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Chengdu instability clinical examination

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Chengdu instability clinical examination

  1. 1. Shoulder Instability Clinical Examination Manos Antonogiannakis Director of Center for Arthroscopy & Shoulder Surgery IASO General Hospital
  2. 2. History: degree of violence Level of athletic participation number of dislocations Age of the patient Clinical examination: Generalized Joint laxity direction of aprehension dictates treatment
  3. 3. Contributors to stability Static stabilizers 1. ligamentous structures labrum and capsule 2. bony configuration of glenoid and humeral head Dynamic stabilizers 1. rotator cuff 2. scapula muscles
  4. 4. Clinical examination
  5. 5. Laxity vs. Instability LAXITY Looseness of stabilizers Asymptomatic Control of joint position INSTABILITY Abnormal joint movement Symptomatic Pain, Subluxation, Dislocation Loss of control of Joint Position
  6. 6. Clinical examination
  7. 7. Active Range of Motion
  8. 8. Passive Range of Motion
  9. 9. Examination Under Anesthesia
  10. 10. Check for generalized Hyperlaxity Hyperlaxity Knee recurvatum Elbow hyperextention Thumb to wrist Increased Shoulder ROM
  11. 11. Laxity Testing – Hawkins Classification Grade 0 = No Translation Grade 1 = HH moves slightly up face of glenoid Grade 2 = HH rides up glenoid face to but not over the rim - subluxation Grade 3 = HH rides up and over the rim - dislocation Hawkins, 1987, Can J Sport Sci
  12. 12. Laxity Testing – Hawkins Modification On Clinical Examination The examiner feels: • HH go over the rim (Grade 2) or • Not over the rim (Graded 1) or • Dislocation (Grade 3) Modified Hawkins scale is the most valid and reproducible method for reporting laxity McFarland 2006
  13. 13. Shoulder Tests • Over 114 tests have been described, so far • Not all of them are reliable, reproducible, specific, accurate • Only some of them have been validated • You DO NOT NEED ALL of them
  14. 14. Posterior Drawer Test • Supine • Shoulder out of the table • Zero – loose packed position • Hold wrist • Elbow flexion • Other hand=thumb anterior over the HH and fingers posterior to feel the move • Thumb presses posterior to sublux/dislocate HH • Release pressure • Grade according to Hawkins Classification Posterior Laxity Testing Gerber & Ganz 1984
  15. 15. Posterior Drawer Test Young, ASYMPOMATIC athletes, 65% of females, 50% of males Demonstrate Posterior Drawer Test Grade II laxity = Sublux McFarland, 1996, AJSM It is normal to be able to subluxate posteriorly in young athletes Posterior Laxity Testing
  16. 16. Posterior Drawer Test • Asymmetry of laxity between one patient’s shoulder is common. NOT to be mistaken for instability • Shoulder laxity increases under anesthesia • Grade III laxity (=dislocation) is very uncommon even under anesthesia Linter, 1996, AJSM McFarland, 2006 Posterior Laxity Testing
  17. 17. Anterior Drawer Test • Patient Supine • Zero position, wrist to the examiner’s hip • One hand over the shoulder to stabilize (thumb on the coracoid, fingers over the shoulder to the spine of the shoulder • Other hand to the upper arm, appying some axial load, anterior force and roll HH • Release force • Grade according to Hawkins Classification Anterior Laxity Testing Gerber & Ganz 1984
  18. 18. Load and Shift Test • Sitting or supine • One hand stabilizes scapula as on ant drawer test • Arm is held on the proximal humerus in 20ABD, 20FF, NEU R • Load HH to the glenoid • Apply anterior and then posterior force while keeping the load • Grade according to Hawkins Classification Laxity Testing Silliman and Hawkins, 1993
  19. 19. Push-Pull Test • Supine • Hold the wrist, elbow 90 flexion, 90ABD, scapular plane, NEU R • Other hand midhumerus, applies posterior force • Grade according to Hawkins Classification Matsen, 1990 Posterior Laxity Testing
  20. 20. Sulcus Sign • Sitting or Supine • Forearms on midfemur, • Both arms pulled inferiorly simultaneously from the elbow • Then on each shoulder separately (once in INT R and repeat on EXT R) Inferior Laxity Testing Neer & Foster, 1980
  21. 21. Sulcus Sign Inferior Laxity Testing Neer & Foster, 1980 Positive = dimple at the subacromial area
  22. 22. Sulcus Sign • If increased translation with the arm in external rotation, consider Rotator Interval lesion Inferior Laxity Testing Ferrari, 1990, AJSM Harryman, 1992, JBJS Warner, 1992, AJSM
  23. 23. Sulcus Sign Inferior Laxity Testing Grade I : < 1cm Grade II: 1 - 2cm Grade III: > 2cm Or Grade I = Low Grade Grade II & III = High Grade High Grade Sulcus Sign shows LAXITY, NOT INSTABILITY Better not to be Graded, but reported as POSSITIVE or NEGATIVE
  24. 24. Sulcus Sign Inferior Laxity Testing No study defines how much inferior shoulder laxity indicates structural insufficiency that requires surgical treatment Normally there is a wide range of inferior laxity in the shoulder It is very uncommon to reproduce patients symptoms when performing the Sulcus sign Sulcus Sign measures inferior laxity and reflects instability only when reproduces symptoms
  25. 25. Hyperabduction (Gagey) Test • Sitting patient • Examiner behind, stabilizes with his forearm (or palm) the scapula and abducts in 0FF and NEU R until the scapula starts moving. • Measure the abduction • The Range of Passive Abduction (RPA) should be <105° Positive for laxity of inferior glenohumeral complex if RPA>105 ° Laxity Testing Gagey, 2001, JBJS
  26. 26. Hyperabduction (Gagey) Test Laxity Testing Gagey, 2001, JBJS
  27. 27. Anterior Drawer as an Instability Test Anterior Instability Testing The same maneuver as for the Anterior Drawer test for laxity, but the patient reports the test reproduces the sensation of instability. Limited sensitivity (McFarland, 2003) It is not necessary for patients that have confirmed ant. instability by other tests or history. Gerber & Ganz, 1984
  28. 28. Apprehension Test Anterior Instability Testing Rowe, 1981, JBJS Standing, sitting or supine (scapula unsupported) One hand holds the wrist in 90 ABD, 90EXT R, 0FF If the Other hand applies a gentle pressure anteriorly Positive if patient becomes apprehensive and complained for pain May be positive in more EXT R or ABD Not positive at the same position for all patients. May be positive in thoracic outlet syndrome (pain & weekness)
  29. 29. Apprehension Test Anterior Instability Testing Pain is not predictive of traumatic instability. The Apprehension Test is important for true anterior instability when it produces apprehension, but not when reproduces pain alone McFarland, 2006 Speer, 1994, AJSM
  30. 30. Apprehension Test Anterior Instability Testing Test in deferent abduction angles indicates: 45° anterior labrum and capsule lesion 90° anterior & inferior labrum and capsule lesion 120° lesion extends posteriorly Rockwood & Wirth, 1996
  31. 31. Variations of Apprehension Test Anterior Instability Testing Augmentation Test Instead of gentle anterior pressure, apply acute anterior pressure. Can be painful or dislocate Silliman & Hawkins, 1993, Clin. Orth
  32. 32. Variations of Apprehension Test Anterior Instability Testing Fulcrum test Examiners fist is placed behind the shoulder on the table, acts as a fulcrum Matsen & Kirby, 1982, Orth Clin North Am
  33. 33. Relocation Test Anterior Instability Testing Jobe, 1989 First was described for internal impingement in throwing athletes causing pain. Same as for the Apprehension Test (supine) When apprehension is felt, a posterior force is applied by the other palm, that releases Apprehension in overt instability cases or Pain in covert instability on internal impingement So the EXT R can be advanced
  34. 34. Relocation Test Anterior Instability Testing Jobe, 1989 The relocation test is not helpful for the anterior instability diagnosis when pain is used as a criterion for a positive result. The apprehension and relocation test can cause pain in patients with a variety of conditions or diagnosis and they are not reliable when pain is used as a positive result. The relocation test when causes pain may have a role in SLAP diagnosis.
  35. 35. Release Test Anterior Instability Testing Can be performed as a continuity to Relocation Test When patient is relaxed from the posterior applied force, advance EXT R and acute release the posterior pressure. If you do not advance EXT R but just release the posterior pressure, the test is called Surprise Test Lo, 2004, AJSM Can be very painful and has a potential to dislocate shoulder. Silliman & Hawkins, 1993, Clin. Orth
  36. 36. Combined Tests Apprehension – Relocation - Release Anterior Instability Testing
  37. 37. Combined Tests Anterior Instability Testing Apprehension test Relocation test Release/Surprise test Reliable diagnosis of Traumatic Anterior Instability Reliable diagnosis of Occult Anterior Instability ?
  38. 38. Posterior Apprehension Test Posterior Instability Testing Patient sitting or standing FF90, ADD in line with the body and slight INT R, while pushing posteriorly, along the humeral axis. Positive when causes apprehension. Kessel, 1982
  39. 39. Posterior Apprehension Test Posterior Instability Testing BUT: The original position of Kessel is the resting position of the head after posterior subluxation. The real position of Apprehension is different in every patient When (rarely) posterior apprehension test is positive, the patient usually have posterior instability The exact position that joint subluxes posteriorly in most patients with posterior instability is highly variable, so finding the exact location to produce a subluxation is difficult. Hawkins, 1984, JBJS & McFarland, 1990
  40. 40. Posterior Subluxation Test (Miniaci Test) Posterior Instability Testing Patient sitting or supine FF90, ADD and INT R, while pushing posteriorly, along the humeral axis. The other hand is behind the patient’s shoulder to feel the relationship of the HH to the Glenoid rim Then the arm is brought back to extended position and a clunk may be felt when the HH is relocates. Clarnette & Miniaci, 1998, Med Sci Sports Exerc
  41. 41. Push-Pull Test • Supine • Holds the wrist, elbow 90 flexion, 90ABD, scapular plane, NEU R • Other hand midhumerus, applies posterior force • Positive If produces pain or reproduces symptoms • Local Anesthetic to subacromial space differentiate pain from tendinitis • Other test for posterior laxity maybe used for posterior instability (Posterior Drawer Test and Load and Shift Test) Matsen, 1990 Posterior Instability Testing
  42. 42. Sulcus Sign Inferior Instability Testing As previously described for evaluating inferior laxity, but here it reproduced the symptoms. Positive Sulcus Sign only if reproduces symptoms Neer, 1985, Instr Course Lect
  43. 43. Sulcus Sign Inferior Instability Testing High grade Sulcus without reproducing symptoms tends to MDI overdiagnosis In High Grade Sulcus, the major restrain to inferior translation with the arm aside is the SuperiorGHL and the CoracoHumeralL. Sulcus does not reflect laxity in Inferior GH complex because with the arm adducted, that complex is not stressed with an inferior load
  44. 44. Feagin Test (Inferior Apprehension Test) Inferior Instability Testing Standing, Patient places his elbow on examiners shoulder who is standing at his side Examiners hand circulate above shoulder and apply inferior force. Positive = apprehension or reproduces symptoms Compare with the other side Faegin, 2004
  45. 45. Generalized Ligamentous Laxity Criteria: Relative risk factor for surgical treatment But NOT a Contraindication
  46. 46. Generalized Ligamentous Laxity
  47. 47. Generalized Ligamentous Laxity Increased Shoulder ROM
  48. 48. Tests for SLAP lesions • More than 55 tests have been already described • Non of them is accurate alone or pathogonomonic • O’Brien • Anterior Slide Test • SLAPprehension Test • Biceps Load Test 1 • Biceps Load Test 2 • Compression Rotation Test (Crank Test)
  49. 49. O’ Briens Test (active compression test) • Patient sitting or standing • Ff 90, ADD 10-15 deg, max INT R (thumb down) and resist downward force • Repeat in supination • Loads AC joint and Superior Labrum • Pain indicates SLAP or AC joint pathology O’ Brien, 1988
  50. 50. Biceps Load Test 1 • Patient standing or sitting • Examiner behind, ABD 90, EXT R 90, palm forward (as in apprehension test) produces pain • Then resisted active elbow flexion releases pain • Positive = Pain release • Indicates SLAP lesion in anterior instability cases Kim, 1999, Arthroscopy
  51. 51. Biceps Load Test 2 • Similar to BLT1, • but patient supine, • ABD 120 deg, elbow flexion, palm up • Resisted active elbow flexion, elicits or increase pain (the opposite to BLT1) • Indicates SLAP lesion Kim, 2001, Arthroscopy
  52. 52. SLAPprehension test • Similar to O’Briens, but repeat with the arm in supination • Positive = pain eliminated with supination • Indicates SLAP lesion Berg, 1998
  53. 53. Anterior Slide Test • Patient standing, puts hands on hips, thumbs pointing back • Examiner back, one hand holds shoulder and the other pushes the elbow anteriorly and superiorly • Positive if produces pain • Indicative of SLAP lesion Kibler, 1995, Arthroscopy
  54. 54. Compression Rotation Test (Crank Test) • Patient Supine • FF 90, elbow flexed 90, axial compression and internal and external rotation • Pain and click makes test positive, similar to McMurray test for the knee
  55. 55. Locked posterior dislocation is easily missed Locked external rotation