Minor or Occult Shoulder Instability: an Intra-articular Pathology Presenting with Extra-articular Subacromial Impingement Symptoms

Overview

Journal Knee Surg Sports Traumatol Arthrosc

Publisher Wiley

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2011 May 25

PMID 21607736

Citations 2

Authors

Ulf Nordenson

Raffaele Garofalo

Marco Conti

Eva Linger

Jennie Classon

Jon Karlsson

Alessandro Castagna

Affiliations

Soon will be listed here.

Abstract

Purpose: Disruption in the balance of shoulder stability can produce a widely varied spectrum of clinical symptoms, ranging from minor shoulder instability to frank shoulder dislocation, followed by recurrent instability. In this study, a series of patients suffering from minor shoulder instability, all with clinical signs of preoperative subacromial impingement associated with instability, were treated. The shoulder instability alone was addressed, with the aim of eliminating the clinical symptoms of subacromial impingement and pain.

Material: In this study, 20 patients with minor shoulder instability, presenting with subacromial impingement symptoms, underwent arthroscopic treatment to address capsule-labral pathology. All patients underwent a preoperative assessment by one independent physiotherapist, using Constant and WOSI scores, as well as the Castagna test, on both the affected and non-affected sides. The Hawkins test and subacromial pain in 90° of abduction and internal rotation were also evaluated. All patients followed the same rehabilitation protocol by a second physiotherapist. All patients were followed up at 6, 12 and 24 months postoperatively by the same independent physiotherapist.

Results: We observed that 20/20 patients had a positive Hawkins sign at >20° of internal rotation preoperatively, while 4/19 had a positive Hawkins sign--all with less pain--at the 24-month follow-up (P < 0.0001). Moreover, 20/20 had a positive Castagna test preoperatively, while 1/20 had a positive Castagna test at the 24-month follow-up. In terms of shoulder scores, at 24 months, the Constant score had improved from a median value of 70 (51-91) preoperatively to a median value of 91 (86-100). The median WOSI score was 48.3 (12.7-78.6) preoperatively and improved to 84.9 (39.5-98.5) at 24 months postoperatively.

Conclusion: Minor shoulder instability is an intra-articular pathology presenting with extra-articular subacromial impingement symptoms. By treating the intra-articular pathology, the extra-articular symptoms can be relieved in the vast majority of patients.

Citing Articles

Do patients with minor shoulder instability have a different outcome from those with recurrent anteroinferior instability?.

Depovere T, Pouliart N Eur J Orthop Surg Traumatol. 2019; 29(8):1649-1657.

PMID: 31250226 DOI: 10.1007/s00590-019-02484-6.

Minor or occult ankle instability as a cause of anterolateral pain after ankle sprain.

Vega J, Pena F, Golano P Knee Surg Sports Traumatol Arthrosc. 2014; 24(4):1116-23.

PMID: 25429765 DOI: 10.1007/s00167-014-3454-y.

References

Warner J, Goitz R, Irrgang J, Groff Y . Arthroscopic-assisted rotator cuff repair: patient selection and treatment outcome. J Shoulder Elbow Surg. 1997; 6(5):463-72. DOI: 10.1016/s1058-2746(97)70054-5. View

Payne L, Deng X, Craig E, Torzilli P, Warren R . The combined dynamic and static contributions to subacromial impingement. A biomechanical analysis. Am J Sports Med. 1997; 25(6):801-8. DOI: 10.1177/036354659702500612. View

Callanan M, Tzannes A, Hayes K, Paxinos A, Walton J, Murrell G . Shoulder instability. Diagnosis and management. Aust Fam Physician. 2001; 30(7):655-61. View

Boileau P, Zumstein M, Balg F, Penington S, Bicknell R . The unstable painful shoulder (UPS) as a cause of pain from unrecognized anteroinferior instability in the young athlete. J Shoulder Elbow Surg. 2010; 20(1):98-106. DOI: 10.1016/j.jse.2010.05.020. View

Belling Sorensen A, Jorgensen U . Secondary impingement in the shoulder. An improved terminology in impingement. Scand J Med Sci Sports. 2000; 10(5):266-78. DOI: 10.1034/j.1600-0838.2000.010005266.x. View

Garth Jr W, ALLMAN Jr F, Armstrong W . Occult anterior subluxations of the shoulder in noncontact sports. Am J Sports Med. 1987; 15(6):579-85. DOI: 10.1177/036354658701500610. View

Buss D, Freehill M, Marra G . Typical and atypical shoulder impingement syndrome: diagnosis, treatment, and pitfalls. Instr Course Lect. 2009; 58:447-57. View

Pieper H, Quack G, Krahl H . Impingement of the rotator cuff in athletes caused by instability of the shoulder joint. Knee Surg Sports Traumatol Arthrosc. 1993; 1(2):97-9. DOI: 10.1007/BF01565460. View

Fu F, Harner C, Klein A . Shoulder impingement syndrome. A critical review. Clin Orthop Relat Res. 1991; (269):162-73. View

10.

McLeod W, Andrews J . Mechanisms of shoulder injuries. Phys Ther. 1986; 66(12):1901-4. DOI: 10.1093/ptj/66.12.1901. View

11.

Bak K, Fauno P . Clinical findings in competitive swimmers with shoulder pain. Am J Sports Med. 1997; 25(2):254-60. DOI: 10.1177/036354659702500221. View

12.

Jobe F, Kvitne R, Giangarra C . Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev. 1989; 18(9):963-75. View

13.

Castagna A, Nordenson U, Garofalo R, Karlsson J . Minor shoulder instability. Arthroscopy. 2007; 23(2):211-5. DOI: 10.1016/j.arthro.2006.11.025. View

14.

Kirkley A, Griffin S, McLintock H, Ng L . The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998; 26(6):764-72. DOI: 10.1177/03635465980260060501. View

15.

Carter C, Wilkinson J . PERSISTENT JOINT LAXITY AND CONGENITAL DISLOCATION OF THE HIP. J Bone Joint Surg Br. 1964; 46:40-5. View

16.

Garofalo R, Pouliart N, Vinci E, Franceschi G, Aldegheri R, Castagna A . Anterosuperior labral tear without biceps anchor involvement: a subtle isolated cause of a painful shoulder. Arthroscopy. 2010; 27(1):17-23. DOI: 10.1016/j.arthro.2010.05.022. View

17.

PAINE R, Voight M . The role of the scapula. J Orthop Sports Phys Ther. 1993; 18(1):386-91. DOI: 10.2519/jospt.1993.18.1.386. View