The document discusses atraumatic shoulder instability, providing 4 scenarios of 16-year-old girls with unstable shoulders. It describes how to differentiate instability from hyperlaxity and covers the static and dynamic stabilizers of the shoulder. The clinical assessment of atraumatic instability includes assessing contributions from the traumatic history, structural factors like the sulcus sign, and range of motion tests like the Gagey sign. Classification systems for instability including Rockwood and Stanmore are presented.

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Atraumatic Instability-
Principles and assessment
Puneet Monga
Consultant Orthopaedic Shoulder Surgeon

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Scenario 1
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and can demonstrate shoulder
dislocation in clinic…..but has no pain or other
symptoms.
• Hyperlax?
• Unstable?
• Management?

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Scenario 2
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and dislocates her shoulder
when swimming. It is very painful and she has
been to Casualty 5 times.
• Hyperlax?
• Unstable?
• Management ?

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Scenario 3
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and dislocates her shoulder
every morning. Mum feels “queasy” and daughter
has missed school for weeks.
• Hyperlax?
• Unstable?
• Management ?

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Scenario 4
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and injured her shoulder when
fell off a horse 3 months ago. Since then it keeps
coming out of the joint on relatively minor tasks.
• Hyperlax?
• Unstable?
• Management ?

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Defining Instability

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Instability
• “Symptomatic” “abnormal translation” of
humeral head
• Important to differentiate from hyperlaxity

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Understanding Instability

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Understanding Stability
Static Stabilisers
Bone

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Anterior Posterior

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Anterior Posterior

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Anterior Posterior

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Anterior Posterior

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Hill Sach’s lesion
Bony Bankart’s
Anterior Posterior

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Reverse
Hill Sach’s lesion
Reverse Bony
Banakart’s
Anterior Posterior

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Understanding Stability
Static Stabilisers
Bone
Labrum

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Wheel Chocks

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Understanding Stability
Static Stabilisers
Bone
Labrum
GH ligaments

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Attachments
Image courtesy: www.pitt.edu

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Understanding Instability

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MR Arthrogram

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Instability Arthroscopy

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Understanding Instability

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HAGL
Humeral Avulsion Gleno humeral ligament

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Understanding Stability
Static Stabilisers
Bone
Labrum
GH ligaments
Dynamic Stabilisers
Rotator Cuff
Periscapular muscles
+ +

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Concavity compression
Lippitt, Matsen; CORR
“Lad Hugging a Ball”

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Scapulo-humeral balance
+ +

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Atraumatic Instability

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Atraumatic Instability

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Atraumatic Instability

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Atraumatic Instability
• Disruption of dynamic stabilisers.
• Weak Muscles
• Muscle incoordination
• In a predisposed shoulder i.e.
• Lax capsule
• Shallow Glenoid

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Atraumatic instability

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Understanding Stability
Static Stabilisers
Bone
Labrum
GH ligaments
Dynamic Stabilisers
Rotator Cuff
Periscapular muscles
+ +
Proprioceptors

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Classification

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Classification
• Rockwood
• Type I; traumatic. h/o prior dislocation
• Type II; traumatic. no prior dislocation
• Type III; atraumatic. a) with, b) without psychiatric
issues
• Type IV; involuntary

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Classification
• Thomas and Matsen
• TUBS;Traumatic Unidirectional Bankart’s Surgery
• AMBRII;Atraumatic Multidirectional Bilateral Rehab
Inferior Capsular shift

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Classification
• Gerber
• Static
• Dynamic
• Voluntary

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ClassificationFigure 5: The Stanmore classification of instability
It is apparent from the above discussion that the presentation of patients with instability
can vary significantly and hence for the purposes of this study only patients with
recurrent anterior glenohumeral dislocations following a traumatic episode were
included.
Treatment of traumatic anterior shoulder dislocation may range from initial
immobilization followed by rehabilitation to early operative stabilization. The patient’s
Stanmore triangle

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Understanding Instability
Tuesday, 24 May 16
Atraumatic Instability
Tuesday, 24 May 16
+++ +
Tuesday, 24 May 16
Figure 5: The Stanmore classification of instability
It is apparent from the above discussion that the presentation of patients with instability
can vary significantly and hence for the purposes of this study only patients with
recurrent anterior glenohumeral dislocations following a traumatic episode were
included.
Treatment of traumatic anterior shoulder dislocation may range from initial
immobilization followed by rehabilitation to early operative stabilization. The patient’s
age, previous dislocations, joint laxity, co-morbidities, compliance and activity level
Tuesday, 24 May 16

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Clinical Assessment

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Age at Presentation
Ref; Matsen et al

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History
• Usually begins with a minor injury/innocuous
event/s.
• Tilts a compensated “at risk” shoulder
towards symptomatic instability.
• Ask about position of instability

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Assessment
Assess contributions from the three poles
@shoulderpedia Puneet Monga
Understanding Instability
Tuesday, 24 May 16
Atraumatic Instability
Tuesday, 24 May 16
+++ +
Tuesday, 24 May 16
! "$!
Figure 5: The Stanmore classification of instability
It is apparent from the above discussion that the presentation of patients with instability
can vary significantly and hence for the purposes of this study only patients with
recurrent anterior glenohumeral dislocations following a traumatic episode were
included.
Treatment of traumatic anterior shoulder dislocation may range from initial
immobilization followed by rehabilitation to early operative stabilization. The patient’s
age, previous dislocations, joint laxity, co-morbidities, compliance and activity level
guide the choice of treatment. It is common practice to reserve surgical treatment for
patients having recurrent dislocations. Non-operative management generally involves an
initial reduction of the dislocation followed by immobilization of the shoulder for a
period of three to six weeks. This is followed by physiotherapy focusing initially on
regaining the range of motion and then subscapularis strengthening exercises {O'Brien
et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence
of dislocation {Hovelius et al., 1996}.
In the past, tendon or muscle units were shortened to stabilize the shoulder. For
example, the Putti-Platt procedure involved surgical shortening of the subscapularis to
achieve stability. This however led to a loss of movement, especially external rotation,
Tuesday, 24 May 16
Tuesday, 24 May 16

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Assessment
• Traumatic
• History of Trauma
• Positive apprehension / Jerk test / load and shift
• MR Arthrogram
@shoulderpedia Puneet Monga
Tuesday, 24 May 16
Atraumatic Instability
Tuesday, 24 May 16
Figure 5: The Stanmore classification of instability
om the above discussion that the presentation of patients with instability
icantly and hence for the purposes of this study only patients with
or glenohumeral dislocations following a traumatic episode were
traumatic anterior shoulder dislocation may range from initial
followed by rehabilitation to early operative stabilization. The patient’s
islocations, joint laxity, co-morbidities, compliance and activity level
e of treatment. It is common practice to reserve surgical treatment for
ecurrent dislocations. Non-operative management generally involves an
of the dislocation followed by immobilization of the shoulder for a
to six weeks. This is followed by physiotherapy focusing initially on
nge of motion and then subscapularis strengthening exercises {O'Brien
owever, 66% of those between 12 to 22 years of age have a recurrence
Hovelius et al., 1996}.
Tuesday, 24 May 16

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Assessment
• Atraumatic structural
• Brighton Score
• Sulcus Sign (graded / >2cm +)
• Gagey sign (GH passive abduction >105)
@shoulderpedia Puneet Monga
Atraumatic Instability
Tuesday, 24 May 16
presentation of patients with instability
poses of this study only patients with
following a traumatic episode were
dislocation may range from initial
ly operative stabilization. The patient’s
bidities, compliance and activity level
actice to reserve surgical treatment for
ative management generally involves an
y immobilization of the shoulder for a
by physiotherapy focusing initially on
ularis strengthening exercises {O'Brien
12 to 22 years of age have a recurrence
ortened to stabilize the shoulder. For
gical shortening of the subscapularis to
movement, especially external rotation,

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Assessment
• Muscle Patterning
• Scapular Dyskinesia
• Pec Major deactivation
• Latt dorsi deacivation
@shoulderpedia Puneet Monga
Atraumatic Instability
Tuesday, 24 May 16
+++ +
Tuesday, 24 May 16
! "$!
It is apparent from the above discussion that the presentation of patients with instability
can vary significantly and hence for the purposes of this study only patients with
recurrent anterior glenohumeral dislocations following a traumatic episode were
included.
Treatment of traumatic anterior shoulder dislocation may range from initial
immobilization followed by rehabilitation to early operative stabilization. The patient’s
age, previous dislocations, joint laxity, co-morbidities, compliance and activity level
guide the choice of treatment. It is common practice to reserve surgical treatment for
patients having recurrent dislocations. Non-operative management generally involves an
initial reduction of the dislocation followed by immobilization of the shoulder for a
period of three to six weeks. This is followed by physiotherapy focusing initially on
regaining the range of motion and then subscapularis strengthening exercises {O'Brien
et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence
of dislocation {Hovelius et al., 1996}.
In the past, tendon or muscle units were shortened to stabilize the shoulder. For
example, the Putti-Platt procedure involved surgical shortening of the subscapularis to
achieve stability. This however led to a loss of movement, especially external rotation,
Tuesday, 24 May 16
, 24 May 16

49. Providing)the)best)possible)care!@shoulderpedia
Scenario 1
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and can demonstrate shoulder
dislocation in clinic…..but has no pain or other
symptoms.
• Hyperlax
• Instability?
• Management?

50. Providing)the)best)possible)care!@shoulderpedia
Scenario 2
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and dislocates her shoulder
when swimming. It is very painful and she has
been to Casualty 5 times.
• Hyperlax?
• Instability
• Management ?

51. Providing)the)best)possible)care!@shoulderpedia
Scenario 3
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and dislocates her shoulder
when every morning. Mum feels “queasy” and
daughter has has missed school for weeks.
• Hyperlax?
• Unstable- Consider the other Issues
• Management ?

52. Providing)the)best)possible)care!@shoulderpedia
Scenario 4
16 year old girl. Comes with her Mum, who is
very concerned. Mum says her daughter is
“double-jointed” and injured her shoulder when
fell off a horse 3 months ago. Since then it keeps
coming out of the joint on relatively minor tasks.
• Hyperlax?
• Instability - consider traumatic lesions
• Management ?

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Questions and
comments….
@shoulderpedia Puneet Monga
Understanding Instability
Tuesday, 24 May 16
Atraumatic Instability
Tuesday, 24 May 16
+++ +
Tuesday, 24 May 16
! "$!
Figure 5: The Stanmore classification of instability
It is apparent from the above discussion that the presentation of patients with instability
can vary significantly and hence for the purposes of this study only patients with
recurrent anterior glenohumeral dislocations following a traumatic episode were
included.
Treatment of traumatic anterior shoulder dislocation may range from initial
immobilization followed by rehabilitation to early operative stabilization. The patient’s
age, previous dislocations, joint laxity, co-morbidities, compliance and activity level
guide the choice of treatment. It is common practice to reserve surgical treatment for
patients having recurrent dislocations. Non-operative management generally involves an
initial reduction of the dislocation followed by immobilization of the shoulder for a
period of three to six weeks. This is followed by physiotherapy focusing initially on
regaining the range of motion and then subscapularis strengthening exercises {O'Brien
et al., 1987}. However, 66% of those between 12 to 22 years of age have a recurrence
of dislocation {Hovelius et al., 1996}.
In the past, tendon or muscle units were shortened to stabilize the shoulder. For
example, the Putti-Platt procedure involved surgical shortening of the subscapularis to
achieve stability. This however led to a loss of movement, especially external rotation,
Tuesday, 24 May 16
Tuesday, 24 May 16