Phys Med Rehabil Clin N Am 15 (2004) 575605

Glenohumeral instability and dislocation

Jonathan T. Finno, DOa,b,*, Susan Doucette, PT,MSc, Gregory Hicken, MDb
Department of Health, Physical Education and Recreation, Utah State University, Logan, UT 84341, USA b Alpine Orthopedic Specialists, 2380 North 400 East, Suite A, North Logan, UT 84341, USA c Logan Physical Therapy, 550 East 1400 North, Suite M, Logan, UT 84341, USA
a

Glenohumeral joint instability is a common disorder of the shoulder. The glenohumeral joint is the most mobile joint in the body, and by design, it has gained the extra mobility at the expense of stability. Instability may present in a variety of ways. Pain may be the only symptom experienced by some patients, whereas others may present with a frank dislocation. A thorough understanding of the regional anatomy and biomechanics, the pathophysiology of glenohumeral joint instability, and the performance of an appropriate history and physical examination should lead the examiner to the correct diagnosis. This article reviews the anatomy of the shoulder joint complex; discusses the complex interplay of static and dynamic structures that provide glenohumeral joint stability; presents a classication system for glenohumeral joint instability; discusses the pathophysiology of glenohumeral joint instability; presents a logical approach to the history, physical examination, and radiologic examination for glenohumeral joint instability; and discusses the current nonoperative and operative treatment options for this disorder. Anatomy and biomechanics The shoulder complex is composed of the sternoclavicular joint, acromioclavicular joint, scapulothoracic articulation, and glenohumeral joint [1]. The glenohumeral joint, which is considered an enarthrodial joint
* Alpine Orthopedic Specialists, 2380 North 400 East, Suite A, North Logan, UT 84341, USA. E-mail address: nno@msn.com (J.T. Finno ). 1047-9651/04/$ - see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2003.12.004

576

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

(ball and socket), depends on static and dynamic factors for joint stability. A more detailed description of shoulder anatomy is presented in another article elsewhere in this issue. Static stabilizers The static stabilizers of the glenohumeral joint include the bony congruence of the joint surfaces, the geometry of the glenohumeral joint, the glenoid labrum, the joint capsule and ligaments, and the negative intraarticular pressure [2]. The humeral head to shaft angle is 130 to 140 , and the humeral head is retroverted 30 relative to the elbows transepicondylar axis [3]. The humeral head composes approximately one third of a sphere on the proximal humerus, which equates to an arc of 120 [3]. The glenoid fossa is the articular surface on the scapula where the humeral head articulates. The scapula rests in a position of 30 to 45 anterior to the coronal plane, and the glenoid fossa is approximately 7 retroverted relative to the scapula with a 5 cephalad tilt [3]. The orientation of the glenoid fossa relative to the humeral head provides a barrier to posterior and inferior glenohumeral joint instability [4]. Proper scapulothoracic movement is required to maintain the appropriate glenohumeral joint orientation for static glenohumeral joint stability. The glenoid fossa is relatively shallow and covers only about 25% of the humeral head surface [3]. This percentage is increased to approximately 35% with the addition of the glenoid labrum [3]. The glenoid labrum is a brocartilaginous structure that is attached rmly to the rim of the glenoid in all regions except for the superior area, where it is attached loosely. The glenoid labrum increases the glenoid fossa depth by 50% and provides an attachment point for the glenohumeral ligaments. The forces required to dislocate the humeral head are decreased by 20% after removal of the glenoid labrum, indicating that this structure has an important role as a static stabilizer of the glenohumeral joint [5]. The glenohumeral joint capsule attaches proximally to the glenoid labrum and distally to the surgical neck of the humerus [6]. The capsule is lax in the mid ranges of glenohumeral joint motion and becomes taut at the extremes of motion. The glenohumeral joint capsule acts as a static stabilizer at end ranges of glenohumeral joint motion [6]. The glenohumeral ligaments are thickenings of the glenohumeral joint capsule and include the superior, middle, and inferior glenohumeral ligaments. Another ligament involved in the static stability of the glenohumeral joint is the coracohumeral ligament. Dempster [7] hypothesized that the capsuloligamentous restraints of the glenohumeral joint acted in a global or ring fashion. Any translation of the humerus on the glenoid would result in tension of the capsuloligamentous structures on the same and opposite sides of the translation. This theory has been supported by research designed to identify the stabilizing role of the glenohumeral ligaments.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

577

The superior glenohumeral ligament is the most constant of the three glenohumeral ligaments and provides resistance to inferior and posterior glenohumeral instability [4,8]. The superior glenohumeral ligament resists posterior and inferior instability most eciently when the humerus is in adduction and external rotation [9]. The coracohumeral ligament seems to have a similar role to the superior glenohumeral ligament in preventing posterior and inferior glenohumeral joint instability [4,9,10]. The superior glenohumeral ligament, coracohumeral ligament, and long head of the biceps tendon all are located within the rotator interval, an area between the supraspinatus and subscapularis tendons [11]. The middle glenohumeral ligament is the least consistent of the glenohumeral ligaments and is the primary restraint to anterior glenohumeral joint instability when the humerus is abducted to 45 [12]. The inferior glenohumeral ligament includes an anterior band and a posterior band, which are divided by a loose area of capsule referred to as the axillary pouch [13]. With the humerus in 90 of abduction, the anterior band of the inferior glenohumeral ligament becomes the primary restraint to anterior glenohumeral instability [13]. Selective incision of the posterior capsule and posterior band of the inferior glenohumeral ligament results in posterior subluxation of the glenohumeral joint, but an incision of the rotator interval is required before full dislocation can occur [14,15]. The posterior stabilizing eect of the inferior glenohumeral ligaments posterior band is most eective at 90 of humeral abduction [16]. The requirement of pathology to the anterior and the posterior static stabilizers of the glenohumeral joint before full posterior dislocation serves to reinforce further the circle theory of capsuloligamentous glenohumeral stability. The intact glenohumeral joint has a negative intra-articular pressure creating a vacuum eect across the glenohumeral joint [17]. Loss of this intraarticular pressure results in inferior subluxation of the glenohumeral joint [17]. Although the vacuum-stabilizing eect of the negative intra-articular pressure is primarily a stabilizer against inferior instability, it also serves to prevent instability in all other directions [18]. Dynamic stabilizers The dynamic stabilizers of the glenohumeral joint include the scapular stabilizing and rotator cu muscles and the long head of the biceps [19]. Dynamic stability not only depends on the sucient strength, exibility, and endurance of these muscles, but also appropriate proprioceptive input and neuromuscular control [20]. The importance of optimal scapular function for glenohumeral joint stability cannot be overemphasized. The scapular stabilizing muscles orient the scapula properly in relation to the humerus for optimal static and dynamic stability of the glenohumeral joint and stabilize the scapula during glenohumeral joint movements [21]. The scapular stabilizing muscles include

578

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

the serratus anterior, trapezius, pectoralis minor, rhomboideus minor and major, latissimus dorsi, and levator scapulae [21]. The rotator cu muscles include the supraspinatus, infraspinatus, subscapularis, and teres minor. These muscles contribute to dynamic glenohumeral joint stability through many mechanisms. Concavity compression, rst described by Lippitt et al [22], refers to the compressive forces placed on the glenohumeral joint during rotator cu muscle cocontractions. These forces press the humeral head into the glenoid fossa, center the humeral head within the glenoid fossa, and help resist glenohumeral translation. Because the glenohumeral ligaments are lax in the mid ranges of glenohumeral joint motion, coordinated rotator cu muscle contraction and concavity compression are particularly important mechanisms for glenohumeral joint stability in these ranges [19]. At the distal insertion of the rotator cu muscles on the humerus, there is an intertwining of the joint capsule with the rotator cu tendons. With rotator cu muscle contraction, it is possible that the glenohumeral joint capsule develops tension and increases in stiness, acting as a dynamic musculoligamentous stabilizing system [19]. The rotator cu muscles also provide glenohumeral joint stability through passive muscle tension and act as barriers to glenohumeral joint translation during active motion [23,24]. In particular, the subscapularis seems to be an important stabilizer of anterior and posterior glenohumeral joint stability [14,25]. Proprioception and neuromuscular control refer to the mechanism by which the position and movements of the shoulder girdle are sensed (proprioception), are processed, and result in an appropriate motor response (neuromuscular control) [20]. Glenohumeral joint instability often is associated with a concomitant decrement in proprioception [26]. The abnormal proprioception is restored after surgical correction of the joint instability, suggesting that the mechanism of proprioceptive decits in unstable glenohumeral joints is a lack of appropriate capsuloligamentous tension [27].

Classication of glenohumeral joint instability The classication of glenohumeral joint instability includes the degree, frequency, etiology, and direction of instability [6]. The degree includes dislocation, subluxation, and microinstability. A dislocation implies that the humeral head is disassociated from the glenoid fossa and often requires manual reduction. A subluxation occurs when the humeral head translates to the edge of the glenoid, beyond normal physiologic limits, followed by selfreduction. Microinstability is due to excessive capsular laxity, is multidirectional, and is associated frequently with internal impingement of the rotator cu [6]. The frequency of instability can be acute or chronic [6]. Acute instability involves an acute injury resulting in subluxation or dislocation of the glenohumeral joint. Chronic instability refers to repetitive instability episodes.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

579

The etiology of glenohumeral joint instability can be traumatic or atraumatic [6]. Unidirectional instability frequently is caused by a traumatic event resulting in disruption of the glenohumeral joint. Atraumatic instability refers to glenohumeral joint instability due to congenital capsular laxity or repetitive microtrauma. Atraumatic instability can be subclassied into voluntary and involuntary categories. An individual who can sublux or dislocate the glenohumeral joint volitionally has voluntary instability, whereas an individual who cannot do so has involuntary instability. Some patients with voluntary instability have associated psychological pathology, which portends a poor outcome if surgical stabilization is performed [28]. Glenohumeral joint instability can be unidirectional or multidirectional. Unidirectional instability refers to instability only in one direction. The most frequently occurring type of unidirectional instability is traumatic anterior instability [6]. Multidirectional instability is instability in two or more directions and is usually due to congenital capsular laxity or chronic repetitive microtrauma [6]. Pathophysiology of glenohumeral joint instability Glenohumeral joint instability may result from three primary etiologies: acute major trauma, chronic repetitive microtrauma, or congenital abnormalities [10]. This section discusses common pathologic lesions associated with glenohumeral joint instability. Anterior instability Anterior instability is caused most frequently by a tear in the anteriorinferior glenohumeral joint capsule (involving the middle glenohumeral ligament or anterior band of the inferior glenohumeral ligament) or detachment of the anterior-inferior glenoid labrum from the glenoid rim [19]. The latter of these two entities frequently is referred to as a Bankart lesion [29]. Bankart lesions also can involve a fracture of the anterior-inferior glenoid rim, commonly referred to as a bony Bankart lesion [30]. Variations of the Bankart lesion include the Perthes lesion and the anterior labroligamentous periosteal sleeve avulsion lesion [30]. Other anatomic lesions that contribute to anterior glenohumeral joint instability include humeral avulsion of the glenohumeral ligament, superior labral anterior posterior lesions, injury to the rotator interval, and rotator cu tear (particularly to the subscapularis muscle) [19]. Acute anterior glenohumeral joint dislocations also frequently are associated with a compression fracture of the posterolateral aspect of the humeral head, referred to as a Hill-Sachs defect [30]. Inferior instability Inferior glenohumeral joint instability typically does not occur in isolation. Causes of inferior glenohumeral joint instability include

580

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

capsuloligamentous laxity; absence of the glenoid fossa upward tilt; and lesions to the rotator interval, inferior glenohumeral ligament, superior glenohumeral ligament, coracohumeral ligament, and inferior glenoid labrum. Posterior instability Congenital glenoid hypoplasia or excessive glenoid or humeral retroversion has been reported to contribute to posterior glenohumeral joint instability. More common lesions that lead to posterior glenohumeral joint instability include excessive capsuloligamentous laxity and injury to the rotator interval, superior glenohumeral ligament, posterior band of the inferior glenohumeral ligament, coracohumeral ligament, or subscapularis muscle [10]. A tear of the posterior-inferior glenoid labrum causing separation from the glenoid fossa rim, often referred to as a reverse Bankart lesion, or a fracture of the posterior inferior glenoid fossa rim also may cause posterior glenohumeral joint instability [10,31]. A reverse Hill-Sachs defect also may be present, representing an impaction fracture of the anterior humeral head [10,31]. Multidirectional instability Multidirectional instability may be due to primary or secondary capsuloligamentous laxity. It frequently is seen bilaterally and may be accompanied by generalized joint laxity [6]. Occasionally, recurrent unilateral joint instability stretches the glenohumeral capsuloligamentous structures to the point where multidirectional instability develops secondarily [6]. Another possible cause for secondary multidirectional instability is the presence of an underlying connective tissue disorder, such as Marfans or Ehlers-Danlos syndromes [6].

History The history should include the patients chief complaint, age, hand dominance, and vocational and avocational activities. Although many patients with glenohumeral joint instability have vague symptoms, common complaints of patients with shoulder instability include pain, popping, catching, locking, an unstable sensation, stiness, and swelling [32]. When the patient reports pain, the location, quality, intensity, and any radiation of the pain should be determined. The patient should be asked about exacerbating and alleviating factors. It also is important to determine when the symptoms rst were noticed, the frequency of symptoms, and positions or activities that result in instability episodes. A history of acute trauma or chronic, repetitive microtrauma should be obtained. Some patients may have a history of glenohumeral joint dislocation, and the examiner should determine the direction of dislocation,

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

581

the duration of the dislocation, whether it has reoccurred, and whether it required manual reduction or reduced spontaneously. Subluxation episodes commonly are associated with a burning or aching dead feeling in the arm. Repetitive overhead activities, such as baseball pitching, may cause enough microtrauma to lead to symptomatic laxity [32]. The patient should be asked whether he or she or any family members have a history of generalized ligamentous laxity or connective tissue disorder. The direction of instability may be elicited through historical information. Instability that occurs with the patients shoulder in the abducted and externally rotated position suggests anterior instability [32]. Posterior instability is suggested by instability that occurs when the patients shoulder is forward exed and internally rotated [32]. Pain, paresthesias, and weakness while carrying heavy objects may indicate inferior instability [32]. Patients with multidirectional instability may report symptoms of two or more instability patterns. Physical examination The physical examination should include inspection, palpation, glenohumeral joint range of motion (ROM), upper extremity strength, sensation (including proprioception), reex evaluations, and special tests for glenohumeral joint instability. Adjacent joints should be evaluated to rule out referred pain or concomitant pathology. A kinetic chain evaluation also should be performed to ensure that decits in distant regions are not contributing to the glenohumeral joint instability. The patients shoulder girdle should be inspected for posture, discoloration, swelling, scars, muscle atrophy, and deformity. Scapular position should be noted. Winging of the scapula may be associated with scapulothoracic dyskinesis, muscle imbalance or fatigue, or an injury to the spinal accessory nerve or long thoracic nerve [1]. Scars that are thin or spreading may suggest an underlying connective tissue disorder [32]. Palpation should begin at the sternoclavicular joint and progressive laterally to encompass the anterior, posterior, superior, inferior, and lateral aspects of the shoulder. Areas of deformity or tenderness should be noted. ROM should be assessed actively and passively, including exion, extension, abduction, adduction, and internal and external rotation. Internal and external rotation should be assessed with the arm at the side and with the shoulder abducted 90 . During the concentric and eccentric phases of active shoulder abduction and forward exion, scapulothoracic motion should be assessed for the presence of winging and abnormalities in the scapulothoracic rhythm, indicating scapulothoracic dyskinesis or weakness of the scapular stabilizers. The lateral scapular slide measurement can be used as an objective test for scapulothoracic movement symmetry. The distance from the inferior

582

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

angle of the scapula to the nearest spinous process is measured in three positions: arms at the side, hands on the hips, and arms abducted 90 . A side-to-side dierence of 2 or more cm is considered signicant [33]. Strength testing should include all of the upper extremity muscles, with an emphasis on the rotator cu and scapular stabilizing muscles. Sensation should be assessed in the C5 through T1 dermatomes and in the cutaneous nerve distributions of the upper extremities. Reex testing should include the biceps reex (C5-6), brachioradialis or pronator reex (C5-6), and triceps reex (C7-8) [34]. Clinical tests used to measure the proprioceptive and kinesthetic abilities of the shoulder commonly consist of angular reproduction and threshold to sensation of movement maneuvers. Functional testing procedures, such as the closed kinetic chain upper extremity stability test [35] and functional throwing performance index [36], also can provide reliable information. Special tests for instability Anterior apprehension (crank) and relocation tests The anterior apprehension (crank) and relocation tests (Fig. 1) are for anterior glenohumeral joint instability. The patient is placed in the supine position. The examiner abducts the patients shoulder 90 and exes the elbow 90 . The examiner uses one hand slowly to externally rotate the patients humerus using the patients forearm as the lever, while the other hand is placed posterior to the patients proximal humerus and exerts an anteriorly directed force on the humeral head. The test is considered positive if the patient indicates a feeling of impending anterior dislocation [37]. The relocation test is positive if the examiner removes the hand from behind the proximal humerus, places it over the anterior proximal humerus, and exerts a posteriorly directed force, and the patient reports a reduction in the apprehension [37]. Anterior and posterior drawer tests The anterior drawer test (Fig. 2A) is used to evaluate anterior glenohumeral joint instability, whereas the posterior drawer test (Fig. 2B) is used to evaluate posterior glenohumeral joint instability. The patient is placed supine on the examination table. The hand of the patients aected shoulder is placed in the examiners axilla and grasped by the examiners arm. The patients shoulder is abducted 80 to 120 and exed 0 to 20 . The examiner uses the other hand to stabilize the scapula and monitor for anterior translation of the shoulder. The examiner grasps the patients proximal humerus with the remaining hand and exerts an anteriorly directed force on the humeral head. A positive test is indicated by excessive anterior translation of the humerus relative to the glenoid. This test may be accompanied by apprehension or a click [38].

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

583

Fig. 1. (A) Anterior apprehension test. (B) Relocation test.

The posterior drawer test begins with the patient in a supine position. The examiner grasps the patients proximal forearm with one hand, exing the patients elbow to 120 , abducting the shoulder to 80 to 120 , and exing the shoulder 20 to 30 . The examiners other hand stabilizes the scapula with the thumb over the anterior aspect of the shoulder just lateral to the coracoid process and the remaining ngers along the posterior shoulder. The test occurs when the examiner forward exes the shoulder 60 to 80 while placing a posteriorly directed force against the patients humeral head with the thumb of the other hand. The same hand that is exerting the posteriorly directed force on the humeral head also monitors the humeral head for posterior translation, which indicates a positive test [38].

584

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Fig. 2. (A) Anterior drawer test. (B) Posterior drawer test.

Load and shift test For the load and shift test (Fig. 3), the patient is in a seated position with the arms at the sides. The examiner stabilizes the patients aected shoulder with one hand, while pressing the humeral head into the glenoid fossa with the other hand. An anterior and posterior force is placed on the proximal humerus, and the amount of humeral anterior and posterior translation is assessed [39]. Posterior apprehension test The posterior apprehension test (Fig. 4) evaluates posterior glenohumeral joint stability. The patients aected shoulder is forward exed to 90 , then

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

585

Fig. 3. (A) Anterior load and shift test. (B) Posterior load and shift test.

maximally internally rotated. A posteriorly directed force is placed on the patients elbow by the examiner. A positive test causes a 50% or greater posterior translation of the humeral head or a feeling of apprehension in the patient [40]. Jerk test The jerk test is another test to evaluate posterior glenohumeral joint stability. The patient is seated, and the shoulder is abducted 90 and maximally internally rotated. The patients elbow is grasped by the examiner, and an axial load is placed through the humerus. The patients arm is adducted horizontally across the body while maintaining the axial load. A

586

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Fig. 4. Posterior apprehension test.

positive test is indicated by a posterior jerk of the humeral head as it displaces posteriorly. It may relocate with another jerk as the arm is returned back to an abducted position [40]. Sulcus sign The sulcus sign (Fig. 5) is used to evaluate inferior glenohumeral joint instability. The patient is seated or standing with the arm relaxed at the side. The patients forearm is grasped by the examiner, and a distal traction force

Fig. 5. Sulcus sign.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

587

is placed through the patients arm. In the presence of inferior instability, a sulcus develops between the humeral head and the acromion [40]. Feagin test The Feagin test (Fig. 6) also is used to assess inferior glenohumeral joint stability. The patient is seated or standing with the arm abducted 90 , the elbow extended, and the forearm resting on the examiners shoulder. The examiner clasps the hands together over the patients proximal humerus and exerts a downward force. The test is considered positive if the patient feels apprehension [40].

Radiologic evaluation The various lesions commonly seen with glenohumeral joint instability were discussed earlier. The most common initial radiographic views for the evaluation of glenohumeral joint instability include the anteroposterior shoulder view, axillary lateral view, and scapular Y view [6]. The anteroposterior view allows visualization of the osseous structures of the shoulder, including the scapula, clavicle, upper ribs, humeral head, and glenoid rim [30]. With internal rotation, the anteroposterior view also may allow visualization of a Hill-Sachs defect [30]. The scapular Y view can help to assess glenohumeral joint alignment after acute dislocations [30]. The axillary lateral view can assess anterior or posterior subluxation or dislocation and fractures of the anterior or posterior glenoid rim [30]. Other specialized views include the Garth view and the West Point view, both of which are useful in the detection of Bankart fractures; the Stryker Notch view for the evaluation

Fig. 6. Feagin test.

588

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

of Hill-Sachs defects; and stress views for the documentation of the degree of glenohumeral joint instability [30]. CT was previously the gold standard for glenoid labral evaluation. With the advent of MRI and magnetic resonance arthrography, however, CT now has a limited role. MRI and magnetic resonance arthrography provide superior visualization of the labrum, cartilage, and joint capsule without the ionizing radiation of CT. Visualization of nondisplaced injuries to the inferior glenohumeral ligament or anterior-inferior glenoid labrum is improved by placing the arm in an abducted and externally rotated position.

Treatment The treatment options for glenohumeral joint instability and dislocation include nonoperative and operative approaches. After glenohumeral joint subluxation episodes and in patients with multidirectional instability, a comprehensive rehabilitation program that addresses kinetic chain decits; scapulothoracic mechanics; and shoulder girdle strength, exibility, and neuromuscular control is appropriate. Such a program is discussed in the nonoperative treatment section. For patients who have a rst-time anterior glenohumeral joint dislocation, the decision between trials of nonoperative treatment versus immediate surgical stabilization is more controversial. Although the rehabilitation of acute anterior glenohumeral joint dislocation is addressed in the nonoperative treatment section, the controversy between surgical and nonsurgical treatment is addressed in the surgical section. Regardless of whether a patient chooses early surgical intervention, closed reduction conrmed by radiologic examination should be performed on all patients who sustain an acute glenohumeral joint dislocation that does not reduce spontaneously. Radiologic studies should be performed in two planes (eg, anteroposterior with the humerus in internal rotation and axillary lateral views) to conrm relocation and exclude an associated fracture [30]. Sensory testing over the deltoid muscle is important because the axillary nerve is the most commonly injured nerve after shoulder dislocation [6]. Immobilization of the glenohumeral joint after relocation does not seem to aect the rate of glenohumeral joint redislocation and should be considered only a comfort measure [4143]. Medications such as nonsteroidal anti-inammatory drugs and mild narcotics may be considered for initial pain control. Specic surgical and rehabilitative treatments are discussed in subsequent sections. Nonoperative treatment After a thorough examination, an individualized rehabilitation program based on the specic decits identied is developed. The nonoperative treatment of glenohumeral joint instability should include pain and edema control, monitoring and restoring shoulder girdle ROM, protection of the static glenohumeral joint stabilizers, obtaining full function of the dynamic

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

589

stabilizers, restoring joint proprioception, and correcting associated kinetic chain decits. The ultimate goal of this program should be the unrestricted return of the patient to preinjury activities. Initially, treatment of the unstable shoulder emphasizes controlling pain and edema, protecting healing tissues, and decreasing the deleterious eects of immobilization. After acute dislocation, positions of tissue stress should be avoided, such as shoulder abduction and external rotation in patients who have sustained an anterior dislocation. Modalities such as interferential electrical stimulation, ultrasound, soft tissue mobilization, and cryotherapy may be benecial for reduction of pain and edema and promotion of tissue healing. Taping the unstable shoulder can help to decrease pain, improve joint biomechanics, and enhance neuromuscular reeducation of the shoulder complex musculature. Taping can reduce anterior humeral head translation in patients with anterior instability and can be used to elevate and center the humeral head in the glenoid fossa for patients with multidirectional instability (Fig. 7). This positioning maintains proper shoulder girdle alignment during neuromuscular reeducation training [44]. The principles of glenohumeral joint tissue protection include avoiding impingement positions, decreasing capsular stress, and preventing tendon overload. Strategies include keeping the humerus at less than 90 of elevation and at or anterior to the plane of the scapula and using a low-resistance, highrepetition exercise format [45]. Exercising in the plane of the scapula often is recommended because it optimizes rotator cu length-tension relationships, reduces stress on capsuloligamentous structures, and provides maximal glenohumeral joint surface conformity [46,47]. Exercising in the plane of the scapula also is functional because most shoulder activities occur in this plane. Occasionally, patients with anterior instability display posterior glenohumeral joint capsular tightness. This tightness can cause an increase in anterior glenohumeral joint capsular stress. Posterior glenohumeral joint capsular tightness frequently is found in throwing athletes [48]. Mobilizing the glenohumeral joint using a posterior glide technique and horizontally adducting the internally rotated arm are useful techniques for stretching the posterior capsule (Fig. 8). Reestablishing appropriate force couples about the glenohumeral and scapulothoracic joints is important during rehabilitation. One signicant force couple involves the synergistic contraction of the deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis to allow glenohumeral joint abduction. Another force couple involves the coordinated contraction of the serratus anterior and upper and lower trapezius to facilitate upward rotation of the scapula during shoulder elevation. Patients with glenohumeral joint instabilities frequently have abnormalities in these force couples, particularly in the scapular stabilizers [49,50]. When strengthening the rotator cu for the treatment of specic instability patterns, it is important to remember Dempsters ring concept

590

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Fig. 7. (A) Anterior instability taping. Tape is used to lift the head of the humerus superiorly and posteriorly so that the head of the humerus is slightly externally rotated. The tape is pulled diagonally across the scapula, ending just medial to the inferior border of the scapula. (B) Multidirectional instability taping. Tape is used to elevate the humeral head and center it in the glenoid. The patient rests the arm in 45 of abduction. The humeral head is placed manually in neutral position. The rst piece of tape is anchored over the middle deltoid and pulled superiorly to attach over the acromion. The second piece begins anteriorly on the humerus, passes diagonally over the clavicle, and is anchored on the spine of the scapula. The third piece of tape is placed along the posterior deltoid and is anchored along the upper trapezius.

of glenohumeral joint instability, as mentioned earlier [7]. It has been found that any stress on the stabilizers of one side of the glenohumeral joint also places stress on the stabilizers of the opposite side of the joint. This nding suggests that the reciprocal also is truethat strengthening the stabilizers on either side of the glenohumeral joint helps prevent unidirectional instability.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

591

Fig. 7 (continued )

Using this rationale, it is important to strengthen the anterior and posterior cu and scapular muscles for the treatment of anterior and posterior unidirectional glenohumeral joint instability [51,52]. For inferior glenohumeral joint instability, strengthening the deltoid and supraspinatus helps prevent inferior migration of the humerus. Multidirectional instability requires strengthening of all of the rotator cu muscles, the long head of the biceps, and the deltoid. Because the rotator cu muscles provide dynamic stability for the glenohumeral joint, and the length-tension relationship of the rotator cu depends on scapular position, the rehabilitation program needs to address the strength, endurance, and neuromuscular control of the rotator cu and

592

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Fig. 8. Posterior glide in the loose pack position.

scapular stabilizing muscles. Initial strengthening exercises should include multiple angle, submaximal isometric muscular contractions to begin neuromuscular reeducation, develop strength, and improve local blood ow [53]. This program progresses to isotonic exercises within a limited ROM using manual resistance, light weights, or resistance cords. Initial scapular neuromuscular control training may begin with manually assisted or resisted protraction and retraction in sitting or side-lying position using a lowresistance, high-repetition format. Rehabilitation exercises eventually should progress to multiplanar activities in the full range of shoulder motion, incorporating isotonic, isokinetic, and isodynamic resistance at submaximal and maximal levels. Strength training should be activity specic so that exercises are performed in a functional position and proper muscle synergies are used [54]. A swimmer should be trained in a prone or supine position (depending on his or her stroke), whereas a tennis player should train in an upright position, and the exercise movements should simulate those of a swimming or tennis stroke. Plyometric exercises are the last to be added because they generate the most force through the shoulder girdle. These exercises are an important component of the rehabilitation program, however, because many activities, particularly sports, require explosive movements that can be mimicked only through plyometric exercises. Rotator cu strengthening can be done with resisted internal and external rotation of the shoulder with the arm in the scapular plane [55]. Exercises that commonly are used to produce increased levels of posterior rotator cu electromyographic activation include resisted prone external rotation with the shoulder abducted 90 , resisted side-lying external shoulder rotation, and resisted prone shoulder extension, abduction with external rotation, and rowing [5557]. Strengthening of the supraspinatus involves humeral elevation in the plane of the scapula. This exercise can be performed with the humerus in an externally rather than internally rotated position because

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

593

this reduces subacromial impingement and does not appear to alter electromyographic activity in the supraspinatus muscle [55]. Elastic tubing or pulleys can be used to strengthen the infraspinatus, teres minor, and posterior deltoid muscles eccentrically, which is important because these muscles frequently are called on to decelerate the shoulder. Biceps strengthening is important and may include exercises such as resisted elbow exion at multiple angles of shoulder exion and scapular plane elevation. Strengthening exercises for the scapular stabilizers need to address the superior, middle, and inferior aspects of the trapezius muscle and the rhomboideus major and minor, levator scapula, serratus anterior, and pectoralis minor muscles. Commonly used exercises include rowing, push-ups with a plus, shoulder shrugs, and seated press-ups (Fig. 9) [58].

Fig. 9. (A) Push-up with a plus. The scapula is protracted at the end of a push-up to increase serratus anterior activation. (B) Prone rowing.

594

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Exercises with combined movement patterns also are used to reestablish function. Combined movement patterns, such as the proprioceptive neuromuscular facilitation D2 exion pattern for the upper extremities, which consists of abduction, exion, and external rotation, can be used during functional neuromuscular reeducation (Fig. 10) [49]. The use of the closed kinetic chain exercise also is important for strengthening the unstable shoulder. The benets of closed chain exercise include muscular cocontraction, cohesion of joint surfaces, and multijoint training [59]. Examples of closed kinetic chain exercise include hand step-ups; rhythmic stabilization activities in biped, triped, and quadruped positions; push-ups with additional scapular protraction; and seated press-ups (Fig. 11). Throughout the rehabilitation program, postural and kinetic chain decits need to be identied and corrected. Kinetic chain decits frequently present in patients with shoulder instability and include dynamic pes planus, inexible quadriceps, hip exors, iliotibial band, latissimus dorsi, and pectoralis major and minor muscles; weak hip girdle musculature; and restricted hip internal rotation and thoracic rotation. Patients with glenohumeral joint instability also frequently have postural abnormalities, such as a head-forward position and protracted scapula with rounded shoulders. As discussed earlier, patients with shoulder instability frequently experience proprioceptive decits [6062]. Rehabilitative exercises to enhance proprioception include rhythmic stabilization and ball tossing activities in varying degrees of abduction and external rotation and proprioceptive neuromuscular facilitation drills using exercise tubing and manual resistance concomitantly (Fig. 12) [49]. Surgical treatment Surgical treatment options for shoulder instability are based on the information gathered during the history, physical examination, diagnostic imaging, and examination under anesthesia. The age of the patient, activity level, extremity dominance, degree of instability, traumatic versus atraumatic origin, and its direction all are important determinants of appropriate treatment. Finally, the pathology indicated by imaging studies or ndings at the time of surgery dictates the appropriate surgical interventions. In addition to the standard risks of surgery, complications unique to shoulder stabilization surgery include recurrent instability; migration of suture anchors or suture tacks, which may cause articular damage; and injury to the axillary or suprascapular nerves [63]. These complications need to be explained to the patient in detail before any surgical intervention so that the patient can make an informed decision regarding treatment. One classication system that frequently is used to divide patients into nonoperative and surgical categories is the TUBS and AMBRI mnemonics. TUBS stands for traumatic instability that is unidirectional and has an associated Bankart lesion, which responds best to surgical treatment. AMBRI

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

595

Fig. 10. Proprioceptive neuromuscular facilitation D2 exion pattern. This is a diagonal pattern consisting of shoulder abduction, external rotation, and exion.

stands for atraumatic instability that is multidirectional and bilateral. The treatment begins with rehabilitation, and if this fails, surgical treatment involves an inferior capsular shift. This classication is oversimplied, does not address patients with unidirectional instability patterns that are not just anterior, and does not address patients who sustain recurrent dislocations. These areas are addressed in subsequent sections. Examination under anesthesia A meticulous examination under anesthesia must be performed before shoulder surgery. Passive shoulder ranges of motion, including elevation,

596

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

Fig. 11. Examples of closed chain shoulder exercises to facilitate cocontraction and enhance neuromuscular control. (A) Hand step-ups. Stepping on and o of a step with the scapula in a protracted position. (B) Rhythmic stabilization. Perturbation of a patient in the biped position.

external rotation, and internal rotation with the arm at the side and at 90 of abduction, are recorded. The examination should be performed with the patient supine or in the beach-chair position with both arms available for comparison. Anterior and posterior stability is assessed with the arm abducted 90 and in neutral rotation with anterior and posterior forces applied. Application of axial pressure during this maneuver is crucial. Translation is graded as follows: 1no translation, 2mild translation, 3moderate translation with progression to the rim of the glenoid, 4dislocation of the glenohumeral joint. Physiologic translation is usually a grade 2. The arm is tested in 90 of external rotation and 45 of internal rotation to assess the anterior-inferior and anterior-posterior capsules. Studies comparing the

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

597

Fig. 12. Rhythmic stabilization exercise in which the patient tries to hold the shoulder in a static position against stretch cord resistance, while the clinician places perturbations against the patients arm.

examination under anesthesia with eventual ndings observed at surgery show sensitivity of 100% and specicity of 93% [63]. Surgical treatment of anterior instability After a traumatic anterior glenohumeral joint dislocation, treatment options include nonoperative and surgical interventions. In older, less active patients, nonoperative management frequently is successful [64]. In younger, more active patients involved in contact sports, studies have shown a high redislocation rate in patients treated nonoperatively compared with patients receiving early operative intervention [63,6567]. Open and arthroscopic techniques can be used, and modalities such as laser, thermal probes, or traditional suturing may be indicated based on the pathoanatomy. Indications for surgery in rst-time traumatic anterior glenohumeral joint dislocation patients include patients who have failed conservative management and young patients who are involved in contact sports or other highdemand occupations [65,68,69]. Historically, surgical intervention was limited to scarication of the anterior capsule for dislocations. Early procedures created soft tissue contracture and bony block to prevent further dislocation. The increased pathoanatomic understanding of shoulder instability has allowed signicant improvements in surgical techniques and their subsequent outcomes [68,70]. Open stabilization of anterior glenohumeral instability has been used frequently in the athletic population, with one study reporting that 96% of professional athletes treated with this technique were able to return to their sport [68]. Open stabilization is done best with the patient in the beach-chair

598

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

position. An anterior axillary approach allows separation of the deltopectoral interval, preservation of the cephalic vein, and adequate visualization of the damaged tissue. The subscapularis tendon is incised 1 cm medial to its insertion, and the capsule is separated from its undersurface. The Bankart lesion is repaired using direct suture to the glenoid or with suture anchors, and the capsular redundancy is eliminated with a superior shift. The subscapularis tendon is repaired and the skin approximated. Postoperative rehabilitation needs to allow the repaired tissue adequate time to heal. Arthroscopic stabilization procedures seem to have many benets over open procedures, including decreased operating room time, blood loss, narcotic use, hospital stay, time lost from work, and complications compared with open procedures [68,7176]. The rst arthroscopic shoulder stabilization procedure using a capsular staple was done in 1982 [63]. Arthroscopic techniques, including transglenoid suture repair, suture anchors, suture tacks, thermal capsulorrhaphy, and laser, all have been compared with open techniques. Although early studies revealed relatively high redislocation rates after arthroscopic repair, more recent literature indicates that the redislocation rate after arthroscopy is now only 15%, and the redislocation rate after open repair is approximately 10% [7176]. Bioabsorbable suture anchors have become popular; the most common bioabsorbable material used today in the shoulder is poly-L-lactic acid. Contraindications to arthroscopic techniques include patients with glenoid bone loss, attenuated capsulolabral tissue, engaging Hill-Sachs lesions, and humeral avulsion of the glenohumeral ligament lesions. Thermal or laser shrinkage of the capsule addresses capsular stretching that may occur with instability events [77]. This technique has the advantage of not altering the inherent anatomy, and it is not technically demanding. These tissues are at risk for recurrent stretching, however, and long-term success with this treatment is questionable [7783]. Arthroscopic capsular plication or capsular tucks have been performed to avoid using the thermal energy on capsular tissue. Capsular plication involves roughening the capsule using a shaver, followed by the passage of a suture through the capsule and the labrum. Capsular tucks are made inferiorly and progressing superiorly to the rotator interval. The sutures are tied resulting in a tightening of the joint capsule and glenohumeral ligaments. The size of the tucks determines the degree of capsular and ligamentous shortening. The most dicult portion of this technique is tensioning the capsule appropriately [84]. Surgical treatment of multidirectional instability Multidirectional instability is a dicult problem and should be treated surgically only if conservative measures fail. Neer and Foster [83] rst described the open capsular shift for multidirectional instability in 1980, and it continues to be the gold standard today with reported success rates of 92% to 94% [8590]. More recent advances in the treatment of multidirectional

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

599

instability have been accomplished using the arthroscope with success rates of 70% to 90% [9196]. Capsular tension can be addressed with plication sutures in the anterior and the posterior capsule, followed by thermal capsulorrhaphy for any further redundancy. Thermal capsulorrhaphy now is used primarily for augmentation of capsular plication rather than as a primary form of treatment for global instability [9396]. Two anterior portals are required to allow access to appropriate areas of the capsule. For posterior plication, two posterior portals also are required to place sutures and use the electrothermal device to tension this tissue appropriately. Rotator interval closure has been advocated to assist in capsular tensioning. Additional pathology, such as superior labral anterior posterior lesions and posterior impingement lesions resulting from this instability, also need to be addressed at the time of surgery. Surgical treatment of posterior instability Treatment of posterior instability is initially nonoperative. If this treatment fails, however, open or arthroscopic posterior Bankart repair with appropriate capsular plication is eective in 80% to 90% of these patients [10,97100]. Postoperative rehabilitation Although the specic postsurgical rehabilitation protocol varies according to the surgeon and type of surgery performed, the goal of rehabilitation is the sameto obtain full static and dynamic function of the shoulder. Many of the exercises used postoperatively are similar to the exercises used for the standard nonoperative treatment of shoulder instabilities. Postoperative ROM considerations are crucial in these patients, however. Frequently a short period of shoulder immobilization is required after shoulder stabilization surgery. Early protected ROM activities are important to institute as soon as possible, however, to prevent the adverse eects of immobilization, such as collagen malalignment and articular cartilage degeneration, to name a few. Evaluation of tissue readiness, type of instability, type of surgical procedure, tissue status, and method of xation should be considered before performing ROM and strengthening activities [49]. Specic postoperative rehabilitation protocols Bankart procedure Frequently after open anterior stabilization surgery, external rotation is limited to 40 in the plane of the scapula for the rst 4 weeks and is progressed to 90 of external rotation in the abducted position 6 weeks postoperatively. Full ROM is allowed by 8 weeks postoperatively. If the subscapularis muscle is detached then reattached during open reconstruction, resistive internal rotation should be limited initially.

600

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

After arthroscopic surgery, the rate of progression is more conservative. External rotation usually is limited to 25 in the plane of the scapula for the rst 6 weeks and progressed to full ROM at 10 weeks. A common complication after anterior shoulder stabilization surgery is loss of motion, particularly external rotation. Should this loss of motion occur, joint mobilization and stretching may be performed to stretch the anterior shoulder capsule to increase shoulder external rotation (Fig. 13). Capsular-shift procedures (anterior or inferior) Postoperative rehabilitation for multidirectional instability is treated with a more conservative program than used for anterior instability. Patients with congenital instability are progressed more slowly than patients with acquired instability. The goal is to restore shoulder motion to approximately 10 to 15 less than the preoperative level by 10 to 12 weeks postoperatively [50]. The ROM exercises are progressed based on end feel. If the patient exhibits a soft end feel and motion is greater than guidelines, motion is slowed; conversely, if the patient exhibits a hard or rm end feel and less motion than the guideline, motion is accelerated [50]. Posterior instability procedures There is usually a period of immobilization after posterior stabilization due to the thin posterior capsule. The combined movement of exion, internal rotation, and horizontal adduction is avoided for 6 weeks postoperatively. Thermal capsulorrhaphy Rehabilitation for thermal capsulorrhaphy involves a period of immobilization before beginning ROM activities. The ROM is usually restored within 8 weeks.

Fig. 13. Anterior glide mobilization of the shoulder for anterior capsular tightness.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

601

Summary Glenohumeral joint instability involves multiple dierent diagnoses with a broad range of underlying pathology. It is important to understand the anatomy, pathology, history, physical examination, and classication systems to diagnose these patients correctly. After arriving at an accurate diagnosis, an appropriate treatment program that may entail nonoperative or surgical interventions can be instituted. References
[1] Clarnette R, Miniaci A. Clinical exam of the shoulder. Med Sci Sports Exerc 1998;30 (4 Suppl):S16. [2] Abboud J, Soslowsky LJ. Interplay of the static and dynamic restrains in glenohumeral instability. Clin Orthop 2002;400:4857. [3] Soslowsky L, Carpenter JE, Kuhn JE. Biomechanics of the shoulder. In: Garrett W, Speer KP, Kirkendall DT, editors. Principles and practice of orthopaedic sports medicine. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 36798. [4] Basmajian J, Bazant FJ. Factors preventing downward dislocation of the adducted shoulder joint. J Bone Joint Surg Am 1959;41:1182. [5] Lippit S, Matsen F. Mechanisms of glenohumeral joint stability. Clin Orthop 1993;291: 208. [6] Backer M, Warren RF. Glenohumeral instabilities. In: DeLee J, Drez D, Miller MD, editors. DeLee and Drezs orthopaedic sports medicine principles and practice. Philadelphia: WB Saunders; 2003. p. 102034. [7] Dempster W. Mechanisms of shoulder movement. Arch Phys Med Rehabil 1965;46A:49. [8] Warner J, Deng XH, Warren RF, Trozilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675. [9] Patel P, Debski RE, Imho AB. Anatomy and biomechanics of the coracohumeral and superior glenohumeral ligaments. Trans Orthop Res Soc 1996;21:702. [10] Antoniou J, Harryman DT. Posterior instability. Orthop Clin North Am 2001;32:46373. [11] Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop 1987;223:4450. [12] OBrien S, Schwartz RE, Warren RF, Torzilli PA. Capsular restraints to anterior/ posterior motion of the shoulder. Orthop Trans 1988;12:143. [13] Turkel S, Panio MW, Marshall JL, Gurgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:120817. [14] Blasier R, Soslowsky L, Malicky D. Posterior glenohumeral subluxation: active and passive stabilization in a biomechanical model. J Bone Joint Surg Am 1997;79:43340. [15] Harryman D, Sidles J, Harris S. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:5366. [16] Schwartz R, OBrien SJ, Torzilli PA, Warren RF. Capsular restraints to anteriorposterior motion of the shoulder. Trans Orthop Res Soc 1987;12:78. [17] Kumar V, Balasubramaniam P. The role of atmospheric pressure in stabilizing the shoulder: an experimental study. J Bone Joint Surg Br 1985;67:719. [18] Gibb T, Sidles JA, Harryman DT. The eect of capsular venting on glenohumeral laxity. Clin Orthop 1991;268:120. [19] Levine W, Flatow EL. The pathophysiology of shoulder instability. Am J Sports Med 2000;28:9107. [20] Myers J, Lephart SM. Sensorimotor decits contributing to glenohumeral instability. Clin Orthop 2002;400:98104. [21] Ellen M, Gilhool JJ, Rogers D. Scapular instability: the scapulothoracic joint. Phys Med Rehabil Clin N Am 2000;11:75570.

602

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

[22] Lippitt S, Vanderhooft E, Harris SL. Glenohumeral stability from concavity-compression: a quantitative analysis. J Shoulder Elbow Surg 1993;2:2735. [23] Cleland. Notes on raising the arm. J Anat Physiol 1884;18:275. [24] Browne A, Homeyer P, Tanaka S. Glenohumeral elevation studies in three dimensions. J Bone Joint Surg Br 1990;72:843. [25] DePalma A, Coker AJ, Probhaker M. The role of the subscapularis in recurrent anterior dislocation of the shoulder. Clin Orthop 1969;54:35. [26] Liphart S, Henry TJ. The physiological basis for open and closed kinetic chain rehabilitation for the upper extremity. J Sport Rehabil 1996;5:7187. [27] Liphart S, Warner JP, Borsa PA, Fu FH. Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders. J Shoulder Elbow Surg 1994;3:37180. [28] Rowe C, Pierce DS, Clark JG. Voluntary dislocation of the shoulder: a preliminary report on a clinical, electromyographic and psychiatric study of twenty-six patients. J Bone Joint Surg Am 1973;62:897908. [29] Bankart A. The pathology and treatment of recurrent dislocation of the shoulder joint. Br J Surg 1938;26:239. [30] Sanders T, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med 2000;28:41433. [31] Petersen S. Posterior shoulder instability. Orthop Clin North Am 2000;31:26383. [32] Beasley L, Faryniarsz DA, Hannan JA. Multidirectional instability of the shoulder in female athletes. Clin Sports Med 2000;19:33149. [33] Kibler W. Rehabilitation of the shoulder. In: Kibler W, Herring SA, Press JM, Lee PA, editors. Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg (MD): Aspen Publishing; 1998. p. 14970. [34] Magee D. Elbow joints. In: Magee D, editor. Orthopedic physical assessment. Philadelphia: WB Saunders; 1992. p. 14367. [35] Cappell K, Clark MA, Davies GJ, Ellenbecker TS. Clinical examination of the shoulder. In: Tovin BJ, Greeneld BH, editors. Evaluation and treatment of the shoulder: an integration guide to the physical therapist practice. Philadelphia: FA Davis; 2001. p. 75131. [36] Davies GJ, Dickho-Homan S. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sports Ther 1993;18:449. [37] Jobe F, Kvitne RS. Shoulder pain in the overhand or throwing athlete: the relationship of anterior instability and the rotator cu impingement. Orthop Rev 1989;18:96375. [38] 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;66:5516. [39] Silliman J, Hawkins RJ. Classication and physical diagnosis of instability of the shoulder. Clin Orthop 1993;291:719. [40] Magee D. Shoulder. In: Magee D, editor. Orthopedic physical assessment. Philadelphia: WB Saunders; 1992. p. 90142. [41] Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults: ve year prognosis. J Bone Joint Surg Am 1987;69:3939. [42] Simonet W, Coeld R. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984; 12:19. [43] Hovelius L, Eriksson K, Fredin H. Recurrences after initial dislocation of the shoulder: results of a prospective study of treatment. J Bone Joint Surg Am 1983;65:343. [44] McConnell J. Neuromuscular re-education strategies for the shoulder girdle. In: Tovin BJ, Greeneld BH, editors. Evaluation and treatment of the shoulder: an integration of the guide to physical therapist practice. Philadelphia: FA Davis; 2001. p. 3514. [45] Ellenbecker TE. Impaired joint mobility, muscle performance, and range of motion associated with ligament or other connective tissue disorders. In: Tovin BJ, Greeneld BH, editors. Evaluation and treatment of the shoulder: an integration of the guide to physical therapist practice. Philadelphia: FA Davis; 2001. p. 181209.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

603

[46] Dvir Z, Berme N. The shoulder complex in elevation of the arm: a mechanism approach. J Biomech 1978;11:219. [47] Kelley MJ. Biomechanics of the shoulder. In: Kelley MJ, Clark WA, editors. Orthopedic therapy of the shoulder. Philadelphia: JB Lippincott; 1995. p. 64103. [48] Cavallo R, Speed KP. Shoulder instability and impingement in throwing athletes. Med Sci Sports Exerc 1998;30(4 Suppl):S1825. [49] Wilk KE. Current concepts in the rehabilitation of athletic shoulder injuries. In: Andrews JR, Wilk KE, editors. The athletes shoulder. New York: Churchill Livingstone; 1994. p. 33554. [50] Wilk KE. Rehabilitation after shoulder stabilization surgery. In: Warren RF, Craig EV, Altchek DW, editors. The unstable shoulder. Philadelphia: Lippincott-Raven; 1999. p. 367. [51] Burkhead WZJ, Rockwood CAJ. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992;74:890. [52] McMahon PJ, Jobe FW, Pink MM. Computive electromyographic analysis of shoulder muscles during planar motions: anterior glenohumeral instabilty verses normal. J Shoulder Elbow Surg 1996;15:118. [53] Jensen BR. Intramuscular laser-doppler owmetry in the supraspinatus muscle during isometric contractions. Eur J Appl Physiol 1995;71:373. [54] Sale D. Inuence of exercise and training on motor unit activation. Exerc Sports Sci Rev 1987;5:95. [55] Hintermeister RA. Electromyographic activity and applied load during shoulder rehabilitation exercises using elastic resistance. Am J Sports Med 1998;26:210. [56] Blackburn T. EMG analysis of posterior cu exercises. Athletic Training 1990;25:40. [57] Cain PR, Mutschler TA, Fu FH. Anterior stability of the glenohumeral joint: a dynamic model. Am J Sports Med 1987;15:144. [58] Moseley JB. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med 1992;20:128. [59] Ellenbecker TE, Mattalino AJ. Comparison of open and closed kinetic chain upper extremity upper extremity tests in patients with rotator cu pathology and glenohumeral joint instability. J Orthop Sports Phys Ther 1997;25:84. [60] Lephart SM. Shoulder proprioception and function following thermal capsulorraphy. Arthroscopy 2002;18:770. [61] Lephart SM, Ricmann BL, Fu FH. Introduction to the sensorimotor system. In: Lephart SM, Fu FH, editors. Proprioceptive and neuromuscular control in joint stability. Champaign (IL): Human Kinetics; 2000. p. 7708. [62] Davies GJ, Dickho-Homan S. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sports Phys Ther 1993;18:449. [63] Stein D, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: a review of the literature. Arthroscopy 2002;18:91224. [64] Abrams J, Savoie FH III, Tauro JC, Bradley JP. Recent advances in the evaluation and treatment of shoulder instability: anterior, posterior, and multidirectional. Arthroscopy 2002;18(9 Suppl 2):113. [65] Arciero R, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:58994. [66] Aronen J, Regan K. Decreasing the incidence of recurrence of rst time anterior shoulder dislocations with rehabilitation. Am J Sports Med 1984;12:28391. [67] Kirkley A, Grin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the eectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in rst traumatic anterior dislocations of the shoulder. Arthroscopy 1999;15:50714. [68] Pagnani M, Dome DC. Surgical treatment of anterior shoulder instability in American football players. J Bone Joint Surg Am 2002;84:7115.

604

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

[69] DeBarardino T, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: two- to ve-year follow-up. Am J Sports Med 2001;29:58692. [70] Gill T, Steadman JR. Open repairs for the treatment of anterior shoulder instability. Am J Sports Med 2003;31:14253. [71] Kim S, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy 2002;18:7. [72] Cole B, LInsalata J, Irrgang J, Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization: a two to six-year follow-up study. J Bone Joint Surg Am 2000;82: 110814. [73] Bottoni C, Wilckens JH, DeBarardino TM, et al. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, rst-time shoulder dislocations. Am J Sports Med 2002;30:57680. [74] Karlsson J, Magnusson L, Ejerhed L, Hultenheim I, Lundin O, Kartus J. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion. Am J Sports Med 2001;29:53842. [75] Kailes S, Richmond JC. Arthroscopic vs. open Bankart reconstruction: a comparison using expected value decision analysis. Knee Surg Sports Traumatol Arthrosc 2001;9:37985. [76] Sperber A, Hamberg P, Karlsson J, Sward L, Wredmark T. Comparison of an arthroscopic and an open procedure for posttraumatic instability of the shoulder: a prospective, randomized multicenter study. J Shoulder Elbow Surg 2001;10:1058. [77] Gerber A, Warner JJ. Thermal capsulorrhaphy to treat shoulder instability. Clin Orthop 2002;400:10516. [78] Dugas J, Anderews JR. Thermal capsular shrinkage in the throwing athlete. Clin Sports Med 2002;21:7716. [79] Clark G, Erickson KK, Mikutis J. Thermal capsulorrhaphy for acute or chronic shoulder instability. AORN J 2001;74:80915. [80] Levy O, Wilson M, Williams H, et al. Thermal capsular shrinkage for shoulder instability: Mid-term longitudinal outcome study. J Bone Joint Surg Br 2001;83:6405. [81] Tibone J, Lee TQ, Black AD, Sandusky MD, McMahon PJ. Glenohumeral translation after athroscopic thermal capsuloplasty with a radiofrequency probe. J Shoulder Elbow Surg 2000;9:5148. [82] Savoie FR, Field LD. Thermal versus suture treatment of symptomatic capsular laxity. Clin Sports Med 2000;19:6375. [83] Mishra D, Fanton GS. Two-year outcome of arthroscopic Bankart repair and electrothermal-assisted capsulorrhaphy for recurrent traumatic anterior shoulder instability. Arthroscopy 2001;17:8449. [84] Tauro J. Arthroscopic inferior capsular split and advancement for anterior and inferior shoulder instability. Arthroscopy 2000;16:4516. [85] Neer C, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am 1980;62:897908. [86] Pollock R, Bigliani LU. Glenohumeral instability: evaluation and treatment. J Am Acad Orthop Surg 1993;1:2432. [87] Pollock R, Owens JM, Flatow EL, Bigliani LU. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am 2000;82:91928. [88] Choi C, Ogilvie-Harris DJ. Inferior capsular shift operation for multidirectional instability of the shoulder in players of contact sports. Br J Sports Med 2002;36:2904. [89] van Tankeren E, de Waal Malejt MC, van Loon CJ. Open capsular shift for multidirectional shoulder instability. Arch Orthop Trauma Surg 2002;122:44750. [90] Bak K, Spring BJ, Henderson JP. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med 2000;28:4.

J.T. Finno et al / Phys Med Rehabil Clin N Am 15 (2004) 575605

605

[91] Gartsman G, Roddey TS, Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2 to 5-year follow-up. Arthroscopy 2001;17:23643. [92] Gartsman G, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: two- to ve-year follow-up. J Shoulder Elbow Surg 2001;10: 2836. [93] Joseph T, Williams JS Jr, Brems JJ. Laser capsulorrhaphy for multidirectional instability of the shoulder: an outcome study and proposed classication system. Am J Sports Med 2003;31:2635. [94] Lyons T, Grith PL, Savoie FH III, Field LD. Laser-assisted capsulorrhaphy for multidirectional instability of the shoulder. Arthroscopy 2001;17:2530. [95] Favorito P, Langenderfer MA, Colosimo AJ, Heidt RS Jr, Carlonas RL. Arthroscopic laser-assisted capsular shift in the treatment of patients with multidirectional shoulder instability. Am J Sports Med 2002;30:3228. [96] Fitzgerald BT, Lapoint JM. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg 2002;11:10813. [97] Petersen S. Posterior shoulder instability. Orthop Clin North Am 2000;31:26374. [98] Misamore G, Facibene WA. Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000; 9:4038. [99] Fuchs B, Jost B, Gerber C. Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:1625. [100] Antoniou J, Duckworth DT, Harryman DT II. Capsulolabral augmentation for the management of posteroinferior instability of the shoulder. J Bone Joint Surg Am 2000;82: 122030.