This is an enhanced PDF from The Journal of Bone and Joint Surgery

The PDF of the article you requested follows this cover page.

Principles for the Evaluation and Management of Shoulder Instability

Frederick A. Matsen, III, Caroline Chebli and Steven Lippitt
J Bone Joint Surg Am. 2006;88:647-659.

This information is current as of October 23, 2007

Subject Collections Articles on similar topics can be found in the following collections

Adult Trauma (567 articles)

Reprints and Permissions
Publisher Information
Shoulder/Elbow (361 articles)
Shoulder (260 articles)
Dislocation (91 articles)
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
 647

Selected

The American Academy of Orthopaedic Surgeons

Printed with permission of the
American Academy of
Orthopaedic Surgeons. This article,
as well as other lectures presented
at the Academy’s Annual Meeting,
will be available in February 2007 in
Instructional Course Lectures,
Volume 56. The complete
volume can be ordered online
at www.aaos.org, or by
calling 800-626-6726
(8 A.M.-5 P.M., Central time).
J. L AWRENCE M ARSH
EDITOR, VOL. 56
C OMMITTEE
J. L AWRENCE M ARSH
CHAIRMAN
FREDERICK M. A ZAR
PAUL J. D UWELIUS
TERR Y R. L IGHT
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

J AMES D. HECKMAN
EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006
Principles for the
Evaluation and Management
of Shoulder Instability
BY FREDERICK A. MATSEN III, MD, CAROLINE CHEBLI, MD, AND STEVEN LIPPITT, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
During use of the normal shoulder,
the humeral head is centered within
the glenoid and the coracoacromial
arch. When the shoulder cannot main-
tain this centered position during use,
it is unstable. An unstable shoulder pre-
vents normal function of the upper ex-
tremity. Shoulder instability is not the
same as joint laxity. Joint laxity is a
property of normal joints and allows
the shoulder to attain its full range of
functional positions.
The concavity of the glenoid and
the coracoacromial arch along with the
passive and active forces that press the
humeral head into the glenoid and the
coracoacromial arch maintain the head
in its centered position. This concavity-
compression mechanism is dependent
on the integrity of the glenoid and the
coracoacromial arch, muscular com-
pression, and restraining ligaments
of the shoulder. Loss of any of these
elements due to developmental, de-
generative, traumatic, or iatrogenic
factors may compromise the ability of
the shoulder to center the humeral head
in the glenoid.
The questions to answer during
an evaluation of a patient with sus-
pected instability are: (1) Is the problem
in the glenohumeral joint? (2) Is the
problem one of failure to maintain the
humeral head in its centered position?
(3) What mechanical factors are con-
648
PR I N C I P L E S F O R T H E EV A L U A T I O N
OF SHOULDER INSTABILITY
tributing to this instability? (4) Are the
identified mechanical factors amenable
to surgical repair or reconstruction?
This evaluation is based primarily on
a carefully elicited history, a physical
examination of the stability mechanics,
and plain radiographs. If more com-
plex imaging methods are needed to
discover subtle or “occult” instability,
the condition is often not responsive to
surgical correction.
For surgical treatment of gleno-
humeral instability to be appropriate,
the instability must be attributable to
mechanical factors that can be modified
by surgery. The causes may be deficien-
cies of the glenoid concavity, deficien-
cies in the muscles that compress the
head into the socket, and/or deficiencies
in the capsule and ligaments.
Instability is one of the most
commonly diagnosed and treated con-
ditions of the shoulder. Diverse and ad-
mittedly confusing approaches to this
problem have been proposed, making it
difficult to understand how best to eval-
uate and manage affected patients. This
lecture offers a practical foundation to
aid in the understanding of clinical
shoulder stability and instability1,2.
Glenohumeral stability requires
that the humeral head remain centered
in the glenoid fossa. When the humeral
head does not remain centered, the pa-
tient has glenohumeral instability.
AND MANAGEMENT
The glenohumeral joint is a bal-
ance between mobility and stability3. Its
mobility is limited by the joint capsule,
which prevents the humeral head from
rotating into excessive positions. The
joint capsule and associated ligaments
act as checkreins to rotation and func-
tion only at the extremes of motion,
when they come under tension. While
they also limit translation of the hu-
meral head on the glenoid, restraint of
translation alone cannot keep the head
centered (just as a dog’s leash cannot
keep the dog in the center of the yard
unless it severely limits the dog’s mo-
tion). During the midrange of motion,
the capsule and ligaments are lax and,
therefore, allow the humeral head to be
passively translated during physical as-
sessments such as the sulcus and drawer
tests. In spite of the capsuloligamen-
tous laxity, which is required for normal
shoulder mobility, the humeral head
remains precisely centered in the glen-
oid fossa during active motion of the
normal shoulder4. This centering is nec-
essary in order for the hand to be pre-
cisely and securely positioned in space.
If the relative position of the humeral
head and glenoid fossa were not secure
and precise, the hand could not write,
paint, throw, lift, hit, or operate with
accuracy. The fact that the humeral
head remains precisely centered, even
in the shoulders of a gymnast with ex-

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006
Fig. 1
Concavity-compression. The deeper the concavity, the greater the displacing force that can be re-
sisted for a given compressive load. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt
SB. Principles of glenohumeral stability. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder
surgery: principles and procedures. Philadelphia: Saunders; 2004. p 83.)
treme joint laxity who is performing a
vault or holding the iron-cross position,
demonstrates the remarkable ability of
the shoulder to be stabilized by concavity-
compression5.
Stability of the glenohumeral
joint is critical for precise and strong
function of the upper extremity. In the
past, the mechanisms providing stabil-
ity have been categorized as “static” and
“dynamic” or as “active” and “passive.”
We now recognize that the entire system
functions as an integrated whole. For
example, in the past it was stated that
the anteroinferior glenohumeral liga-
ment is the primary static stabilizer of
the shoulder. This is patently not the
case because when we sleep or rest in a
chair the inferior glenohumeral liga-
ment is not under tension (and thus is
not functional) and, although the mus-
cles around the shoulder are relaxed,
the glenohumeral joint is not unstable.
Similarly, the rotator cuff muscles have
been called “dynamic stabilizers” of the
shoulder, but, even in an anesthetized
shoulder, the passive tension in these
muscles provides sufficient compres-
sion to stabilize the ball in the socket (as
observed in the operating room when
the shoulder muscles are paralyzed).
The glenohumeral stabilizing sys-
tem has a number of key elements. The
concavity of the glenoid, the muscles
649
PR I N C I P L E S F O R T H E EV A L U A T I O N
OF SHOULDER INSTABILITY
that compress the humeral head into
the glenoid, the coracoacromial arch,
the capsuloligamentous restraints, and
adhesion-cohesion of the articular sur-
faces all contribute to stability. Defi-
ciencies or defects in any of these
structures can lead to instability.
Glenoid Concavity
A ball sitting on a flat table has no ten-
dency to center itself. Even a slight dis-
placing force causes it to slide or roll. If
the table has a concavity, the ball will sit
at the base of the concavity. The deeper
the concavity, the more force it takes to
move the ball out of it. The stability is
increased if a greater force presses the
ball into the concavity (Fig. 1). This
Fig. 2
The glenoid concavity. The socket is deepened by the thicker cartilage on its periphery and by the
glenoid labrum. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of
glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles and
procedures. Philadelphia: Saunders; 2004. p 88.)
AND MANAGEMENT
mechanism is known as concavity-
compression6.
The glenoid concavity has three
components: the osseous glenoid,
which is slightly concave; the articular
cartilage, which is thicker at the periph-
ery and thinner in the center and thus
makes the concavity deeper; and the
glenoid labrum, which further deepens
the glenoid concavity7 (Fig. 2). Because
of its increased compliance, the glenoid
labrum optimizes the surface area of
glenohumeral contact and creates a
conforming seal with the head of the
humerus. This flexible periphery en-
ables small deviations from fixed ball-
and-socket kinematics without com-
promising the intrinsic stability of the
articulation. The glenoid center line is
perpendicular to the glenoid articular
surface and points slightly posterior to the
plane of the scapula (Figs. 3-A and 3-B).
The adequacy of the glenoid
concavity in different directions can
be assessed with use of three related
measures. We use the term glenoido-
gram to describe the path taken by
the center of the humeral head as it is
translated over the surface of the glen-
oid in a given direction. It normally
has a gull-wing shape with a medially
pointing apex at the glenoid center line
(Figs. 4-A and 4-B). This shape results
from the fact that when the humeral
head moves away from the center of
the glenoid concavity its center dis-
places laterally. A glenoid lacking a lip
has a flattened glenoidogram: when
the head moves toward the flattened
part of the glenoid lip, it does not
 650
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

concavity is deepest. The stability ra-

tio is lower when the humeral head is
not centered in the glenoid. The stabil-
ity ratio is calculated from the slope of
the glenoidogram. The so-called load-
and-shift test is a clinical analogue of
the stability ratio. The load-and-shift
test is performed by pressing the hu-
meral head into the glenoid fossa and,
while the compression is maintained,
noting the resistance to translation of
the head toward the lip in different
directions.
The balance stability angle is the
maximal angle between the glenoid
center line and the net humeral joint-
reaction force before the humeral head
Fig. 3-A dislocates from the glenoid (Fig. 6).
The glenoid center line is perpendicular to the center of the glenoid concavity. (Reproduced, with Experimentally, the contribution of
permission, from: Matsen FA 3rd, Lippitt SB. Principles of glenoid concavity. In: Matsen FA 3rd, the glenoid shape to glenohumeral sta-
Lippitt SB, DeBartolo SE. Shoulder surgery: principles and procedures. Philadelphia: Saunders; bility can be measured by orienting the
2004. p 89.) glenoid with the center line pointing
vertically upward and then tipping it
until an unconstrained ball rolls out.
move laterally. The lateral movement necessary to displace the head from In this case, the net force on the ball is
of the humeral head as it is translated the glenoid divided by the load com- the vertically oriented force of gravity,
across the face of the glenoid can be pressing the head into the concavity so the angle of tip at the moment of
noted on physical examination of the (Fig. 5). The stability ratio is greatest dislocation is the balance stability an-
normal shoulder. when the head is at the center of the gle. The so-called jerk test, in which
The stability ratio is the force glenoid fossa because that is where the the humeral head slips out the back of

Fig. 3-B
The glenoid center line is close to perpendicular to the medial border of the scapula (left) and points slightly posterior to the plane of the scapula
(right). (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE.
Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. p 89.)
 651
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

the glenoid with cross-body adduc-
tion, is a clinical analogue of the labo-
ratory measurement of the balance
stability angle.
Scapular Factors in Instability
The Glenoid
The glenoid faces slightly posteriorly.
A line perpendicular to the glenoid
concavity is the glenoid center line. This
line normally is approximately 10° from
the plane of the scapula (Figs. 3-A and
3-B). Anterior deviation of this line lat-
erally is referred to as anteversion; pos-
terior deviation of this line laterally is
retroversion. When maximal shoulder
stability is needed—for example, when
performing a bench press—the scapula
and glenoid rotate forward to ensure
that all forces remain aligned with the
glenoid center line.
A scapula that is malaligned be-
cause of poor shoulder kinematics may
increase the angle between the glenoid
center line and the net humeral joint-
reaction force to a point where the
centering of the humeral head is com-
promised. Clinically, problems of scap-
ular misalignment are suggested when
the scapulothoracic muscles fail to posi-
tion the glenoid to best align it with the
net humeral joint-reaction forces.
An anteverted or retroverted
glenoid is less effective in centering the
humeral head in the glenoid because
the glenoid center line is no longer
aligned with the forces generated by
the scapulohumeral muscles. Glenoid
version can be estimated clinically from
standardized axillary radiographs or
from computed tomography scans.
A flattened glenoid may not pro-
vide sufficient concavity for effective
concavity-compression. The glenoid
may be flattened in a given direction
because it is dysplastic, because the
glenoid labrum and peripheral carti-
lage are excessively small or compliant,
because the glenoid labrum and pe-
ripheral cartilage are worn, because
the labrum is avulsed from the glenoid
lip, or because the glenoid lip is frac-
tured8. A flattened glenoid is suggested
when the humeral head translates
without a feeling of going over a lip,
when there is diminished resistance to
the load-and-shift test, or when there is
a positive jerk test.
The Muscles
The humeral head is compressed into
the glenoid by the muscles of the rota-
tor cuff and other scapulohumeral and
thoracohumeral muscles. The line of
action of each of these muscles is not, as
is often described, one of “depression”
of the humeral head away from the ac-
romion; rather, it is one of compression
of the humeral head into the glenoid
concavity (Fig. 5).
The subscapularis muscle is the
primary anterior compressor. Its effec-

Fig. 4-A Fig. 4-B

Figs. 4-A and 4-B The glenoidogram. Fig. 4-A The glenoidogram is the path taken by the center of the humeral head as it
translates across the face of the glenoid. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of
glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles and procedures. Philadelphia:
Saunders; 2004. p 100.) Fig. 4-B Translation anteriorly and posteriorly across a normally concave glenoid traces a gull-wing-
shaped path. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of glenoid concavity. In: Matsen FA
3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. p 101.)
 652
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

tive strength is assessed by positioning

the arm in maximal internal rotation
(with the elbow flexed to a right angle
and the hand behind the back) to mini-
mize the contribution of other internal
rotators, such as the pectoralis major,
the latissimus dorsi, and the teres ma-
jor, and then noting the amount of iso-
metric internal rotation torque that can
be generated. This is known as the lum-
bar push-off test.
The supraspinatus muscle is the
primary superior compressor. Its effec-
tive strength is assessed by positioning
the arm in 90° of elevation in the plane
of the scapula and in internal rotation
(so that the supraspinatus lies over the
top of the humeral head) and then not-
ing the amount of isometric elevation
torque that can be generated. This is
known as the supraspinatus test.
The infraspinatus is the primary
posterior compressor (assisted to a de-
gree by the teres minor). Its effective
strength is assessed by positioning the
arm in neutral rotation and slight eleva-
tion in the plane of the scapula with the
Fig. 5
elbow bent to a right angle and then The stability ratio is the force necessary to displace the humeral head from the glenoid center di-
noting the amount of isometric external vided by the load compressing the humeral head into the glenoid. (Reproduced, with permission,
rotation torque that can be generated.
from: Matsen FA 3rd, Lippitt SB. Principles of glenoid concavity. In: Matsen FA 3rd, Lippitt SB, De-
This is known as the infraspinatus test.
Bartolo SE. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. p 105.)
The important characteristic of
the muscles of the rotator cuff is that
they can function as head compressors shoulder. Even with the minimal com- of the tuberosities and the rotator cuff).
in almost any position of the gleno- pressive force generated by gentle active The principle of concavity-com-
humeral joint. Other muscles, such as abduction, the humeral head can no pression applies to the ball-and-socket
the deltoid, long head of the biceps, longer be translated by the examiner. joint between the proximal humeral
pectoralis, latissimus, teres major, and Paralysis, detachment, or dysfunc- convexity and the coracohumeral arch.
pectoralis major, can contribute to hu- tion of the subscapularis, supraspinatus, The primary compressor of this arti-
meroglenoid compression in certain and/or infraspinatus result in loss of hu- culation is the deltoid. Compression
glenohumeral positions. For example, meral head compression. Instability in into the arch also results when the arm
when the arm is elevated 90° in the the direction of the affected tendon may presses down, such as when the arms
plane of the scapula, the deltoid be- result. As an example, supraspinatus de- are used to rise from an armchair, dur-
comes a strong compressor of the head ficiency is commonly associated with su- ing walking with a cane or crutches, and
into the glenoid. perior displacement of the humeral head when an athlete performs bar dips, ac-
The effectiveness of concavity- relative to the glenoid. tivities in which stability of the shoulder
compression can be dramatically dem- is essential. The marvel of the design of
onstrated by first performing an ante- The Coracoacromial Arch the shoulder is that the centers of rota-
rior-posterior drawer test on the relaxed As Codman recognized in the 1920s, the tion for the humeral head, the proxi-
shoulder and noting the ability of the glenohumeral joint is not the only im- mal humeral convexity, the glenoid
head to translate on the glenoid. The portant articulation between the hu- fossa, and the coracoacromial arch are
same drawer test is then repeated while merus and the scapula9. Of comparable all superimposed in the normal stable
the arm is held in abduction by the pa- importance is the articulation between shoulder (Fig. 7).
tient, increasing the net humeral joint the coracoacromial arch and the proxi- The critically important sta-
force vector pressing the humeral head mal humeral convexity (the spherical bilizing effect of the articulation be-
into the glenoid fossa in the normal contour provided by the external surface tween the coracoacromial arch and
 653
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

Fig. 6
The balance stability angle is the maximal angle that the net force on the humeral head forms
with the glenoid center line before dislocation occurs. The net humeral joint-reaction force is the
vector sum of the displacing force and the compressive load. The tangent of the balance stability
angle is the stability ratio. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Princi-
ples of glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: princi-
ples and procedures. Philadelphia: Saunders; 2004. p 108.)

the proximal humeral convexity is
demonstrated by the devastating an-
terosuperior instability that results
when an acromioplasty is performed
in the presence of rotator cuff defi-
ciency. Even when the rotator cuff is
intact, disruption of the coracoac-
romial arch may compromise the
ability of the joint to remain centered
in the presence of a superiorly direc-
ted force.
The Glenohumeral
Ligaments and Capsule
In mid-range positions, the gleno-
humeral capsule and its associated
ligaments are lax and do not exert a
centering effect. At the extremes of
motion, however, these structures be-
come important contributors to hu-
meral centering10. First, they prevent
humeral rotation beyond the point
where the muscles are effective. As is
the case for muscles in general, the ro-
tator cuff muscles are able to generate
the most force when they are in mid-
excursion. They become less effective
when they are maximally extended.
It is the job of the capsule and liga-
ments to prevent the rotator cuff
muscles from becoming overstretched.
Second, the ligaments come under
progressively greater tension at the ex-
tremes of motion. This tension creates
a compressive force that is essentially
collinear with the force that would
otherwise be exerted by the muscle
overlying it. This force takes over in
positions where the muscle force drops
off (Fig. 8).
Third, the ligaments substitute
for muscle forces in positions where no
muscle is present. For example, the co-
racohumeral ligament and rotator in-
terval capsule that lie between the
supraspinatus and the subscapularis
tendons provide a compressive force
when the arm is in adduction11. An-
other example is the inferior gleno-
humeral ligament complex that lies
Fig. 7
a, b, and c: Centers of rotation. b: In the stable
and normally aligned shoulder, the centers of
rotation of the humeral articular surface and
the glenoid concavity and the proximal hu-
meral convexity and the coracoacromial arch
are all superimposed. c: The difference in the
radius of the humeral head (r) and that of the
proximal humeral convexity (R) is made up by
the rotator cuff and the tuberosities. (Repro-
duced, with permission, from: Matsen FA 3rd,
Lippitt SB. Principles of glenohumeral stability.
In: Matsen FA 3rd, Lippitt SB, DeBartolo SE.
Shoulder surgery: principles and procedures.
Philadelphia: Saunders; 2004. p 82.)
in the tendon-free zone beneath the
glenohumeral joint and provides a
compressive force when the arm is
abducted. These capsuloligamentous
 654
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

effects are energy-efficient. For exam-
ple, the compressive effect of the ten-
sion in the coracohumeral ligament
and the rotator interval capsule centers
the humeral head when the arm is at
rest by the side without consuming
muscular energy. Similarly, the com-
pressive effect of the inferior gleno-
humeral ligament helps to center the
humeral head when the arm is in the
cocking and early acceleration phases
of the throw without consuming addi-
tional energy.
When the capsuloligamentous
restraints are deficient, the joint can
over-rotate into positions in which
the muscles are less able to provide
adequate compression. As a result,
patients with a substantial avulsion of
the capsule from the glenoid often de-
scribe weakness of the arm when it is
abducted and externally rotated. Simi-
larly, patients with a deficiency of the
inferior glenohumeral ligament have
difficulty throwing because muscular
contraction cannot substitute for the
compressive forces provided by the in-
tact ligament.

Adhesion-Cohesion and
the Suction Cup
There are two other centering mecha-
nisms that do not require energy. One is
adhesion-cohesion, a process in which
the wettable surfaces of the humeral
and glenoid cartilage and the wettable
surfaces of the coracoacromial arch and
the proximal humeral convexity adhere
to each other because of the adhesive
and cohesive properties of water mole-
cules. These properties enable the two
sets of surfaces to glide easily on each
other while simultaneously preventing
Fig. 8 them from separating. The power of ad-
Hypothetical graph showing the interplay between muscular and capsular tension. As the humerus hesion-cohesion can be demonstrated
is passively externally rotated, the force that the subscapularis can generate drops off while the by placing a drop of water between two
force generated by the anterior capsular ligaments increases in a complementary manner. microscope slides and noting the ease

Fig. 9
Mechanics of the Bankart lesion. When a 33-lb (147-N) load is applied to the hand of the outstretched arm,
the resulting torque can produce a tension in the inferior glenohumeral ligament (IGHL) of 1000 lb (4448 N).
This is due to the difference between the external load lever arm (30 in [76 cm]) and the inferior glenohumeral
ligament lever arm (1 in [2.5 cm]). (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles
of glenohumeral ligaments and capsule. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: princi-
ples and procedures. Philadelphia: Saunders; 2004. p 122.)
 655
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

with which they slide and the difficulty to reply while one listens for descrip- tion of the initial episode can also indi-
of distracting them. The second mecha- tions suggestive of mechanical symp- cate the likelihood of traumatic injury
nism is the glenohumeral suction cup12. toms, such as “slip,” “goes out,” or to the stabilizing structures. Here, a lit-
The center of a suction cup is noncom- “gives way.” The history is more indi- tle understanding of basic mechanics is
pliant while the periphery is flexible. cative of instability if these symptoms helpful (Fig. 9). When a 33-lb (147-N)
This is exactly the structure of the glen- are episodic with interspersed periods force is applied to the hand of the ab-
oid surface: thin cartilage overlies bone of relatively normal function. It is help- ducted, externally rotated upper ex-
in the center, and compliant capsule, ful to have the patient describe or show tremity, its lever arm to the center of the
labrum, and thicker cartilage are at the the arm positions in which these epi- humeral head is about 30 in (76 cm). In
periphery (Fig. 2). As a result, the glen- sodes of instability occur. Instability in opposition to this torque is the tension
oid can stick to the humeral head, like abduction, extension, and external rota- in the anterior-inferior glenohumeral
a child’s suction-cup arrow can stick tion is usually anteroinferior, whereas ligament that works through a lever
to a glass window. The suction-cup instability in flexion, internal rotation, arm of 1 in (2.5 cm). The torque equi-
mechanism is enhanced by the slightly and adduction is usually posterior. The librium equation indicates that essen-
negative intra-articular pressure within severity of the instability is indicated tially 1000 lb (4448 N) of tension in the
the joint. by the frequency of these episodes, the inferior glenohumeral ligament would
Neither the adhesion-cohesion functional disruption that they cause, result from the 33-lb force exerted on
nor the suction-cup mechanism con- and whether the patient can recenter the outstretched arm, clearly enough
sumes energy, and both provide so- the humerus without help. A descrip- to avulse the capsulolabral complex
called low-cost centering when the arm
is at rest. These mechanisms also have
the convenient property of working in
any position of the shoulder.
When the conforming glenoid lip
is lacking or when the joint surfaces are
no longer covered with smooth wetta-
ble hyaline cartilage, the shoulder will
often feel “out of place.” For example, in
a total shoulder replacement, the poly-
ethylene glenoid component neither
conforms to the humeral head, to allow
a suction-cup effect, nor is wettable, to
allow adhesion-cohesion. As a result,
patients treated with total shoulder ar-
throplasty may experience less secure
centering of the humeral head on the
glenoid than do those with a normal
shoulder. The adhesion-cohesion and
suction-cup mechanisms may also be
disrupted when there is a joint effusion
or hemarthrosis.

Evaluation of the
Shoulder for Instability
History
Shoulder stability is the ability to keep
the ball centered in the socket. The
diagnosis of instability is based on a
carefully elicited history and on direct
observation of the shoulder’s centering
capability13. Fig. 10
When one obtains the patient’s Radiographic views of the glenohumeral joint. The anteroposterior view in the plane of the scap-
history, it is useful to start with an ula shows loss of the glenoid surface line inferiorly (arrow) (a), and the axillary view shows an an-
open-ended question such as “How terior defect of the glenoid rim (arrow) (b). (Reproduced, with permission, from: Matsen FA 3rd,
does your arm bother you?” and then Lippitt SB. Principles of glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder
give the patient plenty of opportunity surgery: principles and procedures. Philadelphia: Saunders; 2004. p 117.)
 656
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

Fig. 11-B
Avulsed labrum. (Reproduced, with permis-
Fig. 11-A sion, from: Matsen FA 3rd, Lippitt SB. Princi-
Figs. 11-A through 11-D Deficiencies of the glenoid rim. Fig. 11-A Compressible labrum. (Repro- ples of glenoid concavity. In: Matsen FA 3rd,
duced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of glenoid concavity. In: Mat- Lippitt SB, DeBartolo SE. Shoulder surgery:
sen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles and procedures. Philadelphia: principles and procedures. Philadelphia:
Saunders; 2004. p 109-11.) Saunders; 2004. p 109-11.)

from the anterior-inferior aspect of the
glenoid, producing a Bankart lesion. In
contrast, a rear-end motor-vehicle colli-
sion, even with a relative velocity of 30
mi/hr (48.2 km/hr), would not be ex-
pected to produce a Bankart lesion in
the driver whose hands were on the
steering wheel. Similarly, a hard fall
on the outstretched hand might apply
enough force to avulse the posterior
aspect of the labrum, whereas lifting
a moderately sized box might not. The
clinician needs to visualize what the
suggested mechanism might produce
at the tissue level.
If there is a substantial tissue
injury, surgical intervention may be
needed to achieve strong anatomic
healing. If there is no reason to sus-
pect a tissue injury, rehabilitation of
the strength and coordination of the
stabilizing musculature rather than
surgery is likely to be the treatment of
first choice.
While there are many other criti-
cal elements of the history, three key
questions need to be answered: (1) Is
the humeral head really becoming un-
centered during the symptomatic epi-
sodes or is something else going on? (2)
In which direction is the head moving
when it leaves the glenoid center? (3)
Is the instability the result of a substan-
tial tear or detachment and, if so, what
tissues are likely to be involved? It is
often easier to sort out these questions
by carefully obtaining a history than
by any other means.
Physical Examination
The physical examination should try to
answer these same three questions. An
easy way to start is to have the patient
demonstrate the position of the shoulder
when the initial injury occurred and the
mechanism of the initial injury as well
as the subsequent episodes. It is most
useful if the patient can say, “My shoul-
der goes out when I do this.” Close ob-
servation prevents one from making a
misdiagnosis of glenohumeral instabil-
ity when, in fact, the problem is scapu-
lothoracic snapping, for example. This
“no touch” part of the examination is
non-threatening for the patient and in-
formative for the physician.
When the “no touch” examina-
tion is inconclusive, the examiner can
then look for apprehension and state-
ments of recognition when the shoulder
is placed in positions characteristic of
common instability patterns. The exam-
iner should start with the contralateral
shoulder so that the patient will know
what to expect during the examination
of the involved shoulder. The anterior
apprehension test is conducted by plac-
ing the arm in abduction, extension,
and external rotation. The posterior
apprehension test is conducted by plac-
ing the arm in adduction, midflexion,
and internal rotation. Instability or a
 657
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG PR I N C I P L E S F O R T H E EV A L U A T I O N AND MANAGEMENT
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006 OF SHOULDER INSTABILITY

Posterior lip deficiency may result from

deficiency or detachment of the poste-
rior aspect of the labrum or a posterior
glenoid fracture. In traumatic instabil-
ity, translation of the humeral head over
the edge of the glenoid lip may be ac-
companied by a grinding sensation as
the head moves over the area from which
the labrum has been avulsed or the os-
seous lip has been fractured. If the pa-
tient recognizes this sensation as what he
or she feels when the shoulder goes out
of place, the diagnosis is reinforced.
A third important element of the
physical examination for stability is the
assessment of the muscles that compress
the humeral head into the glenoid. These
evaluations include tests for the isomet-
ric strength of the subscapularis, supra-
spinatus, and infraspinatus.
Other elements of the physical
examination may include tests of lax-
Fig. 11-C ity, such as assessments for the drawer
Fractured glenoid lip. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles and sulcus signs. It must be recognized,
of glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles however, that the ability of the examiner
and procedures. Philadelphia: Saunders; 2004. p 109-11.) to demonstrate that the joint is translat-
able (lax) does not mean that the shoul-

sensation of impending instability in

one of these positions can help confirm
whether the instability is anterior or
posterior. Tests for instability are most
conclusive when the patient volunteers,
“That’s how my shoulder feels when
it’s ready to go out.” Pain alone on these
tests is insufficient evidence of instability.
A second important element of
the physical examination for stability is
to determine the status of the glenoid
concavity, particularly in the direction
of the instability. This is conveniently ac-
complished by having the seated patient
relax with the forearm resting on the
thigh. First, the anterior and posterior
translatability of the humeral head is de-
termined as a measure of joint laxity.
Next, the humeral head is pressed into
the glenoid fossa while anterior and then
posterior translation is attempted (the
load-and-shift test). Easy translation of
the head while it is being pressed into the
glenoid center suggests that the lip of the
glenoid concavity is deficient in that di- Fig. 11-D
rection. Anterior deficiency of the glen- Glenoid dysplasia. (Reproduced, with permission, from: Matsen FA 3rd, Lippitt SB. Principles of
oid lip is most commonly the result of a glenoid concavity. In: Matsen FA 3rd, Lippitt SB, DeBartolo SE. Shoulder surgery: principles and
Bankart lesion or a glenoid lip fracture. procedures. Philadelphia: Saunders; 2004. p 109-11.)

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006
der is unstable. It is important to recall
that lax yet stable joints are essential for
gymnasts.
Imaging of the Shoulder
The primary purpose of the radio-
graphic examination is to determine, on
standardized views, (1) whether the hu-
meral head is seated well in the glenoid,
(2) if there is a major glenoid osseous
defect inferiorly or posteriorly, and (3)
if there is a major humeral head defect
posteriorly or anteriorly (Fig. 10).
It is tempting to perform a
computed tomography scan for every
patient with an unstable shoulder.
However, often the relevant osseous
anatomy can be assessed adequately
on a plain anteroposterior radiograph
in the plane of the scapula, which
shows humeral head centering and
the integrity of the anterior glenoid-
lip line; an apical oblique radiograph,
which shows defects in the posterolat-
eral aspect of the humeral head and
658
PR I N C I P L E S F O R T H E EV A L U A T I O N
OF SHOULDER INSTABILITY
Fig. 12
Typical pathology of traumatic anterior
glenohumeral instability. Top: A trau-
matic dislocation. Bottom: Anatomic
defects persisting after reduction.
(Reproduced, with permission, from:
Matsen FA 3rd, Lippitt SB. Principles of
glenohumeral ligaments and capsule.
In: Matsen FA 3rd, Lippitt SB, DeBar-
tolo SE. Shoulder surgery: principles
and procedures. Philadelphia: Saun-
ders; 2004. p 121.)
anteroinferior aspect of the glenoid lip;
and a true axillary radiograph, which
shows humeral centering along with
anterior humeral head defects and an-
terior or posterior glenoid bone de-
fects. If these studies do not show the
bone anatomy adequately, a computed
tomography scan is indicated.
Under certain circumstances, ad-
ditional information may be desired re-
garding the capsular and labral tissues,
the bone, the rotator cuff, or the neuro-
logical status of the muscles. In such
cases, additional tests such as mag-
netic resonance imaging, computed
tomography, electromyography, or di-
agnostic arthroscopy may be helpful.
These additional examinations are not
commonly needed because most of the
information required for clinical deci-
sion-making when glenohumeral insta-
bility is suspected can be acquired by
carefully obtaining a history, perform-
ing a physical examination, and mak-
ing plain radiographs.
AND MANAGEMENT
Treatment of Instability
Defining the Problem
Before considering a surgical solution,
the surgeon needs to be confident that
(1) the problem is glenohumeral insta-
bility (i.e., the humeral head is not re-
maining centered in the glenoid) and
(2) a mechanical problem that can be
best treated by surgical intervention
(rather than by rehabilitation or activity
modification) has been clearly identi-
fied. We recognize that anteroposterior
drawer tests, sulcus signs, magnetic
resonance images of labral and capsu-
lar abnormalities, translatability on
examination of the patient under anes-
thesia, and “drive-through” signs on
arthroscopy are not diagnostic of gleno-
humeral instability or predictive of the
success of surgical management. It is
also apparent that recurrent instability
associated with uncontrolled epilepsy,
inferior subluxation of the humeral
head in a patient who has had a stroke,
multidirectional instability associated
with generalized ligament laxity, and
voluntary instability may not be best
treated with shoulder surgery.
The primary decision regarding
whether to perform the surgical pro-
cedure in an open fashion or arthro-
scopically depends on whether the
treatment is directed at deepening the
fossa, reorienting a maloriented fossa,
repairing or tightening the ligaments,
reattaching torn tendons, or restoring
osseous defects. Until the anatomic/
mechanical objective is determined,
discussion of the surgical approach is
secondary.
Treatment Principles
Rather than describing the surgical
techniques in detail, which we have
done elsewhere14, we will conclude by
outlining the principles that can be ap-
plied to the treatment of specific me-
chanical problems.
When the concavity is deficient,
many of the stabilizing mechanisms
are compromised (Figs. 11-A through
11-D). When the instability is secon-
dary to glenoid deficiency, this defi-
ciency must be addressed. Soft-tissue
repairs or reconstructions may be suf-
ficient when the soft-tissue elements

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 88-A · N U M B E R 3 · M A RC H 2006
of the concavity are compromised.
However, it is difficult to compensate
for a substantial osseous defect with a
soft-tissue repair because soft tissue
cannot withstand the compressive
loads as well as bone can. When the
osseous lip of the glenoid is flat but
ample, it can be built up with use of a
glenoid osteoplasty in which the bone
beneath the lip is cut, lifted up, and
held up with a wedge-shaped bone
graft15. Major bone loss at the glenoid
periphery can be addressed with a bone
graft placed so that the graft reestab-
lishes the extent of the glenoid fossa16.
When the acromion and the coraco-
acromial ligament have been sacri-
ficed, allowing anterosuperior escape
of the proximal part of the humerus,
no anatomic reconstruction has proved
satisfactory, and a reverse shoulder
prosthesis needs to be considered.
When the cartilage of the glenoid
lip is eroded, the resulting loss of depth
of the glenoid can be restored by repair-
ing the labrum and capsule up on the
surface of the glenoid at its lip. A labrum
that is intact but not as high and stabiliz-
ing as desired can be augmented with
capsulolabral plication and/or injection
1. Lippitt SB, Matsen FA 3rd. Mechanisms of
glenohumeral joint stability. Clin Orthop Relat Res.
1993;291:20-8.
2. Matsen FA 3rd, Titelman RM, Lippitt SB, Rock-
wood CA Jr, Wirth MA. Glenohumeral instability. In:
Rockwood CA Jr, Matsen FA 3rd, Wirth MA, Lippitt
SB, editors. The shoulder. Volume 2. 3rd ed. Phila-
delphia: Saunders; 2004. p 655-794.
3. Matsen FA 3rd, Fu FH, Hawkins RJ, editors. The
shoulder: a balance of mobility and stability. Rose-
mont, IL: American Academy of Orthopaedic Sur-
geons; 1993.
4. Schiffern SC, Rozencwaig R, Antoniou J, Richard-
son ML, Matsen FA 3rd. Anteroposterior centering
of the humeral head on the glenoid in vivo. Am J
Sports Med. 2002;30:382-7.
5. Lippitt SB, Harris SL, Harryman DT 2nd, Sidles J,
Matsen FA 3rd. In vivo quantification of the laxity of
normal and unstable glenohumeral joints. J Shoul-
der Elbow Surg. 1994;3:215-23.
6. Lippitt SB, Vanderhooft EP, Harris SL, Sidles JA,
Harryman DT 2nd, Matsen FA 3rd. Glenohumeral
stability from concavity-compression: a quantitative
659
PR I N C I P L E S F O R T H E EV A L U A T I O N
OF SHOULDER INSTABILITY
augmentation. When the glenoid la-
brum is avulsed from the osseous glen-
oid lip, the fossa-deepening effect of the
labrum can be restored by securely reat-
taching it to the face of the glenoid (not
the neck)17. When the capsule and the
glenohumeral ligaments have been torn
or avulsed from the glenoid, their integ-
rity can be restored with a direct repair
(Fig. 12). Reconstruction to address cap-
sular or ligamentous deficiencies result-
ing from previous surgery or from
chronic or recurrent injury may require
the use of a tendon graft from the hu-
merus to the glenoid.
When the tendon of an otherwise
intact subscapularis is deficient, a ham-
string tendon graft may enable secure
reattachment of the muscle to the bone.
In selected circumstances, muscle trans-
fers such as a pectoralis major transfer
to the lesser tuberosity or other more
complex procedures may be considered.
When instability is due to dener-
vation or irreparable detachment of
the muscles that normally compress
the humeral head into the glenoid
fossa, surgical treatment other than
glenohumeral arthrodesis may not
be effective.
References
analysis. J Shoulder Elbow Surg. 1993;2:27-35.
7. Fehringer EV, Schmidt GR, Boorman RS,
Churchill S, Smith KL, Norman AG, Sidles JA,
Matsen FA 3rd. The anteroinferior labrum helps
center the humeral head on the glenoid. J Shoulder
Elbow Surg. 2003;12:53-8.
8. Lazarus MD, Sidles JA, Harryman DT 2nd, Matsen
FA 3rd. Effect of a chondral-labral defect on glenoid
concavity and glenohumeral stability. A cadaveric
model. J Bone Joint Surg Am. 1996;78:94-102.
9. Codman EA. The shoulder: rupture of the su-
praspinatus tendon and other lesions in or about
the subacromial bursa. Malabar, FL: Robert E
Kreiger; 1984.
10. Harryman DT 2nd, Sidles JA, Clark JM, Mc-
Quade KJ, Gibb TD, Matsen FA 3rd. Translation
of the humeral head on the glenoid with passive
glenohumeral motion. J Bone Joint Surg Am. 1990;
72:1334-43.
11. Harryman DT 2nd, Sidles JA, Harris SL, Matsen
FA 3rd. The role of the rotator interval capsule in
passive motion and stability of the shoulder. J Bone
Joint Surg Am. 1992;74:53-66.
AND MANAGEMENT
Frederick A. Matsen III, MD
Caroline Chebli, MD
Department of Orthopaedics and Sports Med-
icine, University of Washington Medical Cen-
ter, 1959 N.E. Pacific Street, Box 356500,
Seattle, WA 98195. E-mail address for F.A.
Matsen III: matsen@u.washington.edu
Steven Lippitt, MD
Akron General Medical Center, 224 West Ex-
change Street, Suite 440, Akron, OH 44302
The authors did not receive grants or outside
funding in support of their research for or
preparation of this manuscript. They did not
receive payments or other benefits or a com-
mitment or agreement to provide such bene-
fits from a commercial entity. A commercial
entity paid or directed, or agreed to pay or di-
rect, benefits to a research fund, foundation,
educational institution, or other charitable or
nonprofit organization with which the au-
thors are affiliated or associated (DePuy en-
dowed chair.)
Printed with permission of the American
Academy of Orthopaedic Surgeons. This arti-
cle, as well as other lectures presented at the
Academy’s Annual Meeting, will be available in
February 2007 in Instructional Course Lectures,
Volume 56. The complete volume can be or-
dered online at www.aaos.org, or by calling
800-626-6726 (8 A.M.-5 P.M., Central time).
12. Gibb TD, Sidles JA, Harryman DT 2nd, Mc-
Quade KJ, Matsen FA 3rd. The effect of capsular
venting on glenohumeral laxity. Clin Orthop Relat
Res. 1991;268:120-7.
13. Matsen FA 3rd, Lippitt SB, Sidles JA, Harryman
DT 2nd. Practical evaluation and management of
the shoulder. Philadelphia: WB Saunders; 1994.
14. Matsen FA 3rd, Lippitt SB, De Bartolo SE, edi-
tors. Shoulder surgery: principles and procedures.
Philadelphia: WB Saunders; 2004.
15. Metcalf MH, Duckworth DG, Lee SB, Sidles JA,
Smith KL, Harryman DT 2nd, Matsen FA 3rd. Poster-
oinferior glenoplasty can change glenoid shape and
increase the mechanical stability of the shoulder. J
Shoulder Elbow Surg. 1999;8:205-13.
16. Churchill SR, Moskal M, Lippitt SB, Matsen FA
3rd. Extracapsular anatomically contoured anterior
glenoid bone grafting for complex glenohumeral in-
stability. Tech Shoulder Elbow Surg. 2001;2:210-8.
17. Thomas SC, Matsen FA 3rd. An approach to the
repair of avulsion of the glenohumeral ligaments in
the management of traumatic anterior glenohumeral
instability. J Bone Joint Surg Am. 1989;71:506-13.