anterior GH instability

Forceable External Rotation / Horizontal Abduction

Force often exerted on distal arm with shoulder in

• ABD/ER

• Horizontal Abduction

microtrauma/microinstability mechanism for anterior GH instability

More common with overhead throwing/sports/overhead work

SLAP lesion

key components of ROM exam for anterior instability

Pain or apprehension at or near end-range

Apprehension with ABD/ER

Altered movement patterns - altered scapulohumeral rhythm

key components of joint mobility exam for anterior instability

Apprehension with anterior assessment / glide

key components of strength exam for anterior instability

Assess ER & IR at 90, scaption, mid trap/low trap, and serratus anterior

• If possible based on presentation*

steps of anterior apprehension/relocation test

Patient is supine

Passively bring shoulder to 90 abduction

Slowly bring into ER - CONFIRM POSITIVE APPREHENSION

Return out of ER position

Provide posteriorly directed force to humeral head

Repeat the passive ER assessment

positive anterior apprehension/relocation test

apprehension with step 1, that reduces with step 2 (relocation)

GH anterior microinstability mechanism

repetitive (throwing athlete)

what does GH anterior microinstability result in?

increased ER

decreased IR

anatomical mechanisms of anterior GH microinstability

due to anterior laxity & anatomical changes

• Laxity of anterior capsule and GH Ligament

• Retroversion of the humeral shaft

• Soft tissue contracture of the posterior shoulder

what impingement does anterior GH microinstability result in?

posterior internal impingement

what is posterior internal impingement a physical impingement between?

greater tuberosity of humeral head

posterior-superior glenoid rim

causes posterior internal impingement

repetitive abrasion/microtrauma to supraspinatus, infraspinatus, superior labrum

due to/associated with posterior shoulder tightness (soft tissue)

common history in posterior GH instability

Occurs in younger athletes

Especially in contact sports

Presents as posterior shoulder pain with UE WB or positions of FLEXION & HORIZONTAL ADDUCTION

mechanism of injury for posterior GH instability

Posteriorly directed force

With the shoulder in Flexion/H. Adduction/IR

High % (30%) secondary to seizures

primary restraint to posterior instability when shoulder abd to 90

posteroinferior capsule and the IGHL

Reverse Bankart lesion

detachment of posterior labrum

kim lesion

tear between posterior labrum and glenoid cartilage without complete detachment of the labrum

what type of lesion may patients develop after posterior shoulder dislocation?

reverse hill-sachs lesion on the humeral head

patient complaints for posterior GH instability

vague complaints and rarely diagnosed with shoulder dislocation

single traumatic event yielding posterior GH instability - what should you ask

direction of applied force and position of arm during event

insidious event yielding posterior GH instability

often participate in activities that repetitively place their UE in at risk positions of flexion, abduction, and IR (football, weightlifters)

common symptoms reported for posterior GH instability

Muscle weakness

Fatigue

Pain

Possible clicking or popping

Infrequently report sensations of "instability"

posterior GH instability ROM exam

Apprehension in positions of

• Flexion

• Horizontal adduction

• IR

• Combination of the 3 above

Pain at end ranges and look for scapular dyskinesis

posterior GH instability strength exam

Assess ER, IR (0 & 90), scaption, MT, LT

Consider assessment of willingness to perform CKC ex.

posterior GH instability palpation exam

Posterior joint line tenderness may be present

steps of posterior drawer test for posterior GH instability

A posterior load and shift that is performed in supine

Stabilize the shoulder joint with one hand

Other hand provides a medially and posteriorly directed force on the humerus

Assess for excessive posterior translation

grades 1-3 of posterior GH instability

Grade I - less than the glenoid margin

Grade II - beyond margin / reduces

Grade III - beyond margin / no spontaneous reduction

steps of jerk test

Patient sitting in the upright position

Place arm in FORWARD FLEXION + ADDUCTION + INTERNAL ROTATION

Examiner applies a posterior-directed force along humerus

This will cause a posterior translation of the humeral head and as the arm is brought into extension a painful clunk may be appreciated

- This is the humerus reducing

- Indicative of a posterior labral tear

what is presence of a painful jerk test associated with?

poor outcomes with nonoperative management

steps of kim test

Patient in upright sitting position

Shoulder in ABDUCTED + INTERNALLY ROTATED

Examiner cups the patient's elbow with one hand and grabs over the patient's bicep with the other.

Apply an axial load to the elbow, and move the arm into

HORIZONTAL ADDUCTION while applying a posterior-directed force on the humerus

Causes humerus to posteriorly translate out of the glenoid socket

positive kim test

pain, clunk, or click

what scale is used for generalized hypermobility

beightons

Beighton's Scale

(1) Hyperextension of the elbow beyond 10° (+ 1 point for each elbow) (+2)

(2) Hyperextension of the knee beyond 10° (+ 1 point for each knee) (+2)

(3) Forward Flexion of the trunk, knees straight, palms rest easily on floor (+1)

(4) Passive dorsiflexion of the little finger beyond 90° (+1 for each finger) (+2)

(5) Passive apposition of the thumbs to the flexor aspects of the forearm (+1 for each thumb) (+2)

9-point scale total possible

what score on beighton's indicates hypermobility?

>4

management of posterior GH instability

begin non-operative with PT

if non-op fails then surgical management

focus of PT for posterior GH instability

Strengthen dynamic stabilizers of the shoulder and scapulothoracic muscles

Patients with Atraumatic history of instability tend to have more favorable results with conservative treatment.

Gradually build up tolerance to axial loading of the humerus (i.e. CKC activities)

surgical management of posterior GH instability

2 broad categories - soft tissue or bony anatomy

soft tissue injury surgical management for posterior GH instability

posterior capsulorrhaphy (capsular shift) and labral repair

osseous involvement surgical management for posterior GH instability

posterior wedge osteotomy or posterior bone block procedures

usually only after failure of soft tissue management alone

history components leading to inferior GH instability

< 40 years old

Atraumatic

If traumatic/isolated (rare):

• Inferiorly directed force on proximal arm while in ABD

Generalized laxity (Beighton scale)

Often presents with Multi-Directional Instability (MDI)

• MDI:

• 1) at least 2 directions

• 2) Beighton Scale ≥ 5/9

• 3) + Sulcus sign

ROM exam findings inferior GH instability

apprehension in abd

pain/instability at end range

strength exam findings inferior GH instability

Assess ER/IR (0/90), Scaption, mid trap, low trap

Assess willingness to perform CKC activities

Consider assessing core/endurance

special tests for inferior GH instability

hyperabduction test

steps of hyperabduction test

Patient is seated, PT stabilizes the shoulder to prevent

scapulothoracic rotation

PT will then raise arm to end-range GH ABD

Normal range is ~90°

positive hyperabduction test

apprehension OR increased laxity (> 105° abduction)

concomitant pathologies with GH instability

1. Bony Bankart lesion (anterior instability)

2. Hill-Sachs lesion (anterior instability)

3. Reverse Bony Bankart lesion (posterior instability)

4. Reverse Hill-Sachs lesion (posterior instability)

5. Glenoid Bone Loss

6. Bipolar bone loss - combo glenoid and humeral bone loss

7. Greater Tuberosity fractures

rotator cuff tears frequency

Posterior-superior (traumatic dislocations) (<5%)

More common in pts > 40 years (30%)

Subscapularis most frequently involved (~20%)

labral lesions

bankart lesions (100%)

SLAP lesion (33%)

when do brachial plexus injuries occur?

high-energy injuries

increased risk with incresed age

mechanism of brachial plexus injuries

impact --> inf cord

traction --> medial cord

result of vascular injury --> less common

what nerves are affected with brachial plexus injuries?

more often multiple

axillary almost never