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    A Case of Multidirectional Instability of the Shoulder

    When physical therapy fails to resolve a 23-year-old female patient’s chronic multidirectional shoulder instability, she agrees to undergo an arthroscopic capsulorraphy.

    Author

    William Emper, MD

    Disclosures

    Dr. Emper has no disclosures relevant to this article.

    Background

    Multidirectional instability (MDI) of the shoulder is a condition that is characterized by instability in more than one direction. It is generally accepted that the pathoanatomy of MDI is a redundant joint capsule, specifically inferior.

    In some cases, rotator interval deficiency also contributes to the laxity. Atraumatic presentations are very common, but in some cases, trauma in the presence of underlying MDI can cause a labral tear.

    Patients with associated connective tissue disorders, such as Ehlers-Danlos Syndrome, often have multiple joint laxity in addition to MDI of the shoulder.

    The physical examination is characterized by shoulder joint laxity in multiple directions. Patients have a positive sulcus sign and positive load and shift tests, particularly posterior. Patients with generalized joint laxity may demonstrate classic findings such as elbow hyperextension, MCP hyperextension, and thumb abduction to the ipsilateral forearm (Figures 1-3).


    Figures 1-3. Sulcus sign (Figure 1, left), thumb to forearm (Figure 2, center), and elbow hyperextension (Figure 3, left).

    The first line of treatment is generally a physical therapy program aimed at strengthening the dynamic stabilization muscle groups affecting the shoulder [1]. If this rehabilitation program fails, then surgery can be successful.

    The surgical approach must address the patulous inferior joint capsule, specifically the anterior and posterior bands of the IGHL, and the rotator interval if deficient. [2] Although open surgical approaches have been used in the past, arthroscopic techniques are now recognized as viable and successful alternatives. If a labral tear is identified during arthroscopy, it can be addressed in addition to capsular plication and rotator interval closure if appropriate.

    Recent studies indicate that suture anchors, which allow capsular shift to the labrum, are more successful than just suture capsulorraphy. [4]

    Case Study

    Patient Presentation

    A 23-year-old female presented with a chronic history of bilateral shoulder instability, the right shoulder being more symptomatic than the left, with an atraumatic etiology. She complained of pain and involuntary shoulder instability. She had participated in appropriate, supervised physical therapy programs with no success.

    Physical Examination

    • Full, symmetric range of motion
    • No evidence of scapular dyskinesis
    • Strength testing 5/5 and symmetric
    • Positive sulcus sign
    • Positive anterior and posterior load and shift tests
    • Multiple joint laxity with hypertension of the elbow; MCP flexion greater than 90°, thumb to forearm

    Imaging

    Radiographs

    • Negative anterior-posterior, outlet, and axillary views

    Magnetic Resonance Arthrography

    • Patulous capsule with no labral tear (Figure 4)


    Figure 4. MRA patulous capsule.

    Diagnosis

    • Multidirectional instability of the shoulder unresponsive to non-operative treatment

    Treatment

    The patient agreed to undergo arthroscopic capsulorraphy.

    • The patient had an interscalene nerve block and general anesthesia, and she was placed in a lateral decubitus position.
    • Anterior and posterior arthroscopic portals were established.
    • Diagnostic arthroscopy demonstrated a patulous capsule, no labral tears, fraying of the anterior/inferior and posterior/inferior labrum consistent with multidirectional laxity (Figure 5).
    • Appropriate accessory portals were used as necessary for suture placement through the inferior aspects of the anterior and posterior bands of the inferior glenohumeral ligaments.
    • Standard curved suture passers were used to pass non-absorbable suture through the capsule and labrum in a luggage tie technique (Figure 6).
    • Anterior and posterior capsulorraphies were performed using biodegradable knotless suture anchors (Figure 7). This allowed tightening of the redundant inferior joint capsule
    • A 270° capsulorraphy and closure of the rotator interval were achieved (Figure 8).


    Figure 5. Arthroscopy-redundant anterior inferior capsule.


    Figure 6. Suture passer through capsule and labrum.


    Figure 7. Knotless anchor incorporating capsule and labrum anterior-inferior.


    Figure 8. From superior view 270o capsulorraphy.

    Postoperative Course

    • The patient’s arm was placed in sling and pillow in slight abduction and neutral rotation.
    • The first 6 weeks involved isometric strengthening.
    • From weeks 6 to 12, the patient was allowed to perform active and passive range of motion exercises, forward flexion to 140°, external rotation to 45° with her arm at her side, and abduction to 45°.
    • Months 3 to 6 included progression to full motion and shoulder and scapulothoracic strengthening as tolerated.
    • Sport-specific activities, specifically overhead and throwing activities, began at 6 months after surgery.
    • The patient was allowed to return to full sports activities at 9 months after surgery.

    Follow-Up

    • At 1 year after surgery, the patient had no pain or instability.
    • She had full range of motion, with negative sulcus sign and negative stress tests.

    Discussion

    Multidirectional instability of the shoulder is a condition often seen in athletes who participate in overhead activities, such as volleyball, swimming, and throwing sports.

    The initial treatment is always a well-supervised, well-designed rehabilitation program. If unsuccessful, arthroscopic capsulorraphy can be performed, and studies demonstrate good results in up to 85% of patients. [3]

    Author Information

    William Emper, MD, is Associate Professor, Jefferson Medical College, Philadelphia, Pennsylvania.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios P. Tjoumakaris, MD

    References

    1. Warby SA, Pizzari T, Ford JJ, Hahne AJ, Waston L. The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review. J Shoulder Elbow Surg. 2014 Jan;23(1): 128-42.
    2. Burt DM. Arthroscopic repair of inferior labrum from anterior to posterior lesions associated with multidirectional instability of the shoulder. Arthrosc Tech. 2014 Dec 22;3(6):e727-30. doi:
    3. Alpert JM, Verma N, Wysocki R, Yanke AB, Romeo AA. Arthroscopic treatment of multidirectional shoulder instability with minimum 270 degrees labral repair: minimum 2-year follow-up. Arthroscopy 2008 Jun;24(6): 704-11.
    4. Bradley JP, McClincy MP, Arner JW, Tejwani SG. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 200 shoulders. Am J Sports Med. 2013 Sep;41(9): 2005-14.