11 patients (7 girls and 4 boys) with multidirectional instability of the shoulder were treated between 1999 and 2000. The average age was 15 years 8 months (range, 14–17), with a follow-up of 1 year 6 months. In the examination under general anesthesia it was confirmed that the luxation had more than one direction. The surgery was performed with general anesthesia using a standard arthroscope with video camera and classic approach for the shoulder. In order to decrease the capsular volume, capsular plicature and retraction by heat were used The plicatures were anterior, inferior and posterior. Patients were immobilized postoperatively in plaster splints or casts during 3 weeks and then they were placed in a rehabilitation program. The patients were followed up postoperatively, the UCLA Score was used during this period. Results were excellent and good in 90% of the patients, who were pain free and had full external rotation. Only one patients (10%) presented recurrence of the instability. Patients showed the same pre surgical sport performance. Only one case presented capsule laxity and an open surgery was performed. This patient was reexamined and was labeled as a psychiatric case wrongly selected. Only 2 patients presented capsule inflammation with limited external rotation. They were treated with intensive rehabilitation. The arthroscopic method allows for capsular volume reduction. Results were similar to the ones described with the open technique. The reduction of the capsular volume is done mixing capsular plicature and retraction by heat. This arthroscopic techniques, previously described for adult patients with multidirectional instability, proved to be useful in adolescents

Purpose: The objective of the study was to perform a prospective evaluation of thermal capsulorraphy for the treatment of multidirectional instability of the shoulder. Summary of Methods: Over a period of two years, 19 patients with multidirectional instability were treated with thermal shrinkage. Fifteen patients had involuntary dislocation and four voluntary. The predominant direction of instability was anterior/inferior in 10, posterior in 5 and multiple directions in 4. Patients were followed for a minimum of two years or until surgical failure and recurrence of symptomatology. Postoperatively patients were immobilised in a sling for a period of 3 weeks and were reviewed at 6 weeks and 3, 6, 9 and 12 months and then at six monthly intervals. The Western Ontario shoulder Instability Index was used as a clinical outcome measure as well as subjective and objective evaluation of patient’s function, range of motion, pain and instability. Results: Nine patients had recurrence of their instability occurring at an average of nine months following their surgical procedure (range 7–14 months). One patient had axillary nerve dysfunction postoperatively with difficulty in abducting the shoulder. Three patients had sensory dysaesthesia related to the axillary nerve territory. All neurological subjective evaluations recovered within 9 months. Four of five patients with a predominantly posterior direction to their instability failed this surgical procedure. Only 2 of 10 (20%) with predominantly anterior instability failed. Conclusion: Analysis of patients with multidirectional laxity determined that thermal capsulorraphy had a high failure rate (9/19, 47%) with associated significant postoperative complications including axillary nerve dysaesthesias and stiffness

Purpose

The presence of a Hill-Sachs lesion is a major contributor to failure of surgical intervention following anterior shoulder dislocation. The relationship between lesion size, measured on pre-operative MRI, and risk of recurrent instability after surgery has not previously been defined.

Hypothesis: We hypothesized that the size of Hill-Sachs lesions on pre-op MRI would be greater among patients who failed soft tissue stabilization when compared to patients who did not fail. We also hypothesized that the existence of a glenoid lesion would lead to failure with smaller Hill-Sachs lesions.

Thermal capsular shrinkage presents the prospect of reducing redundant capsule, and therefore may be a suitable method of treating capsular-type instability. A prospective study of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. The mean Rowe score improved from 33.1 to 74.1 points at followup of up to 48 months. Twenty of the fifty-eight shoulders had recurrence instability. Recurrent instability was related to the type of instability: 76.9% for voluntary instability, 30.3% for involuntary instability and none of 12 shoulders for instability/impingement pain. Recurrence was related as well to previous instability surgery (70%). The outcome was not related to the direction of instability, type of radiofrequency probe used, age of patient or ligamentous laxity. Twenty-two (57.9%) of thirty-eight patients returned to their pre-instability level of sporting activity. By using repeated RF treatments for the failed thermal shrinkage cases the failure rate was reduced from (20/58) 34.5% to (13/58) 22.4% and cumulative changes were seen on electron microscopy. These results are comparable to some of the results for open inferior capsular shift for patients with multidirectional instability with substantial less morbidity. The application of the minimal effective energy is controlled according to the tissue response without any charring or burning effect to the tissue. No scar was seen in repeated arthroscopies, or in electron microscopy studies. Thermal shrinkage does not negatively affect a later open stabilisation, but rather may provide better conditions for secure open surgery. We have found significant improvement in proprioception following thermal shrinkage treatment. We believe that by re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and that there is a greater dynamic muscular contribution to shoulder stability. When using the correct technique for the right indications, Radiofrequency thermal shrinkage is a viable alternative to open inferior capsular shift in patients with capsular type of instability

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA).

Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up.

Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed.

Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation.

Purpose: The purpose of our work was to report causes and results of treatment of anterior shoulder instability after implantation of a shoulder prosthesis. Material and methods: This retrospective multicentric study included 51 patients with prosthetic anterior instability: 42 patients after first-intention shoulder prosthesis and nine after prosthesis revision. There were 39 women (79%) and 12 men, mean age 67 years, who underwent total shoulder arthroplasty (n=29, 57%) or hemiarthro-plasty (n=22, 43%). Thirty-eight patients (75%) had prosthetic dislocation and 13 (25%) subluxation associated with pain an loss of anterior elevation. The initial prosthesis was implanted for degenerative disease (n=29), rheumatoid arthritis (n=7), or fracture (n=15). Anterior prosthetic instability occurred early in 23 shoulders (first six weeks) and lat in 28 shoulders (7 after trauma, 21 without trauma). Conservative treatment by reduction-immobilisation was performed in 16 cases and prosthetic revision in 35. The patients were reviewed radiographically at mean 41 months follow-up (range 24–62). Results: Subscapular tear or incompetence was the main cause of prosthetic anterior instability, observed in 87% of the cases. Technical errors concerning the prosthesis were also observed: oversized head, malrotation of the prosthesis. Associated complications were frequent: glenoid loosening (24%), polyethylene dissociation from the metal glenoid implant (10%), infection (10%), humeral fracture (4%). The final Constant score was 54 points and 55% of the patients were disappointed or dissatisfied. None of the shoulders were stable after consevative treatment. The prosthetic revision provided disappointing results with 51% recurrent anterior instability. Discussion: Anterior instability of shoulder prostheses is a serious complication which responds poorly to treatment. Loosening of the subscapular suture is the main cause

Expert North American shoulder surgeons were poled on the diagnosis and treatment of five shoulder conditions. To quantify inter-observer agreement in the diagnosis and treatment of shoulder instabilities, they chose one of five diagnostic conditions and one or more of seven treatment options. The greatest diagnostic and treatment differences were noted for a painful shoulder in a throwing athlete with subtle anterior instability and a patient with voluntary posterior instability with an asymptomatic sulcus sign. An arthroscopic approach was consistently preferred to open surgery. These inconsistencies highlight the need for standardized diagnostic criteria and more universal treatment plans.

To quantify inter-observer agreement in the diagnosis and treatment of shoulder instabilities among expert North American shoulder surgeons.

These inconsistencies, particularly in diagnosis, highlight the need for standardization of diagnostic criteria and guidelines working towards more universal treatments and evaluations of outcomes.

The greatest diagnostic differences were noted for a painful shoulder in a throwing athlete with subtle anterior instability(Ksc0.46, 55% agreement) and a patient with voluntary posterior instability with an asymptomatic sulcus sign(Ksc0.41, 50% agreement). The presence of an asymptomatic sulcus sign alone may have been mistakenly interpreted as inferior instability rather than inferior laxity. There was a high level of agreement in diagnosing anterior and bi-directional instability. An arthroscopic approach to treatment was consistently preferred to open surgery. The greatest differences in treatment choice were for the throwing athlete(Ksc0.38, 47% agreement on arthroscopic repair), a patient with voluntary posterior instability(Ksc0.34, 43% agreement on arthroscopic capsular repair) and a patient with bi-directional instability(Ksc0.23, 34% agreement on arthroscopic anterior Bankart repair).

Active members of the American Shoulder and Elbow Surgeons and JOINTS Canada (Orthopaedic Initiatives for National Trials of the Shoulder) were poled on the diagnosis and treatment of five shoulder conditions. They were to choose one of five conditions and one or more of seven treatment options. A Kappa coefficient of agreement was used to assess inter-observer reliability; a Ksc of 1 denotes perfect agreement on a category and a Ksc of −1 denotes perfect agreement on not endorsing a category.

Purpose: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. The purpose of this study was to evaluate the results of arthroscopic methods in the treatment of athletes with symptomatic multidirectional instability of the shoulder. Method: Forty patients (43 shoulders) with multidi-rectional instability of the shoulder were treated via arthrscopic means and were evaluated at a mean of 33.5 months post-operatively. The mean patient age was 19.1 years (range 14 to 39). There were 24 male patients and 16 female patients. Patients were evaluated with the ASES and WOSI scoring systems. Stability, strength, and range of motion were evaluated with patient-reported scales. Results: The mean ASES score postoperatively was 91.4 out of 100. The mean WOSI post-operative percentage score was 91.1 out of 100. Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% of patients were able to return to their sport with little or no limitation. Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population

Introduction. The highest incidence of recurrent shoulder instability is in young patients, surgical repair can reduce recurrent instability and improve shoulder function. This has led to an increasing rate of stabilisation and use of MRI to identify associated injuries in first time dislocations. MRA has the benefit of distending the joint and is becoming increasingly used. The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. Methods. A retrospective analysis of patients undergoing both magnetic resonance arthrography and arthroscopy after a traumatic anterior shoulder dislocation between January 2011 and 2014. Images were interpreted by eight musculoskeletal radiologists and arthroscopic findings were obtained from surgical notes and used as a reference. The sensitivity, specificity and positive predictive value for the different injuries were calculated. Results. 60 patients were reviewed; 88% were male, mean age was 28 years (range 18 to 50) and 27% were primary dislocations. The overall sensitivity and specificity of MRA to all associated injuries was 0.9 (CI 0.83–0.95) and 0.94 (CI 0.9–0.96) retrospectively. The lowest sensitivity was seen in osseous Bankart 0.8 (CI 0.44–0.96) and SLAP lesions 0.5 (CI 0.14–0.86). Conclusion. MRA has a high sensitivity when used to identify associated injuries in shoulder dislocation although in 8 patients (13%) arthroscopy identified an additional injury. The overall agreement between MRA and arthroscopic findings was good but identification of GHL and rotator cuff injuries was poor. Level of Evidence. IV. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Background: The results of arthroscopic anterior labral (Bankart) repair have been shown to have high failure rate in patients with significant glenoid bone loss. Several reconstruction procedures using bone graft have been described to overcome the bone loss, including autogenous coracoid transfer to the anterior glenoid (Latarjet procedure) as well as iliac crest autograft and tibial allografts. In recent years, trends toward minimally invasive shoulder surgery along with improvements in technology and technique have led surgeons to expand the application of arthroscopic treatment. Purpose: This study aims to perform a retrospective analysis of prospectively collected data to evaluate the clinical and radiological follow up of patient who underwent anatomic glenoid reconstruction using distal tibia allograft for the treatment of shoulder instability with glenoid bone loss at 1-year post operation time point. Between December 2011 and January 2015, 55 patients underwent arthroscopic stabilisation of the shoulder by means of capsule-labral reattachment to glenoid ream and bony augmentation of glenoid bone loss with distal tibial allograft for recurrent instability of the shoulder. Preoperative and postoperative evaluation included general assessment by the western Ontario shoulder instability index (WOSI) questionnaire, preoperative and postoperative radiographs and CT scans. Fifty-five patients have been evaluated with mean age of 29.73 years at time of the index operation. There were 40 males (mean age of 29.66) and 15 female (mean age of 29.93). Minimum follow up time was 12 months. The following adverse effects were recorded: none suffered from recurrent dislocation, 2 patients suffered from bone resorption but without overt instability, 1 patient had malunion due to screw fracture, None of the patients had nonunion. The mean pre-operative WOSI score was 36.54 and the mean postoperative WOSI score was 61.0. Arthroscopic stabilisation of the shoulder with distal tibia allograft augmentation demonstrates promising result at 1year follow up

We undertook this study to evaluate our results of Arthroscopic Capsular Shrinkage as a treatment of Multi Directional Instability of the shoulder. Patients with symptomatic multidirectional instability (MDI) have excess capsular laxity. Arthroscopic capsular shrinkage is a fairly new procedure, to treat laxity with variable results in the reported literature. We analysed the records of patients who under went 20 (10 males, nine females) arthroscopic thermal capsular shrinkage procedures for MDI of the shoulder, which were performed by the senior author between 2000 and 2004. The mean age was 28.3 years (median 29.4, range 18 to 46 years) and the mean follow up was 44.5 months (median 43, range 20 to 69 months). All patients had undergone specialist shoulder physiotherapy for four months or more prior to surgery. The type of shoulder instability was subcategorised (based upon the predominant symptomatology as perceived by the patient) as follows: dislocation (seven), subluxation +/− pain (nine), and impingement (four). The procedure and postoperative regimen were standardised. Clinical outcome measures were: patient satisfaction, pain and instability. Sixteen shoulders (80%) were symptom free and fully satisfied at last follow up. One patient (5%) had some pain but a stable shoulder. Three patients (15%) [two dislocators and one subluxator] had recurrent instability between six to eight months post operatively and underwent further surgery. The less the instability, the more likely it was, that the procedure would succeed. We conclude that out results are encouraging particularly in patients with less severe instability despite the small size (20) of our cohort of patients. We think that careful patient selection may be important for success from this surgery

The April 2013 Shoulder & Elbow Roundup. 360 . looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow

Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. A prospective, randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited. 169 professional rugby players with no history of instability in either shoulder and 46 players with one shoulder with clinical instability symptoms were assessed. Shoulder laxity was measured by clinical evaluation, questionnaires and ultrasound. Anterior, posterior and inferior translation was measured in both shoulders for healthy players and the uninjured shoulder only for injured players. The results showed there was no significant difference between the left (anterior: mean 2.92 +/− 1.15 mm; posterior: mean 5.10 +/− 1.75 mm; inferior: mean 3.08 +/− 1.00 mm) and right (anterior: mean 3.07 +/− 1.14 mm; posterior: mean 4.87 +/− 1.61 mm; inferior: mean 2.91 +/− 0.99 mm) shoulders in healthy players (P > 0.05). The comparison between healthy shoulders (anterior: mean 3.00 +/− 1.15 mm; posterior: mean 4.99 +/− 1.68 mm; inferior: mean 3.00 +/− 1.00 mm) from healthy players and the uninjured shoulder (anterior: mean 4.16 +/− 1.70 mm; posterior: mean 6.16 +/− 3.04 mm; inferior: mean 3.42 +/− 1.18 mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P < 0.05). This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with “lax” shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport

The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation. Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group. The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069). This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder

Objective. Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. Methods. A randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited in 2006. 169 professional rugby players (mean age 25.1 years) with no history of instability in either shoulder were assessed and 46 injured players with one shoulder with a history of Bankart lesion or dislocation (mean age 27.5 years) also took part in this study. Shoulder laxity was measured by dynamic ultrasound. Anterior, posterior and inferior translations were measured in both shoulders for healthy players and the uninjured shoulder only for injured players. Results. No significant difference between the non-dominant (anterior: mean 2.9±1.2mm; posterior: mean 5.1±1.8mm; inferior: mean 3.1±1.0mm) and dominant (anterior: mean 3.1±1.1mm; posterior: mean 4.9±1.6 mm; inferior: mean 2.9±1.0mm) shoulders in healthy players (P>0.05). The comparison between healthy shoulders (anterior: mean 3.0±1.2mm; posterior: mean 5.0±1.7mm; inferior: mean 3.0±1.0mm) from healthy players and the uninjured shoulder (anterior: mean 4.2±1.7mm; posterior: mean 6.2±3.0mm; inferior: mean 3.4±1.2mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P<0.05). Conclusion. This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with ‘lax’ shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport even if no symptom is presented

Objectives: A stable shoulder is essential for proper elbow and hand function after oncologic resection of the shoulder girdle. We describe a surgical technique for replacing the shoulder joint capsule using synthetic mesh after resections of the shoulder girdle that resulted in gross intraoperative instability of the shoulder joint. Methods: 68 patients who underwent shoulder girdle resection between 1989 and 2006 were identified in our prospective database. This report focuses on nine patients whose shoulder joint was reconstructed with synthetic mesh. All patients were followed on a 3 monthly basis. Shoulder joint instability was determined from clinical records, database and radiographs. Results: Nine patients underwent shoulder joint reconstruction with synthetic mesh. One patient underwent a shoulder disarticulation within 30 days of the index surgery and was excluded from this rapport. No dislocations were noted during follow-up (range 3–48 months). Radiographs revealed an average vertical displacement of the humeral head compared to its original position of 0.7 cm (range 0–1.7 cm). There were two surgical complications. In one patient the humeral prosthesis migrated proximally and eroded through the skin requiring additional surgery. In another case erosion of the distal clavicle was noted. This was biopsied and foreign body reaction identified. Conclusions: Joint instability following major resections of the shoulder girdle is a source of morbidity and affects the function of the salvaged limb. Synthetic capsular reconstruction using Marlex mesh is a useful adjunct in patients where insufficient shoulder musculature and joint capsule remains after resection to allow for stable suspension of the upper limb

Purpose: Arthroscopic stabilization for post-traumatic anterior glenohumeral instability is designed to minimize soft tissue dissection while achieving similar or improved outcomes relative to open techniques. This study’s purpose was to determine the rate of post-operative recurrent instability and evaluate health related quality of life (HRQL) and shoulder range of motion (ROM) following arthroscopic Bankart repair using a bioabsorbable knotless implant. Method: Forty-three patients were prospectively evaluated following arthroscopic anterior stabilization to assess for recurrent instability, HRQL, and shoulder ROM. Assessments were performed pre-operatively and 3, 6 and 12–24 months postoperatively. The HRQL measures included the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons Score (ASES), and the Constant Score. Repeated measures ANOVA was utilized to evaluate ROM and HRQL. Results: The mean WOSI score improved from 45.67±17.99 pre-operatively to 83.16±18.58 at final follow-up. The mean ASES scores improved from 80.1±13.06 pre-operatively to 92.25±15.08, while the Constant score improved from 77.52±16.11 pre-operatively to 85.18±26.76. At final follow-up, 4 of 43 patients (9.3%) had experienced recurrent instability. For these 4 subjects, the WOSI score was significantly lower at final follow-up than those who did not experience recurrent instability (61.73±5.76 versus 84.38±16.94). The ASES and Constant scores at final follow-up were not significantly different between these two groups. Conclusion: Arthroscopic anterior stabilization using a bioabsorable tack led to a recurrent instability rate similar to previous reports, and resulted in improved HRQL and shoulder ROM. The WOSI score was better able to detect problems in HRQL related to instability than either the ASES or Constant score

Aim: To demonstrate that inappropriate sequencing of activation of shoulder muscles can cause shoulder instability. Methods. The records of 933 cases of recurrent shoulder instability referred to a specialist shoulder service between 1993 and 2003 were reviewed. All patients were assessed clinically. Muscle patterning abnormality (Bayley 1986) was identified in 428 patients (46%). Confirmatory functional electromyography was performed in 166 (36%). Inappropriate pectoralis major activation was identified in 73% of anterior instability. In posterior instability, inappropriate activation of latissimus dorsi and anterior deltoid was present in 72% and infra-spinatus was suppressed in 19%. Arthroscopic assessment was performed in 141 (33%), identifying structural lesions of instability in 86 (20%). All patients diagnosed with muscle patterning disorder received specilalist physical therapy using biofeedback. Symptomatic improvement or stability was achieved in 76% of patients with anterior instability but with no previous surgery, and in 53% of patients with previous surgery. Posterior instability was eliminated in 85% of cases. Conclusion. Muscle patterning abnormalities contribute to recurrent instability of the shoulder in 46% of cases. The success of physical therapy in these patients is high

The aimof this study was to assess proprioception in multi-directional instability of the shoulder before and after a new surgical treatment. A cross-sectional pilot study assessing shoulder proprioception in asymptomatic controls (n=6), pre-operative patients (n=7) awaiting surgery for atraumatic, multidirectional instability having failed a comprehensive rehabilitation programme and post-operative patients (n=7) having undergone thermo-capsular shrinkage of the shoulder and post-operative rehabilitation. Data were obtained using the Proprioception Assessment System developed at this centre following a standardised protocol to record both threshold to detection of passive movement (TTDPM) and reproduction of passive position (RPP) in three positions of rotation. Means and standard deviations are presented. There were no differences between shoulders in controls and post-operative patients. Despite the small numbers, pre-operative patients showed significant differences (p< 0.05) between shoulders in 2 of the 6 test protocols. Post-operative shoulders had means similar to controls suggesting thermo-capsular shrinkage may help regain shoulder proprioception after injury

Introduction and purpose: Our aim was to determine a morphometric relation between the long head of the brachial biceps and the bicipital groove with respect to the subscapular tendon, and its repercussion on functional imbalance of the shoulder. Materials and methods: For this analytical observational crossover study we took a sample of 30 right-handed, sedentary, duly informed male subjects. The morphometric study was carried out with ultrasonography using a cross-section of the long head of the brachial biceps. Results: In the dominant limb: 1. Bicipital groove (depth 2.6 mm, width 13.4 mm, internal angle 149.8°); 2. Long head of the brachial biceps (area 1.35 mm, internal angle 152.53°, echogenicity 97.95); 3. Subscapular thickness 4.53 mm. In the non-dominant limb: 1. Bicipital groove (depth 2.9 mm, width 12.5 mm, internal angle 145.73°); 2. Long head of the brachial biceps (area 1.07 mm, internal angle 141.32°, echogenicity 112.72); 3. Subscapular thickness 4.12 mm. Conclusions: The greater the thickness of the subscapular tendon: 1. Bicipital groove (greater width and internal angle, less echogenicity and depth); 2. Long head of the brachial biceps (greater area and internal angle, less echogenicity). Therefore, there is a greater risk of dislocation of the long head of the brachial biceps and functional instability of the shoulder