2017 cook children’s sports symposium
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2017 Cook Children’s Sports Symposium
Multidirectional Shoulder Instability
Jason Kennedy, M.D.
Disclosures
• I have no financial/ industry disclosures.
Objectives
• Identify anatomy and risk factors related to multidirectional shoulder stability
• Differentiate the features of multidirectional shoulder instability
from traumatic instability • Summarize common patient characteristics and mechanisms
related to multi-directional instability • Apply knowledge of the pathoanatomy of MDI to better
formulate a treatment plan.
MDI
• 15 year female competitive swimmer • symptoms of increasing pain • occasional parasthesias • bilateral • no specific acute event • has had improvement with periods of rest
MDI Imaging
• Plain X-rays • AP, Scapular - Y, axillary lateral • Weighted AP can demonstrate sulcus (unnecessary)
• MRI • Usually not needed unless other pathology suspected
• Acute Dislocation • Exam suggesting labral or cuff patholgy • MR arthrogram most useful
MDI - Imaging
AP
Scapular-Y
Axillary Lateral
MDI
• Described in 1980 by Neer and Foster
• Many times in athletes with generalized laxity
• Commom sports • Swimming • Baseball (or other throwing events) • Raquet sports
MDI
• Microtrauma
• Patulous Inferior capsular pouch
• Widened Rotator Interval
• Decreased Quality and Quantity of collagen
MDI
AMBRI (Historical)
• Atraumatic
• Multi-directional
• Bilateral
• Rehabilitation
• Inferior capsular shift (surgery - unsually involves more)
Dynamic Shoulder Instability
Gerber and Nyffleler 2002
MDI - Static Stablilzers
Gaskill TR, et.al. 2011
MDI -Static Stabilizers
• Anterior Band of IGH ligament - with ABduction and ER
• Inferior Pouch/Posterior Band of IGH - posterior translation
• MGH ligament - resists ABduction/Inferior trans. @ mid range • max tension at 45 Degrees of ABduction
• Superior GH Ligament/Coracoacromial Lig.
• resists Inferior translation and ER • resists Posterior translation with Flexion/ADD/ER
MDI - Pathoanatomy
• Normal • Capsular ligaments
• Provide Proprioception • Cause the Rotator Cuff muscles to contract
• MDI - decreased
• decreased labral height • enlarged posterior capsule • findings are non-specific
Gaskill TR, et.al. 2011
MDI
MDI -Symptoms
• Pain • Internal impingement of cuff on coracoacromial arch • Subluxation episodes
• Instability • Decreased Proprioception • Decreased Rotator Cuff Strength • Sacpular Dyskinesis
Generalized Laxity
• Usually present • Can be familial laxity • Elbow,knee, or MCP hyperextension • Patellar instability • Thumb to ipsilateral forearm
• Can be sign of connective tissue disorder
• Marfan’s, Ehlers-Danlos, Loeys-Dietz • Important for cardiac and other potential problems
Shoulder Special Tests
Gaskill TR, et.al. 2011
MDI - Treatment
• Non-surgical • Rest • Immobilization (if acute event) • Activity modification • NSAIDS • Physical Therapy
• Rotator Cuff strengthening • Scapular Stabilization • Proprioception
MDI - Treatment
• Surgical • Capsular stabilization • Arthroscopic versus open
• Posterior • Anterior • +/- closure of rotator interval
• if sulcus sign does not resolve with External Rotation
• Contraindication - Voluntary Dislocators
Results - Arthroscopic Stabilization
• Treacy SH, et.al, Historical success at 12%recurrent instability after arthroscopic capsular plication
• McIntyre LF - 94% return to pre-surgery sports participation
• Baker et.al. - 86% return to sport with little or no limitation
Surgery Complications
• Subluxation/Dislocation events
• Subscapularis deficiency - failed repair
• Axillary nerve injury
• Stiffness - overtightening (loss of ER)
• Historical - thermal capsulorrhaphy - devastating Chondrolysis
References
• Ahmad CS. Pediatric and Adolescent Sports Injuries. AAOS Monograph Series. 2010.
• AAOS.org
• Gaskil TR, Taylor COL DC, and Millett PJ. Management of Multidirectional Instability of the Shoulder. JAAOS. 2011;19: 758-767.
• Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. JBJS. 1980;62(6): 897-908.
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