Shoulder instability

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Shoulder instability

• Young contact sports athlete dislocates shoulder
• Risk of further dislocation?
• Current standard management?
• Evidence?
• Arthroscopic stabilisation

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Shoulder instability
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SLAP LESIONS

• Beware will mimic A-C joint pain
• Also clicking, instability, pain, secondary
  impingement
• Andrews 1985
• Snyder 1990
• Resists elbow extension in deceleration phase,
  transmitted force avulses attachment
• Often missed at open surgery
• Easily fixed arthroscopically

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Acromioclavicular joint

• Osteolysis of lateral end of clavicle
• Atraumatic
• Excess weight training
• Pain abduction and cross arm
• Steroid ineffective
• Rest or arthroscopic excision

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Management Shoulder Problems

• Coaching
• training methods, throwing technique
• Stable platform
• trunk, scapula
• Posterior tightness/GIRD
• Assess balance of impingement/instability
• Rehabilitation, eccentric force, high speed
• Injection?
• Surgery,
• Decompression, stabilisation, SLAP repair
• AC joint rest/excision

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Elbow - throwing

• Ligaments
• Ulnar collateral, lateral collateral, lateral
  ulnar collateral
• Valgus moment across elbow
• 94.7 N/kg
• Forward sling to release 400 ms
• Angular velocity 5000 degrees/sec
• Peak acceleration 500,000 degrees/sec
• i.e. huge and incomprehensible

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Medial Collateral Ligament

• Primary stabiliser of medial elbow
• Three bands variable morphology - cord or fan
  shaped
• Anterior oblique band resists valgus stress
• Load to failure 260 N
• Functions as a cam, section of functional
  ligament depends upon position of flexion
• Maximum valgus force in cocking and acceleration
  phases at 80 - 120 degrees of flexion

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Medial Collateral Ligament

• Medial muscles protect the MCL dynamically
• Increase in MVC from cocking to acceleration -
  less with medial instability
• Unable to compensate for an unstable MCL
• MCL at risk
• Keep the arm high!!!!

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MCL Injury

• Pain medially during throw
• Follow episode of prolonged throwing and then
  inability to throw gt75
• Gradual onset of medial pain with time
• Acute POP
• Ulnar neuritis
• Valgus instability, not always easy
• USS, stress X-ray, MRI scan

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Case histories

• Examination
• tender over MCL
• pain reproduced on stressing MCL
• laxity not always clinically obvious
• MRI scan
• ligament detachment
• Surgical reconstruction
• Palmaris longus autograft, figure of 8

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