SPORTS MEDICINE  ·  SURGERY OF THE KNEE  ·  SURGERY OF THE SHOULDER  

Multidirectional Instability Print

 

The patient with multidirectional instability usually has a large element of inferior (downward) instability in addition to anterior or posterior instability. Many of these patients have generalized laxity of many of their joints. Often, they have complaints involving both shoulders. Classically, these patients have no history of trauma or suffer a dislocation with trauma which would not dislocate a normal shoulder. In loose-jointed athletes, however, trauma may play a significant role in the development of symptoms. Not all loose shoulders are painful and not all require treatment. Symptomatic patients with multidirectional instability are given a thorough trial of shoulder strengthening. Patients who have traumatic multidirectional instability often respond to nonoperative therapy.

 

Operative Technique For Multidirectional Instability

Patients with inferior laxity may fail to respond to the standard operative procedures designed for shoulder instability. In some cases, these standard procedures may cause excessive tightness on one side of the hypermobile shoulder. Subluxation or dislocation will then occur in the opposite direction, and glenohumeral arthritis may occur. Arthroscopic stabilization procedures are now used in the treatment of multidirectional instability.

Open surgical procedures for multidirectional instability may be used depending on the patient's history and physical findings. Generally, in open procedures, the shoulder is approached from the side which is associated with the greatest amount of clinical instability. In patients whose instability is primarily anterior, the shoulder is approached from the front and those whose primary component of instability is posterior, the shoulder is approached from the back.

Patients with multidirectional instability often have a very large and patulous shoulder capsule. As a result, the shoulder capsule must be tightened and plicated to prevent the development of recurrent instability (Fig. 1A,B,C)

Capsular Shift for Multidirectional Instability
Multidirectional Instability, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 8A Multidirectional Instability, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 8A Multidirectional Instability, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 8A
Figure 1A Figure 1B Figure 1C

 

Figure 2A shows an arthroscopic view of a torn anterior, inferior, and posterior labrum. And Figure 2B shows the arthroscopic repair.

 

multidirectional, instability, Dr. Allen F. Anderson, nashville, orthopaedic surgery, sports medicine, figure 9A multidirectional, instability, Dr. Allen F. Anderson, nashville, orthopaedic surgery, sports medicine, figure 9B
Figure 2A Figure 2B

 Because of problems with soft tissue in general and associated tissue laxity, these patients are generally immobilized for at least six weeks after surgery. Rehabilitation is generally instituted for three to six months in patients who have had a traumatic cause of instability. In those who have no history of trauma, aggressive activities are withheld for nine to twelve months after surgery.

Results of surgical treatment for multidirectional instability have historically been less successful than those for unidirectional anterior instability. Results have improved with current technique, however. In a recent article which utilizes the techniques which is most commonly used at the Tennessee Orthopaedic Alliance, a 95% patient satisfaction rate was noted after surgical treatment for multidirectional instability.

 

Conclusion

Glenohumeral instability is a common cause of disability. The shoulder joint is extremely mobile and bony stability has been sacrificed to allow this motion. Glenohumeral stability is dependent on upon the soft tissues surrounding the joint. These soft tissue stabilizers operate in a complex fashion. While anterior instability is by far the most common type of problem, posterior and multidirectional instabilities of the glenohumeral joint are also important causes of shoulder disability.

Nonoperative treatment and rehabilitation is based on the principal of dynamic strengthening of the shoulder musculature.. If operative intervention is employed, the surgeon carefully defines the problem and addresses the pathologic anatomy accordingly. Standard procedures designed to treat unidirectional anterior instability are likely to fail if used to treat posterior or multidirectional instability and may, in fact, worsen the problem.

 
© Allen F. Anderson, M.D. 2017