Multidirectional instability of the shoulder
- David J Berkoff, MD, FAAEM, CAQSM
David J Berkoff, MD, FAAEM, CAQSM
- Professor of Orthopedics and Emergency Medicine
- Department of Exercise and Sport Science
- University of North Carolina Chapel Hill
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
Multidirectional instability (MDI) of the shoulder is defined as symptomatic laxity of the glenohumeral joint. Patients with this disorder have excessive laxity of the joint capsule in more than one or in all directions (anterior, inferior, and posterior) and have difficulty maintaining the head of the humerus centered within the glenoid fossa.
The clinical presentation, diagnosis, and management of MDI of the glenohumeral joint will be reviewed here. The general evaluation of adults with undifferentiated shoulder complaints, shoulder dislocation, and other common shoulder ailments, such as impingement or rotator cuff tendinopathy, are discussed separately. (See "Evaluation of the patient with shoulder complaints" and "Shoulder dislocation and reduction" and "Shoulder impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)
DEFINITIONS: DISTINGUISHING LAXITY AND INSTABILITY
In the medical literature, a number of definitions exist for multidirectional instability (MDI) of the shoulder, making classification of these patients difficult. To clarify, glenohumeral laxity and instability are not synonymous . Instability implies dysfunction. It can be voluntary or involuntary, unidirectional or multidirectional, and traumatic or nontraumatic. Patients with ligamentous laxity often have no complaints and require no intervention, while those with instability are by definition symptomatic.
The distinction between laxity and instability applies to physical examination findings as well. A patient whose shoulder can be subluxated in one or multiple directions but is asymptomatic has laxity without instability and requires no intervention. In contrast, a patient who presents with shoulder or proximal upper extremity pain, weakness, fatigue, or paresthesias may have laxity with instability. Patients with MDI of the glenohumeral joint often have laxity in both the asymptomatic and symptomatic shoulder, but only the symptomatic shoulder is classified as having instability.
ANATOMY AND BIOMECHANICS
The basic anatomy and biomechanics of the shoulder complex are reviewed separately. (See "Evaluation of the patient with shoulder complaints", section on 'Anatomy and biomechanics'.)
- Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res 2002; :65.
- Neer CS 2nd. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect 1985; 34:232.
- Cameron KL, Duffey ML, DeBerardino TM, et al. Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train 2010; 45:253.
- Zemek MJ, Magee DJ. Comparison of glenohumeral joint laxity in elite and recreational swimmers. Clin J Sport Med 1996; 6:40.
- Borsa PA, Sauers EL, Herling DE. Patterns of glenohumeral joint laxity and stiffness in healthy men and women. Med Sci Sports Exerc 2000; 32:1685.
- Caplan J, Julien TP, Michelson J, Neviaser RJ. Multidirectional instability of the shoulder in elite female gymnasts. Am J Orthop (Belle Mead NJ) 2007; 36:660.
- Jansson A, Saartok T, Werner S, Renström P. Evaluation of general joint laxity, shoulder laxity and mobility in competitive swimmers during growth and in normal controls. Scand J Med Sci Sports 2005; 15:169.
- Borsa PA, Scibek JS, Jacobson JA, Meister K. Sonographic stress measurement of glenohumeral joint laxity in collegiate swimmers and age-matched controls. Am J Sports Med 2005; 33:1077.
- Rupp S, Berninger K, Hopf T. Shoulder problems in high level swimmers--impingement, anterior instability, muscular imbalance? Int J Sports Med 1995; 16:557.
- Warner JJ, Micheli LJ, Arslanian LE, et al. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. Am J Sports Med 1990; 18:366.
- Levy AS, Lintner S, Kenter K, Speer KP. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med 1999; 27:460.
- Bahu MJ, Trentacosta N, Vorys GC, et al. Multidirectional instability: evaluation and treatment options. Clin Sports Med 2008; 27:671.
- Lippitt, SB, Vanderhooft, JE, Harris, SL, et al. Glenohumeral stability from concavity compression. A quantitative analysis. J Shoulder Elbow Surg 1993; 2:27.
- Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998; 6:65.
- Blasier RB, Carpenter JE, Huston LJ. Shoulder proprioception. Effect of joint laxity, joint position, and direction of motion. Orthop Rev 1994; 23:45.
- Illyés A, Kiss RM. Electromyographic analysis in patients with multidirectional shoulder instability during pull, forward punch, elevation and overhead throw. Knee Surg Sports Traumatol Arthrosc 2007; 15:624.
- Guerrero P, Busconi B, Deangelis N, Powers G. Congenital instability of the shoulder joint: assessment and treatment options. J Orthop Sports Phys Ther 2009; 39:124.
- Gaskill TR, Taylor DC, Millett PJ. Management of multidirectional instability of the shoulder. J Am Acad Orthop Surg 2011; 19:758.
- Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am 1992; 74:1516.
- Farber AJ, Castillo R, Clough M, et al. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am 2006; 88:1467.
- Owens BD, Campbell SE, Cameron KL. Risk factors for anterior glenohumeral instability. Am J Sports Med 2014; 42:2591.
- Pollock RG, Bigliani LU. Glenohumeral Instability: Evaluation and Treatment. J Am Acad Orthop Surg 1993; 1:24.
- Borsa PA, Jacobson JA, Scibek JS, Dover GC. Comparison of dynamic sonography to stress radiography for assessing glenohumeral laxity in asymptomatic shoulders. Am J Sports Med 2005; 33:734.
- Cheng SC, Hulse D, Fairbairn KJ, et al. Comparison of dynamic ultrasound and stress radiology for assessment of inferior glenohumeral laxity in asymptomatic shoulders. Skeletal Radiol 2008; 37:161.
- Sanders TG, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med 2000; 28:414.
- Bergin D. Imaging shoulder instability in the athlete. Magn Reson Imaging Clin N Am 2009; 17:595.
- Itoi E. Pathophysiology and treatment of atraumatic instability of the shoulder. J Orthop Sci 2004; 9:208.
- Woertler K, Waldt S. MR imaging in sports-related glenohumeral instability. Eur Radiol 2006; 16:2622.
- Warby SA, Pizzari T, Ford JJ, et al. Exercise-based management versus surgery for multidirectional instability of the glenohumeral joint: a systematic review. Br J Sports Med 2016; 50:1115.
- Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992; 74:890.
- Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy 2001; 17:236.
- Kim SH, Kim HK, Sun JI, et al. Arthroscopic capsulolabroplasty for posteroinferior multidirectional instability of the shoulder. Am J Sports Med 2004; 32:594.
- Karas SG, Creighton RA, DeMorat GJ. Glenohumeral volume reduction in arthroscopic shoulder reconstruction: a cadaveric analysis of suture plication and thermal capsulorrhaphy. Arthroscopy 2004; 20:179.
- Provencher MT, Verma N, Obopilwe E, et al. A biomechanical analysis of capsular plication versus anchor repair of the shoulder: can the labrum be used as a suture anchor? Arthroscopy 2008; 24:210.
- Van der Reis W, Wolf EM. Arthroscopic rotator cuff interval capsular closure. Orthopedics 2001; 24:657.
- Haik MN, Alburquerque-Sendín F, Moreira RF, et al. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med 2016; 50:1124.
- Reinold MM, Curtis AS. Microinstability of the shoulder in the overhead athlete. Int J Sports Phys Ther 2013; 8:601.
- Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J Sports Med 2007; 35:1361.
- Kibler WB, Sciascia A. The role of the scapula in preventing and treating shoulder instability. Knee Surg Sports Traumatol Arthrosc 2016; 24:390.
- Davies GJ, Dickoff-Hoffman S. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sports Phys Ther 1993; 18:449.
- Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998; 26:325.
- Van Tongel A, Karelse A, Berghs B, et al. Posterior shoulder instability: current concepts review. Knee Surg Sports Traumatol Arthrosc 2011; 19:1547.
- Jerosch J, Castro WH. Shoulder instability in Ehlers-Danlos syndrome. An indication for surgical treatment? Acta Orthop Belg 1990; 56:451.
- Bois AJ, Wirth MA. Revision open capsular shift for atraumatic and multidirectional instability of the shoulder. J Bone Joint Surg Am 2012; 94:748.
- Baker CL 3rd, Mascarenhas R, Kline AJ, et al. Arthroscopic treatment of multidirectional shoulder instability in athletes: a retrospective analysis of 2- to 5-year clinical outcomes. Am J Sports Med 2009; 37:1712.
- Chen D, Goldberg J, Herald J, et al. Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2016; 24:630.
- Bradley T, Baldwick C, Fischer D, Murrell GA. Effect of taping on the shoulders of Australian football players. Br J Sports Med 2009; 43:735.
- DEFINITIONS: DISTINGUISHING LAXITY AND INSTABILITY
- ANATOMY AND BIOMECHANICS
- EPIDEMIOLOGY AND ETIOLOGY
- CLINICAL PRESENTATION AND HISTORY
- PHYSICAL EXAMINATION
- Overview of approach and general shoulder examination
- Determining the presence of instability
- Concomitant subacromial impingement or rotator cuff tendinopathy
- IMAGING STUDIES
- Plain radiography
- CT and MR arthrography
- DIFFERENTIAL DIAGNOSIS
- Initial treatment
- Physical therapy
- Persistent symptoms
- Indications for orthopedic referral
- SUMMARY AND RECOMMENDATIONS