S P E C I A L F O C U S
Sports Medicine
Posterior shoulder instability
Brett A. Fritsch and Dean C. Taylor
ABSTRACT
We provide a review of the recent literature of management of
posterior instability of the shoulder. Clarification in defining this
problem and an overview of the ever-expanding anatomical
injuries associated with increased posterior translation of the
humerus are discussed. Particular attention is paid to the
caspulolabral ligamentous complex and the rotator interval
because these anatomical regions have provided the focus for
several recent investigations into both the role played by
particular anatomical constraints to shoulder motion and the
techniques for manipulation of these constraints to treat these
injuries. Several clinical papers have been published recently
reporting the results of surgical management of posterior
instability, reflecting the trend towards arthroscopic surgery
and anatomical reconstruction of these injuries and the
associated improvement in outcomes.
Keywords
posterior instability, rotator interval, shoulder dislocation
INTRODUCTION
M
anagement of posterior shoulder instability con-
tinues to be a challenging problem. Definition
and diagnosis of this entity remain difficult,
particularly in subtle cases. The use and misuse of the termi-
nology surrounding the problem further add to the confu-
sion. Nonetheless, there is continual progress in overcoming
these issues with an ever-increasing recognition of the
anatomical lesions associated with pathological humeral
translation and evolving surgical techniques to treat these
injuries. Recent biomechanical studies shed new light on the
role played by specific components of the shoulder capsule,
in particular, the capsular ligaments in the rotator interval
region and the various openings between these ligaments.
While these investigations challenge some long-held views
regarding surgical manipulation of these structures, they
allow for further advances in treatment of this challenging
clinical entity.
Sports Medicine Section, Duke University Medical Center, Durham, North
Carolina
Correspondence to Dean C. Taylor, MD, Professor of Surgery, Division of
Orthopaedic Surgery, Box 3615, Duke University Medical Center,
Durham, NC 27710
Tel: þ 919 668 1894; fax: þ 919 681 6357;
e-mail: dean.taylor@duke.edu
1940-7041 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
32 Current Orthopaedic Practice
DEFINITION
Defining a dislocation is easy: complete loss of contact bet-
ween articulating surfaces of a diarthrodial joint. Defining
the syndrome of posterior instability is not easy. Separating
physiologic glenohumeral translation (laxity) from pathologic
movements for a given individual is difficult. A given transla-
tion may indicate laxity in one person but instability in
another; even within a single individual the same translation
may at one time be considered laxity only and at another be
considered instability. The key distinction is the presence of
symptoms. Glenohumeral translation that is uncomfortable
(either with pain, apprehension, weakness, or other) defines
the movement as being unstable; the amount that the hume-
ral head has translated does not. Reproduction of symptoms
with translation in a given direction defines that direction as
part of the instability syndrome. Similar (or even greater) tran-
slations in other directions that do not reproduce symptoms
are considered laxity. The factors that make a given translation
symptomatic are yet to be elucidated. Laxity may progress
along the continuum to instability after a given event, but
the exact factor that induces this transition is unclear. This
concept is particularly important in delineating patients with
posterior instability from those with multidirectional instabi-
lity or laxity. Multidirectional instability has been defined
as involuntary symptomatic shoulder laxity in more than
one direction,1 frequently using a positive sulcus sign to add
the direction of inferior instability. However, we consider the
presence of a sulcus sign as insignificant if it is asymptomatic.
The overall concept is simple. Increased glenohumeral trans-
lation that produces symptoms is considered instability.
Translation that is not symptomatic is considered laxity. The
direction in which the symptoms are reproduced defines the
direction(s) of instability.
EPIDEMIOLOGY
The lack of a consensus on defining posterior instability
makes the exact determination of its prevalence or in-
cidence difficult. Increasing awareness of the condition
and appreciation of the clinical manifestations of subtle
instability are increasing the frequency of its diagnosis. A
prevalence of 5% of all shoulder instabilities is frequently
reported, although rates of 2--11.6% can be found in the
literature.2,3 In a report of new instability, events over a
9-month period in over 4100 military cadets, 10.3% were
diagnosed with posterior instability and a 9.4% were
classified with multi-directional instability.4 Most of the
patients with posterior instability were men, between 20--30
years of age. They tended to be active and many were
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Current Orthopaedic Practice
TABLE 1. Factors in classifying posterior instability
Volition  Psychological
 Positional
 Muscular
Initiating event  Clearly traumatic
 Clearly atraumatic
 Cumulative microtrauma
Degree  Dislocation
 Instability without dislocation
Direction  Unidirectional posterior
 Bidirectional---
posterior þ inferior
 Multidirectional
Etiology/identifiable  Bony
pathoanatomy
 Soft tissue
Static constraints
Dynamic constraints
Chronicity  Acute
 Acute on chronic
 Chronic
contact and overhead athletes. Most patients reported an
initiating traumatic event, but a documented occurrence of
a posterior dislocation requiring reduction is uncommon. In
four reports that recorded this information, only 17 of the
74 patients (23%) undergoing surgery for posterior instabil-
ity reported having had a dislocation requiring reduction.5--8
CLASSIFICATION
Several authors have proposed classification symptoms;
however, the difficulty in arriving at a consensus definition,
the multi-factorial nature of the syndrome, and the rapidly
evolving understanding of the pathoanatomy and bio-
mechanics make a definitive classification system an elusive
goal. Nonetheless, the process of attempting to classify each
component of an individual’s presentation is a useful process
to rigorously weight the multiple contributing factors, to
guide the search for pathoanatomy and in turn focus appro-
priate management. For this reason, we use a combination of
several classifications systems in assessing an individual who
presents with posterior instability (Table 1).
Of interest are recent changes in the understanding of the
significance of volition. Previously, any patient who could
consciously demonstrate posterior instability would be
considered a poor surgical candidate, but recent publica-
tions identify a subgroup in whom this is not the case. The
key point is to differentiate the ‘‘willful’’9 or ‘‘habitual’’10
dislocator from the ‘‘positional’’ group. The former harness
unbalanced muscular force couples, often in response to
initial secondary gain motives and respond poorly to
surgery. The latter have recognized and can reproduce (or
avoid) provocative arm positioning, which is a reflection of
pathoanatomy rather than a psychological disturbance. This
group should not be excluded from surgery.11,12
PATHOANATOMY
Increased understanding of the specific anatomical factors
working to constrain translation as the arm is moved
through its range of motion has allowed identification
of the particular anatomical abnormalities that result in
www.c-orthopaedicpractice.com | 33
TABLE 2. Pathoanatomy of posterior instability
1. Static
a. Bony
i. Glenoid morphology
1. Post-traumatic glenoid deficiency
2. Glenoid hypoplasia
ii. Glenoid version---increased retroversion
iii. Humeral head defects---Reverse Hill-Sachs
b. Soft-tissue
i. Posterior capsulo-labral complex
ii. Posterior chondrolabral structures
iii. Posterior capsular injury
iv. Reverse HAGL
v. Coracohumeral ligament
2. Dynamic
a. Muscle---rotator cuff
b. Biceps tendon
c. Scapulothoracic function
HAGL, humeral avulsion glenohumeral ligament.
instability (Table 2). Through biomechanical studies, im-
proved radiographic imaging (particularly MRI) and arthro-
scopic examination, these lesions are being identified, and
repair of these lesions is forming the basis for improving
surgical stabilization.
Recent work is focused on the modes of failure of the post-
erior labrum and associated capsuloligamentous complex.
Posterior Labrum
The posterior labrum differs from its anterior counterpart
in that it is attached less intimately to the surrounding
capsuloligamentous reinforcements.13 This less intimate
attachment allows for an increased possibility of both
posterior instability without a reverse Bankart lesion or for
a reverse Bankart lesion without instability. However, there
is increasing recognition of capsulolabral injuries in patients
with recurrent posterior instability, particularly of traumatic
origin. Cadaver studies have shown an injury to the poster-
ior labrum in 70% of posterior dislocations,14 and several
recent publications confirm high rates of injury. A capsulo-
labral injury was reported in 83% of patients with postero-
inferior instability operated on by Antoniou et al.,15 while
all surgical patients of both Williams et al.7 and Kim et al.16
had a capsulolabral injury. Most recently Bottoni et al.17
reported that 30 of 31 patients with recurrent posterior
instability had posterior glenolabral or capsulolabral injury.
These studies confirm the high rate of pathologic changes
in patients with a history of traumatic injury in whom non-
operative treatment failed. The current literature continues
to trend towards identification of these anatomic lesions
that can be treated with surgical reconstruction. An ever
expanding ‘‘alphabet soup’’ of acronyms (Table 3) describe
the subtle variations in the failure modes of this mechanism.
Some of these are almost ‘‘hidden’’ to cursory examination,
and focused attention on their sites of occurrence is required
to avoid missing the lesion.
Posterior Capsuloligamentous Complex
The posterior capsule itself plays an important role in
maintaining stability. When the arm is brought into forward
34 | www.c-orthopaedicpractice.com Volume 21  Number 1  January/February 2010

TABLE 3. Classification of posterior labral injuries associated with recurrent instability

Reverse Bankart
Posterior labrocapsular
periosteal sleeve avulsion
(POLPSA)
Kim’s lesion
Posterior glenolabral articular
disruption lesion (GLAD)
Extensive posterior labral tears
Unclassifiable posterior labral
tears
1. The posteroinferior labrum is detached from the glenoid with a tear of the scapular periosteum
and no significant erosions of the adjacent glenoid articular surface
2. MR arthrogram demonstrates the detachment of the labrum with an associated tear of the scapular
periosteum
3. These are more common in patients with a traumatic history18
A similar detachment of the labrum, but with an associated avulsion of the adjacent periosteum
without complete detachment. This creates a sleeve that may be filled with fibrous tissue and
will require reduction to reduce the labrum
1. A concealed, intra-substance detachment of the deep part of the posteroinferior labrum from
the glenoid rim with a separate marginal crack on the surface19
2. The labrum does not appear to be detached on initial inspection and probing of the deep part
of the labrum is required to identify the lesion
3. This partial detachment needs to be converted to a complete detachment of the labrum that can
then be reattached to the glenoid rim
1. Recently described in the posteroinferior capsulobral junction20 these lesions involve a disruption
of the chondral surface of the glenoid and a subtle tear of the adjacent labrum
2. Patients with posterior instability and associated chondral defects are reported to have a poorer
outcome from surgery than those without8
1. These are tears as part of Type VIII and IX SLAP lesions, 270-3601 labral tears, and other
combinations
2. Their proper identification allows for avoidance of incomplete labral repair as tears which extend
in length > 15 mm are significantly associated with posterior instability21

flexion and internal rotation, the posterior band of the by focused strengthening and proprioceptive retraining pro-
inferior glenohumeral ligament is the primary ligamentous grams. A directed rehabilitation program improves stability
restraint to posterior humeral head translation. In this and decreases pain in approximately two-thirds of patients
position, the orientation of this ligament is anteroposterior, with posterior or multidirectional instability.32,33 This
thus preventing posterior translation of the humeral head.22 continues to be our initial approach in most patients with
In the flexed, adducted, and internally rotated position, the a focus on strengthening of the dynamic stabilizers of the
posterior capsule and the coracohumeral ligament also act rotator cuff (particularly infraspinatus) and periscapular
to limit posterior translation.22--25 The posterior capsule itself musculature.
frequently is injured after posterior dislocation. In a cadaver
study by Weber and Caspari,14 the capsule was injured in
100% of posterior dislocations, and several studies implicated Operative
permanent stretching of the capsule (even in the absence Either failure to return to full activity or continued symp-
of any labral tear) as a cause of recurrent posterior and toms of posterior instability are indications for operative
multidirectional instability.26,27 In recent years, failure of the
capsular attachments to the humerus has been recognized as
a cause of recurrent instability in a subset of patients.28,29 In
a series of nine patients in which this capsular failure was
present, no defects were identified on preoperative imaging.
Retrospective review of MR arthrography by the treating
surgeon, however, identified six defects.30 Routine viewing
of the posterior capsule through an anterior portal is needed
to make a complete assessment and avoid missing this
uncommon cause of recurrent instability. Bui-Mansfield et
al.31 have proposed a nomenclature for anterior and poster-
ior HAGL (humeral avulsion of the glenohumeral ligaments)
lesions based on the exact site of failure of the ligament that
is useful in communicating this increasingly recognized
cause of recurrent instability (Figure 1).

TREATMENT FIGURE 1. Bui-Mansfield nomenclature for posterior humeral avulsions.

Nonoperative
The mainstay of management of posterior instability is
nonoperative treatment. The altered kinematics observed in
posterior and multidirectional instability can be improved
Figure represents an artist’s rendering of normal appearance of inferior
glenohumeral ligament (IGHL) and posterior band lesions in axial and coronal
planes. A, anterior; P, posterior; PHAGL, posterior humeral avulsion of the
glenohumeral ligament; PBHAGL, posterior bony humeral avulsion of the
glenohumeral ligament; PIGHL, posterior inferior glenohumeral ligament.
Reprinted with permission from AM J Sports Med. 2007; 35:1960–1966.
Current Orthopaedic Practice
intervention. The athletic population and those with a
traumatic etiology are less likely to respond to nonoperative
management. Burkhead and Rockwood34 reported good or
excellent outcomes with nonoperative treatment in 89%
of patients with an atraumatic etiology, but only 16% of
patients with traumatic subluxation obtained similar results.
Results of nonoperative management in the young, athletic
population also have been relatively poor when followed for
7 to 10 years,35 and we have a lower threshold for operative
intervention in this group.
Capsulolabral Repair
Most patients require reattachment of the injured posterior
capsulolabral complex. Current literature focuses on optimiz-
ing soft-tissue labral fixation to the glenoid along with
demonstrating the safety of portals used to access the entire
labrum. Fixation techniques have evolved from open tech-
niques to bioabsorbable tacks to suture anchors of various
configurations. These suture anchors give improved versati-
lity, and most recent authors use them for fixation. These
repairs are being combined with capsular plication techni-
ques, rotator interval closures, or both, to increase the success
of surgery, particularly in patients in whom nonoperative
treatment has failed, or those who have less significant labral
detachments, hyperlaxity, or capsular stretching.
Rotator Interval
Weitbrecht36 first described this anatomic region in the
18th century and Rouviere37 provided further description in
the 19th century. The term ‘‘rotator interval’’ was first used
by Neer in 1970 and defined by the space between the
supraspinatus and subscapularis, bordered medially by the
coracoid.38 Since then the term rotator interval (RI) has
tended to refer to different anatomical structures, depending
upon its context of use. When used in conjunction with
repair of the rotator cuff, authors frequently use ‘‘rotator
interval’’ to designate the soft-tissue connections between
the supraspinatus and subscapularis. When used in refer-
ence to glenohumeral instability, the RI frequently is used
to refer to the capsular structures between the anterior
portion of the supraspinatus and the superior border of the
subscapularis tendons.39 There are multiple anatomic con-
tributions to this area of capsule, and much variation in
its constituents and openings.40 It is these rotator interval
capsular openings (RICO) that can be arthroscopically
manipulated and the basis for modern closure techniques.
The seminal work on the role of this anatomical region to
glenohumeral translation was that of Harryman et al.25 They
showed that imbrication of the ‘‘rotator interval capsule’’
decreased posterior translation in the flexed, adducted arm.
This study has been used as the basis for ‘‘closure’’ of the RI
in many subsequent publications. The problem, however, is
that the clinical closures described do not replicate Harry-
man’s work. While Harryman et al.25 described a medial-
to-lateral imbrication of only the coracohumeral ligament
(CHL), most arthroscopic in-vivo operative techniques tend
to employ a cranial-caudal RICO closure of the middle
glenohumeral ligament to the superior glenohumeral liga-
ment,41--44 capsular structures that were not studied in
www.c-orthopaedicpractice.com | 35
Harryman’s work. Comparing these RICO closures to Harry-
man’s work, which altered only the CHL, and calling them
both a ‘‘rotator interval closure’’ is a flawed extrapolation.
Recently, several biomechanical studies have examined
these RICO closures and have shown that they do not affect
posterior translation of the humeral head.45,46 A further
study by Mologne et al.47 combining these RICO closures
with repair of the labrum (a common clinical scenario)
confirmed no additional effect on posterior translation
conferred by the RICO closure when compared with the
labral repair alone. Indeed it appears that while a RICO
closure does not alter posterior translation, it does in fact
decrease anterior translation.46,48 We do not advocate
routine RICO closure in patients with posterior instability
and prefer to await ongoing biomechanical investigations of
the individual capsular structures in the RI region before
advocating operative manipulation of these components in
patients with posterior instability.
Capsular Volume
Increased capsular volume and laxity have been implicated
in posterior instability. While accurate measurement of
these entities is difficult, the presumption forms the basis for
the accepted use of an inferior capsular shift as the surgical
treatment of choice. Dewing et al.,49 using MR arthrography
to measure the cross-sectional area of the capsule, have
shown significantly greater total cross-sectional area in
patients with posterior and multi-directional instability
(but not those with anterior instability) compared with
controls. Arthroscopic techniques are evolving that mimic
(or improve) the traditional gold standard open inferior
capsular shift. Sekiya et al.50 have shown in a cadaver model
that multi-pleated suture plication of the capsule can
diminish capsular volume at least as effectively, or in some
reports, more effectively as the open capsular shift. Also, in
a cadaver model, Flanigan et al.51 achieved reproducible
results regarding the percentage of capsular volume reduc-
tion produced by incremental plication of the capsule.
Multiple suture placement techniques that achieve capsular
plication have been described.16,52 These techniques include
isolated ‘‘tucks’’ in the capsule to reduce capsular volume
and methods that incorporate the inferior capsule into the
labral repair, shifting it superiorly in the process of fixing
it to the glenoid. Where the capsule is redundant, but
the labrum is intact, the plicated capsule may be attached
directly to the intact labrum.
Operative Results
Bottni et al.17 achieved good results from operative stabiliza-
tion in 31 patients with posterior instability in whom all had
a traumatic etiology. Using a combination of open (12 of 31)
and arthroscopic (19 of 31) repairs, they reported 26 good or
excellent (84%), 3 fair (9.6%) and 2 poor (6.4%) results. Of
the patients with fair and poor results, bioabsorbable tacks,
thermal capsulorrhaphy or both had been used in four of the
five patients. Tacks and capsulorrhaphy have since been
supplanted by the use of suture anchors and techniques for
capsular plication, respectively. The prospective study by
Bradley et al.53 evaluated 100 patients with isolated posterior
36 | www.c-orthopaedicpractice.com
instability treated with arthroscopic posterior capsulolabral
reconstruction. Their technique was tailored to the indivi-
dual pathology to include capsulolabral plication either to
the labrum (when it was not detached), to the glenoid in
combination with labral reattachment using anchors, or one
of the above plus additional plication sutures. At an average
of 27 months, 89% had good or excellent results in regards
to stability, and 89% had returned to sports (74% of the total
at the same level).53 Similarly, Radkowski et al.54 recently
reported 107 athletes with isolated posterior instability who
were treated with arthroscopic reconstructions in which the
reconstruction was tailored between capsular plication
alone, capsulolabral repair without suture anchors, capsu-
lolabral repair with suture anchors, or capsulolabral repair
with anchors plus capsular plication. They achieved good or
excellent results in 89% of the throwers and 93% of the
nonthrowers.54 They did report that throwing athletes were
less likely to return to their preinjury sporting level (55%)
than nonthrowers (71%). These publications are representa-
tive of the recent literature in that they record a transition to
arthroscopic reconstruction, an anatomic reconstructive
approach focusing on the labrum and capsulolabral struc-
tures, and good to excellent results in most patients who are
deemed suitable for surgical intervention.
CONCLUSION
In treating posterior shoulder instability, identification and
classification of increasingly subtle anatomic abnormalities
have refined and improved anatomic repairs and recon-
structions. Cadaver and biomechanical studies continue
to clarify the precise role of anatomical components to
instability, most significantly that of the posterior labrum,
rotator interval capsule and capsular volume. The classic,
but frequently misrepresented, work of Harryman et al.25 has
been augmented by the understanding that modern arthro-
scopic techniques do not recreate the plication he described.
The assumed stretching of the posterior capsule with
recurrent instability has been demonstrated and multiple
arthroscopic techniques have been described to predictably
treat it. The sum of these developments are clinical papers
reflecting the transition from open to arthroscopic repairs,
using appropriate patient selection and anatomic repairs
with resulting improved outcomes.
ACKNOWLEDGMENT
The authors acknowledge the assistance of Donald T. Kirkendall in the
preparation of this manuscript.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period
of review, have been highlighted as:
 of special interest
 of outstanding interest
1. Neer CS, Foster CR. Involuntary inferior and multidirectional
instability of the shoulder. Inst Course Lect. 1985; 34:232--238.
2. McLaughlin H. Posterior dislocation of the shoulder. J Bone Joint
Surg. 1952; 24:584--590.
Volume 21  Number 1  January/February 2010
3. Wolf EM, Eakin CL. Arthroscopic capsular plication for posterior
shoulder instability. Arthroscopy. 1998; 14:153--163.
4. Owens BD, Duffey ML, Nelson BJ, et al. The incidence and
 characteristics of shoulder instability at the United States
Military Academy. Am J Sports Med. 2007; 35:1168--1173.
A descriptive study identifying the epidemiology of shoulder
instability within an active population. Prospective collection of
data within a captured population of over 4000 military recruits in
a 1 year period is used to identify the epidemiologic characteristics
of instability in this active group.
5. Gouiber JN, Iserin A, Duranthon LD, et al. A 4-portal arthro-
scopic stabilisation in posterior shoulder instability. J Shoulder
Elbow Surg. 2003; 12:337--341.
6. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic
treatment of posterior shoulder instability: two-year results of
a multiple suture technique. Arthroscopy. 1997; 13:426--432.
7. Williams RJ III, Strickland S, Cohen M, et al. Arthroscopic repair
for traumatic posterior shoulder instability. Am J Sports Med.
2003; 31:203--209.
8. Wolf BR, Strickland S, Williams RJ III, et al. Open posterior
stabilisation for recurrent posterior glenohumeral instability.
J Shoulder Elbow Surg. 2005; 14:157--164.
9. Pande P, Hawkins R, Peat M. Electromyography in voluntary
posterior instability of the shoulder. Am J Sports Med. 1989;
17:644--648.
10. Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the
shoulder. A preliminary report on a clinical, electromyo-
grasphic, and psychiatric study of twenty-six patients. J Bone
Joint Surg. 1973; 55:445--460.
11. Millett PJ, Clavert P, Hatch GF III. Recurrent posterior shoulder
instability. J Am Acad Orthop Surg. 2006; 14:464--476.
12. Robinson CM, Aderinto J. Recurrent posterior shoulder in-
 stability. J Bone Joint Surg. 2005;87:883--892.
A good review paper with excellent overview of classifications and
decision making for treatment of posterior shoulder instability.
13. Bey MJ, Hunter SA, Kilambi N, et al. Structural and mechanical
properties of the glenohumeral joint posterior capsule.
J Shoulder Elbow Surg. 2005;14:201--206.
14. Weber SC, Caspari RB. A biomechanical evaluation of the
restraints to posterior shoulder dislocation. Arthroscopy. 1989;
5:115--121.
15. Antoniou J, Duckworth DT, Harryman DT. Capsulolabral
augmentation for the management of posteroinferior instability
of the shoulder. J Bone Joint Surg. 2000;82:1220--1230.
16. Kim SH, Ha KL, Park JH. Arthroscopic posterior labral repair
and capsular shift for traumatic unidirectional recurrent poster-
ior subluxation of the shoulder. J Bone Joint Surg. 2003;85:
1479--1487.
17. Bottoni CR, Franks BT, Moore JH, et al. Operative stabilization
 of posterior instability. Am J Sports Med. 2005;33:996--1002.
Case series of consecutive patients undergoing operative (open
and arthroscopic) posterior stabilization. Reports the pathological
lesions frequently identified, and the results of operative stabiliza-
tion in these patients.
18. Amrami KK, Savcenko V, Dahm DL, et al. Radiologic case study.
Reverse Bankart lesion with posterior labral tear. Orthoapedics.
2002;25:779--780.
19. Kim SH, Ha KL, Yoo JC, et al. Kim’s lesion: an incomplete and
 concealed avulsion of the posteroinferior labrum in posterior or
multidirectional posteroinferior instability of the shoulder.
Arthroscopy. 2004;20:712--720.
A frequently referenced paper describing a difficult to identify lesion
of the posterior labrum.
20. Anderson M, Barr M, Gaskin C, et al. Posterior GLAD Lesions of
the Shoulder (Scientific Presentation). Radiological Society of North
America; 2005. Chicago, IL: RSNA; 2005.
21. Tung GA, Hou DD. MR arthrography of the posterior labro-
capsular complex: relationship with glenohumeral joint align-
ment and clinical posterior instability. Am J Roentgen. 2003;180:
369--375.
22. Blasier RB, Soslowsky LJ, Malicky DM, et al. Posterior gleno-
humeral subluxation: active and passive stabilisation in a
biomechanical model. J Bone Joint Surg. 1997;79:443--450.
Current Orthopaedic Practice
23. Gerber C, Ganz R. Clinical assessment of instability of the
shoulder with special reference to anterior and posterior drawer
tests. J Bone Joint Surg. 1984;66:551--556.
24. Harryman DT, Sidles JA, Clark JM, et al. Translation of the
humeral head on the glenoid with passive glenohumeral
motion. J Bone Joint Surg. 1990;72:1334--1343.
25. Harryman DT, Sidles JA, Harris SL, et al. The role of the rotator
 interval capsule in passive motion and stability of the shoulder.
J Bone Joint Surg. 1992;74:53--66.
The seminal work on the effect of the rotator interval (and its
manipulation) on shoulder motion. Whilst it forms the basis for
many surgical manipulations of the rotator interval it is frequently
misrepresented in extrapolating this work to the in vivo setting, and
recent similar cadaveric investigations have found conflicting results.
26. Matsen FA, Chebli C, Lippitt S. Principles for the evaluation and
management of shoulder instability. J Bone Joint Surg. 2006;88:
648--659.
27. Pollock RG, Bigliani LU. Recurrent posterior shoulder instabil-
ity: diagnosis and treatment. Clin Orthop Relat Res. 1993;291:
85--96.
28. Laurencin CT, Paletta GA, Potter H, et al. Disruption of the
posterior-lateral shoulder capsule. J Shoulder Elbow Surg. 1995;4:
391--394.
29. Safran O, DeFranco M, Hatem S, et al. Posterior humeral avulsion
of the glenohumeral ligament as a cause of posterior shoulder
instability: a case report. J Bone Joint Surg. 2004;86:2732--2736.
30. Castagna A, Snyder SJ, Conti M, et al. Posterior humeral
 avulsion of the glenohumeral ligament: a clinical review of
9 cases. Arthroscopy. 2007;23:809--815.
The largest series (9 patients) in the literature of rHAGL injuries,
highlighting the poor sensitivity of imaging modalities in identify-
ing this injury, and the need for rigorous inspection of the posterior
capsule both on imaging, and during arthroscopy, in order to
identify this uncommon cause of posterior instability.
31. Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the
glenohumeral ligaments: the HAGL lesion. Am J Sports Med.
2007; 35:1960--1966.
32. Hurley JA, Anderson TE, Dear W, et al. Posterior shoulder
instability: surgical versus conservative results with evaluation
of glenoid version. Am J Sports Med. 1992; 20:396--400.
33. Tibone JE, Bradley JP. The treatment of posterior subluxation in
athletes. Clin Orthop Relat Res. 1993; 291:124--137.
34. Burkhead WZ, Rockwood CA. Treatment of instability of the
 shoulder with an exercise program. J Bone Joint Surg. 1992;74:
890--896.
Good review of the success of nonoperative treatment in regards to
etiology of the instability. Emphasizes the poor results of non-
operative treatment in those patients with a traumatic etiology.
35. Misamore GW, Sallay PI, Didelot W. A longitudinal study of
patients with multidirectional instability of the shoulder with
seven- to ten-year follow-up. J Shoulder Elbow Surg. 2005;14:
466--470.
36. Weitbrecht J. Syndesmology. Philadelphia: W. B. Saunders
Company; 1742.
37. Rouviere H. Anatomie Humaine: Descriptive et topographique.
In: Delmas A, ed. Vol 3. Paris: Libraires de l’academie de
medecine; 1875:35--51.
38. Neer CS. Displaced proximal humeral fractures, I: classification
and evaluation. J Bone Joint Surg. 1970;52:1077--1089.
39. Gartsman GM, Taverna E, Hammerman SM. Arthroscopic
 rotator interval repair in glenohumeral instability: description
of an operative technique. Arthroscopy. 1999;15:330--332.
Technical note on arthroscopic rotator interval technique that
forms the basis for common in vivo interval closures.
40. DePalma AF. Surgery of the Shoulder. 2nd ed. Philadelphia: JP
Lippincott; 1973.
41. Cole BJ, Mazzocca AD, Meneghini RM. Indirect arthroscopic
rotator interval repair. Arthroscopy. 2003; 19:E28--E31.
42. Karas SG. Arthroscopic rotator interval repair and anterior portal
closure: an alternative technique. Arthroscopy. 2002; 18:436--439.
www.c-orthopaedicpractice.com | 37
43. Lewicky YM, Lewicky RT. Simplified arthroscopic rotator
interval capsule closure: an alternative technique. Arthroscopy.
2005; 21:1276.
44. Taverna E, Sansone V, Battistella F. Arthroscopic rotator interval
repair : the three-step all-inside technique. Arthroscopy. 2004;
20:105--109.
45. Plausinis D, Bravman JT, Heywood C, et al. Arthroscopic rotator
 interval closure: effect of sutures on glenohumeral motion
and anterior-posterior translation. Am J Sports Med. 2006;34:
1656--1661.
Cadaveric paper investigating effect of arthroscopic techniques
for RI closure on motion and translation, showing that these
techniques limit anterior translation with no reduction in posterior
translation.
46. Provencher MT, Mologne TS, Hongo M, et al. Arthroscopic
 versus open rotator interval closure: biomechanical evaluation
of stability and motion. Arthroscopy. 2007;23:588--592.
Cadaveric paper investigating the effect of open and arthro-
scopic rotator interval closure on shoulder motion. Highlights that
the structures imbricated differ with the open and arthroscopic
techniques, and that both techniques have little effect on posterior
translation.
47. Mologne TS, Zhao K, Hongo M, et al. The addition of
 rotator interval closure after arthroscopic repair of either
anterior or posterior shoulder instability. Effect on glenohum-
eral translation and range of motion. Am J Sports Med. 2008;
36:1123--1131.
Excellent cadaveric paper investigating the effect of rotator inter-
val closure when performed in addition to Bankart repair. This
reproduces a common clinical scenario, as well as replicating the
common arthroscopic technique used in vivo for interval closures.
48. Yamamoto N, Itoi E, Tuoheti Y. Effect of rotator interval closure
on glenohumeral stability and motion: a cadaveric study.
J Shoulder Elbow Surg. 2006;15:750--758.
49. Dewing CB, McCormick F, Bell SJ, et al. An analysis of capsular
 area in patients with anterior, posterior, and multidirectional
shoulder instability. Am J Sports Med. 2008;36:515--522.
Clinical series using MRI to measure capsular dimensions in a series
of patients with anterior, posterior, and multidirectional instability
and comparing them to controls. Identifies increased cross-sectional
capsular area in those patients with posterior and multi-directional
instability.
50. Sekiya JK, Willobee JA, Miller MD, et al. Arthroscopic multi-
 pleated capsular plication compared with inferior capsular shift
for reduction of shoulder volume in a cadaveric model.
Arthroscopy. 2007;23:1145--1151.
Cadaveric investigation comparing the degree of capsular volume
reduction achieved using an arthroscopic capsular plication tech-
nique, and an open capsular shift technique. Demonstrates that
arthroscopic plication is comparable (or slightly better in this
investigation) to the open capsular shift technique in reducing
capsular volume.
51. Flanigan DC, Forsythe T, Orwin J, et al. Volume analysis of
arthroscopic capsular shift. Arthroscopy. 2006;22:528--533.
52. Hewitt M, Getelman MH, Snyder SJ. Arthroscopic management
of multidirectional instability: pancapsular plication. Orthop
Clin N Am. 2003;34:549--557.
53. Bradley JP, Baker CL, Kline AJ, et al. Arthroscopic capsulolabral
 reconstruction for posterior instability of the shoulder. Am J
Sports Med. 2006;34:1061--1071.
Cohort study (Level 2 evidence) reporting the results of arthroscopic
capsulolabral reconstruction in contact and noncontact athletes
with isolated posterior instability. A good paper for identification of
the success of this procedure in these populations.
54. Radkowski CA, Chhabra A, Baker CL, et al. Arthroscopic
 capsulolabral repair for posterior shoulder instability in throw-
ing athletes compared with non-throwing athletes. Am J Sports
Med. 2008;36:693--699.
Cohort study (Level 2 evidence) reporting the results of arthroscopic
capsulolabral repair in throwing versus nonthrowing athletes.