posterior instability of the shoulder lennard funk

Lennard Funk@theshoulderdoc

PLAN

Posterior instability:!

Pathomechanics!

Diagnosis!

Management !

Results

HISTORY

20th Century!

Plethora of surgical techniques !Poor results (Hawkins, 1984)!Poor understanding

POSTERIOR RESTRAINTS

1. Capsule!

2. Labrum – Posterior Bankart!

3. Glenoid Shape

POSTERIOR LABRUM

POSTERIOR CAPSULE

Thin RHAGL!

Mid-capsule

KIM LESIONSeung-Ho Kim. Arthroscopy. 2004

REDUCED EXTERNAL ROTATION

GLENOID

Version!

Deficiencies

Semogas, Granville-Chapman & Funk, 2014

GLENOID WEAR

POSTERIOR INSTABILITY

1. Traumatic 2. Atraumatic

ATRAUMATIC

Capsular Laxity +/- Muscle Patterning Disorder

TRAUMATIC

Contact sports!

May be minor!

Convulsion

ABER Tackle Direct Impact

Neurological Lesion 32% 15%

Soft tissue Bankart 79% 33%

Bony Bankart 26% 11%

Posterior Labral Tear 11% 50%

SLAP 7% 35%

Partial Cuff Tear 32% 12%

RUGBY SHOULDER INJURIESMalone, Funk, Mohammed, Ball. Shoulder injury patterns in Rugby - the Collision Shoulder. JBJS (Suppl). 2008.

TRADITIONAL TESTS

Specificity Sensitivity Notes Reference

Posterior Drawer Test

No data

Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984

Posterior Apprehension

99% 20% Jia et al. JBJSA. 2009

Jerk Test 85% 90% posteroinf. labral tear

Kim et al. AJSM. 2004

Kim Test 95% 80% posteroinf. labral tear

Kim et al. CORR. 1993

MODIFIED O’BRIEN’S TEST (MOB)!WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)

• Conducted in a similar manner to that initially described by O’Brien

• Patient asked to forward flex the affected arm 90° with the elbow in full extension.

• Adduct the arm fully, medial to the sagittal plane of the body.

• Internally rotate so that the thumb points downward.

• The examiner then applies a downward force to the arm being resisted by the patient.

• The test is considered positive with objective weakness observed by the examiner when downward force on the arm resulted in loss of forward flexion from 90°.

Owen, Mackenzie, Boulter, Funk, 2014

MODIFIED O’BRIEN’S TEST (MOB)!WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)

Owen, Mackenzie, Boulter, Funk, 2014

POSTERIOR INSTABILITY TESTS

Specificity Sensitivity Notes Reference

Posterior Drawer Test

No data

Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984

Posterior Apprehension

99% 20% Jia et al. JBJSA. 2009

Jerk Test 85% 90% posteroinf. labral tear

Kim et al. AJSM. 2004

Kim Test 95% 80% posteroinf. labral tear

Kim et al. CORR. 1993

MOB/WPIT 25% 83% Muscular Athletes

Owen et al. IJSS. 2014

MR ARTHROGRAM

GOLFER’S SHOULDER

MUSCLE EFFECTS

JOINT CAPSULE

EXCESS INTERNAL ROTATION

POSTERIOR STABILISATION

Arthroscopic superseding Open

>85% Success at 2 years !

Lower Morbidity!

Easier Revision!

Treat Associated Pathology:!

Reverse HS; SLAP; Anterior Labrum; Rotator Cuff

OPEN SURGERY

Glenoid bone loss > 25%!

Failed Revision soft tissue repairs!

Massive Reverse Hill-Sachs Lesion!

(Reverse HAGL)

EXAMINATION UNDER ANAESTHESIA

BEACH CHAIR POSITION

PORTALS

POSTERIOR GLENOID BONE LOSS

POST-OP

POST-OP Phase 1: (Level 1 Exercises)

Core stability & Scapula control!

Proprioceptive exercises (minimal weightbearing below 90 degrees)!

Active assisted ROM as comfortable (in 'safe zone' )!

Do not force or stretch

No combined adduction & internal rotation

Phase 2: (Level 2 Exercises)

Progress active assisted to active ROM as comfortable!

Phase 3: (Level 3+ Exercises)

Regain scapula & glenohumeral stability working for shoulder joint control rather than range!

Gradually Strengthen!

Sports-specific rehabilitation - Plyometrics and pertubation training

RESULTS

143 shoulders; 32m FU

Return to Play = 4.3m!

Recurrent Instability = 6/143 (5%)

Badge, Tambe, Funk. Arthroscopic isolated posterior labral repair in rugby players. Int J Should Surg. 2009.

Pre-Op Post-Op Constant Score 65 99 Oxford Score 33 18 Oxford Instability Score 52 13

SUMMARY

Posterior instability:!

Types!

Mechanisms!

Management !

Results

THANK YOU

lenfunk@shoulderdoc.co.uk

@theshoulderdoc

@THESHOULDERDOC

LENFUNK@SHOULDERDOC.CO.UK

Full Time / Part Time