Shoulder Instability:

- Inability to maintain the humeral head centered in the glenoid fossa due to laxity of the shoulder
capsule, ligaments and/or rotator cuff muscle imbalances or congenital joint anomalies.

Brief description of significant clinical findings (Examinations);

Classification:
Mechanism Reasons Directionals
Traumatic High force events affect Traumatic Unidirectional Instability with bankart
the integrity of lesion (TUBS)
stabilizing structures - Anterior dislocation
- Posterior dislocation
Atraumatic Generalized connective Unidirectional instability
tissue laxity - Anterior shoulder instability
- Posterior shoulder instability
Overuse from repetitive - Inferior shoulder instability
activities Atraumatic, multidirectional, bilateral,
rehabilitation and inferior capsular shift (AMBRI)
- Multidirectional shoulder instability (MDI)
FEDS Classification:
- Asking patient Frequency, Etiology, Direction and Severity

Stanmore Classification of Shoulder Instability:

- FEDS, TUBS and AMBRI unable to clearly differentiate the type of shoulder instability.
- The purpose of this classification is to describe the types of instability and guide appropriate
management, to avoid surgery in inappropriate cases and ensure effective rehabilitation.
 Stanmore Classification
Polar type I Shoulder instability is related to structures damaged of GH joint and/or
(traumatic- stabilizing structures (structural) due to trauma
structural - Due to disruption in the capsulolabral complex from trauma (Bankart
instability) lesion, SLAP lesion)

Common findings:
- anterior apprehension
- weakness rotator cuff especially subscapularis
- History of trauma

Imaging is more useful for structural damage

- To examine any capsular detachments, bony defects and bulk and
quality of rotator cuff muscles
Polar Type II Shoulder instability is related structural damaged of GH joint and/or
(atraumatic stabilizing structure due to capsular laxity
structural - Due to generalized capsule laxity
instability) - Due to overuse or microtrauma such as throwing, swimming, over head
activities

Common findings:
- Anterior apprehension
- Sign of increased capsular laxity (excessive external rotation and sulcus
sign)
- Associate with GIRD

Factors:
- Excessive anterior capsular laxity, scapular dyskinesis, tight posterior
capsule, muscular imbalance, congenital labral pathology
Polar Type III Shoulder instability is not related to changes of GH joint and stabilizing
(muscle structures (non-structural) but is related to muscle patterning
patterning - Due to motor control deficits
instability) - Often bilateral

Common findings:
- Frequently activation of large muscles while simultaneous suppression
of the rotator cuff
Overactive Large muscles:
- Latissimus dorsi, pectoralis major and anterior deltoid

Inhibition of stabilizing muscles:

- Infraspinatus, lower trapezius, serratus anterior and posterior deltoid

Plan of management;
Goal:
- Increase Strength and Stability*, pain-free when ROM
- In holistic approach, provide psychologically ready especially for sport

Managements:
Stretching To gain ROM
Exercises - Only for limited ROM such as GIRD or post surgery
- Table top exercise
Proprioception To gain stabilizing muscle recruitment Swiss ball exercise Perturbation
Exercises Exercises
Strengthening Strengthening Rotator cuff muscles
Exercises - Infraspinatus*, teres minor
- Subscapularis

A study made by Jaggi A which observed muscle patterning in atraumatic

shoulder instability,

found that even antagonist muscles including pectoralis major and

latissimus dorsi were more active during shoulder movement than
expected and found reduced activity of infraspinatus.
They hypothesized these muscle activity imbalance between large
muscle groups and infraspinatus could be the cause of shoulder
instability.
Scapular Strengthen and provide proprioception of scapular stabilizer including
Stabilizer serratus anterior and lower trapezius
Exercises
Lower trapezius:
- Y-raise*
- T-raise, I-raise
- Scapular row
Serratus anterior:
- Push up
- Wall press
Surgery According to Stanmore classification;
- Polar Type I usually recommend for surgery
- Polar Type II recommend for rehabilitation first, if fail recommend for
surgery
- Polar Type III avoid surgery and recommend for rehabilitation

Outline three areas of clinical work where you performed well.

1) We able to provide management for the shoulder instability
2) Able to classify the type of the shoulder instability
3) Able to focus the muscle imbalance

Using an evidenced-based framework generate three clinical questions relevant to the areas where
additional learning is required. Incorporate the results of your investigations into patient care.
Remember, clinical questions should be relevant to central tasks of clinical work i.e.; etiology,
epidemiology, clinical findings, diagnostic tests, diagnosis, prognosis, intervention, prevention,
meaning, self-improvement

i) Clinical question
- What the etiology and epidemiology for Shoulder Instability?

ii) Seach strategy

- Google scholar
- Youtube
- Textbook
- Semantic Scholar
iii) Evaluating yield (validity/utility) and clinical application
Etiology [1,3]:
Shoulder instability is mostly due to disruption to the static and/or dynamic stabilizers of the
glenohumeral joint.

Traumatic injury:
- High force events occur at the shoulder joint and affect the integrity of stabilizing structures.
- Usually shoulder dislocation causes shoulder instability.

Ligamentous laxity:
- shoulders laxity that they are unable to completely restrain the ball within the socket. This can result
in subluxation or dislocation of the shoulder without a significant injury.
- Mostly bilateral

Muscle patterning disorder:

- Some muscle groups overactive (agonist) while other muscles group (antagonist) weak or inhibited
cause muscle imbalance
Stabilizer of Scapula and Glenohumeral Joint [1]:

Muscle Patterning
Direction of Overactive Inhibited
Instability
Anterior Pectoralis major* Subscapularis
Latissimus dorsi
Anterior deltoid
Posterior Latissimus dorsi* Infraspinatus
Pectoralis major

Epidemiology
Types Prevalence Gender
Anterior 80% Male > Female
Posterior 10%
Multidirectional 10%

Iv) Self-evaluation:
I have better understanding about examination to the patient who suffering Shoulder Instability as
well as provide proper exercises and other treatment to reduce instability.

References Lists:
1) Vizniak. N. Orthopedic Condition. Prohealth. 2014
2) Giangarra CE, Manske RC. Clinical Orthopaedic Rehabilitation: A Team Approach E-Book. Elsevier
Health Sciences; 2017 Jan 4.
3) Therapeutic Exercise Foundations and Techniques, Seventh Edition
4) Kuhn JE. A new classification system for shoulder instability. British journal of sports medicine. 2010
Apr 1;44(5):341-6.
5) Jaggi A, Lambert S. Rehabilitation for shoulder instability. British journal of sports medicine. 2010
Apr 1;44(5):333-40.
6) Varacallo M, Musto MA, Mair SD. Anterior shoulder instability.
7) Jaggi A, Noorani A, Malone A, Cowan J, Lambert S, Bayley I. Muscle activation patterns in patients
with recurrent shoulder instability. International journal of shoulder surgery. 2012 Oct;6(4):101.
8) Bateman M, Osborne SE, Smith BE. Physiotherapy treatment for atraumatic recurrent shoulder
instability: updated results of the Derby Shoulder Instability Rehabilitation Programme. Journal of
arthroscopy and joint surgery. 2019 Jan 1;6(1):35-41.

Approved by: Date: