Multidirectional Instability: Evaluation and Treatment Options

doi:10.1016/j.csm.2008.07.002

Clinics in Sports Medicine

Volume 27, Issue 4, October 2008, Pages 671-689

https://doi.org/10.1016/j.csm.2008.07.002 Get rights and content

Multidirectional instability of the shoulder is a condition defined by symptoms of shoulder instability in more than one direction. Patients typically have generalized ligamentous laxity and may be involved in repetitive overhead activities. Initial treatment is with a physical therapy program. Patients who fail non-operative treatment are candidates for arthroscopic or open stabilization procedures.

Section snippets

Anatomy and biomechanics

The glenohumeral joint has a tremendous range of motion in all planes and depends on sufficient capsular laxity for normal function.3, 4 Therefore, the healthy shoulder in the repetitive overhead athlete requires a delicate balance of mobility and stability. Normal laxity must be distinguished from instability or pathologic laxity, which, with subluxations or dislocations, provokes symptoms of pain and dysfunction during active shoulder motion.⁵ Because of the shallow and relatively smaller

Patient evaluation

The diagnosis of MDI is highly clinical, making a thorough patient history and physical examination fundamental to proper evaluation. Diagnosis is complicated by the fact that patients can present with a myriad of symptoms, ranging from vague generalized shoulder symptoms of pain without the perception of instability to the presentation of frank instability. Between these extremes, patients usually experience varying degrees of painful “loose” shoulders, including the sensation of popping,

Nonoperative Management

The initial management of MDI is nonoperative and consists of patient education, activity modification, and rehabilitation aimed at strengthening the rotator cuff and scapular stabilizers, and also improving proprioception.13, 44, 45 Significant pain can be managed by an initial period of immobilization, nonsteroidal anti-inflammatory drugs, and mild analgesics before beginning the physical therapy program.13, 46 The physical therapy program consists of two phases. Phase I uses a set of

Summary

MDI is a clinical disorder in which the young athlete experiences variable symptoms of instability in more than one direction. The etiology is multifactorial and most commonly includes both predisposition in the form of generalized ligamentous laxity and activity, especially with repetitive overhead sports (such as swimming and throwing). The diagnosis is clinical and depends on a thorough history and physical examination. Imaging studies are usually of little confirmatory value, but play a

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Cited by (40)

Recurrent bilateral atraumatic shoulder dislocation in a young patient with bilateral shoulder multidirectional instability: Treatment consideration and description of a surgical technique
2023, International Journal of Surgery Case Reports
Multidirectional instability is defined as symptomatic glenohumeral joint subluxation or dislocation occurring in more than one direction. Multidirectional shoulder instability with recurrent shoulder dislocation is a rare condition with controversies in the literature about the best treatment strategy. Physiotherapy remains the initial treatment of choice, and surgical intervention should be performed only if debilitating symptoms continue to be experienced.
A young healthy male presented with bilateral shoulder multidirectional instability and recurrent shoulders atraumatic dislocation. The patient was treated with a supervised physiotherapy regimen, which succeeded on his non-dominant shoulder but failed on the contralateral dominant side. A surgical technique aimed at reducing the right shoulder capsule volume to gain stability was performed and described in detail in this paper. Patient was able to return to his normal daily activities, including sports, without new complaints.
The aim of surgery is to restore passive stability by reducing the shoulder capsular volume. Common surgical techniques for Multidirectional instability include an inferior capsular shift and open or arthroscopic capsular plication with variable outcomes have been proposed in the literature.
Surgical management should be individualized to address the anatomical cause of instability and should only be considered if conservative treatment with supervised physiotherapy fails. Using an arthroscopic grasper to apply appropriate capsule traction and tension while performing the plication and using an extra superior anchor contributed to attaining optimal capsular volume reduction.
Rehabilitation for atraumatic shoulder instability in circus arts performers: delivery via telehealth
2022, Journal of Shoulder and Elbow Surgery
The Watson Instability Program (WIP1) is current best evidence for conservative management of atraumatic shoulder instability, but it is unknown if this program can be effectively delivered via tele-consultation. The purpose of this longitudinal pre-post intervention study was to determine the effects of the WIP1 on patient-reported outcome measures, scapular position, shoulder strength, and handstand stability in student circus performers with atraumatic shoulder instability when delivered via tele-consultation.
Student circus performers aged between 15 and 35 years from the National Institute of Circus Arts were recruited. A 12-week shoulder exercise program was delivered via tele-consultation during the Melbourne, Australia COVID-19 (coronavirus disease 2019) lockdown. The primary outcome measures were the Western Ontario Shoulder Instability Index score and the Melbourne Instability Shoulder Scale score. Secondary outcomes measures included the Orebro Musculoskeletal Pain Questionnaire, the Tampa Scale for Kinesiophobia, and physical assessment measures including strength via handheld dynamometry, scapular position using an inclinometer, and handstand stability via center-of-pressure fluctuation. Patient-reported outcomes were collected at baseline and 6-week, 12-week, 6-month, and 9-month time points, and physical outcomes were measured at baseline and 9-month time points. A repeated-measures mixed model (with effect sizes [ESs] and 95% confidence intervals [CIs]) was used to analyze patient-reported outcomes, handstand data, strength, and scapular measures. Significance was set at P < .05.
Twenty-three student circus arts performers completed the study. Significant improvements were found in both Western Ontario Shoulder Instability Index scores (effect size [ES], 0.79 [95% CI, 0.31-1.33] at 6 weeks; ES, 1.08 [95% CI, 0.55-1.6] at 12 weeks; ES, 1.17 [95% CI, 0.62-1.78] at 6 months; and ES, 1.31 [95% CI, 0.74-1.95] at 9 months; P < .001) and Melbourne Instability Shoulder Scale scores (ES, 0.70 [95% CI, 0.22-1.22] at 6 weeks; ES, 0.83 [95% CI, 0.34-1.37] at 3 months; ES, 0.98 [95% CI, 0.46-1.54] at 6 months; and ES, 0.98 [95% CI, 0.43-1.50] at 9 months; P < .001), as well as Orebro Musculoskeletal Pain Questionnaire scores at all follow-up time points. The Tampa Scale for Kinesiophobia scores reached significance at 6 weeks and 12 weeks. Following rehabilitation, we found statistically significant increases in shoulder strength in all positions tested and increased scapular upward rotation measured at end-of-range abduction, as well as during loaded external rotation. The affected arm showed greater instability than the unaffected arm with a significant intervention effect on the affected arm showing a greater consistent anterior-posterior movement pattern.
In a group of circus performers with atraumatic shoulder instability, treatment with the WIP1 via telehealth resulted in clinically and statistically significant improvements in shoulder symptoms and function.
Shoulder and elbow pathology in the female athlete: sex-specific considerations
2021, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Surgeons should counsel these patients accordingly to manage expectations. Multidirectional instability (MDI) is characterized as symptomatic subluxation or dislocation of the glenohumeral joint in at least 2 directions.2,6,8,25,47,57 MDI was recognized as an entity different from unidirectional instability in 1980 by Neer, and the female bias toward MDI is well established.8,16
Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.
Muscle activity and scapular kinematics in individuals with multidirectional shoulder instability: A systematic review
2021, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
However, this definition is general and rather vague [11–13]. Shoulder stability is a complex interplay between static (articular) and dynamic (mostly extra-articular) stabilizers [8,14], of which the relative contribution differs according to the position of the shoulder joint [15,16]. Static stabilizers, such as the glenoid labrum, shape of the glenoid surface and humeral head, intra-articular suction force, and tension of the shoulder capsule all limit excessive glenohumeral translations [15–18].
Several studies reported the importance of glenohumeral and scapular muscle activity and scapular kinematics in multidirectional shoulder instability (MDI), yet a systematic overview is currently lacking.
This systematic review evaluates and summarizes the evidence regarding muscle activity and shoulder kinematics in individuals with MDI compared to healthy controls.
The electronic databases PubMed and Web of Science were searched in September 2020 with key words regarding MDI (population), muscle activity, and glenohumeral and scapular movement patterns (outcomes). All studies that compared muscle activity or scapular kinematics between shoulders with MDI and healthy shoulders were eligible for this review, except for case reports and case series. All articles were screened on the title and abstract, and remaining eligible articles were screened on full text. The risk of bias of included articles was assessed by a checklist for case–control data, as advised by the Cochrane collaboration.
After full text screening, 12 articles remained for inclusion and one study was obtained by hand search. According to the guidelines of the Dutch Institute for Healthcare Improvement, most studies were of moderate methodological quality. We found moderate evidence that MDI individuals show increased or prolonged activity of several rotator cuff muscles that control and centre the humeral head. Furthermore, we found evidence of decreased and/or shortened activity of muscles that move or accelerate the arm and shoulder girdle as well as increased and/or lengthened activity of muscles that decelerate the arm and shoulder girdle. The most consistent kinematic finding was that MDI individuals show significantly less upward rotation and more internal rotation of the scapula during elevation of the arm in the scapular plane as compared with controls. Finally, several studies also suggest that the humeral head demonstrates increased translations relative to the glenoid surface.
There is moderate evidence for altered muscle activity and altered humeral and scapular kinematics in MDI individuals as compared with controls.
Subacromial space outlet in female patients with multidirectional instability based on hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder measured by ultrasound
2020, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Only patients with hEDS and HSD presenting with multidirectional shoulder instability (MDI) were selected. MDI was defined as “symptoms of glenohumeral joint instability in more than 1 direction.”3,48 Inclusion criteria were: (1) women with a current subjective experience of shoulder instability in daily life (eg, recurrent subluxations/dislocations) without a traumatic onset; (2) shoulder pain for at least 3 months before the study; (3) symptomatic at the time of testing; (4) shoulder instability in at least 2 directions on the frequency, etiology, direction, and severity tests:25 a positive sulcus sign (increased laxity), and a positive apprehension-relocation test (anterior instability), and/or a positive jerk test (posterior instability), and/or a load-and-shift test positive for another direction than the 3 previous tests.
The objective of the study was to compare the acromiohumeral distance (AHD) between patients diagnosed with hypermobility type of the Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD) and healthy controls by evaluating the relative amount the tendon occupies in the subacromial area. Furthermore, the aim was to evaluate if there was a change in AHD with arm elevation within and between groups.
Twenty-nine female patients with hEDS/HSD (aged 34 ± 12.9 years) and 20 healthy controls (aged 33 ± 10.8 years) participated in the study. The supraspinatus tendon (SST) thickness and AHD were measured using ultrasound. The interplay between the SST and the AHD was expressed as the occupation ratio (OcAHD), calculated as the SST thickness as a percentage of AHD. The measures were performed in the resting position and in subsequently 45° and 60° of active arm elevation in the scapular plane.
The main finding is that patients with hEDS/HSD have a larger subacromial space outlet compared with the controls when measured by ultrasound. Furthermore, in both groups, we found an increased OcAHD during active arm elevation compared with the resting position, which indicates that similar mechanisms occur for patients with hEDS/HSD and healthy controls.
Patients with hEDS/HSD have a larger available subacromial space outlet compared with healthy individuals. OcAHD increased during active arm elevation compared with the resting position in both groups. This knowledge is important when designing rehabilitation exercise programs for shoulder instability patients with abnormal glenohumeral biomechanics.
Analysis of the kinetic chain in asymptomatic individuals with and without scapular dyskinesis
2018, Clinical Biomechanics
This study measured strength of the trunk and hip, and compared Y Balance Test and Upper Quarter Y Balance Test in individuals without and with scapular dyskinesis. Strength and endurance of the scapulothoracic muscles were also assessed.
Forty-four individuals without shoulder pain were divided in 2 groups: without scapular dyskinesis (age 26.00, SD 4.10 years) and scapular dyskinesis (age 23.68, SD 4.20 years). Scapular dyskinesis was assessed by clinical observation of the scapular motion during arm elevation, and was classified as present or absent. A handheld dynamometer was used to measure the isometric strength of the trunk flexors and lateral flexors, hip extensors and abductors, lower trapezius, serratus anterior, and latissimus dorsi. Y and Upper Quarter Y Balance Tests were performed with the individual in single-limb and 3-point plank position, respectively. Endurance of the scapulothoracic muscles was assessed with the individuals in prone with the arm at 135° abduction. Independent t-test and Mann-Witney test were used for comparison between groups. A P < 0.05 was considered significant. Effect sizes between groups were also calculated.
No differences (P > 0.05) were demonstrated between groups for all variables. Moderate effect size (d ~ 0.40) was found for the trunk flexors and hip extensors, and endurance of the scapulothoracic muscles, whereas the scapular dyskinesis group showed less strength and endurance in relation to the group without dyskinesis.
Strength of the trunk flexors and hip extensors, and endurance of the scapulothoracic muscles seem to have influence in scapular dyskinesis in non-athletes without shoulder pain.

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Multidirectional Instability: Evaluation and Treatment Options

Section snippets

Anatomy and biomechanics

Patient evaluation

Nonoperative Management

Summary

J Shoulder Elbow Surg

Clin Sports Med

J Shoulder Elbow Surg

Clin Neurophysiol

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Sports Med

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Sports Med

J Shoulder Elbow Surg

Clin Sports Med

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

Oper Tech Sports Med

Arthroscopy

Arthroscopy

Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report

J Bone Joint Surg Am

The effect of variation in definition on the diagnosis of multidirectional instability of the shoulder

J Bone Joint Surg Am

Comparison of dynamic sonography to stress radiography for assessing glenohumeral laxity in asymptomatic shoulders

Am J Sports Med

Mechanics of glenohumeral instability

Clin Sports Med

Glenohumeral joint stability. Selective cutting studies on the static capsular restraints

Clin Orthop Relat Res

Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule

Am J Sports Med

The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder

Am J Sports Med

Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint

J Bone Joint Surg Am

Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint

Am J Sports Med

The role of the rotator interval capsule in passive motion and stability of the shoulder

J Bone Joint Surg Am

Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management

J Am Acad Orthop Surg

Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability

Am J Sports Med