Assessment of the unstable shoulder - abbas rashid

1. Assessment of the unstable
shoulder
Abbas Rashid FRCS (Tr&Orth)
Wrightington Upper Limb Unit

2. Classification
Structural
• traumatic
- soft tissue (e.g. Capsulolabral injury)
- bony (e.g. Glenoid bone loss or Hill Sachs defect)
• Atraumatic
- soft tissue ( e.g. Capsulolabral deficiency)
- bony (e.g. Glenoid dysplasia)
Non-structural
• Unbalanced muscle
recruitment

3. Instability Biomechanics
Static Stabilisers
• Vacuum
- negative intracapsular pressure
- suction effect
- adhesion cohesion
• Labrum
- 9mm thick
- 50% increase in glenoid depth
- chock block strongest AI (Bankart) and PS (SLAP)
• Capsule
- IGHL
• Bone geometry
- glenoid 7o retro vs. scapula 30o ante
- effective glenoid arc (balance stability angle)
Dynamic Stabilisers
• Proprioception
- mechanoreceptors in AI capsule
- activated when capsule contact HH
- feedback to muscles
• Muscles
- force couples
- subscap: ant stability when arm in
neutral
- ISS & Tm: reduce strain on ant IGHL in
ABER
- scapular muscles: stable base for
shoulder movement

4. Assessment of Bony Anatomy

5. Bony Anatomy: Humeral Head

6. Bony Anatomy: Glenoid

7. Biomechanics
Static Stabilisers
• Vacuum
- negative intracapsular pressure
- suction effect
- adhesion cohesion
• Labrum
- 9mm thick
- 50% increase in glenoid depth
- chock block strongest AI (Bankart) and PS (SLAP)
• Capsule
- IGHL
• Bone geometry
- glenoid 7o retro vs. scapula 30o ante
- effective glenoid arc (balance stability angle)
Dynamic Stabilisers
• Proprioception
- mechanoreceptors in AI capsule
- activated when capsule contact HH
- feedback to muscles
• Muscles
- force couples
- subscap: ant stability when arm in
neutral
- ISS & Tm: reduce strain on ant IGHL in
ABER
- scapular muscles: stable base for
shoulder movement

8. Assessment of Hypermobility
Beighton Score
>6/9 = hypermobility but NOT
BJHS
joint finding
little finger DF beyond 90o
thumb PF to forearm
elbow HE beyond 10o
knee HE beyond 10o
FF trunk Palms on floor

9. Abnormal muscle patterning
• Abnormal activation or suppression
• De-stabilisation of force couples
• Clinical exam wrong in 50% of cases
• EMG quantifies muscle activity
• Jaggi et al. Muscle activation patterns in patients with recurrent
shoulder instability. Int J Shoulder Surg. 2012. Vol 6.4:101-7
Anterior posterior MDI
overactivity PM (60%)
LD (81%)
AD (22%)
LD (80%)
PM (37%)
AD (18%)
PM
LD
inactivity IS (2%) IS (25%) PM
LD

10. Assessment of Muscle Patterning
Pec Major
• stand or supine
• 90 deg FF and IR
• Palpate sup/med border
• Test resisted AD
Lat Dorsi
• Standing
• Arm AB 90 deg elbow flexed
• Palpate posterior pectoral fold
• Test resisted AD

11. Assessment of Muscle Patterning
Anterior Deltoid
• Arm FF 90 deg
• Palpate between lat clavicle &
coracoid
• Patient resists downward force
on above elbow
Infraspinatus
• Elbow flexed 90 deg
• Arm AD, neutral rotation
• Palpate IS fossa
• Push against patients wrist

12. Instability Biomechanics
Static Stabilisers
• Vacuum
- negative intracapsular pressure
- suction effect
- adhesion cohesion
• Labrum
- 9mm thick
- 50% increase in glenoid depth
- chock block strongest AI (Bankart) and PS (SLAP)
• Capsule
- IGHL
• Bone geometry
- glenoid 7o retro vs. scapula 30o ante
- effective glenoid arc (balance stability angle)
Dynamic Stabilisers
• Proprioception
- mechanoreceptors in AI capsule
- activated when capsule contact HH
- feedback to muscles
• Muscles
- force couples
- subscap: ant stability when arm in
neutral
- ISS & Tm: reduce strain on ant IGHL in
ABER
- scapular muscles: stable base for
shoulder movement

13. Soft Tissue Anatomy

14. Which tests?
• Capsulolabal restraints
• Eric J Hegedus. Which physical examination tests provide clinicians with the
most value when examining the shoulder? Update of a systematic review with
meta-analysis of individual tests. Br J Sports Med.2012;46:964-978
• Systematic review WITH meta-analysis
• Nov 2006 – Feb 2012
• Exclusions:
- non-English articles
- cadaveric studies
- EUA studies
- use of equipment to readily available
• 32 studies

15. Anterior Instability
Test Sensitivity
(%)
Specificity
(%)
Paper
Anterior load and shift 50 100 Tzannes & Morrell. Sports Med 2002
Anterior drawer test n/a n/a Gerber & Ganz. J Bone Joint Surg Br 1984
Anterior apprehension 52 99 Lo et al. Am J Sports Med 2004
Jobe relocation 79 97 Fowler et al. Sports med Arthrosc Rahabil Ther Technol
2010
Surprise test 82 86 Hegedus et al Br J Sport Med 2012
Anterior slide 43 82 Walsworth et al. Am J Sports Med 2008
Dynamic anterior jerk test 31 98 Lerat et al. Rev Chir Orthop Repatrtrice Appar Mot
1994
Crank 61 55 Walsworth et al. Am J Sports Med 2008
Modified Dynamic labral
shear
72 98 Kibler et al. Am J Sports Med 2009
Bony apprehension test 100 86 Bushnell et al. Arthroscopy 2008
Kinetic medial rotation
test
n/a n/a Comerford & Mottram. Manual Therapy 2001
Leffert n/a n/a
Rowe n/a n/a
Thrower n/a n/a
Clunk 1 & 2 n/a n/a

16. Anterior Load & Shift
• Sillman & Hawkins 1993
• sitting
• arm in 20 deg AB & 20 deg FF
• concentrically load HH
• push anteriorly
• Assess traslation
• If +tive, LR >100

17. Anterior Apprehension
• Rowe & Zarins 1981
• standing or supine
• arm in 90 deg AB & 90 deg ER
• ER force until apprehension/pain
• ?pain alone NOT predictive
• Apprehension alone ! specificity
• PPV 98% and NPV 73%

18.
Jobe Relocation
• Jobe 1989
• Anterior apprehension
• Posterior directed force on HH
• Relief of apprehension
• Relief of apprehension alone !
specificity
• PPD 100%

19. Surprise Test
• Lo 2004
• Apprehension & Jobe relocation
• No further ER
• Release pressure
• Apprehension or Pain =
instability
• PPV 98%
• If all 3 tests +tive, then
specificity and PPV = 100%

20. Surprise Test
• Lo 2004
• Apprehension & Jobe relocation
• No further ER
• Release pressure
• Apprehension or Pain =
instability
• PPV 98%
• If all 3 tests +tive, then
specificity and PPV = 100%

21. Dynamic Labral Shear Test
• O’Driscoll 2012
• Standing
• Arm AB in scapular plane to 120
deg
• Shear load applied by max ER
• Arm lowered from 120 to 60deg
• Pain, click or catch between 120
and 90 deg
• If +tive, LR=32

22. Bony Apprehension Test
• Bushnell 2008
• Similar to ant apprehension
• Arm at 45deg Ab & 45 ER
• Apprehension +/- pain = bony
instability
• PPV = 73%
• If +tive then LR=71

23. Posterior Instability
Test Sensitivity
(%)
Specificity
(%)
Paper
Posterior apprehension 19 99 Jia et al. J bone Joint Surg Am 2009
Posterior load and shift 14 100 Tzannes & Morrell. Sports Med 2002
Posterior drawer n/a n/a Gerber & Ganz. J Bone Joint Surg Br 1984
Jerk test 73 98 Kim et al. Am J Sports Med 2005
Fukuda test n/a n/a Fukuda & Neer. Orthopaedics 1988
Kim Test 80 94 Kim et al. Am J Sports Med 2005
Posterior subluxation test n/a n/a Clarnette & Miniaci. Med Sco Sports Excec 1098

24. Posterior Apprehension
• Kessel 1982
• FF & IR to 90 deg, posterior force
• Apprehension = instability
• Modified by O’Driscoll & Evans 1991
• Inject SAS & repeat test (RTC)
• pain = posterior instability

25. Posterior Load & Shift
• Sillman & Hawkins 1993
• Sitting
• arm in 20 deg AB & 20 deg FF
• concentrically load HH
• push posteriorly
• If +tive then LR>100
• If –tive then LR<1

26. Jerk Test
• Kim 2004
• AB to 90 deg and full IR
• Apply axial load through elbow
• Other hand stabilises scapula
• move arm horizontally across
body
• Feel for sudden jerk

27. Kim Test
• Kim 2005
• Seated
• Arm in 90 deg AB, 45 deg FF,
• posterior force through elbow
• Pain = posterior instability

28. Inferior laxity
Test Sensitivity
(%)
Specificity
(%)
Paper
Gagey’s hyper abduction
test
n/a n/a Gagey & Gagey. J Bone Joint Surg Br 2001
Sulcus sign at 0 degrees n/a n/a Neer. J Bone Joint Surg Am 1980
Inferior apprehension test n/a n/a Feagin. Personal communication 2004

29. Gagey’s Test
• Gagey 2001
• Measure passive AB
• scapula stabilised
• >105o = IGHL laxity

30. Sulcus Sign
• Neer 1980
• Seated
• Pull on AD arm (neutral)
• Assess acromio-humeral distance
• >2cm = capacious capsule
• Repeat with arm in ER
• If still >2cm, then RI deficiency
(MGHL & CHL) 1cm 1+
2cm 2+
3cm 3+

31. Inferior Apprehension Test
• Feagin 2004
• Standing
• Support arm on examiners
shoulder
• Downward pressure on upper
arm
• Apprehension/pain = IGHL laxity

32. References
1. Lewis A, Kitamura T & Bayley I. The classification of shoulder instability: new light through old windows. Current Orthopaedics. 2004. Vol 18 (2):
97-108.
2. Jaggi A, Noorani A, Malone A, Cowan J, Lambert S, Bayley I. Muscle activation patterns in patients with recurrent shoulder instability. Int J
Shoulder Surg. 2012 Oct;6(4):101-7.
3. Hegedus E. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review
with meta-analysis of individual tests. Br J Sports Med.2012;46:964-978
4. Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Med. 2002;32(7):447-57.
5. Gerber C, Ganz R. Clinical assessment of instability of the shoulder. With special reference to anterior and posterior drawer tests. J Bone Joint Surg
Br. 1984 Aug;66(4):551-6.
6. Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder
instability. Am J Sports Med. 2004 Mar;32(2):301-7.
7. Fowler EM, Horsley IG, Rolf CG. Clinical and arthroscopic findings in recreationally active patients. Sports Med Arthrosc Rehabil Ther Technol. 2010
Jan 15;2:2. doi: 10.1186/1758-2555-2-2.
8. Walsworth MK, Doukas WC, Murphy KP, Mielcarek BJ, Michener LA.Reliability and diagnostic accuracy of history and physical examination for
diagnosing glenoid labral tears. Am J Sports Med. 2008 Jan;36(1):162-8. Epub 2007 Oct 11.
9. Lerat JL, Chotel F, Besse JL, Moyen B, Brunet Guedj E. Dynamic anterior jerk of the shoulder. A new clinical test for shoulder instability. Preliminary
study. Rev Chir Orthop Reparatrice Appar Mot. 1994;80(6):461-7.
10. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and
superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009 Sep;37(9):1840-7.
11. Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008
Sep;24(9):974-82.
12. Comerford MJ, Mottram SL. Movement and stability dysfunction--contemporary developments. Man Ther. 2001 Feb;6(1):15-26.
13. Jia X, Petersen SA, Khosravi AH, Almareddi V, Pannirselvam V, McFarland EG. Examination of the shoulder: the past, the present, and the future. J
Bone Joint Surg Am. 2009 Nov;91 Suppl 6:10-8. doi: 10.2106/JBJS.I.00534.
14. Kim SH, Park JS, Jeong WK, Shin SK. The Kim test: a novel test for posteroinferior labral lesion of the shoulder--a comparison to the jerk test. Am J
Sports Med. 2005 Aug;33(8):1188-92.
15. Fukuda H, Neer CS 2nd. Archer's shoulder. Recurrent posterior subluxation and dislocation of the shoulder in two archers. Orthopedics. 1988 Jan;
11(1):171-4.
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17. Gagey OJ, Gagey N. The hyper abduction test. J Bone Joint Surg Br. 2001 Jan;83(1):69-74.
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Joint Surg Am. 1980 Sep;62(6):897-908.
19. Charles A. Rockwood. Rockwood and Green's Fractures in Adults (v. 1 & 2). 4ed. 1996