Anterior shoulder instability is a condition where the humeral head subluxate is dislocates from the glenoid.
The shoulder allows great motion but compromises stability due to their mobility. Anterior shoulder instability involves excessive forward movement of the humeral head.
The stability of the shoulder depends on static and dynamic stabilizers respectively.
The glenohumeral joint enables coordinated movement in multiple planes through a ball-and-socket structure.
The shallow glenoid fossa and larger humeral head enable extensive physiological motion.
Shoulder movements depend on four distinct joint articulations including:
Acromioclavicular
Glenohumeral
Sternoclavicular
Scapulothoracic
Shoulder instability causes excessive humeral head translation on the glenoid that causes pain, weakness, and dysfunction.
Accurate diagnosis of shoulder instability requires distinguishing joint laxity from actual instability with associated symptoms and abnormal laxity.
Epidemiology
1% to 2% of people experience glenohumeral dislocation lifetime. The overall incidence rate was 23.9 per 100,000 person-years, with males being 2.6 times higher.
A 1980s study found an incidence of 8.2 initial traumatic shoulder dislocations per 100,000 person-years, with higher rates in males than females.
An 1980s Danish study found shoulder dislocation incidence at 17 per 100,000 person-years.
Young athletes receive notable focus in literature due to various risk factors for dislocation events.
Around 55% of athletes in this subset experienced shoulder dislocations, while football shows rates up to 0.51 per 1,000 athlete’s exposures.
Anatomy
Pathophysiology
Unidirectional instability can arise from acute trauma or low-energy events, with or without hyperlaxity present.
The Hill-Sachs lesion arises from anteroinferior dislocation of the humeral head, causing compression fracture upon collision with the anterior glenoid rim.
Three-dimensional CT scans effectively distinguish true bony Bankart lesions from erosive changes indicative of attritional bone loss in glenoid defects.
Chronic glenoid erosive changes may arise post high-energy dislocation with initial injury.
Afferent endings injury during instability causes delayed proprioceptive signalling and impaired signal transmission.
Etiology
The causes of anterior shoulder instability are:
Traumatic Causes
Atraumatic Causes
Congenital or Developmental Factors
Presence or absence of accompanying soft tissue hyperlaxity
This results from high-energy injuries such as falls on an outstretched arm or direct impact.
Due to contact sports e.g., football, rugby
Genetics
Prognostic Factors
Patients receive education on recurrence risk from providers post-management.
The Instability Severity Index Score (ISIS) was introduced in 2007 to guide shoulder instability surgical management.
Athletes in contact or overhead sports face higher recurrence risks post-treatment.
Patients must understand that fewer risk factors typically lead to improved 5-year overall success rates.
Clinical History
Clinical History:
Collect details including the chief complaint, history of present illness, sports and activity history to understand clinical history of patients.
Physical Examination
Range of Motion Testing
Strength Testing
Neurovascular Examination
Anterior Instability assessment
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Acute symptoms are:
Sudden, severe pain at the shoulder, visible deformity, inability to move the shoulder due to pain and instability.
Chronic symptoms are:
No history of trauma but progressive shoulder instability, pain and discomfort with overhead movements, feeling of looseness
Differential Diagnoses
Acromioclavicular Joint Injury
Multidirectional Instability
Rotator Cuff Tear
Axillary Nerve Injury
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment Paradigm:
Manual reduction is essential after confirming a dislocation.
Acute management requires sling immobilization and thorough assessment before returning to play.
After initial immobilization and cryotherapy for pain, formal PT protocols differ based on provider preferences in acute instability cases.
After immobilization, patients will gradually stop using slings, then focus on achieving full ROM and strengthening exercises for glenohumeral and periscapular stabilizers.
Surgical technique aims to repair and relocate detached capsulolabral complex to its anatomical position in soft tissue.
During the arthroscopic procedure, shoulder abduction and external rotation are utilized to assess for lesions causing postoperative instability recurrence.
Burkhart and De Beer highlighted using arthroscopy as a dynamic diagnostic tool to identify osseous lesions that might jeopardize glenohumeral stability post-capsulolabral repair.
In the immediate post injury phase, the goal is to Protect the healing structures, reduce pain/inflammation and prevent muscle stiffness.
Pharmacologic therapy is effective in the treatment phase as it includes the use of NSAIDs, opioid analgesics, and muscle relaxants.
In supportive care and management phase, patients should receive required attention such as lifestyle modification and surgical interventional therapies.
The regular follow-up visits with the surgeon are scheduled to check the improvement of patients along with treatment response.
Anterior shoulder instability is a condition where the humeral head subluxate is dislocates from the glenoid.
The shoulder allows great motion but compromises stability due to their mobility. Anterior shoulder instability involves excessive forward movement of the humeral head.
The stability of the shoulder depends on static and dynamic stabilizers respectively.
The glenohumeral joint enables coordinated movement in multiple planes through a ball-and-socket structure.
The shallow glenoid fossa and larger humeral head enable extensive physiological motion.
Shoulder movements depend on four distinct joint articulations including:
Acromioclavicular
Glenohumeral
Sternoclavicular
Scapulothoracic
Shoulder instability causes excessive humeral head translation on the glenoid that causes pain, weakness, and dysfunction.
Accurate diagnosis of shoulder instability requires distinguishing joint laxity from actual instability with associated symptoms and abnormal laxity.
1% to 2% of people experience glenohumeral dislocation lifetime. The overall incidence rate was 23.9 per 100,000 person-years, with males being 2.6 times higher.
A 1980s study found an incidence of 8.2 initial traumatic shoulder dislocations per 100,000 person-years, with higher rates in males than females.
An 1980s Danish study found shoulder dislocation incidence at 17 per 100,000 person-years.
Young athletes receive notable focus in literature due to various risk factors for dislocation events.
Around 55% of athletes in this subset experienced shoulder dislocations, while football shows rates up to 0.51 per 1,000 athlete’s exposures.
Unidirectional instability can arise from acute trauma or low-energy events, with or without hyperlaxity present.
The Hill-Sachs lesion arises from anteroinferior dislocation of the humeral head, causing compression fracture upon collision with the anterior glenoid rim.
Three-dimensional CT scans effectively distinguish true bony Bankart lesions from erosive changes indicative of attritional bone loss in glenoid defects.
Chronic glenoid erosive changes may arise post high-energy dislocation with initial injury.
Afferent endings injury during instability causes delayed proprioceptive signalling and impaired signal transmission.
The causes of anterior shoulder instability are:
Traumatic Causes
Atraumatic Causes
Congenital or Developmental Factors
Presence or absence of accompanying soft tissue hyperlaxity
This results from high-energy injuries such as falls on an outstretched arm or direct impact.
Due to contact sports e.g., football, rugby
Patients receive education on recurrence risk from providers post-management.
The Instability Severity Index Score (ISIS) was introduced in 2007 to guide shoulder instability surgical management.
Athletes in contact or overhead sports face higher recurrence risks post-treatment.
Patients must understand that fewer risk factors typically lead to improved 5-year overall success rates.
Clinical History:
Collect details including the chief complaint, history of present illness, sports and activity history to understand clinical history of patients.
Range of Motion Testing
Strength Testing
Neurovascular Examination
Anterior Instability assessment
Acute symptoms are:
Sudden, severe pain at the shoulder, visible deformity, inability to move the shoulder due to pain and instability.
Chronic symptoms are:
No history of trauma but progressive shoulder instability, pain and discomfort with overhead movements, feeling of looseness
Acromioclavicular Joint Injury
Multidirectional Instability
Rotator Cuff Tear
Axillary Nerve Injury
Treatment Paradigm:
Manual reduction is essential after confirming a dislocation.
Acute management requires sling immobilization and thorough assessment before returning to play.
After initial immobilization and cryotherapy for pain, formal PT protocols differ based on provider preferences in acute instability cases.
After immobilization, patients will gradually stop using slings, then focus on achieving full ROM and strengthening exercises for glenohumeral and periscapular stabilizers.
Surgical technique aims to repair and relocate detached capsulolabral complex to its anatomical position in soft tissue.
During the arthroscopic procedure, shoulder abduction and external rotation are utilized to assess for lesions causing postoperative instability recurrence.
Burkhart and De Beer highlighted using arthroscopy as a dynamic diagnostic tool to identify osseous lesions that might jeopardize glenohumeral stability post-capsulolabral repair.
Orthopaedic Surgery
Keep frequently used items at waist or chest level to reduce excessive abduction and external rotation.
Patient should avoid sleeping on the affected shoulder to reduce stress on the joint.
Avoid low couches or deep chairs that require excessive arm use to get up.
Athletes in contact sports should use a shoulder stabilizer brace to limit excessive external rotation.
Avoid high-risk movements until strength and stability are restored.
Proper awareness about anterior shoulder instability should be provided and its related causes with management strategies.
Appointments with surgeon and preventing recurrence of disorder is an ongoing life-long effort.
Orthopaedic Surgery
Ibuprofen:
It inhibits synthesis of prostaglandins in body tissues with COX-1 and COX-2 inhibitors.
Orthopaedic Surgery
Tramadol:
It binds to opioid mu receptors that causes inhibition of ascending pain pathways.
Orthopaedic Surgery
Cyclobenzaprine:
It reduces tonic somatic motor activity to influence alpha and gamma motor neurons.
Orthopaedic Surgery
Surgical procedure includes bankart repair, latarjet, remplissage, and capsular shift as per patient condition.
Orthopaedic Surgery
In the immediate post injury phase, the goal is to Protect the healing structures, reduce pain/inflammation and prevent muscle stiffness.
Pharmacologic therapy is effective in the treatment phase as it includes the use of NSAIDs, opioid analgesics, and muscle relaxants.
In supportive care and management phase, patients should receive required attention such as lifestyle modification and surgical interventional therapies.
The regular follow-up visits with the surgeon are scheduled to check the improvement of patients along with treatment response.
Anterior shoulder instability is a condition where the humeral head subluxate is dislocates from the glenoid.
The shoulder allows great motion but compromises stability due to their mobility. Anterior shoulder instability involves excessive forward movement of the humeral head.
The stability of the shoulder depends on static and dynamic stabilizers respectively.
The glenohumeral joint enables coordinated movement in multiple planes through a ball-and-socket structure.
The shallow glenoid fossa and larger humeral head enable extensive physiological motion.
Shoulder movements depend on four distinct joint articulations including:
Acromioclavicular
Glenohumeral
Sternoclavicular
Scapulothoracic
Shoulder instability causes excessive humeral head translation on the glenoid that causes pain, weakness, and dysfunction.
Accurate diagnosis of shoulder instability requires distinguishing joint laxity from actual instability with associated symptoms and abnormal laxity.
1% to 2% of people experience glenohumeral dislocation lifetime. The overall incidence rate was 23.9 per 100,000 person-years, with males being 2.6 times higher.
A 1980s study found an incidence of 8.2 initial traumatic shoulder dislocations per 100,000 person-years, with higher rates in males than females.
An 1980s Danish study found shoulder dislocation incidence at 17 per 100,000 person-years.
Young athletes receive notable focus in literature due to various risk factors for dislocation events.
Around 55% of athletes in this subset experienced shoulder dislocations, while football shows rates up to 0.51 per 1,000 athlete’s exposures.
Unidirectional instability can arise from acute trauma or low-energy events, with or without hyperlaxity present.
The Hill-Sachs lesion arises from anteroinferior dislocation of the humeral head, causing compression fracture upon collision with the anterior glenoid rim.
Three-dimensional CT scans effectively distinguish true bony Bankart lesions from erosive changes indicative of attritional bone loss in glenoid defects.
Chronic glenoid erosive changes may arise post high-energy dislocation with initial injury.
Afferent endings injury during instability causes delayed proprioceptive signalling and impaired signal transmission.
The causes of anterior shoulder instability are:
Traumatic Causes
Atraumatic Causes
Congenital or Developmental Factors
Presence or absence of accompanying soft tissue hyperlaxity
This results from high-energy injuries such as falls on an outstretched arm or direct impact.
Due to contact sports e.g., football, rugby
Patients receive education on recurrence risk from providers post-management.
The Instability Severity Index Score (ISIS) was introduced in 2007 to guide shoulder instability surgical management.
Athletes in contact or overhead sports face higher recurrence risks post-treatment.
Patients must understand that fewer risk factors typically lead to improved 5-year overall success rates.
Clinical History:
Collect details including the chief complaint, history of present illness, sports and activity history to understand clinical history of patients.
Range of Motion Testing
Strength Testing
Neurovascular Examination
Anterior Instability assessment
Acute symptoms are:
Sudden, severe pain at the shoulder, visible deformity, inability to move the shoulder due to pain and instability.
Chronic symptoms are:
No history of trauma but progressive shoulder instability, pain and discomfort with overhead movements, feeling of looseness
Acromioclavicular Joint Injury
Multidirectional Instability
Rotator Cuff Tear
Axillary Nerve Injury
Treatment Paradigm:
Manual reduction is essential after confirming a dislocation.
Acute management requires sling immobilization and thorough assessment before returning to play.
After initial immobilization and cryotherapy for pain, formal PT protocols differ based on provider preferences in acute instability cases.
After immobilization, patients will gradually stop using slings, then focus on achieving full ROM and strengthening exercises for glenohumeral and periscapular stabilizers.
Surgical technique aims to repair and relocate detached capsulolabral complex to its anatomical position in soft tissue.
During the arthroscopic procedure, shoulder abduction and external rotation are utilized to assess for lesions causing postoperative instability recurrence.
Burkhart and De Beer highlighted using arthroscopy as a dynamic diagnostic tool to identify osseous lesions that might jeopardize glenohumeral stability post-capsulolabral repair.
Orthopaedic Surgery
Keep frequently used items at waist or chest level to reduce excessive abduction and external rotation.
Patient should avoid sleeping on the affected shoulder to reduce stress on the joint.
Avoid low couches or deep chairs that require excessive arm use to get up.
Athletes in contact sports should use a shoulder stabilizer brace to limit excessive external rotation.
Avoid high-risk movements until strength and stability are restored.
Proper awareness about anterior shoulder instability should be provided and its related causes with management strategies.
Appointments with surgeon and preventing recurrence of disorder is an ongoing life-long effort.
Orthopaedic Surgery
Ibuprofen:
It inhibits synthesis of prostaglandins in body tissues with COX-1 and COX-2 inhibitors.
Orthopaedic Surgery
Tramadol:
It binds to opioid mu receptors that causes inhibition of ascending pain pathways.
Orthopaedic Surgery
Cyclobenzaprine:
It reduces tonic somatic motor activity to influence alpha and gamma motor neurons.
Orthopaedic Surgery
Surgical procedure includes bankart repair, latarjet, remplissage, and capsular shift as per patient condition.
Orthopaedic Surgery
In the immediate post injury phase, the goal is to Protect the healing structures, reduce pain/inflammation and prevent muscle stiffness.
Pharmacologic therapy is effective in the treatment phase as it includes the use of NSAIDs, opioid analgesics, and muscle relaxants.
In supportive care and management phase, patients should receive required attention such as lifestyle modification and surgical interventional therapies.
The regular follow-up visits with the surgeon are scheduled to check the improvement of patients along with treatment response.
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