124 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]
PATRICK GUERRERO, DO 8k|AN 8u560N|, MD
N|60LA 0AN6L|5, MD 6|NA P0wk5, DPT, OCS
4
Congenital Instability of the Shoulder
Joint: Assessment and Treatment Options
1
Orthopedic Surgery and Sports Medicine Physician, Central Cal Orthopedic, Turlock, CA.
2
Associate Professor of Orthopedics, University of Massachusetts Medical School,
Worcester, MA; Chief of Sports Medicine, University of Massachusetts Medical School, Worcester, MA; Director of Sports Medicine Fellowship Program, University of Massachusetts
Medical School, Worcester, MA.
3
Assistant Professor of Orthopedics, University of Massachusetts Medical School, Worcester, MA; Assistant Director, Sports Medicine Fellowship
Program, University of Massachusetts Medical School, Worcester, MA.
4
Physical Therapist, Orthopedics/Sports, University of Massachusetts Medical School, Worcester, MA.
Address correspondence to Dr Brian Busconi, U-Mass Memorial-Hahnemann, Orthopedic Surgery, 281 Lincoln Street, Worcester MA 01605. E-mail: BusconiB@ummhc.org
C
ongenital instability is a form of multidirectional instability
(MDI), which is difcult to diagnose and treat in great part
due to a lack of understanding of the pathogenesis of this
condition. Congenital instability is not caused by a traumatic
event; rather, it is present in some individuals from birth. The exact
incidence is not known because the etiology is atraumatic and there is
a broad spectrum of pathology, ranging from mild pain to dislocations.
ing shoulder activity associated with
symptoms such as pain, discomfort, par-
esthesia, apprehension or fatigue, then
the term instability is used. Because of
instability in multiple directions, these
individuals often present with global
shoulder pain, which usually cannot be
pinpointed to a specic location. Second-
ary rotator cuf impingement is also seen
in this population, and microtraumatic
events, caused during participation in
sports such as gymnastics, swimming,
and weight training, can precipitate in-
stability in a patient with laxity. Some pa-
tients with MDI may report symptoms in
both shoulders, which is consistent with
generalized capsular laxity.
Physical therapy has become the pri-
mary approach for the treatment of MDI
as we have gained more knowledge and
experience with the treatment of these
individuals.
9
Neer and Foster
53
were the
rst to describe the concept of MDI and
attributed the pathology to redundancy of
the capsule. Other authors have postulat-
ed that MDI was due to an enlargement
of the capsule,
29
incompetence of the gle-
nohumeral ligaments,
34
or increased in
glenohumeral volume.
67
Lipitt et al
42
and
Thomas and Matsen
70
have described a
classication of what we now refer to as
TUBS (traumatic, unilateral, associated
Bankart lesion, and requires surgery)
and AMBRII (atraumatic, multidirec-
tional, bilateral, rehabilitation, inferior
Variations in denition, such as voluntary
or involuntary instability, or traumatic
versus atraumatic instability, make the di-
agnosis of this entity even more difcult.
48
In some previous studies the diagnosis of
MDI was obtained based on the ability
to sublux or dislocate the glenohumeral
joint even in the absence of symptomatic
instability.
32,64
Other authors have used
the sulcus sign to dene inferior instabil-
ity when, in fact, it may only be an indi-
cation of laxity.
19,21
Finally, instabilities in
2 directions, such as antero-inferior and
postero-inferior, have been grouped as
diferent entities from MDI.
1,5,45
Laxity of the glenohumeral joint is an
asymptomatic hypermobile joint with
the ability to maintain centering of the
humeral head in the glenoid fossa. When
there is loss of this centering ability dur-
5YN0P5|5: Congenital instability of the
shoulder is a form of multidirectional instability
not caused by a traumatic event. It is believed
that excess laxity may be responsible for an overly
elastic capsule and, therefore, can contribute to
multidirectional instability. Minor microtraumatic
events can progressively lead to the develop-
ment of pain and lead to instability. The current
preferred treatment is largely nonoperative with
extensive rehabilitation of the dynamic restraints
of the shoulder complex. In recalcitrant cases,
operative intervention to restore stability may be
necessary. It is of paramount importance to notice
the directions of instability and to address each of
them. Surgical procedures include open capsular
shift, as well as arthroscopic capsular plication.
Because multidirectional instability can be difcult
to diagnose, this article will attempt to provide
the clinician with a better understanding of the
pathophysiology involved in this condition, the
necessary steps for diagnosis, and considerations
for treatment. A comprehensive guide to both
nonoperative and operative treatment is reviewed
in this article, as well as the surgical techniques
used to decrease the capsular volume.
LL 0F |0N6: Level 5. J Orthop Sports
Phys Ther 2009; 39(2):124-134. doi:10.2519/
jospt.2009.2860
kY w0k05: capsular plication, inferior capsu-
lar shift, multidirectional instability, rotator interval
closure, shoulder
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 125
capsular shift, interval closure). Although
simplistic, this classication allows us to
guide treatment accordingly. This article
will focus on the latter group of individu-
als, discussing the potentially causative
factors for the condition, as well as the
possible treatment strategies.
PAIh0ANAI0NY
F
actors that can be associated
to MDI include excessive laxity, in-
adequate glenoid concavity, glenoid
hypoplasia, muscular imbalance, and lack
of neuromuscular control.
26,34,67
Some in-
dividuals may present with collagen dis-
orders, such as Ehlers-Danlos syndrome,
in which minor injuries often precede the
development of instabilities.
34
Shoulder
instability occurs when there is inability
to keep the humeral head centered in the
glenoid when the arm is elevated.
31
Al-
though most people with MDI experience
involuntary subluxations and dislocations,
a select and unusual group may have the
ability to voluntarily sublux or dislocate
their shoulder, to possibly provide some
form of psychological gratication.
It is of paramount importance to ac-
knowledge that to diagnose clinical insta-
bility, symptoms, such as pain or feeling
of excessive looseness, must be present.
With shoulder instability, 1 or more of the
mechanisms involved in maintaining a
tight and congruent articulation is failing.
One of the mechanisms involved in pro-
viding stability of the glenohumeral joint is
the negative intra-articular pressure. This
negative pressure provides stability even
when the rotator cuf musculature has
been removed, until an incision is made
in the capsule and allows air to enter.
7
The
magnitude of this negative pressure is ap-
proximately 13.6 kg.
23
It is, therefore, pos-
tulated that a larger glenohumeral joint
volume would require a larger magnitude
negative pressure (vacuum efect) to
keep the joint surfaces congruent in the
relaxed state,
79
as well as with inferior
loading (translation) of the joint.
46,47
Another possible factor for MDI in-
volves incompetence of the glenohumeral
ligaments, which act as static stabilizers
of the joint. The superior glenohumeral
ligament (SGHL) is located in the an-
terosuperior quadrant, along with the
middle glenohumeral ligament (MGHL).
The MGHL is known to provide anterior
and inferior stability when the shoulder
is in a midabduction position.
56
The an-
terior and posterior bands of the inferior
glenohumeral ligament (IGHL) provide
anterior and posterior stability, respec-
tively, when the shoulder is abducted
to 90.
47
The coracohumeral ligament
(CHL), spanning from the coracoid pro-
cess to the humeral head, along with the
SGHL and the MGHL, when subjected to
translational forces, resist anterosuperior
motion of the humeral head when the
shoulder is in exion and slight abduc-
tion. These ligaments also provide poste-
rior and inferior stability.
6,68
Along with the glenohumeral liga-
ments, the rotator cuf interval plays an
important role in providing shoulder sta-
bility. The interval is bordered superiorly
by the anterior margin of the supraspina-
tus and inferiorly by the superior border
of the subscapularis. The apex of the in-
terval consists of the transverse humeral
ligament and its base the coracoid pro-
cess. A large interval increases translation
of the humeral head in the anterosuperior
direction. Because the SGHL and CHL
strengthen the interval, when enlarged it
can also cause posterior instability.
Dysfunction of the dynamic stabiliz-
ers may also lead to MDI. The rotator cuf
musculature creates compression of the
humeral head against the glenoid and cre-
ates stability in the midrange of shoulder
motion. This compression becomes more
efective by virtue of having a concave gle-
noid and a convex humeral head. The role
of the glenoid labrum adds to the concav-
ity/compression efect, thereby increasing
stability by 50%.
46
The primary dynamic
stabilizers are the rotator cuf musculature
(supraspinatus, infraspinatus, teres minor,
and subscapularis), the deltoid, and the
long head of the biceps. The secondary
dynamic stabilizers include the teres ma-
jor, latissimus dorsi, and pectoralis major
muscles. These muscles work to reach
equilibrium and counterbalance to provide
stability to the glenohumeral joint.
76
With congenital MDI, the glenoid can
be hypoplastic, have increased retrover-
sion, or have a decreased antero-poste-
rior diameter.
29
Based on arm elevation
and 3-dimensional magnetic resonance
imaging (MRI) analysis in patients with
hypoplastic postero-inferior glenoid rim,
Inui et al
31
demonstrated excessive mo-
tion of the humeral head in the posterior
and inferior direction. Just as important
as the bony anatomy and the rotator cuf
function is scapular motion. For instance,
it is not uncommon to see individuals
with MDI having abnormal upward ro-
tation of the scapula during arm abduc-
tion.
55
There is a delay in scapular motion
in this population, in which less upward
rotation of the scapula causes less in-
clination of the glenoid in the scapular
plane, and, therefore, less stability in the
inferior direction.
33
Increased retroversion of the glenoid
can cause posterior instability by decreas-
ing the efective bony restraint. The same
can be inferred from having a glenoid
with a decreased anteroposterior diam-
eter. MDI appears to be a rather gradual
progression of multiple variables. Patients
usually present with bilateral laxity and
may have hereditary congenital laxity.
When this laxity is compounded with re-
petitive overhead activities, the structures
already predisposed to stretch, that serve
to provide stability, gradually fail. This
failure then gives rise to symptomatic lax-
ity or instability. Patients with MDI may
present with glenohumeral joint instabil-
ity in 2
2,56
or 3 major directions (anterior,
inferior, and posterior).
59
Inferior insta-
bility is one of the major clinical ndings
in individuals with MDI.
The amount and composition of colla-
gen, elastin, as well as collagen cross-link-
ing, may be diferent in people with MDI.
In a histological study, patients with MDI
and anterior instability did not difer sig-
nicantly on the amount of collagen in
their tissue; however, those who failed
MDI surgery did have a smaller amount
126 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY ]
of collagen brils.
17
In a diferent study,
a comparison of collagen crosslinks, -
bril diameter, amino acid composition,
and elastic bers of the glenohumeral
joint capsule and skin was made among
4 groups. The groups included individu-
als with unidirectional instability, MDI-
primary surgery, MDI-revision surgery,
and no instability. Compared to those
with a normal capsule, the capsule of the
individuals with unidirectional instabil-
ity and MDI-primary surgery had more
stable and reducible collagen cross-links,
greater bril diameter, more cysteine,
and a higher density of elastin staining.
In individuals with MDI-revision sur-
gery, more reducible cross-links, small-
er-diameter collagen brils, decreased
bril density, and increased elastin were
observed, when compared to those in the
other groups. Skin collagen bril diam-
eter was signicantly less in the MDI
groups compared to the individuals in
the group with unidirectional instability.
The authors hypothesized that repeated
capsular deformation may lead to chang-
es that increase capsular strength and
resistance to stretching, and that there
may be an underlying connective tissue
abnormality in individuals with MDI.
63
ALuAI|0N
T
he evaluation begins by taking
a good history. Patients present-
ing with MDI may not be able to
provide adequate information to obtain
a detailed history, mainly due to the
vagueness in symptom presentation. The
usual presenting symptom in our clinic is
global pain around the shoulder, rather
vague in location, and most often activity
related. Attention should be paid to pro-
voking maneuvers, as well as perceived
direction of instability. Often patients
with MDI present with scapular dyski-
nesia, as well as patellofemoral pain syn-
drome. Ill-dened pain and weakness in
the shoulder are also common presenta-
tions in this population.
20
Of note is that
patients may not be able to accurately
determine the direction of subluxation
when the sense of instability is present.
Some other patients may be able to self-
reduce their glenohumeral joint.
Inspection of both shoulders for com-
parison is performed to determine any
diferences between the symptomatic
and asymptomatic shoulder. As with any
examination, beginning with the nonaf-
fected shoulder may allow the examiner to
notice any laxity, as well as get the neces-
sary patients condence prior to examin-
ing the symptomatic limb. The examiner
needs also to pay particular attention to
scapular motion, including winging and
protraction.
A method to determine MDI is by
measuring translation beyond the gle-
noid rim in 2 or more directions. Our
preferred tests are the sulcus sign and
load-and-shift test.
26,53
These tests are
reliable and simple to perform. The sul-
cus sign is performed by applying infe-
rior traction to the arm with the arm at
the patients side (F|6uk I). An increase
in space greater than 1 cm between the
humeral head and the lateral edge of the
acromion is considered abnormal (IA8L
1).
53
It should be added that inferior laxity,
assessed with the arm in neutral abduc-
tion (arm at the side), needs to be mea-
sured with the arm in neutral rotation,
as well as externally rotated to assess for
patency of the rotator cuf interval or the
SGHL. This ligament tightens with gle-
nohumeral external rotation (ER), and,
by keeping the arm at the side, the infe-
rior glenohumeral ligament does not play
a role in providing inferior stability.
The load-and-shift test (F|6uk Z) is
used to assess anterior and posterior
translation (IA8L Z).
26
It is performed
with the examiners hand applying an
anterior-to-posterior translation on the
humeral head, and the other hand hold-
ing the arm while applying an axial load
in the direction of the glenoid center.
This centering of the humeral head on
the glenoid allows better assessment of
translation by starting at the midpoint.
An anterior and posterior force is then
applied, and the translational motion is
graded based on the amount of humeral
head riding over the glenoid rim.
26
The sulcus sign and the load-and-shift
test indicate inferior laxity and anterior
or posterior laxity, respectively, and not
necessarily instability. Careful attention
should be paid to pain and apprehension
when performing these tests.
Elbow hyperextension and knee recur-
vatum, as well as thumb hyperextension,
should be evaluated. In athletes, the type
IA8L I
Grading Inferior Laxity
Using the Sulcus Sign
Grade Translation (Inferior)
1 1 cm translation
2 1-2 cm translation
3 2 cm translation
IA8L Z
Grading Anterior and Posterior Laxity
Using the Load-and-Shift Test to Assess
Translation of the Humeral Head With
Respect to the Glenoid Rim
Grade Translation
0 No translation
1 50% translation of head
2 Translation onto the glenoid rim
3 Translation over the glenoid rim
4 Complete dislocation
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 127
0|A6N05I|6 |NA6|N6 I5I5
P
lain radiographs may show
evidence of a hypoplastic glenoid,
increased retroversion, and/or
evidence of glenohumeral erosion due
to chronic subluxation or dislocations.
Radiographs of a true antero-posterior
(AP) view, a scapular Y view, and an axil-
lary view should be obtained. With plain
radiographs, especially the axillary view,
the amount of glenoid retroversion can
be assessed.
29,32
This retroversion is de-
ned as the angle made by the glenoid
with respect to the plane of the scapula
on an axial view. Computed tomography
(CT) may be needed to study the details
of the glenoid architecture, especially
when plain radiography does not pro-
vide sufcient visualization of the bony
anatomy.
29,32
MRI arthrography may help iden-
tify capsular redundancy, as well as aid
in preoperative planning for addressing
possible labral tears, including superior
labrum anterior posterior (SLAP) tears.
The routine use of CT or MRI arthrog-
raphy may be unnecessary, unless there
is the need to discern between other pos-
sible and confusing diagnoses. Kim et al
39
reported that patients with atraumatic
postero-inferior instability tend to have
increased bony and labral retroversion,
decreased labral height in the postero-
inferior quadrant, and shallower glenoid
depth in the middle and inferior planes.
Weishaupt et al
73
demonstrated that
patients with recurrent posterior insta-
bility had a deciency of the postero-
inferior glenoid rim. Also, a signicant
diference in the glenoid version is seen
between stable and unstable shoulders
with a greater degree of retroversion in
the unstable shoulders.
N0N5uk6|6AL IkAINNI
T
he most commonly recommended
treatment for MDI is nonoperative,
with emphasis on rehabilitation and
activity modication.
9,44,65
Surgery is re-
served for those patients who have failed
an extensive course of a well-designed
rehabilitation program and continue to
have shoulder symptoms.
Considering the risk for subluxation,
an individual requires rotator cuf muscle
balance and strength to properly contain
the humeral head within the glenoid.
Scapulothoracic motion should also be
evaluated and any dysfunction correct-
ed.
33,53
The examiner should assess this
motion by having the patient elevate the
arms simultaneously, while observing if
both scapulae move in symmetry. With
instability and dysfunction, the scapula
of the afected side will often shift more
quickly, move more lateral, or wing away
from the ribcage. Most authors have ac-
knowledged the importance of strength-
ening exercises of the rotator cuf and
scapular stabilizers as a means to con-
trol excessive translation of the humeral
head.
27
Postural education should also be
emphasized to encourage scapular retrac-
tion and minimize scapular protraction
during daily activity for optimal humeral
head congruity in the glenoid
41
and in-
crease performance of the rotator cuf
muscles.
62
Proper posture is critically im-
portant in these individuals, as protract-
ed scapulae can lead to further anterior
instability.
41
Posture is emphasized with
verbal, manual, and visual cues.
To optimize the strengthening pro-
gram, the periscapular stabilizers, lower
trapezius, middle trapezius, upper trape-
zius, rhomboids, and serratus anterior
should be addressed rst, as the rotator
cuf muscles originate from the scapula,
51
and scapular stability is required to pro-
vide a solid base for rotator cuf function.
The ideal exercises for this phase of re-
habilitation were determined through
electromyography (EMG) by Moseley et
al.
52
These exercises consist of elevation
in the plane of the scapula for the up-
per trapezius: press-downs (from a sit-
ting position, lifting the body weight up
through both arms with extended elbows,
depressing the scapula) for the lower
trapezius, latissimus dorsi, teres major,
pectoralis major and minor; rowing for
the middle trapezius and rhomboids; and
of sport participation may provide clues
to the kinds of injuries they may have.
Participation in swimming, volleyball,
tennis, throwing, and gymnastics should
raise clinical suspicion of glenohumeral
joint instability. An overlapping of symp-
toms is present between acquired and
congenital instability, because participat-
ing in sports may exacerbate the underly-
ing congenital instability condition. The
position of the arm when symptoms are
present should also be investigated. For
instance, during throwing, pain during
the follow-through phase could indicate
posterior instability, in contrast to pain
during the cocking motion, which may
indicate anterior/inferior instability. It is
often difcult to determine if the insta-
bility began prior to sports participation
or by performing sports, repetitive mi-
crotrauma having caused the instability.
By the time the athlete presents to our
ofce, instability is usually present but
might have started with only laxity.
F|6uk I. Sulcus sign. Note skin indentation below
the lateral acromion when traction is applied
inferiorly on the arm.
F|6uk Z. Load-and-shift test. Anterior and
posterior force is alternately applied while providing
compression force toward the glenoid using the
humerus and humeral head.
128 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY ]
push-ups with a plus (purposeful pro-
traction of the scapula) for the serratus
anterior (progressing from wall push-
ups to push-ups on the oor as stability
increases).
15,43,52
Further, EMG studies of the periscapu-
lar muscles indicate that prone arm raises
with elbow extension are also benecial,
particularly with the arms placed at 90
of abduction for recruitment of middle
trapezius, and arms between 140 to 150
of abduction for recruitment of lower tra-
pezius (F|6uk 3).
18
In these positions, it is
important to maintain the glenohumeral
joint in ER to minimize iatrogenic im-
pingement of the supraspinatus against
the anterior acromion.
14,24,61
An exercise
to progress from the prone position to
work on the periscapular musculature is
to wrap Thera-Band around the patients
hands and have the patient maintain
tension through the Thera-Band as he/
she alternately walks the hands up a wall
to maximal tolerated elevation. This en-
courages scapular retraction, stabilizing
the rotator cuf base as the patient works
in an overhead position.
40
Stabilization exercises of the scapula
using manual resistance and isomet-
ric exercises can be used to prepare the
periscapular muscles for the exercises
listed above. With sufcient periscapular
stabilization, rehabilitation can subse-
quently address the rotator cuf. To initi-
ate rotator cuf strengthening, rhythmic
stabilization exercises (gently resisting
antagonistic musculature in an alternat-
ing pattern)
54
are used to initiate cocon-
traction of the rotator cuf muscles while
maintaining the glenohumeral joint in
a static position.
77
Positions of rhythmic
stabilization can be varied to address the
patients directions of greatest weakness/
stability. These exercises are typically
initiated in a supine position and include
resisted external/internal rotation (ER/
IR) with the shoulder abducted 20 to
30, exion/extension with the shoulder
exed to 90, and horizontal abduction/
horizontal adduction with the shoulder
exed to 90. The exercises can prog-
ress into larger amount of exion and
abduction positions, and into upright
positions.
14,77
Townsend et al
72
measured rotator
cuf and glenohumeral muscle recruit-
ment patterns via EMG for specic exer-
cises. Some of the optimal exercises they
identied overlap with those suggested
by Moseley et al.
52
Scapular abduction in
the open-can position (thumb-up) best
recruits the supraspinatus, anterior del-
toid, and middle deltoid; press-downs
(from a sitting position, lifting body
weight up through both arms with ex-
tended elbows, depressing the scapula)
best recruit the lower bers of the in-
fraspinatus, teres minor, and subscapu-
laris; exion of the shoulder recruits the
anterior deltoid and coracobrachialis;
and prone horizontal abduction with
ER best recruits the infraspinatus, teres
minor, and posterior deltoid.
72
It should
be further noted that, while past EMG
studies found the empty-can (thumb-
down) position of scapular abduction to
be optimal for supraspinatus activation,
subsequent studies have shown that the
open-can position (thumb-up) not only
equally or better recruits the supraspi-
natus
8,13,35,60
but also protects against iat-
rogenic impingement of the rotator cuf
under the anterior acromion.
8,24,60
The following exercises may be includ-
ed for rotator cuf muscles recruitment:
side-lying glenohumeral ER (F|6uk 4)
for infraspinatus,
3
teres minor,
3
and su-
praspinatus,
13
and seated or standing
resisted glenohumeral IR for activation
of subscapularis and pectoralis major.
13
With these exercises it should be noted
that the optimal position of the humerus
is in approximately 30 of scapular ab-
duction to optimize the blood ow to the
rotator cuf tendon.
4,58
Also, the use of an
object for the humerus to adduct against
while performing these shoulder rota-
tion exercises has been shown to increase
EMG signal amplitude of the infraspina-
tus (F|6uk5 4 AN0 5).
60
Once perfected
with the humerus relatively at the side,
these exercises can be progressed to per-
formance in 90 of scapular abduction
to minimize anterior glenohumeral liga-
ment strain with overhead throwing.
11
In studies to examine the efects of
muscle fatigue,
74,75
radiographs were
used to document glenohumeral me-
chanics, showing that the humeral head
migrated superiorly at 45, 90, and 120
of abduction. This demonstrates the im-
portance of rotator cuf and periscapular
stabilization.
Once sufcient strength is noted in
the periscapular, glenohumeral, and
F|6uk 3. Strengthening of the lower trapezius
muscle.
F|6uk 4. Active range-of-motion exercise for
external rotation. A towel is placed between the arm
and the patients side to slightly abduct the shoulder
so as to optimize blood perfusion to the rotator cuf
and increase infraspinatus recruitment.
F|6uk 5. Resisted shoulder external rotation using
Thera-Band.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 129
rotator cuf muscle groups, functional
training must begin in patterns recruit-
ing all muscle groups together. Joint pro-
prioceptive training is important for the
unstable glenohumeral joint, as the joint
receptors and stretch receptors in the
ligaments surrounding the joint provide
feedback for the contractile structures
to maximize stability in unstable situa-
tions.
37
A proposed mechanism to aid in
re-establishing the role of proprioception
was described by Inman.
30
His theory re-
volved around the idea of subjecting the
shoulder to certain motions and positions
promoting instability during treatment to
elicit a reective muscular protective re-
sponse during unstable events. Diagonal
proprioceptive neuromuscular facilita-
tion (PNF) patterns can be used to this
efect in various positions with varying
resistance. Particularly the diagonal ex-
ion pattern 2 (D2F) recruiting middle tra-
pezius, lower trapezius, posterior deltoid,
infraspinatus, supraspinatus, and teres
minor.
54
Perturbation training (rhyth-
mic stabilization) can be used both in
nonweight-bearing and weight-bearing
progressions for proprioceptive training
at a variety of glenohumeral angles,
3,30
progressing from known to random pat-
terns, from resistance applied proximal
to distal to the glenohumeral joint, and
from submaximal to maximal eforts.
14
Weight-bearing activity also generates
specic patterns of cocontraction of the
rotator cuf, glenohumeral muscles, and
periscapular stabilizers, as this is how
these muscles are used in many activities
of daily life.
14,28,30,36
Wall wash exercises
in clockwise/counterclockwise circles
and gure-eight patterns, while main-
taining pressure through a towel or ball,
are a good initiation of weight-bearing
exercise for dynamic stability.
40
Other
weight-bearing exercises include hand-
walking on a treadmill, and kneeling with
1 or both hands on the Protter (movable,
unstable surface) and moving the arms
in angles varying from exion/extension,
scapular abduction, to horizontal ab-
duction/adduction.
40
Progression from
wall push-up, to standard push-up, to
push-up on a tilt board or physioball, to
walking push-up stepping up and down
a step with alternating hands can also be
utilized to improve dynamic stability as
well as joint proprioception.
14
The use of a Bodyblade is very efec-
tive in gaining glenohumeral and scapu-
lothoracic stability with the shoulder in
any position and is excellent for endur-
ance training of rotator cuf muscles. The
Bodyblade is a long, slender portion of
exible plastic that the patient vibrates
in quick oscillatory movements in par-
ticular positions or throughout shoulder
range of motion (ROM) to encourage
maximal cocontraction of the rotator cuf
and periscapular muscles.
10
Exercise pro-
gression with the Bodyblade begins with
the glenohumeral joint in relative neutral
(maintaining a towel roll or bolster to
abduct the shoulder), with oscillations in
ER/IR. With the elbow extended, oscil-
lations next move medial to lateral, with
the shoulder exed and maintained at
angles between 45 and 90, then prog-
ress into positions of scapular abduction
maintained at angles of 45 to 90. An-
other progression is to redirect the angle
of oscillations inferior to superior. Once
satisfactory glenohumeral and scapu-
lothoracic mechanics can be maintained,
these exercises can be progressed to mov-
ing through these angles of exion and
scapular abduction, then into overhead
positions. Most difcult is mimicking the
diagonal PNF patterns.
10
For those patients looking to return
to sports or other higher-level activ-
ity, sport and activity training should be
used, including plyometric training.
14
Plyometrics allow the muscles around the
glenohumeral joint to respond to a quick
stretch, protect the joint, and rapidly re-
verse direction to produce the appropriate
action, with rapid contraction of the pre-
viously stretched muscle.
28
Plyometrics
can be progressed from 2- to 1-handed
drills, drills below 90 to overhead drills,
and small to larger weight. Rebounders
(F|6uk 6) can be used to initiate throw-
ing patterns for patients, beginning with
sagittal plane 2-handed, to transverse
plane 2-handed, to 1-handed throw. It
must be stressed that these programs are
individually based on the level of activ-
ity desired and the patients goals, and
appropriateness given shoulder stability
achieved with previous strengthening.
We advocate the use of a SAWA brace
(Brace International, Atlanta, GA) in ad-
dition to therapy in our athletic popu-
lation or in those individuals who are
very active. This allows participation in
sports with a higher amount of stability
(F|6uk 7).
Rowe and Zarins
65
reported that the
majority of their patients with atraumatic
instability did well with physical therapy
F|6uk 7. Anterior and posterior views of a SAWA
brace (Brace International, Georgia). This brace
provides stability with relatively good mobility.
F|6uk 6. Two-handed overhead plyometric drill with
a medicine ball.
130 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY ]
in a short-term follow-up. Burkhead and
Rockwood
9
showed that when using a
conservative rehabilitation program for
atraumatic shoulder instability, 66 (86%)
of their patients obtained good to excel-
lent results. In contrast to these encour-
aging results, Tillander et al
71
reported
that less than 50% of their 20 patients
were satised with rehabilitation alone.
Misamore et al,
50
in a study using a 7- to
10-year follow-up, showed that only 17
of their 57 patients had satisfactory out-
comes from nonoperative measures.
Patient education, activity modi-
cation, and patience from all involved
parties are needed to obtain the desired
results. An extensive course of physical
therapy of 6 months may provide greater
than 90% satisfactory results. Only after
failure of an extensive course of reha-
bilitation should surgical intervention be
entertained.
5uk6|6AL IkAINNI
5
urgical intervention for MDI
requires the difcult task of decreas-
ing abnormal translation of the hu-
meral head while retaining adequate
mobility. A thorough physical exam of
the shoulder under anesthesia provides
the surgeon the opportunity to exam-
ine the extent of the instability. An open
capsular shift has been used with good
success as the procedure of choice to re-
duce the amount of capsular volume. The
amount of shift and tension can be seen
and felt directly to achieve the desired ef-
fect. There can be a large amount of pain
postsurgery if the combined anterior and
posterior approach is used. Arthroscopic
capsular plication has demonstrated
equivalent success to the open procedure
with less postoperative pain, no disrup-
tion of the subscapularis muscle, and less
cosmetic scarring; but this technique
involves a learning curve. Also, long-
term results from arthroscopic capsular
plication surgery are not available. This
manuscript will not discuss arthroscopic
thermal capsulorrhaphy due to poor re-
sults obtained with this procedure.
0peo 5urg|ca| Ireatmeot
Neer and Foster
53
rst reported on per-
forming an inferior capsular shift proce-
dure in 1980. In their report, however, 26
of their 29 patients had a traumatic event
and 17 were labeled as having ligamen-
tous laxity. Patients were followed for 1
year, with 1 having unsatisfactory results
and 3 having axillary nerve injuries. Nine
patients returned to competitive sports.
The focus of the surgical procedure was
on tightening the glenohumeral liga-
ments using an inferior-to-superior ad-
vancement (shift) of the capsule.
69
The
basic surgical technique through a del-
topectoral approach involves detaching
the subscapularis tendon. Once detached
from the humerus, careful dissection al-
lows separation of the subscapularis from
the capsule. A horizontal capsular incision
is made from the glenoid to the humeral
neck, and a vertical incision is then made
around the humeral neck. This resembles
a sideways T. Superior advancement with
the inferior ap is made until the laxity is
eliminated from the inferior pouch. The
superior ap is then brought down over
the inferior ap and laterally. Sutures are
used to secure the repair in this new posi-
tion in a vest over pants fashion (F|6uk
8). Reattachment of the subscapularis is
then performed, followed by closure of
the skin. The results are satisfactory in
80% to 95% of patients treated in this
fashion, with recurrence rates less than
10%.
21,38
Wirth et al
78
have described an al-
ternative technique that uses a vertical
incision through the mid portion of the
capsule. Using this technique he reports
a recurrence rate of 6%. A glenoid-based
shift was performed by Altchek et al,
2
with recurrence rates of approximately
10%. A biomechanical study in cadav-
eric specimens showed that a glenoid
based shift (the vertical incision made
near the glenoid) produced less posterior
translation of the humeral head than a
humeral-based capsular shift, but the
latter resulted in a greater reduction in
capsular volume.
16
When the primary direction of insta-
bility is in the posterior direction, a pos-
terior approach is taken and a capsular
shift is also performed. The capsular shift
from inferior to superior is performed to
tighten the capsular structures (F|6uk 9).
F|6uk 8. Anterior open capsular shift. Top drawing
depicts line of capsular incision as a sideways T.
Bottom drawing shows capsular closure with a
superior shift of the inferior capsule.
F|6uk 9. Posterior open capsular shift. A
longitudinal incision is made in line with the
infraspinatus bers to the capsular level.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 131
However, this presents a predicament: al-
though the outcomes appear more than
reasonable in regard to recurrence rates,
instability and laxity may still be present
in this population even after the surgical
procedure.
Arthroscop|c Procedure
Arthroscopic management has evolved to
the point that results are comparable to
open procedures, with less perioperative
risk. This is currently the authors pre-
ferred surgical technique. The goals of
surgery are similar: identify the directions
of instability and reduce capsular volume
to restore stability to the shoulder.
Surgical options include placing an-
chors along the glenoid rim and shifting
the capsule using stitches, capsular pli-
cation techniques that involve gathering
the capsule and bringing it to the labrum,
and thermal capsulorrhaphy (which is
falling out of favor due to poor results).
These procedures can be combined with
a rotator interval closure.
49
Arthroscopic treatment of MDI in-
volves rst a standard diagnostic ar-
throscopic examination, followed by
abrasion of the capsule in preparation
for capsular plication. The next step in-
volves performing a multipleated plica-
tion from as low as the 5 oclock position
for an anterior capsular shift. A suture
is passed with or without a transglenoid
anchor through the capsule, making
sure to grab capsular tissue from the in-
ferior aspect of the gutter. A soft-tissue
penetrator is used to make the passes
through the capsule and labrum (F|6-
URE 10). A monolament suture is used
to pass the #2 braided nonabsorbable
suture through the tissue. This suture
should capture the more inferior cap-
sule, as well as the labrum slightly more
superior. This process is repeated while
moving superiorly, achieving the de-
sired tightness (F|6uk5 II AN0 IZ). Then,
a posterior capsular shift is performed in
a similar fashion, signicantly reducing
the volume of the capsule.
69
The poste-
rior shift begins at about 7 oclock and
moves superiorly ending at about the 9
oclock position. This latter part of the
procedure is done as needed, depending
on the directions of initial instability, as
well as the amount of stability obtained
after anterior capsular shift.
Rotator interval closure may be per-
formed if the sulcus sign of 2+ does not
improve when tested with the arm in
ER. A curve-shuttling device or soft-
tissue penetrator is inserted through the
anterosuperior cannula and a #1 mono-
lament suture is advanced superior to
the subscapularis tendon. A penetrating
instrument is passed just anterior to the
subscapularis tendon and the suture is
retrieved through the anterosuperior
portal. A knot is tied outside the capsule
blindly. A second suture may be passed
lateral to the rst suture if further closure
is needed.
Postoperat|ve Ireatmeot
The postoperative rehabilitation of the
surgically corrected multidirectional un-
stable shoulder is tailored based on the
surgical procedure, the surgical technique
used, and the quality of the tissue found
at the time of surgery. Initially, a period of
immobilization of approximately 2 weeks
in a sling is advocated. Our patients wear
an abduction brace in neutral for 4 to
6 weeks to protect the repair, including
during sleep. As with any shoulder sur-
gery, ROM of the elbow, wrist, and hand
is encouraged from day 1. Cryotherapy is
recommended for 20 minutes every 2 to
3 hours postsurgically for the rst week
and after every therapy session. We often
recommend gentle, small-arc pendulum
exercises from day 1.
Physical therapy may begin earlier
than, for instance, after rotator cuf re-
pair because the quality of rotator cuf
tissue is usually good and, therefore,
does not present a problem with early
ROM. During this phase of treatment,
ROM is restricted to prevent excessive
strain to the repaired tissue, typically for
6 weeks. For the rst 2 weeks, passive
ROM (PROM) and active assisted ROM
(AAROM) should be limited to neutral
for ER, 30 of scapular abduction, and
45 of exion.
77
Isometric exercises for
the scapulothoracic musculature are
initiated during the rst week postsur-
gery, followed by isometric exercises for
the glenohumeral musculature at week
2, with all isometrics being performed
at submaximal intensities with no to
minimal pain.
77
Also, at 2 weeks post-
operatively, AAROM can be performed
with shoulder exion to 60, ER to 5 to
10, and IR to 45, unless an open repair
F|6uk I0. A soft-tissue penetrator is used to
capture the capsule and labrum. Note that there is
considerable space in between the humeral head
superiorly and the glenoid labrum inferiorly.
F|6uk II. A crescent soft-tissue penetrator is used
to capture the capsule and labrum.
F|6uk IZ. Arthroscopic capsular plication for the
treatment of instability. Note the reduction in space
between the humerus and glenoid after the capsular
plication, compared to F|6uk I0.
132 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY ]
was performed, in which case we delay
AAROM for IR until the sixth week.
PROM can be increased at 4 weeks to a
maximum of 90 for exion and scapular
abduction, and ER/IR performed at 20
scapular abduction to tolerance.
77
Upper
extremity rhythmic stabilization exercis-
es at glenohumeral angles less than 60
of elevation are initiated by the fourth
week, including ER and IR.
27
During
these rst 4 weeks, exibility of the tho-
racic and lumbar areas is also addressed
and therapy implemented.
27
Once the
glenohumeral motion has reached ap-
proximately 90 of elevation, progression
to weight-bearing exercises is instituted,
using the progressions mentioned in the
nonoperative section.
29
Weeks 5 and 6 are dedicated to re-
storing further ROM. Shoulder exion
ideally should reach 135 to 140 by the
end of week 6.
77
It is critical to recognize
that to progress with ROM, the absence
of pain and apprehension is required.
Scapular protraction and retraction ex-
ercises are emphasized. Light resistance
can be added to ER and IR active ROM
(AROM) for rotator cuf strengthening
using Thera-Band.
77
We recommend
working through smaller arcs of mo-
tion to begin with, and progressing to
larger arcs over the following 4 weeks
to protect the repair and allow gradual
adaptation.
From weeks 6 to 14 we hope to achieve
full and painless ROM, restore strength,
and allow return to some daily activity.
In weeks 7 and 8 exion and scapular
abduction ROM are increased to 180,
ER to 80, and IR to 70 to 75.
76
ER/IR
isotonic exercises are performed at angles
up to 90 abduction. After the sixth week,
strengthening is initiated with concentric
exercises, as described in the nonopera-
tive section (periscapular stabilization,
rotator cuf strengthening). Light PNF
techniques may be used at this time.
Free weights are implemented once larg-
er arcs of ROM have been achieved.
17,66
All strengthening, including that of the
periscapular and rotator cuf muscles,
progresses, as mentioned previously, in
the nonoperative section. The goal is to
achieve normal scapulothoracic and gle-
nohumeral mechanics and good muscle
endurance.
77
Eccentric exercises should be
performed by the twelfth week. Once the
patient has full strength of the periscap-
ular muscles, rotator cuf, and shoulder
muscles, as well as good scapulothoracic
rhythm with full ROM, advanced train-
ing can begin.
In weeks 14 to 20, strength and en-
durance are improved, with continued
progression of therapeutic exercise.
77
Functional activity is gradually initiated,
and plyometric training may begin. Golf-
ers may initiate swings around weeks 14
to 16, and athletes may begin interval
programs at week 18. Beyond week 20,
aggressive strengthening may take place,
as well as advanced PNF drills, plyo-
metrics, and full sports activityexcept
for throwing, which is allowed at 8 to 9
months postoperatively.
77
In the high-velocity throwing athlete,
this may present as a career-ending event
due to ER ROM limitations after reha-
bilitation. Frequent follow-up visits with
the surgeon should be made to monitor
therapy progression. In our practice we
see our patients within 10 days following
the operation, at which point stitches are
removed and the incisions inspected. The
patient then returns at 6 weeks, followed
by visits at 3, 6, and 12 months postsur-
gically. The goal for these patients is to
return to their normal daily functions,
including work, sports, and high-level
activity.
0uI60N5
A
great number of surgical and
nonsurgical failures arise as a con-
sequence of incorrect diagnosis.
Failure to address the other components
of MDI can result in a substandard out-
come. Nonoperative treatment failures
can also present from inadequate reha-
bilitation of the supporting periscapular
and shoulder musculature.
With open surgical treatment for
MDI, Neer and Foster,
53
and then Al-
tcheck et al,
2
reported 90% satisfactory
results in their studies. Similarly, Cooper
and colleagues
12
obtained 91% satisfac-
tory results, and Pollock et al
57
had 96%.
Based on these studies and a few oth-
ers, postsurgical outcomes appear to be
promising. But the population used in
these studies was rather heterogeneous,
without a strict denition or criteria for
inclusion; therefore, results should be in-
terpreted with caution.
Based on the work of Misamore
and colleagues,
50
90% of their patients
achieved good results and were able to
perform activities of daily living post-
surgery. Of those, 66% were able to
return to sporting activities, but only
about 50% were able to return to high
level of participation. It is therefore
worth advising patients in the high-level
athletic population that the results are
not as good compared to the general
population.
22
Hamada et al
25
treated 34 shoulders
with an inferior capsular shift obtaining
85% satisfactory outcome. They, how-
ever, had a recurrence rate of 50% in the
12 voluntary dislocators compared to 14%
recurrence rate in the other 22 patients.
When performing revision surgery for
MDI, Zabinsky et al
80
reported that at an
average 61.5-month follow-up only 39%
of patients achieved good or excellent re-
sults, compared to 78% achieving good
results for revision surgery for anterior
instability.
5uNNAkY
w
ith a better understanding
of the pathological process in-
volved with MDI, we are now
able to more successfully treat this popu-
lation. Nonoperative treatment is the rst
option to treat a patient with MDI. When
nonsurgical treatment fails, then surgery
should be considered.
Advances in technology and im-
provements in arthroscopic surgical
techniques have made this surgical ap-
proach at least equal, if not better than,
open surgical procedures. Understand-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 133
kFkN65
I. Allen AA. Clinical evaluation of the unstable
shoulder. In: Warren RF, Craig EV, Altchek DW,
eds. The Unstable Shoulder. Philadelphia, PA:
Lippincott-Raven; 1999:93-106.
Z. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-
plasty modication of the Bankart procedure for
multidirectional instability of the anterior and in-
ferior types. J Bone Joint Surg Am. 1991;73:105-
112.
3. Ballantyne BT, OHare SJ, Paschall JL, Et al.
Electromyographic activity of selected shoulder
muscles in commonly used therapeutic exer-
cises. Phys Ther. 1993;73:668-682.
4. Biberthaler P, Wiedemann E, Nerlich A, et al.
Microcirculation associated with degenerative
rotator cuf lesions. In vivo assessment with
orthogonal polarization spectral imaging during
arthroscopy of the shoulder. J Bone Joint Surg
Am. 2003;85-A:475-480.
5. Bigliani LU, Kurzweil PR, Schwartzbach CC,
Wolfe IN, Flatow EL. Inferior capsular shift pro-
cedure for anterior-inferior shoulder instability
in athletes. Am J Sports Med. 1994;22:578-584.
6. Bowen MK, Warren RF. Ligamentous control of
shoulder stability based on selective cutting and
static translation experiments. Clin Sports Med.
1991;10:757-782.
7. Browne AO, Hofmeyer P, An KN, Et al. The
inuence of atmospheric pressure on shoulder
instability. Orthop Trans. 1990;14:259-263.
8. Burke WS, Vangsness CT, Powers CM. Strength-
ening the supraspinatus: a clinical and
biomechanical review. Clin Orthop Relat Res.
2002;292-298.
9. Burkhead WZ, Jr., Rockwood CA, Jr. Treatment of
instability of the shoulder with an exercise pro-
gram. J Bone Joint Surg Am. 1992;74:890-896.
I0. Buteau JL, Eriksrud O, Hasson SM. Re-
habilitation of a glenohumeral instabil-
ity utilizing the body blade. Physiother
Theory Pract. 2007;23:333-349. http://dx.doi.
org/10.1080/09593980701247337
II. Cain PR, Mutschler TA, Fu FH, Lee SK. Anterior
stability of the glenohumeral joint. A dynamic
model. Am J Sports Med. 1987;15:144-148.
IZ. Cooper RA, Brems JJ. The inferior capsular-shift
procedure for multidirectional instability of the
shoulder. J Bone Joint Surg Am. 1992;74:1516-
1521.
I3. Dark A, Ginn KA, Halaki M. Shoulder muscle
recruitment patterns during commonly used ro-
tator cuf exercises: an electromyographic study.
Phys Ther. 2007;87:1039-1046. http://dx.doi.
org/10.2522/ptj.20060068
I4. Davies GJ, Dickof-Hofman S. Neuromuscular
testing and rehabilitation of the shoulder com-
plex. J Orthop Sports Phys Ther. 1993;18:449-
458.
I5. Decker MJ, Hintermeister RA, Faber KJ, Hawkins
RJ. Serratus anterior muscle activity during
selected rehabilitation exercises. Am J Sports
Med. 1999;27:784-791.
I6. Deutsch A, Barber JE, Davy DT, Victorof BN.
Anterior-inferior capsular shift of the shoulder:
a biomechanical comparison of glenoid-based
versus humeral-based shift strategies. J Shoul-
der Elbow Surg. 2001;10:340-352. http://dx.doi.
org/10.1067/mse.2001.115365
I7. Dines DM, Levinson M. The conservative man-
agement of the unstable shoulder including
rehabilitation. Clin Sports Med. 1995;14:797-816.
I8. Ekstrom RA, Donatelli RA, Soderberg GL. Sur-
face electromyographic analysis of exercises for
the trapezius and serratus anterior muscles. J
Orthop Sports Phys Ther. 2003;33:247-258.
I9. Emery RJ, Mullaji AB. Glenohumeral joint in-
stability in normal adolescents. Incidence and
signicance. J Bone Joint Surg Br. 1991;73:406-
408.
Z0. Fischer SP. Arthroscopic treatment of multi-
directional shoulder instability. Sports Med and
Arthrosc Rev. 2004;12:127-134.
ZI. Flatow EL, Warner JJP. Instructional course
lectures, the American Academy of orthopedic
Surgeons - Instability of the shoulder: Complex
problems and failed repairs. Part 1. Relevant
biomechanics, multidirectional instability and
severe loss of glenoid and humeral bone. J Bone
Joint Surg Am. 1998;80:122-140.
ZZ. Gerber C, Ganz R. Clinical assessment of insta-
bility of the shoulder. With special reference to
anterior and posterior drawer tests. J Bone Joint
Surg Br. 1984;66:551-556.
Z3. Gibb TD, Sidles JA, Harryman DT, 2nd, McQuade
KJ, Matsen FA, 3rd. The efect of capsular vent-
ing on glenohumeral laxity. Clin Orthop Relat
Res. 1991;120-127.
Z4. Graichen H, Bonel H, Stammberger T, et al.
Three-dimensional analysis of the width of the
subacromial space in healthy subjects and
patients with impingement syndrome. AJR Am J
Roentgenol. 1999;172:1081-1086.
Z5. Hamada K, Fukuda H, Nakajima T, Yamada N.
The inferior capsular shift operation for insta-
bility of the shoulder. Long-term results in 34
shoulders. J Bone Joint Surg Br. 1999;81:218-
225.
Z6. Hawkins RJ, Bokor DJ. Clinical evaluation
of shoulder problems. In: Rockwood CA, Jr.,
Matsen FA, 3rd, eds. The Shoulder. Philadelphia,
PA: WB Saunders; 1990:149-177.
Z7. Hayes K, Callanan M, Walton J, Paxinos A,
Murrell GA. Shoulder instability: management
and rehabilitation. J Orthop Sports Phys Ther.
2002;32:497-509.
Z8. Heiderscheit BC, McLean KP, Davies GJ. The ef-
fects of isokinetic versus plyometric training on
the shoulder internal rotators. J Orthop Sports
Phys Ther. 1996;23:125-133.
Z9. Ikeda H, Tsukanishi S, Nobuhara K. Shoulder in-
stability: Its relationship to glenoid dysplasia [in
Japanese]. Seikesaigaigeka. 1984;27:1757-1765.
30. Inman VT, Saunders JB, Abbott LC. Observa-
tions on the function of the shoulder. J Bone
Joint Surg Am. 1944;26:1-30.
3I. Inui H, Sugamoto K, Miyamoto T, et al. Three-
dimensional relationship of the glenohumeral
joint in the elevated position in shoulders with
multidirectional instability. J Shoulder Elbow
Surg. 2002;11:510-515.
3Z. Itoi E. Pathophysiology and treatment of atrau-
matic instability of the shoulder. J Orthop Sci.
2004;9:208-213. http://dx.doi.org/10.1007/
s00776-003-0748-1
33. Itoi E, Motzkin NE, Money BF, Et al. Scapular
inclination and inferior stability of the shoulder.
J Shoulder Elbow Surg. 1992;1:131-139.
34. Jerosch J, Castro WH. Shoulder instability in
Ehlers-Danlos syndrome. An indication for sur-
gical treatment? Acta Orthop Belg. 1990;56:451-
453.
35. Kelly BT, Kadrmas WR, Speer KP. The manual
muscle examination for rotator cuf strength. An
electromyographic investigation. Am J Sports
Med. 1996;24:581-588.
36. Kibler WB. The role of the scapula in ath-
ing the pathoanatomy present in each
patient helps to address all pathologies
involved at the time of surgery. The goals
of arthroscopic and open techniques
involve restoration of capsular tension.
It is the authors preferred method to
perform capsular plication arthroscopi-
cally and in the lateral decubitus posi-
tion. This allows traction of the arm as
well as good visualization of the inferior
capsule.
Rehabilitation after surgery is simi-
lar for both open and arthroscopic ap-
proaches. A protocol beginning with
scapular stabilization is started soon
after surgery and progression is made
over the rst 4 weeks with gentle PROM.
Strengthening of the rotator cuf muscles
is not implemented until the sixth week
after surgery.
We must bear in mind that not all
patients with MDI fall in the category of
having a patulous capsule, but some may
present with hypoplastic or retroverted
glenoid. We do not routinely encounter
this population in our practice; however,
addressing the bony pathology by per-
forming glenoid osteotomies is warranted
in selected cases.
31
With future research in genetics and
molecular biology, perhaps more specic
testing could be performed to determine
the exact diference in collagen composi-
tion between normal subjects and indi-
viduals with MDI.

134 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY ]
@
N0k |NF0kNAI|0N
WWW.JOSPT.ORG
letic shoulder function. Am J Sports Med.
1998;26:325-337.
37. Kibler WB, Livingston B. Closed-chain rehabilita-
tion for upper and lower extremities. J Am Acad
Orthop Surg. 2001;9:412-421.
38. Kibler WB, McMullen J, Uhl T. Shoulder reha-
bilitation strategies, guidelines, and practice.
Orthop Clin North Am. 2001;32:527-538.
39. Kim SH, Park JC, Park JS, Oh I. Painful jerk
test: a predictor of success in nonoperative
treatment of posteroinferior instability of the
shoulder. Am J Sports Med. 2004;32:1849-1855.
40. Kisner C, Colby L. Therapeutic Exercise: Founda-
tions and Techniques. Philadelpia, PA: FA Davis
Co; 2002.
4I. Lewis JS, Wright C, Green A. Subacromial
impingement syndrome: the efect of chang-
ing posture on shoulder range of movement. J
Orthop Sports Phys Ther. 2005;35:72-87. http://
dx.doi.org/10.2519/jospt.2005.1578
4Z. Lippitt SB, Harryman DT, 2nd, Sidles JA, al E. Di-
agnosis and management of AMBRI syndrome.
Techniques Orthop. 1991;6:61-73.
43. Ludewig PM, Hof MS, Osowski EE, Meschke
SA, Rundquist PJ. Relative balance of serratus
anterior and upper trapezius muscle activity
during push-up exercises. Am J Sports Med.
2004;32:484-493.
44. Mallon WJ, Speer KP. Multidirectional instabil-
ity: current concepts. J Shoulder Elbow Surg.
1995;4:54-64.
45. Massoud SN, Levy O, Copeland SA. Inferior
capsular shift for multidirectional instability fol-
lowing failed laser-assisted capsular shrinkage.
J Shoulder Elbow Surg. 2002;11:305-308. http://
dx.doi.org/10.1067/mse.2002.121479
46. Matsen FA, 3rd, Harryman DT, 2nd, Sidles JA.
Mechanics of glenohumeral instability. Clin
Sports Med. 1991;10:783-788.
47. Matsen FA, 3rd, Thomas SC, Rockwood CA, Jr.
Anterior glenohumeral instability. In: Rockwood
CA, Jr, Matsen FA, 3rd, eds. The Shoulder. Phila-
delphia, PA: WB Saunders; 1990:526-569.
48. McFarland EG, Kim TK, Park HB, Neira CA,
Gutierrez MI. The efect of variation in denition
on the diagnosis of multidirectional instability
of the shoulder. J Bone Joint Surg Am. 2003;85-
A:2138-2144.
49. Millett PJ, Clavert P, Warner JJ. Arthroscopic
management of anterior, posterior, and multidi-
rectional shoulder instability: pearls and pitfalls.
Arthroscopy. 2003;19 Suppl 1:86-93. http://
dx.doi.org/10.1016/j.arthro.2003.09.031
50. Misamore GW, Sallay PI, Didelot W. A longitu-
dinal study of patients with multidirectional in-
stability of the shoulder with seven- to ten-year
follow-up. J Shoulder Elbow Surg. 2005;14:466-
470. http://dx.doi.org/10.1016/j.jse.2004.11.006
5I. Moore KL, Dalley AF. Upper limb. In: Moore KL,
Dalley AF, eds. Clinically Oriented Anatomy.
Baltimore, MD: Lippincott, Williams & Wilkins;
1999:691-699.
5Z. Moseley JB, Jr., Jobe FW, Pink M, Perry J, Tibone
J. EMG analysis of the scapular muscles during
a shoulder rehabilitation program. Am J Sports
Med. 1992;20:128-134.
53. Neer CS, 2nd, Foster CR. Inferior capsular shift
for involuntary inferior and multidirectional
instability of the shoulder. A preliminary report.
J Bone Joint Surg Am. 1980;62:897-908.
54. OSullivan SB, Schmitz TJ. Physical Rehabilita-
tion Laboratory Manual: Focus on Functional
Training. Philadelphia, PA: FA Davis Co; 1999.
55. Ozaki J. Glenohumeral movements of the invol-
untary inferior and multidirectional instability.
Clin Orthop Relat Res. 1989;107-111.
56. Pagnani M, Warren RF. Stabilizers of the
glenohumeral joint. J Shoulder Elbow Surg.
1994;3:173-190.
57. Pollock RG, Owens JM, Flatow EL, Bigliani LU.
Operative results of the inferior capsular shift
procedure for multidirectional instability of the
shoulder. J Bone Joint Surg Am. 2000;82-A:919-
928.
58. Rathbun JB, Macnab I. The microvascular pat-
tern of the rotator cuf. J Bone Joint Surg Br.
1970;52:540-553.
59. Reid DC, Saboe LA, Chapena JC. Anterior
shoulder instability in athletes: comparison
of isokinetic resistance exercises and the
electromyographic biofeedback re-education
program-a pilot program. Physiother Can.
1996;48:251-256.
60. Reinold MM, Macrina LC, Wilk KE, et al. Electro-
myographic analysis of the supraspinatus and
deltoid muscles during 3 common rehabilitation
exercises. J Athl Train. 2007;42:464-469.
6I. Reinold MM, Wilk KE, Fleisig GS, et al. Elec-
tromyographic analysis of the rotator cuf and
deltoid musculature during common shoulder
external rotation exercises. J Orthop Sports
Phys Ther. 2004;34:385-394. http://dx.doi.
org/10.2519/jospt.2004.0665
6Z. Roberts CS, Davila JN, Hushek SG, Tillett ED,
Corrigan TM. Magnetic resonance imaging anal-
ysis of the subacromial space in the impinge-
ment sign positions. J Shoulder Elbow Surg.
2002;11:595-599. http://dx.doi.org/10.1067/
mse.2002.127095
63. Rodeo SA, Suzuki K, Yamauchi M, Bhargava
M, Warren RF. Analysis of collagen and elas-
tic bers in shoulder capsule in patients
with shoulder instability. Am J Sports Med.
1998;26:634-643.
64. Rowe CR. Recurrent transient anterior sub-
luxation of the shoulder. The dead arm syn-
drome. Clin Orthop Relat Res. 1987;11-19.
65. Rowe CR, Zarins B. Recurrent transient sublux-
ation of the shoulder. J Bone Joint Surg Am.
1981;63:863-872.
66. Sale DG. Neural adaptations to strength train-
ing. In: Komi PV, eds. Strength and Power in
Sport. Oxford: Blackwell Publishing; 2003:
67. Schenk TJ, Brems JJ. Multidirectional instability
of the shoulder: pathophysiology, diagnosis,
and management. J Am Acad Orthop Surg.
1998;6:65-72.
68. Schwartz E, Warren RF, OBrien SJ, Fronek J.
Posterior shoulder instability. Orthop Clin North
Am. 1987;18:409-419.
69. Sekiya JK. Arthroscopic labral repair and cap-
sular shift of the glenohumeral joint: technical
pearls for a multiple pleated plication through a
single working portal. Arthroscopy. 2005;21:766.
http://dx.doi.org/10.1016/j.arthro.2005.03.024
70. Thomas SC, Matsen FA, 3rd. An approach to
the repair of avulsion of the glenohumeral liga-
ments in the management of traumatic anterior
glenohumeral instability. J Bone Joint Surg Am.
1989;71:506-513.
7I. Tillander B, Lysholm M, Norlin R. Multidirection-
al hyperlaxity of the shoulder: results of treat-
ment. Scand J Med Sci Sports. 1998;8:421-425.
7Z. Townsend H, Jobe FW, Pink M, Perry J. Electro-
myographic analysis of the glenohumeral mus-
cles during a baseball rehabilitation program.
Am J Sports Med. 1991;19:264-272.
73. Weishaupt D, Zanetti M, Nyfeler RW, Gerber
C, Hodler J. Posterior glenoid rim deciency in
recurrent (atraumatic) posterior shoulder insta-
bility. Skeletal Radiol. 2000;29:204-210.
74. Wickiewicz TL, Chen SK, Otis JC, Et al. Gle-
nohumeral kinematics in a muscle fatigue
model. Specialty Day Meeting. New Orleans, LA:
American Orthopedic Society for Sports Medi-
cine; 1994.
75. Wickiewicz TL, Pagnani M, Kennedy K. Rehabili-
tation of the unstable shoulder. Sports Med and
Arthrosc Rev. 1993;1:227-235.
76. Wilk KE, Arrigo CA, Andrews JR. Current
concepts: the stabilizing structures of the
glenohumeral joint. J Orthop Sports Phys Ther.
1997;25:364-379.
77. Wilk KE, Reinold MM, Andrews JR. Postoperative
treatment principles in the throwing athlete.
Sports Med and Arthrosc Rev. 2001;9:69-95.
78. Wirth MA, Blatter G, Rockwood CA, Jr. The
capsular imbrication procedure for recurrent
anterior instability of the shoulder. J Bone Joint
Surg Am. 1996;78:246-259.
79. Yamamoto N, Itoi E, Tuoheti Y, et al. The ef-
fect of the inferior capsular shift on shoulder
intra-articular pressure: a cadaveric study. Am
J Sports Med. 2006;34:939-944. http://dx.doi.
org/10.1177/0363546505283834
80. Zabinski SJ, Callaway GH, Cohen S, Warren RF.
Revision shoulder stabilization: 2- to 10-year
results. J Shoulder Elbow Surg. 1999;8:58-65.