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
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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'.)
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- 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