Shoulder

1. Dr. Hein Htet Zaw
01.02.21
Glenohumeral instability,
Adhesive Capsulitis and
Superior Labral Anteroposterior
Leisions
1

2. The glenoid labrum
The glenohumeral ligaments
The coracohumeral ligament
The overhanging coracoacromial arch
The surrounding muscles
Glenohumeral instability
INSTABILITY
Failure of any of these mechanisms
The humeral
head is held in
the shallow
glenoid socket
2

3. • Joint laxity - Degree of translation in the
glenohumeral joint which falls within a
physiological range and which is
asymptomatic
• Joint instability – Joint instability is an
abnormal symptomatic motion for that
shoulder which results in pain, subluxation or
dislocation of the joint.
3

4. • Dislocation - complete separation of the
glenohumeral surfaces
• Subluxation - symptomatic separation of the
surfaces without dislocation.
4

5. • Pathogenetic classification
Stanmore Instability Classification system (Royal
National Orthopaedic Hospital in London)
- Structural changes due to major trauma such as
acute dislocation or recurrent micro-trauma
- Unbalanced muscle recruitment (as opposed to
muscle weakness) resulting in the humeral head
being displaced upon the glenoid.
5

6. Clinical and therapeutic point of view
• Type I – traumatic structural instability
• Type II – atraumatic (or minimally traumatic)
structural instability
• Type III – atraumatic non-structural instability
(muscular dyskinesia).
6

7. • Three polar types of disorder
7

8. • Pathological changes in each of the polar types
8

9. TRAUMATIC ANTERIOR INSTABILITY – POLAR TYPE I
Pathology
• Commonest - 95%
• An acute injury - the arm is forced into abduction,
external rotation and extension.
9

10. Bankart lesion
Labrum and capsule are often
detached from the anterior
rim of the glenoid.
- An avulsion of the
anteroinferior glenoid labrum
at its attachment
to IGHL complex;
- Lesion is felt to result
from anterior shoulder
dislocation and is felt to be
primary lesion in recurrent
anterior instability;
10

11. Hill–Sachs lesion
• An indentation on the
posterolateral aspect of the
humeral head, a compression
fracture due to the humeral
head being forced against the
anterior glenoid rim each time
it dislocates.
11

12. • Recurrent subluxation may alternate with
recurrent dislocation
• In patients over the age of 50 years,
dislocation is often associated with tears of
the rotator cuff.
12

13. Clinical features
• History of the shoulder ‘coming out’, perhaps
during a sporting event.
• Mechanism : an applied force with the
shoulder in abduction, external rotation and
extension.
• Pain is often severe
13

14. • The patient supports the arm
with the opposite hand and is
loathe to permit any kind of
examination.
• The lateral outline of the
shoulder may be flattened
• If the patient is not too muscular,
a bulge may be felt just below
the clavicle
• The arm must always be
examined for nerve and vessel
injury before reduction is
attempted.
14

15. • The diagnosis may have been
verified by X-ray
• The injury treated by closed
reduction and ‘immobilization’
in a bandage or sling for
several weeks.
Stimson’s technique
Hippocratic method 15

16. Recurrent dislocation
• Age under 20 yrs – between 88% and 95%
• Age under 30 yrs – 1/3
• Older patients – 20%
• Over all – 48%
16

17. RECURRENT SUBLUXATION
• Symptoms and signs - less obvious.
• The patient may describe a ‘catching’ sensation,
followed by ‘numbness’ or ‘weakness’ – the so-called
‘dead arm syndrome’
• whenever the shoulder is used with the arm in the
overhead position (for example when throwing a ball,
serving at tennis or swimming).
• Pain with the arm in abduction may suggest a rotator
cuff syndrome; it is as well to remember that recurrent
subluxation may actually cause supraspinatus
tendinitis.
17

18. The apprehension test
• Patient seated or lying
• Examiner cautiously lifts the arm into
abduction, external rotation and then
extension
• Patient senses that the humeral head is
about to slip out anteriorly and his or
her body tautens in apprehension
• repeated with the examiner applying
pressure to the front of the shoulder
• Patient feels more secure and the
apprehension sign is negative.
18

19. The apprehension test
• Posterior dislocation
can be tested for in the
same way
• Drawing the arm
forward and across the
patient’s body
(adduction and internal
rotation).
19

20. The fulcrum test
• patient lying supine
• arm abducted to 90 degrees
• Examiner places one hand
behind the patient’s shoulder to
act as a fulcrum over which the
humeral head is levered forward
by extending and laterally
rotating the arm; the patient
immediately becomes
apprehensive.
20

21. The drawer test may be positive
in instability
• With the patient supine
• Scapula is stabilized with one
hand
• The upper arm is grasped
firmly with the other so as to
manipulate the head of the
humerus forwards and
backwards.
21

22. Investigations
• Most cases can be diagnosed from the history and
examination alone.
X-ray
• The Hill–Sachs lesion is best shown by an
anteroposterior X-ray with the shoulder internally
rotated, or in the axillary view.
• Subluxation is seen in the axillary view.
MRI or MR arthrography
• Useful for demonstrating bone lesions and labral tears.
22

23. Arthroscopy
• Sometimes needed to define the labral tear.
Examination under anaesthesia
• Can help to determine the direction of instability.
• This forms an essential part of assessing
instability.
• Both shoulders need to be examined.
• Sensitivities and specificities of 100% and 93%,
respectively.
23

24. Treatment
• OPERATIVE TREATMENT
Indications
• Frequent dislocation, especially if this is painful,
• Recurrent subluxation or a fear of dislocation
sufficient to prevent participation in everyday
activities, including sport.
• young adults engaged in highly demanding
physical activities following first acute traumatic
dislocation.
24

25. Anatomical repairs
• These are operations
that repair the torn
glenoid labrum and
capsule, such as the
Bankart procedure.
Bankart procedure
Anchor
25

26. • Deltopectoral approach
• Arthroscopic techniques
• Recurrence rate (about 20%), usually following
another injury for both tech:
• If there is bone loss on either the glenoid aspect
or the humeral head, the outcome following
arthroscopic surgery is considerably worse, and in
selected cases a non-anatomical procedure such
as a Latarjet (non-anatomical) may be more
appropriate.
26

27. Non-anatomical repairs
• These procedures are designed to counteract the
pathological tendency to joint displacement:
Putti–Platt operation
• Shorten the anterior capsule and subscapularis by
an overlapping repair
• Prevent redislocation
• Significant loss of external rotation.
• They are now not commonly used.
27

28. vBristow–Laterjet operation
• Reinforce the anteroinferior capsule
by redirecting other muscles across
the front of the joint
• The coracoid process with its
attached muscles is transposed to
the front of the neck of the scapula
(through subscapularis split)
• Produce less restriction of external
rotation.
28

29. RECONSTRUCTION OF ANTERIOR GLENOID
USING ILIAC CREST BONE AUTOGRAFT
• Glenoid bone loss approaching 40% of the
anterior glenoid or posterior bone loss of 25%
with recurrent posterior dislocation
• tricortical iliac crest autograft 2 cm wide and
3 cm long
29

30. MULTIDIRECTIONAL INSTABILITY OF THE
SHOULDER (CAPSULAR SHIFT)
- The primary abnormality in
multidirectional instability is a
loose, redundant inferior pouch.
- Failed adequate trial of
conservative treatment
emphasizing muscular and rotator
cuff rehabilitative exercises
- Detach the capsule from the neck
of the humerus and shift it to the
opposite side of the calcar (inferior
portion of the neck of the
humerus) 30

31. • Operations to correct a reduced retroversion
angle of the humeral head by osteotomy.
31

32. ATRAUMATIC STRUCTURAL INSTABILITY
• Recognized problem in athletes, particularly
swimmers and throwers
• Due either to
- Repetitive micro-trauma which has placed
undue stress upon the soft tissues or
- To rapid, forceful movements that contribute
to the development of overall laxity of the joint;
32

33. Treatment
vREHABILITATIVE MEASURES
• Focused on strengthening the muscles normally
involved in stabilizing the shoulder and restoring
muscular coordination and control.
• Patients may need special instruction in the
kinematics of shoulder movements and control of
stability, as well as advice about modification of
physical activities.
33

34. vSURGICAL TREATMENT
• If rehabilitative measures fail
• Capsular plication (which can be performed
arthroscopically)
• Capsular shift (by open operation).
34

35. • Altered coordination with
protagonistic and antagonistic
muscles
• Muscle patterning instability usually
occurs in younger patients who can
voluntarily slip the shoulder out of
joint as a trick movement (habitual
subluxation )
• The shoulder may then go on to
dislocate repeatedly (uncontrolled
or involuntary dislocation).
ATRAUMATIC NON-STRUCTURAL INSTABILITY
(ALTERED MUSCLE PATTERNING)
35

36. Treatment
• The aim is to regain normal neuromuscular control
and patterning.
• This can be difficult, time- consuming
• Require the participation of a full team comprising a
- Specialist shoulder physiotherapist
- Shoulder surgeon
- Sometimes an occupational therapist
- Psychologist.
• Treatment follows much the same lines as for
atraumatic structural instability but surgery should
be avoided if possible. 36

37. INFERIOR SUBLUXATION
• Some weeks after an injury to the shoulder
girdle
• Patient feel instability in the shoulder
• ‘slips out of joint’, particularly when carrying
something heavy with that arm
37

38. X-ray of a young woman who
developed ‘clicking’ and
instability in the right shoulder
after recovering from an injury
to the neck and right upper
limb. Plain X-ray examination
showed no abnormality
when the anteroposterior view
was repeated with the patient
carrying 10 kg weights in both
hands, subluxation due to laxity
of the anteroinferior capsule
was demonstrated to the right
side 38

39. • The condition is due to (temporary) weakness of
the shoulder muscles, usually because of
prolonged splintage of the arm and lack of
exercise.
• The condition usually corrects itself after a period
of normal muscular activity
• Physiotherapy will help to speed up the process.
• In the occasional case, tissue laxity is more
persistent and capsular reefing may be advisable.
39

40. POSTERIOR INSTABILITY
v Pathology
• This condition is usually due to a violent jerk in an unusual
position or following an epileptic fit or a severe electric shock.
• Dislocation may be associated with fractures of the proximal
humerus,
• the posterior capsule is stripped from the bone or stretched,
• there may be an indentation on the anterior aspect of the
humeral head.
• Recurrent instability is almost always a posterior subluxation
with the humeral head riding back on the posterior lip of the
glenoid.
40

41. Clinical features
• Rare, and when it does occur it is often missed.
• There may be a history of fairly violent injury or an
electric shock.
• On examination the arm is held in internal rotation and
attempts at external rotation are resisted.
• The anteroposterior X-ray may show a typical ‘light
bulb’ appearance of the proximal humerus (the
humeral head looks symmetrically bulbous because the
shoulder is internally rotated ).
• If the arm can be abducted, an axillary view will show
the dislocation quite clearly.
41

42. (a) In the anteroposterior view the humeral
head looks globular – the so-called ‘light bulb’
appearance.
(b) In the lateral view one can see the
humeral head is lying behind the
glenoid fossa, with an impaction
fracture on the anterior surface of the
head.
42

43. Recurrent posterior instability
• This usually takes the form of subluxation
when the arm is used in flexion and internal
rotation.
• On examination, the posterior drawer test and
posterior apprehension test confirm the
diagnosis.
43

44. Treatment
• Due to muscle patterning and proprioceptive
problems should be treated with
physiotherapy.
• It is essential that this is undertaken by a
therapist trained and experienced in dealing
with shoulder instability, as the rehabilitation
can be long and arduous.
44

45. Surgery
• If the primary abnormality is found to be structural (for
example, a Bankart lesion, bony lesion or capsular injury).
• No single operation applies to all patients with posterior
instability.
• Soft-tissue reconstructions are the mainstay of treatment.
• Rarely there is a bone problem, such as excessive glenoid
retroversion (shown on CT scan), in which case glenoid
osteotomy should be considered.
• In extreme cases a bony block to posterior translation of
the humeral head is employed but failure rates are
reported to be high.
45

46. ADHESIVE CAPSULITIS
(FROZEN SHOULDER)
• Characterized by progressive pain and stiffness of
the shoulder which usually resolves spontaneously
after about 18 months.
• 40% may develop mild to moderate persistent
symptoms.
• The cause remains unknown.
• Histological features are similar to those of
Dupuytren’s disease
• With active fibroblastic myofibroblastic
proliferation in the rotator interval, anterior
capsule and coracohumeral ligament.
46

47. • (a) Natural history
• of frozen shoulder.
• The face tells the
• story. (b,c) This
• patient has hardly
• any abduction but
• manages to lift her
• arm by moving the
• scapula. She cannot
• reach her back with
• her left hand
(a) Natural history of frozen shoulder.
The face tells the story.
(b,c) This patient has hardly any
abduction but manages to lift her
arm by moving the scapula.
She cannot reach her back with
her left hand.
Range
Pain
47

48. • The condition is particularly associated with
- Diabetes
- Dupuytren’s disease
- Hyperlipidaemia
- Hyperthyroidism
- Cardiac disease
- Hemiplegia.
It occasionally appears after recovery from
neurosurgery.
48

49. Clinical features
• Aged 40–60
• May give a history of trauma, often trivial, followed by
aching in the arm and shoulder.
• Pain gradually increases in severity and often prevents
sleeping on the affected side.
• After several months it begins to subside, but as it does
so stiffness becomes an increasing problem, continuing
for another 6–12 months after pain has disappeared.
• Gradually movement is regained, but it may not return
to normal and some pain may persist.
49

50. • Apart from slight wasting, the shoulder looks
quite normal; tenderness is seldom marked.
• The cardinal feature is a stubborn lack of
active and passive movement in all directions
• X-rays are normal unless they show reduced
bone density from disuse.
• Their main value is to exclude other causes of
a painful, stiff shoulder.
50

51. Diagnosis
• Not every stiff or painful shoulder is a frozen shoulder
• Indeed the criteria for diagnosing ‘frozen shoulder’ are
controversial.
• Stiffness occurs in a variety of conditions –
- Arthritic,
- Rheumatic,
- Post-traumatic and postoperative.
• The diagnosis of frozen shoulder is clinical, resting on two
characteristic features:
- Painful restriction of movement in the presence of normal X-rays
- A natural progression through three successive phases.
51

52. Shoulder pain – the scratch test ‘Shoulder’ pain may be due to disorders
of the shoulder joint itself (for example, glenohumeral arthritis), the
acromioclavicular joint (injury or arthritis) or structures around the joint
(for example, the rotator cuff syndromes). But it could also be referred
from more distant lesions (for example, brachial neuralgia, cervical
spondylosis or cardiac ischaemia).
If the patient can scratch the opposite scapula in these three ways
(a,b,c), the shoulder joint and its tendons are unlikely to be at fault.
a b c
52

53. DIFFERENTIAL DIAGNOSIS
• When the patient is first seen, the following
conditions should be excluded.
• Infection
In patients with diabetes, it is particularly
important to exclude infection.
During the first day or two, signs of inflammation
may be absent.
53

54. • Post-traumatic stiffness
- After any severe shoulder injury, stiffness may persist
for some months.
- It is maximal at the start and gradually lessens, unlike
the pattern of a frozen shoulder.
• Diffuse stiffness
- If the arm is nursed over-cautiously (for example,
following a forearm fracture), the shoulder may stiffen.
- Again, the characteristic pattern of a frozen shoulder
is absent.
54

55. • Reflex sympathetic dystrophy
- Shoulder pain and stiffness may follow myocardial
infarction or a stroke.
- The features are similar to those of a frozen shoulder
and it has been suggested that the latter is a form of
reflex sympathetic dystrophy.
- In severe cases the whole upper limb is involved, with
trophic and vasomotor changes in the hand (the
‘shoulder–hand syndrome’).
55

56. Treatment
vCONSERVATIVE TREATMENT
• Conservative treatment aims to relieve pain and
prevent further stiffening while recovery is awaited.
• It is important not only to administer analgesics and
anti-inflammatory drugs but also to reassure the
patient that recovery is likely.
• Exercises are encouraged, the most valuable being
‘pendulum’ exercises.
• The role of physiotherapy is unproven and the benefits
of steroid injection are debatable.
56

57. Manipulation under general anaesthesia
• May improve the range of movement.
• The shoulder is moved gently but firmly into external
rotation, then abduction and flexion.
• At the end, the joint is injected with steroid and local
anaesthetic.
• There are many studies showing rapid improvement
and good pain relief.
• Risk of tearing of the rotator cuff, labral injuries and
fractures have been described.
57

58. • An alternative method of treatment is to distend the
joint by injecting a large volume (50–200 mL) of sterile
saline and steroid under pressure.
• Arthroscopy has shown that both manipulation and
distension achieve their effect by rupturing the
capsule.
• The results of conservative treatment are subjectively
good, with most patients eventually regaining painless
and satisfactory function; however, examination is
likely to show some residual restriction of movement
(especially external rotation) in over 50% of cases.
58

59. SURGICAL TREATMENT
• The main indication for surgery is prolonged and
disabling restriction of movement which fails to
respond to conservative treatment.
• Arthroscopic capsular release is increasingly employed.
• New techniques enable the surgeon to release intra-
articular, subacromial and subdeltoid adhesions
without dividing the subscapularis.
• Active range of motion can be started immediately.
• Good results of pain relief and increased range of
motion can be expected in the majority over a short
time frame.
59

60. SLAP LESIONS
• Compressive loading of the shoulder in the
Flexed abducted position (for example, in a fall
on the outstretched hand)
Can damage the superior labrum anteriorly and
posteriorly (SLAP).
• The injury of the superior labrum begins
posteriorly and extends anteriorly, stopping
before or at the mid-glenoid notch and including
the ‘anchor’ of the biceps tendon to the labrum.
60

61. • Four main types are described:
1. Non-traumatic superior labral degeneration,
usually in older people and often asymptomatic
2. Avulsion of the superior part of the labrum – the
commonest type
3. A ‘bucket handle’ tear of the superior labrum
4. As for type 3 with an extension into the tendon
of LHB.
61

62. (a) Diagram of the normal anatomy, looking
into the glenoid fossa. Note that the biceps
tendon takes its origin from the superior part
of the labrum.
(b) The labrum may tear or become detached
from the glenoid. This illustration shows a
partial tear.
62

63. Clinical features
• There is usually a history of a fall on the arm.
• As the initial acute symptoms settle, the
patient continues to experience a painful
‘click’ on lifting the arm above shoulder
height, together with loss of power when
using the arm in that position.
• He or she may also complain of an inability to
throw.
63

64. O’Brien’s test
• The patient is instructed to flex the arm to
90 degrees with the elbow fully extended
and then to adduct the arm 10–15 degrees
medial to the sagittal plane.
• The arm is then maximally internally rotated
and the patient resists the examiner’s
downward force.
• The procedure is repeated in supination.
• Pain elicited by the first manoeuvre which is
reduced or eliminated by the second
signifies a positive test.
64

65. Imaging
• MRI arthrography is the modality of choice
though the diagnosis is best confirmed by
arthroscopic examination and at the same
time the lesion is treated by debridement or
repair
• Different lesions require different surgical
procedures.
65

66. MRA of SLAP in neutral and ABER position
66

67. lesions Arthroscopic appearance of a type 3
SLAP lesion. 67

68. Treatment
• Very few patients with SLAP lesion injuries return to
full capability without surgical intervention.
• Arthroscopic repair of an isolated superior labral lesion
is successful in the large majority (91%) of patients.
• However, the results in patients who participate in
overhead sports are not as satisfactory as those in
patients who are not involved in overhead sports.
• Simple lesions are simply debrided. In more significant
detachments the labrum is either repaired or excised
with a tenotomy or tenodesis of the biceps.
68

69. Thank You.
69