SHOULDER INSTABILITY

TANUSHRI.N
3rd year BPT

ACOP
INTRODUCTION
• Shoulder instability is the pathological mobility of joint
ranging from symptomatic laxity to frank dislocations
• Shoulder instability is also called as glenohumeral
instability
SHOULDER INSTABILITY CAN RESULT FROM
Impairments or imbalance in muscle function
Ligamentous laxity
Bony abnormalities

ANATOMY:
The stability of the joint is primarily a consequence of static and
dynamic stabilisers
Static stabilisers includes:
Bone
Glenoid labrum
Capsular and ligamentous complex
The SGHL along with MGHL are important stabilizers & limits
external rotation of adducted arm
IGHL prevents anterior translations shoulder in abduction
&external rotation

Dynamic stabilisers are:

• Rotator cuff muscles
• Biceps tendon
SHOULDER STABILISERS
Static stabilizers Dynamic stabilizers
CAUSES
• Hill-sachs lesion
• Posterior glenoid bone loss
• Failure of bankart repair
• Bony defect
• Capsular lesion
• Anterior glenoid deffect
CLASSIFICATION
• 1.Stanmore triangle
• Polar1-traumatic
• Polar2-atraumatic
• Polar3-muscule patterning or non structural

• 2.Based on direction
• Anterior
• Posterior
• multidirectional
3.TRAUMATIC UNIDIRECTIONAL INSTABILITY WITH BANKART
LESION
• Anterior
• Posterior
• 4.ACQUIRED STORPS SPECIFIC INSTABILITY
• 5.ATRAUMATIC
• Congenital instability
• Chronic recurrent instability
ANTERIOR INSTABILITY
• It is the most common direction of instability
• Repetitive overhead activities can lead to microtrauma at
shoulder, this leads to breakdown of GH stability
• Symptoms occurs in abduction and externally rotated
positions
• There are 2types
• 1.post traumatic
• 2.atraumatic
1.POST TRAUMA :
• The patient reports a specific incidence that precipitated the
problem
• This is commonly a forceful abduction & externally rotation
injury
• The patient reports that shoulder has not returned to normal
• 2.ATRAUMATIC:
• Common in people with capsular laxity, including sports
person ,eg:baseball pitches, javeline throwers, swimmer
&tennis players
CLINICAL FEATURES:
• Recurrent dislocation and subluxation
• Shoulder pain
• Complain of dead arm
• Pain usually arises from impingment of rotator cuff tendon ,with
recurrent subluxation – leads torotator cuff tendinopathy
• Aggravated by weak rotator cuff muscles
• Increase in joint accessory motions particularly in anterior direction
causes
Subscapularis tears
Humeral avulsions of the glenohumeral ligament (HAGL),
Superior labrum anterior to posterior (SLAP) injuries
Rotator interval lesions
Bony bankart lesion
EXAMINATION
• the presence of any generalized ligamentous laxity.
• A sulcus sign upon downward traction on the arm points to
the diagnosis of generalized ligamentous laxity
• The amount of external rotation at the shoulder should also be
noted.
• power of all the primary and secondary muscles controlling
the shoulder should be performed to exclude any neuro·
logical deficit.
 EXAMINATION
• Supraspinatus strength - as supraspinatus tears commonly
occur with a shoulder dislocation in patients over the age of
50 years.
• Symptoms and dislocations occurs in abduction and external
rota· tion
• Tenderness may be present anteriorly or posteriorly
Special test:
1.LOAD AND SHIFTING TEST:
The patient sits with no back support and with the hand of the test arm
resting on the thigh
The examiner stands or sits slightly behind the patient and stabilizes the
shoulder with one hand over the clavicle and scapula
With the other hand, the examiner grasps the head of the humerus with the
thumb over the posterior humeral head and the fingers over the anterior
humeral head
INVESTIGATIONS
• X rays and CT scan demonstrates Hi11·Sachs' lesion or the
Bankart lesion
• MRI will reliably demonstrate the presence of bony lesions, as
well as soft tissue abnormalities of the labrum, the capsule.
and the associated tendons.
SPECIAL TEST
• Examiner then shifts humerus anteriorly or posteriorly in the
glenoid if necessary to seat it in properly in the glenoid fossa
• This is the load portion of test
• The examiner then tries to translate the humeral head in an
anteromedial direction to assess anterior stability, and the
amount of translation and end feel are noted.
• This is the shift portion of the test.
 Special test:
• The test should be
compared to the
contralateral side.
• Load and Shift test
is Positive when there is
increased translation of the
humeral head compared to
the contralateral side.
Grades of anterior glenohumeral translation
Anterior Drawer Test of the Shoulder.1
• Patient in supine position.
• Relax the affected shoulder by holding patients arm ( or placing hand on
axilla) with therapist one hand.
• Abduct the patient shoulder between the 80 and 120 degree, Forward
flexed up to 20 degree, laterally rotated up to 30 degree.
• Stabilize the patient scapula with the therapist opposite hand by pushing
the spine of the scapula with index and middle finer. Applying
counterpressure on patients coracoid process with the therapist thump.
 Anterior Drawer Test of the Shoulder.
• Draws the humerus forward
(anteriorly) using the hand that is
holding patients arm (or placing hand
on axilla).
• Positive test indicates the anterior
instability decided by the amount of
anterior translation which is accessible
comparing with the normal side.
 APPREHENSION TEST
• The patient should be position in supine.
• The therapist will flex the patient's elbow to
90 degrees and abducts the patient's
shoulder to 90 degrees, maintaining neutral
rotation
• The examiner then slowly applies an external
rotation force to the arm to 90 degrees while
carefully monitoring the patient[
• Patient apprehension from this maneuver,
not pain, is considered a positive test.
RELOCATION TEST
the paint lies in supine position
The examiner abucts and laterally rotates the affected shoulder of
patient along with posterior translation of humerus
The patient commonly loses the apprehension, any pain that is
present commonly decreases,
Further lateral rotation is possible before the apprehension or pain
returns
This relocation is sometimes referred to as the Fowler sign or test or the
Jobe relocation test
RELOCATION TEST
• The test is considered positive if
pain decreases during the
maneuver, even if there was no
apprehension.
• If the patient’s symptoms
decrease or are eliminated when
doing the relocation test, the
diagnosis is glenohumeral
instability, subluxation, dislocation,
or impingement
POSTERIOR INSTABILITY
• The most common type of posterior instability seen in sportspeople is an
atraumatic type that is part of a multidirectional instability
• CLINICAL FEATURES:
• Patient reports symptoms with arm in forward flexed ,adducted position
• They may carry their arm in an internally rotated position revealing a prominence of
the humeral head on the posterior shoulder, with the coracoid process also
appearing more prominently.
CLINICAL FEATURES

• Possible subacromial impingement

• GH internal rotation deficit may be present
• Pain clicking
• Increased joint accessory motion particularly in posterior
direction
CLASSIFICATION
• 1.SUBACROMIAL:
• posterior and inferior to the acromion process—the most common
• 2.SUBGLENOID:
• posterior and inferior to the glenoid rim
• 3.SUBSPINOUS:
• medial to the acromion and inferior to the scapular spine
INVESTIGATION
• Magnetic Resonance (MR) Imaging
• MR arthrography
• Computerized Tomography (CT) scans
SPECIAL TEST:
• 1.POSTERIOR APPREHENSION TEST:
• The patient is in a supine lying or sitting position
• The examiner elevates the patient’s shoulder in the plane of the scapula
to 90° while stabilizing the scapula with the other hand
• The examiner then applies a posterior force on the patient’s elbow
• the examiner horizontally adducts and medially rotates the arm
• A positive result is indicated by a look of apprehension or alarm on the
patient’s face and the patient’s resistance to further motion or the
reproduction of the patient’s symptoms
POSTERIOR DRAWER TEST
• The patient lies supine
• The examiner grasps the patient’s proximal forearm with one hand, flexing
the patient’s elbow to 120° and the shoulder to between 80° and 120° of
abduction and between 20° and 30° of forward flexion.
• With the other hand, the examiner stabilizes the scapula by placing the
index and middle fingers on the spine of the scapula and the thumb on
the coracoid process
• The examiner then rotates the upper arm medially and forward flexes the
shoulder to between 60° and 80° while taking the thumb of the other hand
off the coracoid process and pushing the head of the humerus posteriorly.
POSTERIOR DRAWER TEST

• The head of the humerus can be

felt by the index finger of the
same hand
• A positive test indicates posterior
instability and demonstrates
significant posterior translation
3. Push-Pull Test
• The patient lies supine.
• The examiner holds the patient’s arm at the wrist, abducts the arm 90°,
and forward flexes it 30°
• The examiner places the other hand over the humerus close to the
humeral head.
• The examiner then pulls up on the arm at the wrist while pushing down on
the humerus with the other hand
• Normally, 50% posterior translation can be accomplished
Push-Pull Test
• . If more than 50% posterior
translation occurs or if the patient
becomes apprehensive or pain
results, the examiner should
suspect posterior instability.
4.Jerk Test
• The patient sits with the arm medially rotated and forward flexed to 90°.
• The examiner grasps the patient’s elbow and axially loads the humerus in
a proximal direction.
• the examiner moves the arm horizontally (crossflexion/horizontal
adduction) across the body.
• A positive test for recurrent posterior instability is the production of a
sudden jerk or clunk as the humeral head slides off the back of the glenoid
Jerk Test
INFERIOR INSTABILITY
• It is most uncommon and are caused by carring heavy objects at one side
,or by hyperabduction forces

• MULTIDIRECTIONAL INSTABILITY
• It is a symptomatic GH instability present in more that one direction
• Laxity :- female > male
• CLINICAL FEATURES:

• Antero-inferior laxity most commonly presents with global shoulder pain,

cannot pinpoint to a specific location
• Secondary rotator cuff impingement can be seen with
microtraumatic events caused during participation in sports such
as gymnastics, swimming and weight training
• Lower trapezius and serratus anterior activity is decreased.
• Pectoralis minor and lattissimus dorsi increased, creating a
position of scapular protraction and glenoid tiiting.
• Scapular dyskinesia can be seen
• multidirectional instability also have de cits in shoulder
proprioception
INVESTIGATIONS:
• Hyper extension of thumb to wrist & hyper extension of elbow- ligamentous
laxity
• Sulcus sign for inferior instability
• Anterior and posterior drawer test for anterior and posterior instability
• RADIOLOGICAL: CT , MRI , Magnetic resonance arthrogram
SPECIAL TESTS
• 1. Rowe Test:
• The patient stands forward flexed 45° at the waist with the arms relaxed
and pointing at the floor
• The examiner places one hand over the shoulder
• The index and middle fingers sit over the anterior aspect of the humeral
head and the thumb sits over the posterior aspect of the humeral head.
• The examiner then pulls the arm down slightly
1. Rowe Test:
• To test for anterior instability, the humeral head is pushed anteriorly with
the thumb while the arm is extended 20° to 30° from the vertical position.
• To test for posterior instability, the humeral head is pushed posteriorly with
the index and middle fingers while the arm is flexed 20° to 30° from the
vertical position.
• For inferior instability, more traction is applied to the arm, and the sulcus
sign is evident.
1. Rowe Test:
2. Feagin Test:
• The Feagin test is a modification of the sulcus sign test
• The patient is tested best when relaxed in the sitting position beside the clinician. Patient will
be in either sitting or standing position.
• The clinician holds the patient's upper extremity at 90 degrees of abduction, with the
patient's forearm over the clinician's shoulder and elbow extended
• The clinician uses one hand to apply an inferiorly and slightly anteriorly directed force while
the other hand palpates the edge of the acromion and the humeral head to feel for
displacement anteriorly and inferiorly
• A sense of apprehension, pain, or an increased amount of translation in the inferior direction
(anteroinferior instability)[2] as compared with the uninvolved side is considered a positive
sign.[
2. Feagin Test:
• A sense of apprehension, pain, or
an increased amount of
translation in the inferior
direction (anteroinferior
instability)[2] as compared with
the uninvolved side is considered
a positive sign.
3. Test for Inferior Shoulder Instability (Sulcus Sign)
• The patient stands with the arm by the side and shoulder muscles relaxed.
• The examiner grasps the patient’s forearm below the elbow and pulls the
arm distally
• The presence of a sulcus sign may indicate inferior instability or
glenohumeral laxity
• But should only be considered positive for instability if the patient is
symptomatic (e.g., pain/ache on activity, shoulder does not “feel right”
with activity).
Test for Inferior Shoulder Instability (Sulcus Sign)
PT MANAGEMENT
• DAY 1 to 15:
• Cryotherapy – 5 to 6 times a day
• Passive ROM exercise - limited to 120 degrees of flexion, 90 degrees of
abduction, internal rotation till the abdomen, and external rotation till 30 degrees.
• Isometrics of rotator cuff and scapulothoracic muscles to improve the dynamic joint
stability. – this provides dynamic stability
Isometric exercise for rotator cuff muscles
Shoulder retraction exercise Shoulder rolling exercise
rom in abduction rom in internal rotation
PT MANAGEMENT – shoulder instability

ROM EXERCISES Pendular exercise :

3 sets x 10 rep
3 times a day
 ROM EXERCISE :
ELBOW ROM EXERCISE WRIST ROM EXERCISE
 Shoulder strengthening exercise
Resisted shoulder flexion exercise Resisted internal rotation exercise
Prone shoulder retraction with
glenohumeral joint in IR
Resisted external rotation
PNF exercise – D2 pattern (Flexion, abduction, and ER)
Reference :
• Clinical sports medicine- Brukner & Khans
• CLINICAL ORTHOPEDIC REHABILITATION – S.Brent Brotzman
• ORTHOPEDIC PHYSICAL ASSESSMENT – David J.Magee
• DUTTONS ORTHOPECDIC Examination Evaluation &
Intervention
• physiopedia
Thank You