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Posterior instability of the shoulder lennard funk

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Posterior instability of the shoulder - understanding the pathomechanics, clinical assessment and treatment

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Posterior instability of the shoulder lennard funk

  1. 1. Lennard Funk @theshoulderdoc
  2. 2. PLAN Posterior instability:! Pathomechanics! Diagnosis! Management ! Results
  3. 3. HISTORY 20th Century! Plethora of surgical techniques ! Poor results (Hawkins, 1984)! Poor understanding
  4. 4. POSTERIOR RESTRAINTS 1. Capsule! 2. Labrum – Posterior Bankart! 3. Glenoid Shape
  5. 5. POSTERIOR LABRUM
  6. 6. POSTERIOR CAPSULE Thin RHAGL! Mid-capsule
  7. 7. KIM LESION Seung-Ho Kim. Arthroscopy. 2004
  8. 8. REDUCED EXTERNAL ROTATION
  9. 9. GLENOID Version! Deficiencies Semogas, Granville-Chapman & Funk, 2014
  10. 10. GLENOID WEAR
  11. 11. POSTERIOR INSTABILITY 1. Traumatic 2. Atraumatic
  12. 12. ATRAUMATIC Capsular Laxity +/- Muscle Patterning Disorder
  13. 13. TRAUMATIC Contact sports! May be minor! Convulsion
  14. 14. RUGBY SHOULDER INJURIES Malone, Funk, Mohammed, Ball. Shoulder injury patterns in Rugby - the Collision Shoulder. JBJS (Suppl). 2008. ABER Tackle Direct Impact Neurological Lesion 32% 15% Soft tissue Bankart 79% 33% Bony Bankart 26% 11% Posterior Labral Tear 11% 50% SLAP 7% 35% Partial Cuff Tear 32% 12%
  15. 15. Specificity Sensitivity Notes Reference Posterior Drawer Test No data Load & Shift 100% 14% For Laxity Gerber & TRADITIONAL TESTS Ganz. JBJSB. 1984 Posterior Apprehension 99% 20% Jia et al. JBJSA. 2009 Jerk Test 85% 90% posteroinf. labral tear Kim et al. AJSM. 2004 Kim Test 95% 80% posteroinf. labral tear Kim et al. CORR. 1993
  16. 16. MODIFIED O’BRIEN’S TEST (MOB)! WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT) • Conducted in a similar manner to that initially described by O’Brien • Patient asked to forward flex the affected arm 90° with the elbow in full extension. • Adduct the arm fully, medial to the sagittal plane of the body. • Internally rotate so that the thumb points downward. • The examiner then applies a downward force to the arm being resisted by the patient. • The test is considered positive with objective weakness observed by the examiner when downward force on the arm resulted in loss of forward flexion from 90°. Owen, Mackenzie, Boulter, Funk, 2014
  17. 17. MODIFIED O’BRIEN’S TEST (MOB)! WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT) Owen, Mackenzie, Boulter, Funk, 2014
  18. 18. Specificity Sensitivity Notes Reference Posterior Drawer Test No data Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984 Posterior Apprehension 99% 20% Jia et al. JBJSA. 2009 Jerk Test 85% 90% posteroinf. labral tear Kim et al. AJSM. 2004 Kim Test 95% 80% posteroinf. labral tear Kim et al. CORR. 1993 MOB/WPIT 25% 83% Muscular Athletes Owen et al. IJSS. 2014 POSTERIOR INSTABILITY TESTS
  19. 19. MR ARTHROGRAM
  20. 20. GOLFER’S SHOULDER
  21. 21. MUSCLE EFFECTS
  22. 22. JOINT CAPSULE
  23. 23. EXCESS INTERNAL ROTATION
  24. 24. POSTERIOR STABILISATION Arthroscopic superseding Open >85% Success at 2 years ! Lower Morbidity! Easier Revision! Treat Associated Pathology:! Reverse HS; SLAP; Anterior Labrum; Rotator Cuff
  25. 25. OPEN SURGERY Glenoid bone loss > 25%! Failed Revision soft tissue repairs! Massive Reverse Hill-Sachs Lesion! (Reverse HAGL)
  26. 26. EXAMINATION UNDER ANAESTHESIA
  27. 27. BEACH CHAIR POSITION
  28. 28. PORTALS
  29. 29. POSTERIOR GLENOID BONE LOSS
  30. 30. POST-OP
  31. 31. POST-OP Phase 1: (Level 1 Exercises) Core stability & Scapula control! Proprioceptive exercises (minimal weightbearing below 90 degrees)! Active assisted ROM as comfortable (in 'safe zone' )! Do not force or stretch No combined adduction & internal rotation Phase 2: (Level 2 Exercises) Progress active assisted to active ROM as comfortable! Phase 3: (Level 3+ Exercises) Regain scapula & glenohumeral stability working for shoulder joint control rather than range! Gradually Strengthen! Sports-specific rehabilitation - Plyometrics and pertubation training
  32. 32. RESULTS Badge, Tambe, Funk. Arthroscopic isolated posterior labral repair in rugby players. Int J Should Surg. 2009. 143 shoulders; 32m FU Return to Play = 4.3m! Recurrent Instability = 6/143 (5%) Pre-Op Post-Op Constant Score 65 99 Oxford Score 33 18 Oxford Instability Score 52 13
  33. 33. SUMMARY Posterior instability:! Types! Mechanisms! Management ! Results
  34. 34. THANK YOU lenfunk@shoulderdoc.co.uk @theshoulderdoc
  35. 35. @THESHOULDERDOC Full Time / Part Time LENFUNK@SHOULDERDOC.CO.UK

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