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Background: It has been biomechanically demonstrated that 20% to 25% is a critical glenoid bone loss. Recently, there are several reports describing that a bone loss less than 20% to 25% needed to be treated because patients may have decreased quality of life without recurrent instability events. The purpose of this study was to clarify the presence of subcritical bone loss that would affect postoperative instability or quality of life., Methods: Subjects were 43 patients aged≤40years with less than 25% glenoid bone loss who had undergone arthroscopic Bankart repair. These patients were assessed at a mean follow-up of 32months. The Western Ontario Shoulder Instability (WOSI) and Rowe scores were used for the clinical evaluation. Patients were divided in 3 groups based on the percentage of bone loss: group 1: <8%; group 2: 8% to 17%; and group 3: >17%., Results: The recurrence rate was 7% (3/43 shoulders). A weak negative correlation was seen between bone loss and sports/recreation/work domain of the WOSI score (r=-0.304, p=0.0191). The WOSI for group 3 was significantly lower than that for group 1 and 2 (p=0.0009). The male WOSI scores were significantly lower than the female ones (p=0.0471). The WOSI scores of the contact athletes were significantly lower than those of non-contact athletes (p=0.0275). All the patients in Group 3 were males and participated in contact sports., Conclusion: Glenoid bone loss between 17% and 25% is considered to be a "subcritical bone loss" in our series, especially in male patients who are involved in sports or high-level activities., Level of Evidence: III, retrospective study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Anterior shoulder dislocation in the athlete may result in an assortment of injuries that often benefit from surgical stabilization procedures. These injury patterns can be complex, requiring a multimodal approach to treatment. We present a rare case of a traumatic anterior shoulder dislocation in a teenage athlete that resulted in humeral avulsion of the glenohumeral ligament, rotator cuff tear, and axillary nerve palsy. Surgical treatment enabled return to football within 1 year of injury, and full function was restored.

Purpose: Anterior shoulder dislocation can be associated with many lesions such as Bankart lesions, rotator cuff tears (RCT), Hill-Sachs lesions or greater tuberosity fractures. It has been documented that early management of the associated injury affords better recovery of shoulder function. The aim of this study was to highlight the incidence of associated injuries after anterior shoulder dislocation., Methods: A total of 240 patients with traumatic anterior glenohumeral dislocations were subjected to complete history taking, neurovascular assessment and pre-reduction plain X-ray. An X-ray was taken immediately after reduction. Ultrasonography (US) and magnetic resonance imaging (MRI) were done within one week after reduction in all patients. Nerve conduction studies were ordered for any patient with suspected nerve injury., Results: Associated lesions were reported in 144 (60%) patients. RCT was the most common injury (67 cases). It was isolated in 34 patients (14.15%), while it was combined with other lesions in 33 cases (13.75%). Axillary nerve injury was encountered in 38 patients, of them 8 (3.33%) were isolated and 30 (12.5%) were combined. Greater tuberosity fracture was found in 37 patients, of them 15 (6.25%) were combined with axillary nerve injury, and in the other 22 patients (9.17%) the fracture was isolated. All cases with Hill-Sachs and Bankart lesion were combined lesions with no isolated cases. There was a significant relation between the incidence of associated injuries and age, mechanism of injury and the affected side., Conclusions: Lesions associated with traumatic anterior glenohumeral dislocations are more frequent than expected. Thorough clinical examination and detailed imaging including US and MRI are mandatory to avoid a missed diagnosis.

Purpose: To give an overview of current knowledge and guidelines with respect to evidence-based rehabilitation of athletes with glenohumeral instability., Methods: This narrative review combines scientific evidence with clinical guidelines based on the current literature to highlight the different components of the rehabilitation of glenohumeral instability., Results: Depending on the specific characteristics of the instability pattern, the severity, recurrence, and direction, the therapeutic approach may be adapted to the needs and demands of the athlete. In general, attention should go to (1) restoration of rotator cuff strength and inter-muscular balance, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with special attention to the internal rotation ROM, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) gradually increasing the functional sport-specific load on the shoulder girdle. The functional kinetic chain should be implemented throughout all stages of the rehabilitation program. Return to play should be based on subjective assessment as well as objective measurements of ROM, strength, and function., Conclusions: This paper summarizes evidence-based guidelines for treatment of glenohumeral instability. These guidelines may assist the clinician in the prevention and rehabilitation of the overhead athlete., Level of Evidence: Expert opinion, Level V.

Background: Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport., Objectives: The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes., Methods: A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration., Results: This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion., Conclusion: Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

In the shoulder, the advantages of range of motion are traded for the disadvantages of vulnerability to injury and the development of instability. Glenohumeral instability encompasses a broad spectrum of clinical complaints and presentations. The diagnosis can be obvious or entirely unsuspected. Imaging findings depend on numerous factors and range from gross osseous defects to equivocal labral abnormalities and undetectable capsular lesions. This review focuses on the imaging findings in three distinct clinical scenarios: acute first-time shoulder dislocation, chronic instability with repeated dislocation, and chronic instability without repeated dislocation. The biomechanics of dislocation and the pathophysiology of labral-ligamentous injury are discussed. The authors distinguish the findings that occur in the acutely traumatized shoulder from those that typify the chronic unstable joint. The roles of different imaging modalities are also distinguished, including magnetic resonance arthrography and the value of specialized imaging positions. The goal of imaging depends on the clinical scenario. Image interpretation and reporting may need to emphasize diagnosis and the identification of lesions that are associated with instability or the characterization of lesions for treatment planning., (RSNA, 2013)

Thorough evaluation of the athlete with persistent shoulder instability and appropriate use of imaging modalities, such as 3-dimensional computed tomography, can help quantify the severity of bony deficiency. Based on obtained imaging and examination, surgical and nonsurgical methods can be considered. In many situations both the humeral- and glenoid-sided bone loss must be addressed. Depending on the extent of bone loss, athletic demands, and surgeon experience, arthroscopic or open surgical options can provide shoulder stability and return athletes to their prior level of activity., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: This study aimed to evaluate the two-year clinical outcomes of arthroscopic Bankart repair augmented by plication of the inferior glenohumeral ligament (IGHL) via horizontal mattress suturing., Methods: This study was a retrospective analysis of 76 arthroscopic Bankart repairs by a single surgeon from 2004 to 2008. Bioabsorbable suture anchors were used, with anchors placed at the 5:30, 4 and 3 o'clock positions of the right shoulder (correspondingly at the 6:30, 8 and 9 o'clock positions for the left shoulder). The lower most anchor was tied via horizontal mattress suture with plication of the IGHL, while the remaining two anchors were tied using simple sutures. The patients were postoperatively assessed, clinically and using the University of California Los Angeles (UCLA) shoulder rating scale., Results: The mean age of the patients at the time of presentation was 24.09 ± 7.98 years, and the mean duration of follow-up was 28.7 months. The postoperative recurrence rate of dislocation was 7.89% (six shoulders), of which five shoulders required revision surgeries. Excluding the revision cases, clinical assessment of the strength of the supraspinatus and the range of motion of the operated shoulders at two years post operation were either maintained or full in all patients. Analysis of the UCLA results showed pre- and postoperative mean scores of 25.94 ± 3.43 and 33.77 ± 3.07, respectively (p < 0.05)., Conclusion: Arthroscopic Bankart repair augmented by plication of the IGHL and anchored via horizontal mattress suturing is a safe and reliable treatment for shoulder instability, with good clinical outcomes and low recurrence rates.

Athletes, especially in contact and collision sports, are at risk for anterior and, less commonly, posterior glenohumeral instability. Studies have demonstrated that both types of instability can be successfully treated with surgery, using either open or arthroscopic techniques. For athletes with anterior instability, open stabilization has a slightly lower recurrence rate than arthroscopic stabilization. For posterior instability, arthroscopic techniques facilitate a higher rate of return to sport than open techniques. Throwing athletes have been shown to have a lower rate of return to sport after the surgical treatment of both anterior and posterior instability., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Acute shoulder trauma can result in complex injuries to the bone and soft-tissue structures of the shoulder girdle with the associated risk of development of shoulder girdle instability. Destabilizing injuries to the shoulder girdle and fractures of the proximal humerus can occur in predictable patterns based on the injury mechanism. The objectives of this article are to illustrate the relevant anatomy of the shoulder, use 3D modeling and animation to aid in a mechanistic understanding of some of the most common injury patterns, discuss the most relevant radiologic findings that determine the ultimate treatment approach, and discuss an approach to imaging diagnosis with attention to the common treatment strategies., Conclusion: Understanding the force mechanisms responsible for the most common patterns of traumatic shoulder girdle injuries and proximal humeral fractures can improve detection of associated clinically significant secondary injuries, increase the effectiveness of injury classification, and ultimately direct appropriate and timely intervention.

Background: Glenohumeral dislocation commonly results in permanent deformation of the glenohumeral capsule. Knowing the location and extent of tissue damage may aid in improving diagnostic and repair procedures for shoulder dislocations. Therefore, the objectives of this study were to determine: (1) the strain in the anteroinferior capsule at dislocation and (2) the location and extent of injury to the anteroinferior capsule due to dislocation by quantifying the resulting non-recoverable strain., Methods: A robotic/universal force-moment sensor testing system was used to anteriorly dislocate six cadaveric shoulders. The magnitude of the maximum principle strain at dislocation and the resulting non-recoverable strain due to dislocation in the anteroinferior capsule were measured by tracking the change in the location of a grid of strain markers from a reference position., Findings: The glenoid side of the capsule experienced higher strains at dislocation than the humeral side. The greatest strains at dislocation were found on the glenoid side of the anterior band (strain ratio of 0.60), but the greatest non-recoverable strains were found in the posterior axillary pouch (strain ratio of 0.34 on the glenoid side and 0.31 on the humeral side)., Interpretation: These findings suggest that even though the glenoid side of the anterior band undergoes more deformation during anterior dislocation, the most permanent deformation occurs in the posterior axillary pouch, and surgeons should consider also plicating the posterior axillary pouch when performing repair procedures following anterior dislocation. In the future, the mechanical properties of the normal and injured glenohumeral capsules will be compared., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To explore the effect of recurrent anterior shoulder dislocation on the secondary intra-articular injuries through analyzing the correlation between the number of dislocation, disease duration, and the secondary intraarticular injuries., Methods: The clinical data were analyzed retrospectively from 59 patients with recurrent anterior shoulder dislocation who underwent arthroscopic Bankart reconstruction using suture anchor between January 2005 and June 2009. There were 48 males and 11 females, and the average age was 27.6 years (range, 15-42 years). The causes of first dislocation included contact sports (21 cases), non-contact sports (13 cases), daily activities (11 cases), and trauma (14 cases). The average number of preoperative dislocations was 10.6 times (range, 3-32 times). The time between first dislocation and surgery was 11 months to 12 years (median, 5.9 years). The results of apprehension test and relocation test were positive in all patients. The University of California Los Angeles (UCLA) score was 22.3 +/- 2.4, and Constant-Murley score was 73.1 +/- 5.8 preoperatively. According to the arthroscopic findings, the effect of recurrent anterior shoulder dislocation on the secondary intra-articular injuries was analyzed., Results: All incisions healed by first intention, and no early complication occurred. All 59 patients were followed up 37.3 months on average (range, 16-58 months). At last follow-up, UCLA score was 34.6 +/- 1.7 and Constant-Murley score was 86.7 +/- 6.1, showing significant differences when compared with preoperative scores (P < 0.05). The number of preoperative dislocations was positively correlated with the severity of secondary articular cartilage injury (r(s) = 0.345, P = 0.007) and the severity of Hill-Sachs injury (r(s) = 0.708, P = 0.000). The time between first dislocation and surgery had a positive correlation with the severity of secondary articular cartilage injury (r(s) = 0.498, P = 0.000), but it had no correlation with the severity of Hill-Sachs injury (r(s) = 0.021, P = 0.874)., Conclusion: For patients with recurrent anterior shoulder dislocation, early Bankart reconstruction is benefit to functional recovery of shoulder and can avoid or delay the occurrence or development of secondary intra-articular injuries.

Background: The majority of rotator cuff lesions involving the supraspinatus occur at or near the level of bone-tendon interface. We present a series of supraspinatus injuries at the musculotendinous junction., Methods: Between October 2002 and December 2009, we prospectively evaluated all patients presenting with an injury of the supraspinatus at the musculotendinous junction., Results: Five patients (1 female and 4 males) were identified. Three patients had a clear history of trauma. All patients presented acutely with pain and muscular edema on T2 magnetic resonance imaging (MRI) sequences. Lesions were characterized as stretch injuries in 2 cases and complete rupture at the level of the musculotendinous junction in 3 cases. Electrodiagnostic studies were normal in all cases. All patients were treated nonoperatively. On clinical and radiological examination at an average of 24 ± 10 months (range, 10-38), 1 patient had complete clinical and radiological resolution, 1 improved, and 3 who complained of loss of function demonstrated severe fatty infiltration on MRI., Conclusion: Musculotendinous rupture of the supraspinatus is an unusual lesion of the rotator cuff. With incomplete injuries, recovery can be anticipated with nonsurgical management. However, in the case of a complete rupture with muscle retraction, nonoperative management leads to unsatisfactory outcomes., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objectives: To develop a system of quantification of shoulder girdle injuries that stratifies their severity and to assess the association between shoulder girdle injuries and associated nonbony injuries to the head, thorax, and great vessels., Design: Retrospective review., Setting: Level I trauma center., Patients/participants: Trauma registry data from all patients who required admission to the hospital from October 1995 through January 2008, specifically patients with shoulder girdle injuries. Excluded were patients with isolated burns and late effects of injuries., Intervention: Not applicable., Main Outcome Measures: The patterns of shoulder girdle injury and their association with severe, nonorthopaedic injuries (head, thoracic, and great vessel). Also, the severity of all combinations of shoulder girdle injuries were observed using two systems (relative risk totals and injury severity score)., Results: Of 52,924 patients recorded, 2971 had 3811 shoulder girdle injuries. High-energy mechanisms prevailed, causing over 91% of all shoulder girdle injuries. The rates of head, great vessel, and thoracic injury in patients with a shoulder girdle injury were 31.5%, 3.9%, and 36.8%, respectively, and were significant when compared with nonshoulder girdle injuries (P < 0.001). The two most severe injury combinations included a sternum injury with either a clavicle or scapula fracture., Conclusions: Shoulder girdle injuries are strongly associated with great vessel, thoracic, and head injuries. In the presence of a sternum injury with a clavicle fracture or any open clavicle fracture, we recommend the routine use of a contrast-enhanced spiral thoracic computed tomography scan to aid in the diagnosis of a great vessel injury.

Objective: The purpose of this study was primarily to assess the diagnostic performance of magnetic resonance imaging (MRI) in detecting articular cartilage injuries in patients with glenohumeral instability. A secondary purpose was to assess the diagnostic performance of MRI for detection of Hill-Sachs and Bankart lesions., Materials and Methods: A cohort of 87 consecutive patients who underwent diagnostic MRI and shoulder arthroscopy for instability from 1997 to 2006 were identified. Fifty-five patients (63.2%) underwent MRI with intra-articular contrast medium and 32 patients (36.8%) underwent MRI without contrast medium. MR images were reviewed by two radiologists and interpreted by consensus for the presence of articular cartilage lesions (including Hill-Sachs and Bankart lesions), which were then confirmed by reviewing the operative report and images recorded at arthroscopy., Results: Mean patient age was 27.0 ± 10.2 years with a mean clinical and radiographic follow-up of 29 (range 3-72) months. Cartilage injuries were detected arthroscopically in 55 patients (63%). Bankart and Hill-Sachs lesions were identified arthroscopically in 66 patients (75.9%) and 55 patients (63.2%) respectively. The overall sensitivity and specificity for detection of glenohumeral articular cartilage lesions by MRI were 87.2% and 80.6% respectively. The sensitivity and specificity of MRI in detecting Bankart lesions was 98.4% (95% CI 91.9, 99.7) and 95.2% (95% CI 77.3, 99.2) respectively. The sensitivity and specificity of MRI in detecting Hill-Sachs lesions was 96.3% (95% CI 87.6, 98.9%) and 90.6% (95% CI 75.7, 96.9) respectively. No statistically significant difference was found between MRI examinations with and without intra-articular gadolinium (p = 0.89)., Conclusion: Magnetic resonance imaging demonstrates high sensitivity and specificity for the diagnosis of articular cartilage injuries in patients with glenohumeral instability. MRI with or without intra-articular contrast medium in this study were equally reliable as a non-invasive method for assessment of articular cartilage damage of the glenohumeral joint prior to diagnostic arthroscopy.

Although shoulder instability is common in young athletes, there are limited prospective data to guide treatment for competitive athletes who sustain a dislocation mid-season. The management of athletes during their competitive season requires an understanding of the natural history of shoulder instability, the specific needs of the injured athlete (eg, specific sport, player position), and the duration of treatment. Rehabilitation can enable an athlete with a shoulder dislocation to return to play within 3 weeks of injury. Bracing is an option, but it can result in restricted glenohumeral motion and thereby possibly affect performance. Surgical stabilization should be considered for the athlete with recurrent instability or inability to perform; however, this frequently results in the termination of the player's season. In this article, we review the available literature to help guide physicians treating athletes with shoulder instability.

The incidence of shoulder injuries in the paediatric athletic population continues to increase with increased participation particularly in throwing and overhead sports. While soft tissue injuries can occur, the physis remains the weak link and site of injury in many cases. Injury prevention targets proper throwing mechanics and the avoidance of overuse injuries by monitoring the amount of training and number of throws these young athletes are exposed to.

Objectives: We aimed to compare the functional and stability outcomes of the patients with acute anterior shoulder dislocation, who were stabilized at external versus internal rotation., Methods: A total of 33 patients (31 males and 2 females) with the diagnosis of acute primary traumatic anterior shoulder dislocation were immobilized at internal (n=17) or external rotation (n=16). The mean follow-up period was 20.85 months (range 6-41 months). Patients received rehabilitation program immediately after splinting. We assessed functionality by Constant-Murlay score and stability by Rowe scoring system in 6th month. Control examinations were performed in 12th and 24th months., Results: There were no statistically significant differences between internal rotation and external rotation groups in terms of Constant-Murlay and Rowe scores. Recurrent dislocation rate was 6.3% (1/16) in external rotation group and 29.4% (5/17) in internal rotation group (p>0.05). In the subgroup of patients aged between 21-30 years, while no recurrent dislocation was seen in external rotation group, 5 patients developed recurrent dislocation in internal rotation group(p=0.035)., Conclusion: Immobilization of the shoulder in external rotation is an effective technique for prevention of recurrent dislocations in acute anterior shoulder dislocation and should be preferred to traditional splinting in internal rotation in clinical practice.

The shoulder remains one of the more challenging joints for clinicians to clearly identify, diagnose, and treat within the athletic population. Its complexities involving the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints moving in tandem require the physician and rehabilitation specialist to have a comprehensive understanding of the biomechanics and arthrokinematics associated with athletic activity. This chapter focuses on the evaluation, classification, mechanism of injury, and initial treatment of widespread shoulder injuries involved in sports.

Objective: To study the occurrence of shoulder subluxation, shoulder pain in stroke patients and identify factors associated to these conditions during rehabilitation period., Material and Method: Stroke patients from 9 rehabilitation centers from March to December 2006 were enrolled in the present study. All subjects were registered for demographic data including risk factors and type of stroke. They were assessed for motor recovery, cognitive ability, functional ability, psychological reaction and quality of life by using Brunnstrom stage, Thai Mental State Examination (TMSE), Barthel ADL Index (BI), Hospital Anxiety and Depression Scale (HADS) and WHOQOL-BREF questionnaires respectively at the beginning and the end of the present study. The occurence of shoulder subluxation and shoulder pain were recorded and then were analyzed for the associated factors. All subjects received the conventional rehabilitation program until they reached their rehabilitation goals or discharge criteria., Results: Of 376 stroke patients, 327 met the inclusion criteria, 62 patients (19%) were found to have shoulder pain and 122 (37%) patients had shoulder subluxation. Shoulder pain was significantly more frequent in subjects with shoulder subluxation (odds ratio (OR) 2.48, 95% confidence interval (CI) 1.38-4.46) and at 2-6 months after stroke onset (OR 4.0, 95% CI 2.06-7.79). Shoulder subluxation was significantly associated with hemorrhagic type of stroke (OR 2.06, 95% CI 1.08-3.93), loss of proprioceptive sensation (OR 3.03, 95% CI 1.26-7.29) and negatively associated with Brunnstrom's stage of arm recovery (OR 0.44, 95% CI 0.34-0.56). No significant functional and quality of life impact was found from these conditions., Conclusion: Post stroke shoulder pain and subluxation were common during the rehabilitation period. Shoulder pain significantly occurred within 6 months after stroke onset and increased risk in patients with shoulder subluxation. Shoulder subluxation was correlated with Brunnstrom's stage, proprioceptive loss and hemorrhagic type of stroke.

Background: Previous cadaveric studies suggest that positioning the shoulder in an externally rotated position reduces displaced Bankart lesions through a coaptation effect., Hypothesis: We hypothesized that positioning the glenohumeral joint in an externally rotated position creates contact pressure between the subscapularis and the anterior labrum., Study Design: Descriptive laboratory study., Methods: Eight cadaveric shoulders were used. Contact pressure between the subscapularis and labrum was measured in varying glenohumeral positions using a Tekscan pressure monitor. The position of the anterior band of the inferior glenohumeral ligament was also digitized in those positions. All shoulders were tested in the intact condition, following a surgically created Bankart lesion and following anterior shoulder dislocation. These conditions were also verified by measuring glenohumeral translation and joint forces., Results: For all 8 specimens, the contact pressure between the subscapularis and the anterior labrum was negligible with the humerus externally rotated up to 90 degrees at all abduction angles in intact, surgically created Bankart, and dislocated specimens. There were several glenohumeral positions where the anterior band of the inferior glenohumeral ligament strain in the intact specimens was similar to the postdislocation condition, that is, no statistically significant difference between intact and dislocated specimens. These positions included 30 degrees of glenohumeral abduction with external rotation between 0 degrees and 60 degrees, as well as 45 degrees of abduction with external rotation of 0 degrees and 60 degrees. The anterior band of the inferior glenohumeral ligament strain and glenohumeral anterior-posterior translation measurements revealed that the surgically created Bankart lesion does not simulate the conditions after anterior dislocation of the shoulder., Conclusion: External rotation of the shoulder does not create contact pressure between the subscapularis and the anterior labrum before or after anterior dislocation., Clinical Relevance: The efficacy of external rotation immobilization after anterior-inferior shoulder dislocation is not likely to be related to coaptation of the Bankart lesion by the subscapularis.

Sports-related shoulder pain and injuries represent a common problem. In this context, glenohumeral instability is currently believed to play a central role either as a recognized or as an unrecognized condition. Shoulder instabilities can roughly be divided into traumatic, atraumatic, and microtraumatic glenohumeral instabilities. In athletes, atraumatic and microtraumatic instabilities can lead to secondary impingement syndromes and chronic damage to intraarticular structures. Magnetic resonance (MR) arthrography is superior to conventional MR imaging in the diagnosis of labro-ligamentous injuries, intrinsic impingement, and SLAP (superior labral anteroposterior) lesions, and thus represents the most informative imaging modality in the overall assessment of glenohumeral instability. This article reviews the imaging criteria for the detection and classification of instability-related injuries in athletes with special emphasis on the influence of MR findings on therapeutic decisions.

Objectives: We retrospectively evaluated patients who underwent arthroscopic treatment for superior labrum anterior posterior (SLAP) lesions combined with antero-inferior labral detachment (Bankart lesion, Maffet type 5)., Methods: The study included eight male patients (mean age 31.8 years; range 23 to 50 years) who were treated with suture anchors for type 5 SLAP lesions. In all the patients the symptoms started after trauma, and all presented with shoulder instability findings. The range of motion was measured in the sitting position by a goniometer, and muscle force was assessed manually. In addition, Speed and O'Brien tests and Jobe relocation test were performed. All the patients were examined by standard shoulder magnetic resonance scans. Functional results were evaluated according to the UCLA (University of California at Los Angeles) shoulder score, and the Rowe rating scale for Bankart repairs. The mean follow-up was 37.8 months (range 24 to 52 months)., Results: Functional results were excellent-good in five patients, fair in two patients, and poor in one patient. The mean UCLA score increased from a preoperative 15 (range 14-17) to a postoperative 30 (range 20-35), with a corresponding increase in the mean Rowe score from 25 (range 15-45) to 81 (range 50-95) (p<0.05)., Conclusion: Arthroscopic repair of combined Bankart and SLAP lesions may present technical difficulties. Nevertheless, it is possible to get good results in selected patients in whom intraarticular pathologies are diagnosed and treated appropriately.

Aim: Until now it is unknown to what extent malpositioning of the scapula is a relevant factor in shoulder instability that should be considered in therapy. The objective was to analyse 3D-scapular kinematics and humeral head (de-)centering in patients with atraumatic and/or traumatic shoulder instability and to investigate the correlation between the two factors., Method: The shoulders of 28 healthy volunteers and of 14 patients each with atraumatic or traumatic instability were examined in various arm positions - with and without muscle activity - using open MR imaging. After 3D reconstruction, analyses of scapular kinematics and glenohumeral translation were performed., Results: In atraumatic unstable shoulders, the scapular position [30 degrees of abduction: scapulo-humeral rhythm: 3.5 +/- 2.6 : 1 vs. healthy 2.4 +/- 1.3 : 1; internal rotation: 59 +/- 9 degrees vs. healthy 49 +/- 3 degrees (p < 0.05)] and humeral head position was significantly decentered in both planes (p < 0.05). While the correlation between the two factors was high during passive elevation (r = 0.60-0.87), it was low during muscular activity (r = 0.25-0.62). In patients with traumatic instability no alterations of the scapula kinematics were observed. Significant humeral head decentering (p < 0.05) occurred only during abduction and external rotation., Conclusions: Patients with atraumatic instability demonstrated significant alterations of scapular kinematics and decentering of the humeral head. In traumatic instability a decentering occurred only in specific arm positions with no changes in scapula position. Because of the high correlation between the two factors, physiotherapeutic strategies for the scapula-stabilising muscles should be adapted to the direction of instability.

Superior labral anterior-to-posterior (SLAP) lesions can cause shoulder pain partly by causing glenohumeral instability. The purpose of this study was to examine the effect of a simulated type II SLAP lesion and subsequent repair on glenohumeral translation of the vented shoulder. In eight cadaver joints, a robotic/UFS testing system was used to measure joint translation by applying an anterior, posterior, or inferior load of 50 N to each shoulder. The "apprehension tests" for anterior and posterior instability were simulated by applying an anterior load of 50 N with an external rotation torque of 3 Nm or a posterior load of 50 N with an internal rotation torque of 3 Nm. Each loading condition was applied at 30 degrees and 60 degrees of glenohumeral abduction with a constant joint compressive load (44 N) to the intact, simulated SLAP lesion, and repaired shoulder. Repair of the type II SLAP was then performed by placing a Suretac through the labrum both anterior and posterior to the biceps anchor and testing was repeated. ANOVA was used to compare translation of the intact joint, the joint after the type II SLAP lesion had been simulated, and after repair. At 30 degrees of abduction, anterior translation of the intact vented shoulder joint from anterior loading was 18.7+/-8.5 mm and increased to 26.2+/-6.5 mm after simulation of the type II SLAP lesion ( p< or =0.05). The arthroscopic repair did not restore anterior translation (23.9+/-8.6 mm) to the same degree as the intact joint ( p> or =0.05). At 60 degrees of abduction, anterior translation of 16.6+/-9.6mm in the intact joint was not significantly increased at 19.4+/-10.1 after simulation of the type II SLAP lesion ( p=0.0527). AP loading also resulted in inferior translation. At 30 degrees of abduction it was 3.8+/-4.0 mm in the intact joint and increased to 8.5+/-5.4 mm after the type II SLAP lesion ( p< or =0.05. After repair the inferior translation decreased significantly to 6.7+/-5.3 mm ( p< or =0.05). Although inferior translations were less at 60 degrees of abduction, results were similar to those at 30 degrees after repair. There were no significant increases in translation after SI/AP combined external rotation torque or posterior-anterior combined internal rotation torque loading. In this study the repair of a type II SLAP lesion only partially restored translations to the same degree as an intact vented shoulder joint. Therefore, improved repair techniques or an anteroinferior capsulolabral procedure in addition to the type II SLAP lesion repair might be needed to restore normal joint function.

The superior labral-biceps-tendon-complex forms an anatomical and functional unit and combines static and dynamic elements of shoulder stability. At present, only theoretical hypotheses exist on the etiology of the microtraumatic SLAP-II-lesion. To gain further insight into this, an instrument was developed to simulate throwing motions such as the late-cocking/early acceleration phase as well as deceleration/follow-through. Sixteen freshly frozen shoulder specimens were tested, varying the loads on the biceps tendon (25 N, 50 N, 100 N) and the compression of the humeral head against the glenoid (25 N, 50 N, 80 N). Each shoulder had to run through a certain number of cycles during the particular phase of throwing. The tests were stopped after a SLAP-II-lesion was observed, or after a limit of 15,000 cycles. Every 1,000 cycles the results of the tests were checked arthroscopically. A SLAP-II-lesion developed in only 10% of the specimens during the acceleration/ late cocking phase whereas in the deceleration/ follow-through phase 83% developed such a lesion. According to our results, the deceleration/follow-through of the throwing motion seems to be responsible for creating microtraumatic SLAP-II-lesions. One reason is the loss of the centering function of the long head of the biceps tendon during total internal rotation, another is the increased posterosuperior translation of the humeral head in this position, which leads to a non-physiological contact, creating lesions in this area due to the large sheering forces.

Axillary nerve injuries still go undiagnosed far too often despite their frequency. However the quality of the outcome depends on expert management and prompt surgery. To optimise the latter, we re-examined 83 operated cases of traumatic lesions of the axillary nerve. We analysed the neurological and functional recovery of these patients by means of a follow-up evaluation at 6 years postop. The results were classified by age, mechanism of injury, delay to surgery and the presence or otherwise of associated neurological or osteo-articular lesions. We highlighted that a high index of suspicion ought to exist in all cases of trauma to the shoulder in a patient aged more than 40, any injury associated with palsy of the long head of triceps and in the case of an osteo-articular lesion due to high-velocity trauma. A complete lack of shoulder abduction must always prompt a search for a lesion of the axillary nerve as well as a suprascapular nerve palsy or rotator cuff lesion. There are few literature reports of surgical management of this particular nerve injury. An early MRI scan as part of the management should improve results by a reduction in the delay before surgery. As a result of our investigation we conclude that a lesion of the axillary nerve without signs of recovery at 3 months should be referred to a centre specialized in peripheral nerve surgery.

Background: American football players have been reported to be at high risk for postoperative instability after arthroscopic stabilization of anterior shoulder instability. While some authors have recommended open methods of stabilization in athletes who play contact sports, there are few data in the literature showing more favorable results with use of an open technique. We reviewed the results of an open technique of anterior shoulder stabilization in fifty-eight American football players after a minimum of two years of follow-up., Methods: Fifty-eight American football players underwent open stabilization with use of a standardized technique for the treatment of recurrent anterior shoulder instability. Forty-seven patients had recurrent dislocations, and the remaining eleven had recurrent subluxations. The average age of the patients was 18.2 years, and the average duration of follow-up was thirty-seven months. Patients were evaluated according to the shoulder scoring system of the American Shoulder and Elbow Surgeons and with use of the shoulder instability score described by Rowe and Zarins., Results: There were no postoperative dislocations. Postoperative subluxation occurred in two patients, neither of whom had had a dislocation prior to the operation. Forward flexion and external rotation returned to within 5 of those of the contralateral shoulder in forty-nine patients. The average score according to the system of the American Shoulder and Elbow Surgeons was 97.0 points, and the average Rowe and Zarins score was 93.6 points. Fifty-five patients had a good or excellent result, and fifty-two of the fifty-eight returned to playing football for at least one year. One patient was forced to stop playing because of recurrent instability., Conclusions: Open stabilization is a predictable method of restoring shoulder stability in American football players while maintaining a range of motion approximating that found after arthroscopic stabilization. Postoperative stability appears to be superior to that reported after arthroscopic techniques in this population of patients.

The aim of this study was to evaluate the evolution of intraarticular disease in posttraumatic shoulder instability. Ninety-one patients with posttraumatic shoulder instability were examined arthroscopically. The intraarticular disease was recorded on a special documentation sheet (containing 67 descriptive items). The patients were divided into 5 subgroups: first-time dislocation (n = 9); first or second recurrence (n = 12); 3 to 5 recurrences (n = 23); 6 or more recurrences (n = 32); and chronic subluxations (n = 15). All data were examined statistically. Each lesion was correlated with stage of evolution, age, and number of recurrences. The most frequent lesions were regrouped into "lesion families." The initial and most constant lesion was the periosteal disinsertion of the anteroinferior labrum (single lesion). The labral detachment was succeeded in a second stage by the disinsertion of the glenohumeral ligament complex (double lesion). With additional recurrences, stress mechanisms altered the detached structures through tissue damage (triple lesion). The fourth stage saw the extension of the degenerative process, which led to failure at the insertion site and destruction of the labrum-ligament complex (quadruple lesion). This study reveals that recurrences progressively damage stabilizing structures. A pathophysiological classification into 4 stages is proposed, however, that would permit a precise therapeutic strategy for arthroscopic shoulder stabilization.

Objective: Post-traumatic recurrent dislocation is a major problem in the operative treatment of shoulder dysfunction in young athletes. This prospectively designed study evaluates the long-term results of a modified Eden-Hybinette procedure in young male athletes. The criteria were: capacity in sports, functional limit, and persistent pain. Genuine disorders of the glenoid or muscular imbalance of the shoulder joint were criteria for exclusion., Patients and Methods: From 1982 to 1990, 143 patients underwent surgery. Seventy percent were reevaluated within a minimum period of 18 months after the operation. The functional results were calculated using the ROWE score as well as a visual analog scale (VAS). X-rays were done after the patient had given informed consent., Results: VAS and ROWE score showed excellent/good results in 61%, fair results in 18%, and poor results in 21% of the documented cases. The rate of arthrosis was 25%. Redislocation occurred in 7%, mainly without any relevant trauma. The X-rays showed complete resorption of the bone graft in 30% of the cases. Best functional results and no redislocation were found in the patients who underwent surgery with fewer than 3 dislocations compared to those with more than 4 dislocation episodes., Conclusions: In cases of post-traumatic recurrent dislocation of the shoulder in young athletes, the modified Eden-Hybinette procedure is a good method of reestablishing sufficient stability of the shoulder. The operation should be performed prior to the 3rd dislocation episode. Four or more dislocation episodes show an increased tendency to redislocate and poor functional results.

This study evaluates the role of the glenoid labrum and capsule in the prevention of shoulder dislocation. Fifteen shoulder joints from nine fresh cadavers were used. The labrum and capsule were cut into sections 5 mm wide, and the strength of each slice to rupture was measured. The rupture site was observed microscopically. The anterior-inferior portion was the weakest, with a mean force necessary to cause rupture of 3.84 +/- 1.00 kg/5 mm. The rupture site was the portion of the labrum close to the cartilage of the glenoid. Histologic structure and degenerative changes of the labrum did not differ in the anterior to posterior portions. These results show that the anterior-inferior portion of the labrum is relatively weak. This finding may explain the lesion commonly identified in anterior shoulder dislocation.

Classification of glenohumeral instability is confusing. We think that the existence of trauma, directions of instability, voluntarism, and other factors make classification difficult. The purpose of this article is to create a new classification. One hundred eighty-nine patients with glenohumeral instability involving 207 joints (mean patient age 21.5 years) were subjects of this investigation. Our new classification, which is composed of three main factors (level of trauma, direction of instability, and voluntarism) and some subfactors, simplified it quite well. Abbreviations also make it easier to indicate each joint's condition. About half the subjects had no trauma or mild trauma. Two thirds of the joints with more than one dislocation or subluxation showed instability in other directions in addition to the direction of dislocation or subluxation. This classification is very useful to compare pathogenesis and results of treatment in patients with glenohumeral instability.

The shoulder complex is particularly vulnerable to neurovascular injuries due to its intimate anatomical relationship with the brachial plexus and axillary vessels. Therapists, trainers, and physicians who cover athletic events witness the violence of injury to the neck and shoulder. Fortunately, permanent neurovascular deficits are rare, and many are subtle. However, tragically, some can be career-ending and even life-threatening. Neurovascular injuries may occur in association with musculoskeletal injury or as an isolated finding. Symptoms may present on an acute basis or in a chronic fashion. On the playing field or in the emergency room, focus is often placed on the obvious musculoskeletal injury, ie., dislocation or fracture. Medical personnel must always have a high index of suspicion of neurovascular injuries to the shoulder complex to avoid misdiagnosis. They must consider that failure to progress in rehabilitation for musculoskeletal injuries may be secondary to a previously unrecognized neurovascular lesion. The purpose of this review is to provide a basic reference for diagnosis and treatment of neurovascular injuries to the shoulder complex for therapists, trainers, and physicians. Also, we hope to raise the index of suspicion for neurovascular injuries during evaluation of patients with common shoulder injuries. The review is organized by location and association with specific musculoskeletal injuries.

We report on two 16.5-year-old ski-jumpers who sustained unusual glenohumeral joint injuries. The first fell on landing, the other while running out. Neither could give any indications as to the pathomechanics of the injuries, thus illustrating the high speed nature of the trauma.

Anterior glenohumeral instability is an important cause of shoulder disability in athletes. Recurrent glenohumeral instability can seriously impair the athlete's performance. Since the surgical repair of recurrent instability may result in a loss of flexibility, particularly in the thrower and gymnast, the physician must optimize both joint stability and joint flexibility.