Shoulder instability in thefemale athlete

Glenohumeral instability is relatively commonly observed in the female athlete. Studies have shown an increased incidence of both asymptomatic and pathological laxity among women. Female athletes participating in sports involving repetitive use of the upper extremity may be at particular risk for developing symptoms. Shoulder instability is classified according to etiology, onset, degree, and direction. Accurate diagnosis is important to determine proper management. Female athletes presenting with symptoms of shoulder instability should be initially treated with a comprehensive rehabilitation program emphasizing strengthening of the rotator cuff and dynamic scapular stabilizing muscles. After failure of nonoperative management, satisfactory results can be obtained using either open or arthroscopic surgical techniques.     

Arthroscopic treatment of posterior and multidirectional instability

The author can answer the three fundamental questions which were posed in the beginning of this chapter as follows: Atraumatic posterior and multidirectional laxity is attributable to capsular ligamentous laxity and can be asymptomatic initially. Over the time, repetitive subluxation of the humeral head exerts excessive rim-loading on the posteroinferior glenoid labrum which can develop into retroversion of the glenoid labrum and eventually leading to labral tears. In this stage, a patient develops shoulder pain during daily and sports activities. Besides increased translation, the diagnosis should be based on the symptoms reproduced by the jerk and Kim tests. The jerk test is a hallmark for predicting the prognosis of nonoperative treatment in posteroinferior instability. Shoulders with a painful jerk test have posteroinferior labral lesion and are unresponsive to nonoperative treatment. In these patients, early surgery may be indicated. Any successful surgical procedure should correct both the capsular laxity and the retroversion of the posteroinferior glenoid labrum. Simple capsular plication or an inferior capsular shift is insufficient for correcting the two major pathologies. Arthroscopic capsulolabroplasty restores capsular tension as well as labral height.     

Treatment of glenohumeral instabilityin the pediatric athlete

Shoulder instability in the skeletally immature athlete is an uncommon but challenging clinical problem. Theclassification of shoulder instability in the pediatric athlete is similar to that in the adult athlete, but may also include the voluntary and habitual dislocator. The natural history of such instability depends on the classification of instability type. Traumatic anterior dislocation has an exceedingly high recurrence, and posterior dislocation is less well known. A natural history of voluntary instability is also uncertain. As in the adult athlete, clinical evaluation is made by history and physical exam. An understanding of the bony development of the glenohumeral joint is crucial in interpreting radiographs of the skeletally immature athlete with glenohumeral instability. The treatment of glenohumeral instability will depend on the classification of the instability type. Surgical treatment, when indicated, should emphasize an anatomic approach aimed at correcting the underlying glenohumeral pathology. This article is intended to provide an overview of the approach to diagnosis and treatment of glenohumeral instability in the pediatric athlete.     

Arthroscopic capsulorrhaphy formultidirectional instability

Multidirectional shoulder instability is a common affliction and is increasingly recognized as a debilitating condition in young, athletic patients. Most patients with this condition are in their third decade and have a history of macrotrauma or repetitive microtrauma. Complaints range from frank instability to instability with pain, or to pain alone. These patients may display clinical signs of instability, impingement, or both on physical examination. Generalized ligamentous laxity or shoulder laxity alone are usually present. A positive sulcus sign remains the most sensitive clinical test in distinguishing these patients, even though no data is available on the sensitivity or specificity of this examination. The greater majority of patients are successfully treated with an exercise program stressing rotator cuff and scapular stabilizer strengthening. When patients do not respond to conservative treatment, open capsular shift has been recommended to restore joint stability. Early successes with the arthroscopic treatment of anterior shoulder instability have led to the development of similar procedures for the treatment of multidirectional instability. This paper describes an arthroscopic, multiple suture capsulorrhaphy for the treatment of multidirectional shoulder instability, which is a modification of the procedure advocated by Caspari and reviews the 2-year results of the first 19 patients treated.     

Monopolar electrothermal arthroscopy for treatment of shoulder instability in the athlete

Arthroscopic stabilization of the shoulder has gained considerable interest as a treatment alternative for shoulder instability in athletes. Basic science and clinical studies are helping to define the ideal patient population, surgical techniques, and rehabilitation protocols that will enhance our surgical results and maximize patient satisfaction. We describe here our surgical program, basic science foundation, and early clinical results.[/]ab     

Atraumatic shoulder instability Discussion of classification and results after capsular imbrication

This study consists of 27 shoulders in 24 patients whose atraumatic shoulder instability was treated with the imbrication procedure described by Rockwood. Follow-up after 2 years or more showed the following results: 37% excellent, 30% good, 15% fair and 18% poor (Rowe score). No statistically significant differences in the results were observed between the dominant and non-dominant arm, nor in post-operative return to sports activities. Those with voluntary instability had more laxity at follow-up and tended to have poorer results. Those with unidirectional laxity had only good or excellent results and showed no post-operative laxity. We found no other reliable indication of the results of surgery. The difficulties of classifying shoulder instability by such factors as trauma, laxity and direction of instability are discussed. Overall, we consider capsular imbrication to be a good treatment for involuntary atraumatic shoulder instability.     

Postero-medial elbow problems in the adult athlete

The ligamentous, osseous, musculotendinous, and neural structures at the postero-medial side of the elbow are at risk for various injuries in overhead athletes. The combination of valgus and extension overload during overhead activities results in tensile forces along the medial stabilising structures, with compression on the lateral compartment and shear stress posteriorly. The combination of tensile forces medially and shear forces posteriorly can result in ulnar collateral ligament (UCL) tears, flexor-pronator mass injuries, neuritis of the ulnar nerve, posterior impingement, and olecranon stress fractures. Most symptomatic conditions of the overhead athlete can be treated conservatively initially. In cases where conservative treatment is unsuccessful surgical intervention is indicated. Recent advances in arthroscopic surgical techniques and ligamentous reconstruction ensure that the prognosis for return to pre-injury level is good.     

The relationship of superior labralanteroposterior (SLAP) lesions and pseudolaxity to shoulder injuries in the overhead athlete

Understanding the effect of superior labral lesions on the function of the shoulder is essential to successfullytreating the overhead athlete. Recognizing the pseudolaxity owing to superior labral anteroposterior (SLAP) lesions and the pathological "peel-back" sign is critical in evaluating the injured shoulder in general and repairing the SLAP lesion in particular. The mechanical characteristics of suture anchors are more favorable than tacks in resisting the pathological forces responsible for the peel-back mechanism. The higher success rate of arthroscopic suture anchor repair of SLAP lesions in comparison with open capsulolabral reconstruction suggests that SLAP lesions are the usual cause of the "dead arm" syndrome. In our experience, arthroscopic repair of SLAP lesions can return the overhead athlete to their preoperative level of function in the vast majority of cases (87% return to preoperative level for two or more seasons).     

Arthroscopic capsular plication formultidirectional instability of the shoulder

Involuntary multidirectional instability of the shoulder remains one of the most challenging problems for the orthopedic surgeon. Often these patients are young and athletic, with very high goals for their shoulder function. During the past two decades, the inferior capsular shift procedure has become the surgical mainstay when conservative treatment fails. Various investigators have published techniques for capsular shift, either for the humeral side or glenoid side, with satisfactory results for each. This article reviews our experience with a new technique developed by SJS for arthroscopic capsular plication of the shoulder. A review of the literature, surgical technique, postoperative rehabilitation and results are presented.     

Arthroscopic management of posterior shoulder instability

The etiology of posterior shoulder instability is multifactorial. Similarly, the surgical treatment of posterior shoulder instability requires more than one management technique. During the past 7 years we have used an anatomic specific approach to posterior shoulder instability, relying on physical examination and diagnostic arthroscopy to determine the correct repair technique. This study reports our results with 61 consecutive patients with refractory posterior shoulder instability requiring surgical correction. In each instance, the specific pathologic entity causing instability was corrected in an anatomic specific approach to the disorder. All patients were re-evaluated 1 to 6 years postoperatively (mean, 34 months). Fifty-five of 61 patients maintained stable shoulders, indicating a 90% success rate with this approach to posterior instability. We would recommend this approach in the management of posterior shoulder instability refractory to rehabilitative treatment.     

Traumatic anterior shoulder instability in the athlete

Anterior glenohumeral dislocation is common among athletes and may progress to recurrent instability. The pathoanatomy of instability and specific needs of each individual should be considered to prevent unnecessary absence from sport. Traditionally, primary dislocations have been managed with immobilization followed by rehabilitation exercises and a return to sporting activity. However, arthroscopic stabilization and external rotation bracing are increasingly used to prevent recurrent instability. In addition to the typical capsulolabral disruptions seen following a primary dislocation, patients with recurrent instability often have coexistent osseous injury to the humeral head and glenoid. In patients without significant bone loss, open soft‐tissue stabilizations have long been considered the ‘gold standard treatment’ for recurrent instability, but with advances in technology, arthroscopic procedures have gained popularity. However, enthusiasm for arthroscopic repair has not been supported with evidence, and there is currently no consensus for treatment. In patients with greater bone loss, soft‐tissue stabilization alone is insufficient to treat recurrent instability and open repair or bone augmentation should be considered. We explore the recent advances in epidemiology, classification, pathoanatomy and clinical assessment of young athletes with anterior shoulder instability, and compare the relative merits and outcomes of the different forms of treatment.     

Laser capsulorrhaphy for multidirectional instability of the shoulder

Multidirectional glenohumeral instability secondary to ligamentous laxity, capsular redundancy, and excessive joint volume occurs frequently. Traditional treatment programs have included conservative care, physical therapy, open surgical stabilization, and arthroscopic techniques. The laser-assisted capsular shift procedure uses low-dose, subablative laser energy to cause shrinkage of the shoulder capsule. The shrinkage of the shoulder capsule results in a decrease in glenohumeral volume improving glenohumeral stability. The Holmium:YAG laser appears to be a useful instrument for the arthroscopic treatment of glenohumeral instability. Holmium:YAG laser energy can be used to thermally modify capsular tissue to cause a reduction in its length without detrimental effects to the viscoelastic properties of the tissue. Early clinical reports have been promising and further follow-up is required to assess the long-term outcome of this procedure.     

Evaluation and management of shoulder instability in the elite overhead thrower

The elite throwing athlete places significant forces on the soft-tissue stabilizers of the shoulder with every pitch. Anterior translation forces can be as high as 40% of body weight and distraction forces as high as 80% of body weight during the act of throwing. Injury to the static and dynamic stabilizers can lead to significant pain and loss of function in these athletes. To successfully treat the injured thrower, it is important to accurately diagnose the pathologic process. This article reviews the biomechanics of throwing and pathologic processes seen in the elite thrower. We cover the essentials of the history and physical in this population and concludes with a discussion of the various treatment regimens.