Anterior Shoulder Instability: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==
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<u>Epidemiology<br></u>Anterior shoulder dislocations are much more common than posterior dislocations.<ref name="Andrew et al" />  
<u>Epidemiology<br></u>Anterior shoulder dislocations are much more common than posterior dislocations.<ref name="Andrew et al" />  


Many investigators have showed that the incidence of recurrence of shoulder dislocation is significantly higher in younger patients.<ref name="Arash et al">Arash Araghi, Mark Prasarn, Selvon St. Clair, Ph.D., Joseph D. Zuckerman. Recurrent Anterior Glenohumeral Instability with Onset after Forty Years of Age. The Role of the Anterior Mechanism. Bulletin of the NYU Hospital for Joint Diseases. 2005, 62:Numbers 3 &amp;amp;amp; 4.(B)</ref><ref name="E et al" /> The consequences of initial anterior glenohumeral dislocations in patients over forty years of age are quite different than in the younger population primarily because of the increase incidence of rotator cuff tears and associated neurovascular injuries. Either the anterior or the posterior supporting structures of the shoulder should be disrupted following an anterior dislocation. In the younger patient, anterior capsuloligamentous structures most commonly fail. In the older patient with preexisting degenerative weakening of the rotator cuff, it is more likely that the posterior structures fail rather than the anterior structures.<ref name="Arash et al" />  
Many investigators have showed that the incidence of recurrence of shoulder dislocation is significantly higher in younger patients.<ref name="Arash et al">Arash Araghi, Mark Prasarn, Selvon St. Clair, Ph.D., Joseph D. Zuckerman. Recurrent Anterior Glenohumeral Instability with Onset after Forty Years of Age. The Role of the Anterior Mechanism. Bulletin of the NYU Hospital for Joint Diseases. 2005, 62:Numbers 3 &amp;amp;amp;amp;amp; 4.(B)</ref><ref name="E et al" /> The consequences of initial anterior glenohumeral dislocations in patients over forty years of age are quite different than in the younger population primarily because of the increase incidence of rotator cuff tears and associated neurovascular injuries. Either the anterior or the posterior supporting structures of the shoulder should be disrupted following an anterior dislocation. In the younger patient, anterior capsuloligamentous structures most commonly fail. In the older patient with preexisting degenerative weakening of the rotator cuff, it is more likely that the posterior structures fail rather than the anterior structures.<ref name="Arash et al" />  


<br>
<br>  


<u>Etiology<br></u>The glenohumeral joint is stabilized by dynamic and static structures. <br>The dynamic stabilizer: the rotator cuff, the m. biceps brachii caput longum, and the m. deltoideus. <br>The static stabilizers of the joint: the capsule, the glenohumeral ligaments, the labrum, negative pressure within the joint capsule, and the bony congruity of the joint.<ref name="Andrew et al">Andrew L. Chen,Joseph A. Bosco. Glenohumeral Bone Loss and Anterior Instability. Bulletin of the NYU Hospital for Joint Diseases. 2006, 64:Numbers 3 &amp;amp;amp; 4.(D)</ref><ref name="E et al" /><br>- The labrum: The concavity compression mechanism plays an important role in the stability of the shoulder joint by maintaining the localization of the humeral head at the glenoid against translation forces. The glenoid concavity is established by the glenoid shape, the glenoid cartilage and the glenoid labrum. The glenoid labrum increases the width and depth of the glenoid and achieves stability by spreading the weight inflicted on the shoulder. A glenoid defect is the avulsion of the glenohumeral labral complex accompanied by the fracture of the anterior glenoid rim or body erosion, this leads to reduction in the depth of the glenoid with is associated with anterior instability. Instability increased with the size of the glenoid defect. Many biomechanical studies have proved that a glenoid defect significantly affects the stability of the shoulder joint.<ref name="Yong et al">Yong Girl Rhee &amp;amp;amp; Chan Teak Lim. Glenoid defect associated with anterior shoulder instability: results of open Bankart repair. International Orthopaedics (SICOT). 2007 ,31:629–634.(B)</ref><br>- The glenohumeral ligaments: The superior glenohumeral ligament functions primarily to resist inferior translation and external rotation of the humeral head in the adducted arm.<br>The middle glenohumeral ligament functions primarily to resist external rotation from 0° to 90° and provides anterior stability to the moderately abducted shoulder.<br>The inferior glenohumeral ligament is composed of two bands, anterior and posterior, and the intervening capsule. The primary function of the anterior band is to resist anteroinferior translation.<ref name="E et al" /><br>- A tight posterior shoulder capsule or tight posterior musculature and loss of internal rotation has been associated with a delay or skip in scapular glide with concomitant winging, with may be associated with anterior shoulder instability.<ref name="Yvonne et al" /><br>- Excessive external rotation or overrotation of the thrower’s shoulder is purportedly associated with the development of internal impingement syndrome ( occurs when the shoulder is maximally externally rotated and the intra-articular side of the supraspinatus tendon impinges on the adjacent posterior superior glenoid and glenoid labrum), a potential precursor to anterior instability.<ref name="Yvonne et al" />
<u>Etiology<br></u>The glenohumeral joint is stabilized by dynamic and static structures. <br>The dynamic stabilizer: the rotator cuff, the m. biceps brachii caput longum, and the m. deltoideus. <br>The static stabilizers of the joint: the capsule, the glenohumeral ligaments, the labrum, negative pressure within the joint capsule, and the bony congruity of the joint.<ref name="Andrew et al">Andrew L. Chen,Joseph A. Bosco. Glenohumeral Bone Loss and Anterior Instability. Bulletin of the NYU Hospital for Joint Diseases. 2006, 64:Numbers 3 &amp;amp;amp;amp;amp; 4.(D)</ref><ref name="E et al" />
 
*The labrum: The concavity compression mechanism plays an important role in the stability of the shoulder joint by maintaining the localization of the humeral head at the glenoid against translation forces. The glenoid concavity is established by the glenoid shape, the glenoid cartilage and the glenoid labrum. The glenoid labrum increases the width and depth of the glenoid and achieves stability by spreading the weight inflicted on the shoulder. A glenoid defect is the avulsion of the glenohumeral labral complex accompanied by the fracture of the anterior glenoid rim or body erosion, this leads to reduction in the depth of the glenoid with is associated with anterior instability. Instability increased with the size of the glenoid defect. Many biomechanical studies have proved that a glenoid defect significantly affects the stability of the shoulder joint.<ref name="Yong et al">Yong Girl Rhee &amp;amp;amp;amp;amp; Chan Teak Lim. Glenoid defect associated with anterior shoulder instability: results of open Bankart repair. International Orthopaedics (SICOT). 2007 ,31:629–634.(B)</ref>
*The glenohumeral ligaments: The superior glenohumeral ligament functions primarily to resist inferior translation and external rotation of the humeral head in the adducted arm. The middle glenohumeral ligament functions primarily to resist external rotation from 0° to 90° and provides anterior stability to the moderately abducted shoulder. The inferior glenohumeral ligament is composed of two bands, anterior and posterior, and the intervening capsule. The primary function of the anterior band is to resist anteroinferior translation.<ref name="E et al" />
*A tight posterior shoulder capsule or tight posterior musculature and loss of internal rotation has been associated with a delay or skip in scapular glide with concomitant winging, with may be associated with anterior shoulder instability.<ref name="Yvonne et al" />
*Excessive external rotation or overrotation of the thrower’s shoulder is purportedly associated with the development of internal impingement syndrome ( occurs when the shoulder is maximally externally rotated and the intra-articular side of the supraspinatus tendon impinges on the adjacent posterior superior glenoid and glenoid labrum), a potential precursor to anterior instability.<ref name="Yvonne et al" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Indications for anterior shoulder instability:<br>- Anterior instability accounts for 95% of acute traumatic dislocations.<ref name="E et al">E. Jeffrey Pope, James P. Ward, Andrew S. Rokito. Anterior Shoulder Instability. A History of Arthroscopic Treatment. Bulletin of the NYU Hospital for Joint Diseases. 2011,69(1):44-9.(D)</ref><br>- Dead-arm syndrome indicates pathologic anterior instability. It occurs when the arm is in an abducted, externally rotated&nbsp;position. The patient complains of a sharp anterior shoulder pain and tingling in the hand. The patient drops the arm suddenly. This syndrome can be seen in overhead sports, such as volleyball, tennis, swimming and water polo.<ref name="Yvonne et al">Yvonne E. Satterwhite, MD, CSCS. Evaluation and Management of Recurrent Anterior Shoulder Instability. Journal of Athletic Training. 2000, 35(3):273-277.(C)</ref><br>- Rotator cuff weakness, particularly in external rotation and “empty-can” abduction, is common in athletes with anterior instability.<ref name="Yvonne et al" /><br>- Bankart lesions are the most common sequel of anterior shoulder instability with traumatic origins.<ref name="E et al" /><br>- Humeral avulsion of glenohumeral ligaments lesions are another known cause of anterior shoulder instability.<ref name="E et al" /><br>- Anterior labral periosteal sleeve avulsion is a Bankart variant. Although these lesions eventually heal, the medialisation of the labrum will result in reduced restraint to anterior translation of the humeral head and possible recurrent dislocation.<ref name="E et al" />  
Indications for anterior shoulder instability:<br>
 
*Anterior instability accounts for 95% of acute traumatic dislocations.<ref name="E et al">E. Jeffrey Pope, James P. Ward, Andrew S. Rokito. Anterior Shoulder Instability. A History of Arthroscopic Treatment. Bulletin of the NYU Hospital for Joint Diseases. 2011,69(1):44-9.(D)</ref>
*Dead-arm syndrome indicates pathologic anterior instability. It occurs when the arm is in an abducted, externally rotated&nbsp;position. The patient complains of a sharp anterior shoulder pain and tingling in the hand. The patient drops the arm suddenly. This syndrome can be seen in overhead sports, such as volleyball, tennis, swimming and water polo.<ref name="Yvonne et al">Yvonne E. Satterwhite, MD, CSCS. Evaluation and Management of Recurrent Anterior Shoulder Instability. Journal of Athletic Training. 2000, 35(3):273-277.(C)</ref>
*Rotator cuff weakness, particularly in external rotation and “empty-can” abduction, is common in athletes with anterior instability.<ref name="Yvonne et al" />
*Bankart lesions are the most common sequelae of anterior shoulder instability with traumatic origins.<ref name="E et al" />
*Humeral avulsion of glenohumeral ligaments lesions are another known cause of anterior shoulder instability.<ref name="E et al" />
*Anterior labral periosteal sleeve avulsion is a Bankart variant. Although these lesions eventually heal, the medialisation of the labrum will result in reduced restraint to anterior translation of the humeral head and possible recurrent dislocation.<ref name="E et al" />
*During an anterior dislocation, the posterolateral aspect of the humeral head contacts the anteroinferior rim of the glenoid, often resulting in a classic Hill-Sach defect. This defect has been observed in up to 80% of patients with initial anterior dislocation and in 100% of patients with recurrent anterior instability.<ref name="Andrew et al" /><ref name="E et al" />


- During an anterior dislocation, the posterolateral aspect of the humeral head contacts the anteroinferior rim of the glenoid, often resulting in a classic Hill-Sach defect. This defect has been observed in up to 80% of patients with initial anterior dislocation and in 100% of patients with recurrent anterior instability.<ref name="Andrew et al" /><ref name="E et al" />
<br>  


<br>
Complaints related to recurrent anterior instability:<ref name="Yvonne et al" />


Complaints related to recurrent anterior instability:<ref name="Yvonne et al" /><br>- Glenohumeral joint pain<br>- Shoulder stiffness with difficulty warming up for the sport<br>- Rotator cuff weakness<br>- Sensation of popping, grinding or catching deep in the shoulder joint<br>- Pain when reaching backward or above shoulder height<br>- Apprehension when sleeping with the arm overhead in abduction and external rotation<br>- Neurologic complaints: tingling or burning in the lower arm and hand or localized numbness of the skin overlying the deltoid muscle<br>- Tenderness of the anterior glenohumeral joint line and the posterior rotator cuff<br><br>
*Glenohumeral joint pain
*Shoulder stiffness with difficulty warming up for the sport
*Rotator cuff weakness
*Sensation of popping, grinding or catching deep in the shoulder joint
*Pain when reaching backward or above shoulder height
*Apprehension when sleeping with the arm overhead in abduction and external rotation
*Neurologic complaints: tingling or burning in the lower arm and hand or localized numbness of the skin overlying the deltoid muscle
*Tenderness of the anterior glenohumeral joint line and the posterior rotator cuff


== Differential Diagnosis  ==
== Differential Diagnosis  ==

Revision as of 19:47, 17 August 2012

Original Editors - Liesbeth De Feyter

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Definition/Description[edit | edit source]

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Clinically Relevant Anatomy[edit | edit source]

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Epidemiology /Etiology[edit | edit source]

Epidemiology
Anterior shoulder dislocations are much more common than posterior dislocations.[1]

Many investigators have showed that the incidence of recurrence of shoulder dislocation is significantly higher in younger patients.[2][3] The consequences of initial anterior glenohumeral dislocations in patients over forty years of age are quite different than in the younger population primarily because of the increase incidence of rotator cuff tears and associated neurovascular injuries. Either the anterior or the posterior supporting structures of the shoulder should be disrupted following an anterior dislocation. In the younger patient, anterior capsuloligamentous structures most commonly fail. In the older patient with preexisting degenerative weakening of the rotator cuff, it is more likely that the posterior structures fail rather than the anterior structures.[2]


Etiology
The glenohumeral joint is stabilized by dynamic and static structures.
The dynamic stabilizer: the rotator cuff, the m. biceps brachii caput longum, and the m. deltoideus.
The static stabilizers of the joint: the capsule, the glenohumeral ligaments, the labrum, negative pressure within the joint capsule, and the bony congruity of the joint.[1][3]

  • The labrum: The concavity compression mechanism plays an important role in the stability of the shoulder joint by maintaining the localization of the humeral head at the glenoid against translation forces. The glenoid concavity is established by the glenoid shape, the glenoid cartilage and the glenoid labrum. The glenoid labrum increases the width and depth of the glenoid and achieves stability by spreading the weight inflicted on the shoulder. A glenoid defect is the avulsion of the glenohumeral labral complex accompanied by the fracture of the anterior glenoid rim or body erosion, this leads to reduction in the depth of the glenoid with is associated with anterior instability. Instability increased with the size of the glenoid defect. Many biomechanical studies have proved that a glenoid defect significantly affects the stability of the shoulder joint.[4]
  • The glenohumeral ligaments: The superior glenohumeral ligament functions primarily to resist inferior translation and external rotation of the humeral head in the adducted arm. The middle glenohumeral ligament functions primarily to resist external rotation from 0° to 90° and provides anterior stability to the moderately abducted shoulder. The inferior glenohumeral ligament is composed of two bands, anterior and posterior, and the intervening capsule. The primary function of the anterior band is to resist anteroinferior translation.[3]
  • A tight posterior shoulder capsule or tight posterior musculature and loss of internal rotation has been associated with a delay or skip in scapular glide with concomitant winging, with may be associated with anterior shoulder instability.[5]
  • Excessive external rotation or overrotation of the thrower’s shoulder is purportedly associated with the development of internal impingement syndrome ( occurs when the shoulder is maximally externally rotated and the intra-articular side of the supraspinatus tendon impinges on the adjacent posterior superior glenoid and glenoid labrum), a potential precursor to anterior instability.[5]

Characteristics/Clinical Presentation[edit | edit source]

Indications for anterior shoulder instability:

  • Anterior instability accounts for 95% of acute traumatic dislocations.[3]
  • Dead-arm syndrome indicates pathologic anterior instability. It occurs when the arm is in an abducted, externally rotated position. The patient complains of a sharp anterior shoulder pain and tingling in the hand. The patient drops the arm suddenly. This syndrome can be seen in overhead sports, such as volleyball, tennis, swimming and water polo.[5]
  • Rotator cuff weakness, particularly in external rotation and “empty-can” abduction, is common in athletes with anterior instability.[5]
  • Bankart lesions are the most common sequelae of anterior shoulder instability with traumatic origins.[3]
  • Humeral avulsion of glenohumeral ligaments lesions are another known cause of anterior shoulder instability.[3]
  • Anterior labral periosteal sleeve avulsion is a Bankart variant. Although these lesions eventually heal, the medialisation of the labrum will result in reduced restraint to anterior translation of the humeral head and possible recurrent dislocation.[3]
  • During an anterior dislocation, the posterolateral aspect of the humeral head contacts the anteroinferior rim of the glenoid, often resulting in a classic Hill-Sach defect. This defect has been observed in up to 80% of patients with initial anterior dislocation and in 100% of patients with recurrent anterior instability.[1][3]


Complaints related to recurrent anterior instability:[5]

  • Glenohumeral joint pain
  • Shoulder stiffness with difficulty warming up for the sport
  • Rotator cuff weakness
  • Sensation of popping, grinding or catching deep in the shoulder joint
  • Pain when reaching backward or above shoulder height
  • Apprehension when sleeping with the arm overhead in abduction and external rotation
  • Neurologic complaints: tingling or burning in the lower arm and hand or localized numbness of the skin overlying the deltoid muscle
  • Tenderness of the anterior glenohumeral joint line and the posterior rotator cuff

Differential Diagnosis[edit | edit source]

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Key Research[edit | edit source]

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Clinical Bottom Line[edit | edit source]

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References[edit | edit source]

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  1. ↑ 1.0 1.1 1.2 Andrew L. Chen,Joseph A. Bosco. Glenohumeral Bone Loss and Anterior Instability. Bulletin of the NYU Hospital for Joint Diseases. 2006, 64:Numbers 3 &amp;amp;amp;amp; 4.(D)
  2. ↑ 2.0 2.1 Arash Araghi, Mark Prasarn, Selvon St. Clair, Ph.D., Joseph D. Zuckerman. Recurrent Anterior Glenohumeral Instability with Onset after Forty Years of Age. The Role of the Anterior Mechanism. Bulletin of the NYU Hospital for Joint Diseases. 2005, 62:Numbers 3 &amp;amp;amp;amp; 4.(B)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 E. Jeffrey Pope, James P. Ward, Andrew S. Rokito. Anterior Shoulder Instability. A History of Arthroscopic Treatment. Bulletin of the NYU Hospital for Joint Diseases. 2011,69(1):44-9.(D)
  4. ↑ Yong Girl Rhee &amp;amp;amp;amp; Chan Teak Lim. Glenoid defect associated with anterior shoulder instability: results of open Bankart repair. International Orthopaedics (SICOT). 2007 ,31:629–634.(B)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Yvonne E. Satterwhite, MD, CSCS. Evaluation and Management of Recurrent Anterior Shoulder Instability. Journal of Athletic Training. 2000, 35(3):273-277.(C)
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