Professional Documents
Culture Documents
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a
2 Bradiston Road, Maida Vale, London, UK
b
Department of Orthopaedic Surgery, Kumamoto University School of Medicine,
1-1-1 Honjo Kumamoto 860, Japan
c
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
requiring a range of management techniques. conditions and allow for critical appraisal of
Without an adequate classification system to make treatment outcomes. The elements that need to
sense of all this, management is difficult and the be encompassed when classifying shoulder instabil-
hope of success is diminished. It is at this point that ity should include not only an assessment of the
the imbroglio starts, since there is still confusion in onset of the condition, but also:
the literature and in practice over even quite basic
(a) Degree of instability.
matters, such as the definition of the commonly
(b) Chronicity of instability.
used term multi-directional instability (MDI), the
(c) Volition of instability.
differentiation of voluntary and involuntary in-
(d) Direction of instability.
stability; even the differentiation between instabil-
ity and laxity.
As a result of these concepts, Kessel and Bayley use of this term is that it does not include those
proposed the term ‘‘habitual instability’’ for these cases in which the shoulder is held permanently
patients, but the use of the term has always been dislocated as a result of a muscle patterning
confusing. One reason is that many clinicians apply abnormality. It is the muscle patterning abnorm-
the analogy of habitual instability of the knee to ality which is the central matter in all these
that of the shoulder. Blumensaat initially presented different clinical presentations and classification
a classification system for habitual dislocation of systems should give full weight to the fact.
the patella, however his cases were caused by a
quadriceps contracture, which obliged the patella (d) Direction of instability
to dislocate every time the knee was flexed. A more
accurate term would have been ‘‘obligatory patella The Bankart lesion (described in 1939) causes
instability’’. A similar condition occurs in the so called unidirectional anterior instability and
shoulder with localised deltoid fibrosis. This ana- has historically been the most common pattern
logy has created much of the confusion with of instability. In the 1980s Neer et al. intro-
respect to the shoulder joint. Huber and Gerber duced the concept of multidirectional instability
in 1994 presented a study of 25 patients in which (MDI). This is an important entity to recognise,
they used the term habitual instability. However, it as the surgical management for unidirectional
was not clear whether this group included those instability is not adequate for multidirectional
patients with both voluntary and involuntary use of instability.14 In Neer’s view, to make the diagnosis
abnormal muscle patterns.9 Habitual instability of MDI there must be a component of co-
cannot be used synonymously with voluntary existent inferior instability. However not all
instability.10 It is important to distinguish between these patients have true global instability: a
those who displace their shoulders by a deliberate proportion can have primarily a unidirectional
active voluntary recruitment of abnormal muscle instability and it is the addition of an inferior
couples from those where the displacement is not component that causes them to be descri-
deliberate, but caused by an involuntary recruit- bed perhaps inappropriately as MDI.10 Therefore
ment of abnormal couples and which usually true MDI should have both anterior and poste-
present in certain positions of movement, but can rior instability with an inferior component.
occur with the arm to the side. Voluntary disloca- Bi-directional instability on the other hand may
tion or subluxation will cease to occur if the patient have an inferior component at a certain position of
is appropriately counselled at an early enough imbalance, be it anterior or posterior.
stage to cease the trick movement. In involuntary
instability retraining of muscle patterning is the
essential component of rehabilitation and some 80%
of shoulders can be stabilised in this way.11 Aetiology of instability
Psychiatric conditions have been said to account
for 30% of patients with voluntary instability,7 In any classification system it is important to
but subsequent unpublished work by Fisher and distinguish traumatic and atraumatic causes. This
Bayley found no difference in the incidence of distinction is critical in the selection of treatment.
psychological abnormality between patients with Unfortunately in many classification systems this
a muscle patterning instability and structural distinction is not clear-cut. Rowe reported in 1963
instability. Furthermore there was no difference that approximately 96% of patients will present
between these patients and the normal population with a traumatic component and 4% will have an
distribution.12 atraumatic component.15 However these figures
To avoid this confusion the term Involuntary are likely to be different now with the increased
Positional Instability was recently introduced by popularity of sport together with the tendency for
Takwale and Calvert 200013. This is defined as athletes to start participation at an earlier age and
instability, which is involuntary and ingrained to train more intensively.
where the subluxation or dislocation occurs every In an individual with a clear history of trauma the
time the shoulder joint passes through a particular treatment decision is generally straightforward.
phase of movement and is caused by a unbalanced The difficulty comes when the patient is unable to
muscle action. In this group there will be a give a clear-cut history of specific injury. Further-
proportion of patients who have a psychological more patients with lax joints can sustain trivial
abnormality. Therefore, the pathological factor is injuries which can initiate instability; thus there is
the abnormality of muscle patterning not the a broad spectrum of presentations. Atraumatic
psychological abnormality. The problem with the causes can be confusing to classify and manage.
ARTICLE IN PRESS
100 A. Lewis et al.
Finally there are those patients who have hyper- Thomas and Matsen Classification
laxity of all their joints and others, often athletic,
who have laxity of the shoulders only. Some In 1989 Thomas and Matsen introduced a classifica-
patients have no laxity, but still present with tion system, which used the acronyms:17
atraumatic instability. As our understanding in- TUBSF Traumatic Unidirectional Bankart Lesion
creases it is fair to say that the terms which Treated with Surgery.
describe instability as habitual, voluntary or in- AMBRIF Atraumatic Multidirectional Bilateral
voluntary become inadequate. Treated with rehabilitation and if surgery is
The ideal classification system should satisfy the required an Inferior capsular shift. A second I was
following criteria: later added to denote closure of the rotator
Interval.
* Encompass all clinical presentations. This classification system became popular be-
* Simple to implement in the clinical environment. cause it was easy to remember and simple to apply
* Account for a shift in pathology with time, i.e. a in the clinic: it also contained within it a manage-
dynamic pathology. ment algorithm based on likely pathology.
* Provide a pathway for the treatment. Based on the Rockwood’s original work16 it also
* Provide a prognosis if the patient condition is suggested trauma as the single most important
correctly classified. aetiological determinant and the acronyms repre-
* Be easily reproducible between clinicians study- sent the extremes of a spectrum, therefore tend to
ing the same pathology. over simplify what we now know to be a very
complex issue. Furthermore the system pushes
Concepts of shoulder instability are in a constant ‘‘voluntary’’ instability to one side and does not
state of evolution and over time many different assist the clinician in teasing out the boundary
classification systems have been proposed. between the AMBRII and voluntary groups. There is
therefore a real chance of including some patients
Rockwood classification with muscle patterning problems in the AMBRII
category and ultimately, wrongly, operate on them.
In 1979 Rockwood classified instability on the basis
of the presence or absence of trauma:16 Schneeberger and Gerber classification
Type I Traumatic subluxation without previous In 1998 Schneeberger and Gerber produced a
dislocation. system of classification,18 which was a further
Type II Traumatic subluxation after previous refinement of Rockwood’s and Thomas and Matsen’s
dislocation. concepts.
Type III Atraumatic voluntary subluxation. Degree of Joint Laxity Degree of Trauma Direction of instability
(A) With psychiatric problems.
(B) Without psychiatric problems. Multiple traumatic events Multidirectional Instability
No Laxity
Type IV Atraumatic involuntary subluxation.
Single traumatic event Unidirectional Instability
Unidirectional Instability
Some of the difficulties with this classifi-
Generalised Laxity Minor Traumatic events
cation arise from trying to define the meaning
Multidirectional Instability
of trauma versus no trauma, since there is a
gradation between a severe fall resulting in a
traumatic instability and the absence of injuries in, This classification system assumed that in the
for example, the patient who throws a ball and absence of joint laxity a single traumatic event
‘‘the arm kept going’’. The management of could result in unidirectional instability and that
instability which arises as a result of these MDI simply results from repeated traumatic events.
intermediate degrees of injury can vary. In these The authors, however, recognised that generalised
days of trying to determine, for example, when to joint laxity is not a pathological condition but can
do an arthroscopic repair, classification systems result in instability if the joint is subjected to minor
probably require greater subtlety than can be degrees of repetitive trauma.18 This classification
obtained in the Rockwood system. Neither does it system also over-simplifies and compartmentalises
allow for mixed pathologies nor shifting pathology patients with instability too readily. The system
over time. assumes that the degree of trauma determines the
ARTICLE IN PRESS
The classification of shoulder instability: new light through old windows! 101
Polar Type I
Reducing
subgroup II (III) where the muscle patterning
Traumatic
Muscle disorder was only apparent on functional EMG
Patterning studies. In the absence of functional EMG testing
43
patients in this group require a high index
I(III)21 I(II)47 of suspicion to differentiate them from polar
group III.21
III(I)27 II(I)30 We feel the benefits of this system are:
* The triangle system does provide a means of
classifying all presentations of shoulder instabil-
24 III(II)11 II(III) 4 16
ity with a unifying system.
Polar Type III Polar Type II
Atraumatic
* It allows for a shift in the pattern of instability
Muscle patterning
Non-structural Structural with time.
* It is a simple system to implement and easy to
remember.
Reducing Trauma * It provides a route for treatment of all the
Figure 2 Stanmore classification: the triangle model, varieties of instability.
which demonstrates the subgroup classification, n ¼ 223:
Patients are placed within the classification on
the basis of:
(II). They gave a history of a mechanical event, but
no documented complete dislocation. They went J History
on to complain of pain and, like subgroup I (II), J Clinical examination
there was clear-cut evidence of a structural J Investigations
instability with glenohumeral rim attenuation – Examination under anaesthetic
and/or a humeral head defect. At no time did any – Imaging
of these patients on this axis demonstrate any – Arthroscopy
abnormal muscle patterning. – Functional EMG analysis.
In subgroup I (III) the patients described a
definite traumatic episode, as with subgroup I (II),
and at arthroscopic assessment there was evidence
of structural damage. What was important about History
these patients, however, is that they all demon-
strated a muscle patterning disorder. In subgroup III Taking an adequate history and performing an
(I) there was less trauma and arthroscopy proved accurate and thorough examination remains the
normal, in contrast to subgroup II (I). The patients bedrock in assessing patients with instability. It is
all demonstrated a muscle patterning component. possible, in 90% of cases, to arrive at a correct
Subgroups III (II) and II (III) were the most difficult diagnosis.10,22
to identify and correctly classify. These patients When taking a history from these patients it is
showed some evidence of articular surface damage, important to identify precisely the part which
which could vary from a Broca defect to early trauma played in the onset of the condition. A
erosion of the articular surface with associated documented anterior dislocation associated with
damage to the glenoid labrum. With patients in significant trauma, that later develops into a
subgroup III (II) there was a clinically apparent recurrent problem, is a straightforward manage-
muscle patterning disorder, but this was not so in ment problem (Type I instability). Fortunately
ARTICLE IN PRESS
The classification of shoulder instability: new light through old windows! 103
these account for the majority of cases. What is operation (b) inadequate operation (c) wrong
more of a challenge is the group of patients who diagnosis.23 If a patient has had a previous Putti
present with a non-specific, or even no, history of Platt24 or a Magnuson Stack25 procedure for what
trauma. In these patients it is important to elicit an was thought to be a traumatic anterior instability
accurate description of the initial event from which and the Bankart lesion was not addressed then the
the ongoing symptoms have developed. Generally operation was inadequate and is more likely to fail.
most patients (84%)9 with true voluntary instability Furthermore patients can present with recurrent
present with no history of pain. However pain is an posterior instability having previously been surgi-
important issue where there is no documented cally treated for anterior instability. This may not
history of trauma, as it can imply shoulder necessarily represent unrecognised muscle pattern-
subluxation. Rowe described ‘Dead Arm Syndrome’ ing/atraumatic instability, but could be a true
in patients with voluntary instability.7 structural instability secondary to over-tightening
Age is another important factor. Most patients of the anterior capsular structures.
with atraumatic instability (Type II and III instabil- It is important to know and document any
ity) tend to be adolescent and almost always below abnormal psychosocial disturbance which, if pre-
the age of 25 years. Associated rotator cuff injuries sent, will be important in future management.
are much less common in this age group, but However, we are strongly of the view that those
beware of the older patient presenting with factors have been overemphasised as a cause of
impingement secondary to instability caused by instability. A comparison of the incidence of
an associated cuff tear. psychological conditions between groups of muscle
Documentation of previous treatment cannot be patterning versus structural instability did not
underestimated. Many of the patients referred to reveal any difference in incidence.12
our unit have had some form of treatment. Many
patients have had some form of physiotherapy. It is
important to know what form of physiotherapy was Examination
undertaken. If the incorrect type of physiotherapy
is given to certain types of instability the condition General examination in recurrent instability is
can be made worse. For example, if a patient with important. It is also important to specifically look
a pure muscle patterning problem (Type III) is given at the contour of the shoulder. Look for any muscle
a physiotherapy regimen which concentrates on wasting of the shoulder girdle including the rotator
muscle strengthening it is possible to re-enforce cuff. It is important to assess general posture, since
the abnormal muscle pattern. If the patient is given poor posture can be one of the predisposing factors
a Biofeedback physiotherapy regimen to correct to a muscle patterning disorder, as can a general
the muscle-patterning problem and improve core tendency to poor joint position sense and balancing
stability of the trunk muscles and shoulder girdle mechanisms.
then the instability related to the muscle pattern- There are specific tests for laxity of the shoulder,
ing can improve. Conversely it would be wrong to for example the Sulcus sign (which tests inferior
implement a standard biofeedback regimen to a laxity) and the anterior and posterior drawer tests.
Type I or Type II patient, as their problem is not one It is important however to realise that these
of muscle patterning, but one of muscle imbalance demonstrate laxity and are not tests of instability.
secondary to selective weakness. To test for instability there are both anterior and
If patients have had previous surgery for shoulder posterior apprehension tests. The anterior appre-
instability it important to know what operation was hension tests tend to be more valuable.10 It is
performed. There are essentially three main causes important to assess for impingement and secondary
of recurrent instability following surgery: (a) wrong rotator cuff damage.
ARTICLE IN PRESS
104 A. Lewis et al.
and the inferior flap of the capsule is shifted muscle patterning instability and vice versa; a truly
superomedially.49 The advantage of this procedure anterior and posterior structurally unstable
was less scarring and shortening of the soft tissues. shoulder; a truly anterior and posterior muscle
In 1991 Altcheck proposed a medial capsular shift patterning instability.
procedure. The T-plasty was the reverse of that The initial step when treating atraumatic in-
proposed by Neer and the inferior flap was stability is to assess the muscle patterning/function
advanced superomedially and the Bankart lesion and the direction of instability. The presence of a
repaired simultaneously.50 These operations were muscle-patterning component to the instability
initially described for multidirectional instability of would place the patient on the II/III axis of the
the shoulder, not for traumatic anterior instability. triangle. The more dominant the muscle-patterning
However the principle of the capsular shift has problem, the more the patient migrates towards
been adopted for unidirectional traumatic instabil- the Type III polar group. We often investigate such
ity to cope with the secondary capsular stretching patients with functional EMG analysis. If this
which occurs after multiple dislocations. It was only confirms inappropriate muscle recruitment then
a matter of time before these capsular procedures that is addressed before any surgery is considered.
were performed using a minimally invasive ap- Management requires careful explanation to the
proach, but it is not yet clear whether in this type patient. This is of prime importance to maintain
of instability arthroscopic techniques can yet compliance and can only be achieved through
reliably reproduce the results of open procedures, proper counselling. Patients with a muscle pattern-
although a recent study by Levy and Copeland has ing disorder do not have a problem with muscle
shown this might be the case.51 strength, but have a muscle co-ordination problem
and this is the basis of the biofeedback exercises.
This exercise programme concentrates on improv-
Polar groups II and III (atraumatic structural ing joint position sense and relearning correct
and non-structural muscle-patterning muscle movement patterns. One can utilise mir-
instability) rors, or closed circuit television, or even electronic
biofeedback devices. All these exercises aim to
This type of instability is less common than Polar improve scapulothoracic and glenohumeral muscle
Group I traumatic unidirectional instability. The patterns. There is little published on the subject of
management is complex and traditionally there non-operative management of atraumatic MDI. Kiss
have been difficulties over an agreed treatment followed up 62 patients with atraumatic MDI at
plan suitable for all the patients. In the majority of 3.7 yr. All patients were entered into a biofeed-
cases the treatment involves a multidisciplinary back-retraining programme and ultimately 61% had
approach. These patients may either require no symptoms of instability.52 Tibone reported 70%
surgery, or a non-surgical approach, or both. The satisfaction with a 6-month rehabilitation pro-
problem is that they tend to be lumped together as gramme in athletes with atraumatic posterior
MDI. Some authors argue that true MDI does not subluxation.53 Although published results can be
exist, others label patients as MDI, but define it as variable, it is generally accepted that patients with
instability in at least two directions, i.e. a bi- a muscle patterning problem and an associated
directional instability.52 This makes treatment very psychological component, equally those with a
difficult to standardise and compare between work-related injury and those who have had
different units. previous surgery have a poor outcome with reha-
The matter is simplified by defining whether the bilitation.52
problem is structural or non-structural and there- Surgery should only be considered in patients
fore due to abnormal muscle patterns. Using these along the II–III axis if there is a demonstrable
factors as the determinant it does not then matter structural component to the instability, i.e. bone,
whether the instability is anterior or posterior or cartilage or labral abnormalities, which can best be
multidirectional. Indeed these terms indicate a identified at arthroscopy and the underlying muscle
symptom rather than a diagnosis since, in the same patterning abnormality has been shown to have
way that one can encounter anterior structural and been corrected. If a structural problem is identified
anterior muscle patterning disorders, so one can and any muscle-patterning problem corrected then
encounter the same variation in the multidirec- a number of operations are open to the clinician,
tional displacements. Armed with this knowledge depending on the problem. Neer initially described
one can recognise a variety of situations in a the capsular shift procedure for MDI in 1980.14 He
multidirectional lax shoulder. For example a struc- initially described a laterally based capsular shift,
tural anteriorly unstable shoulder with posterior which can reduce capsular volume by as much as
ARTICLE IN PRESS
The classification of shoulder instability: new light through old windows! 107
57%.54 This procedure was described for both that the Stanmore Triangle is a valuable tool, which
anterior and posterior instability, but recurrence provides the clinician with a clear method to
rates from 20% to 30% have been reported.55–57 classify cases and thereby to advise a sensible
Variations on the original technique have been management plan.
using a medially based shift with similar
results.58,59
In addition to capsular shift procedures, arthro-
scopic techniques have diversified. Laser assisted References
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