The American Journal of Sports
Medicine
http://ajs.sagepub.com/
Arthroscopic Treatment of Multidirectional Shoulder Instability in Athletes : A Retrospective Analysis
of 2- to 5-Year Clinical Outcomes
Champ L. Baker III, Randy Mascarenhas, Alex J. Kline, Anikar Chhabra, Mathew W. Pombo and James P. Bradley
Am J Sports Med 2009 37: 1712 originally published online July 15, 2009
DOI: 10.1177/0363546509335464
The online version of this article can be found at:
http://ajs.sagepub.com/content/37/9/1712
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Arthroscopic Treatment of Multidirectional
Shoulder Instability in Athletes
A Retrospective Analysis of 2- to 5-Year
Clinical Outcomes
Champ L. Baker III,* MD, Randy Mascarenhas,† MD, Alex J. Kline,‡ MD,
§
||¶
#
Anikar Chhabra, MD, Mathew W. Pombo, MD, and James P. Bradley, MD
†
From *The Hughston Clinic, Columbus, Georgia, the University of Manitoba Section
‡
of Orthopaedic Surgery, Health Sciences Centre, Winnipeg, Manitoba, Canada, the University
of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania,
§
Canyon Orthopaedic Surgeons, Phoenix, Arizona, the ¶Sports Medicine & Orthopaedic
#
Institute, Duluth, Georgia, and Burke and Bradley Orthopaedics, Pittsburgh, Pennsylvania
Background: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the
shoulder.
Hypothesis: Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully
return athletes to sports with a high rate of success as determined by patient-reported outcome measures.
Study Design: Case series; Level of evidence, 4.
Methods: Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and
were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male
patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario
Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales.
Results: The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean
Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of
patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to
their sport with little or no limitation.
Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic
population.
Keywords: multidirectional instability; shoulder; arthroscopic; athletes
The landmark article by Neer and Foster20 initially outlined
the difficulties in the diagnosis and treatment of multidirectional shoulder instability (MDI) and proposed an inferior
capsular shift to treat the excessive capsular redundancy
that tends to plague patients with MDI of the shoulder.
Historically, open capsular shift techniques have been the
standard in the operative treatment of patients with MDI.
More recently, however, a number of arthroscopic techniques have been described for treatment of MDI. These
techniques include thermal or radiofrequency capsulorrhaphy, as well as other arthroscopic approaches using
suture techniques and/or suture anchors. Although these
techniques show initial promise, many of the reports detailing outcomes after arthroscopic management have included
small patient populations and relatively short follow-up
periods. We report on the outcomes of 40 symptomatic athletes with shoulder MDI who underwent arthroscopic reconstruction after failure of nonoperative management.
||
Address correspondence to Mathew W. Pombo, MD, Sports Medicine
& Orthopaedic Institute, 3855 Pleasant Hill Road, Suite 470, Duluth, GA
30096 (e-mail: matpombo7@hotmail.com).
Presented at the 32nd annual meeting of the AOSSM, Hershey,
Pennsylvania, June 2006.
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 37, No. 9
DOI: 10.1177/0363546509335464
© 2009 The Author(s)
1712
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Multidirectional Shoulder Instability Treatment 1713
Vol. 37, No. 9, 2009
MATERIALS AND METHODS
A retrospective review was performed of 42 consecutive
athletes (45 shoulders) who underwent arthroscopic treatment of symptomatic MDI by the senior author (JPB)
between August 2002 and May 2005. The criteria used for
inclusion in the study group were athletes of any level with
minimum 2-year follow-up and the presence of MDI.
Patients who displayed unidirectional anterior or posterior
instability and those with habitual or psychogenic voluntary shoulder subluxation were excluded from the study.
No patients were treated with thermal capsular shrinkage.
Two patients (2 shoulders) were lost to follow-up, leaving a
final study group of 40 athletes (43 shoulders).
The authors have defined MDI of the shoulder as symptomatic instability in more than one direction based on a
combination of findings from the patient’s history, physical
examination, evaluation under anesthesia, and pathologic
findings at arthroscopy. A challenge faced by the authors
was the ability to reproducibly define MDI in athletes. The
definition in the literature has inconsistently been defined
as instability in 2 directions1,2,7,9,16,21 or in 3 directions.16,19,20,22
The definition of MDI originally described by Neer and
Foster20 included only patients with uncontrollable, involuntary inferior subluxation or dislocation associated with
both anterior and posterior dislocations/subluxations of the
shoulder. We chose a more inclusive definition for MDI,
similar to definitions provided by McIntyre et al,17 Gartsman
et al,8 and McFarland et al.16 Multi-directional instability
was defined for this study as inferior instability with at
least one other direction (anterior or posterior) of instability. In our practice these patients have been approached
and treated similarly to classically defined MDI patients.
Patient data were collected retrospectively through
review of office charts, operative reports and photographs,
and telephone conversations with all patients at latest
follow-up. Patient demographics included the following: age,
gender, sport, level of competition, dominant versus nondominant arm, traumatic versus atraumatic injury, time to
surgery after the injury, and length of follow-up. At final
follow-up, patient progress was evaluated using the accepted
American Shoulder and Elbow Surgeons (ASES) shoulder
index23 (0-100), combining a subjective functional scale
and a subjective pain scale. The Western Ontario Shoulder
Instability (WOSI) index, a validated disease-specific quality of life measurement tool for patients with shoulder instability,12 was also used as an outcome measure. It consists of
21 questions relating to physical symptoms, sports/work/
recreation, lifestyle, and emotions. Each question is answered
on a 100-point scale, with 0 being normal and 100 being
the worst score. Therefore, the WOSI index has a worst
possible score of 2100. The WOSI percentage score is calculated by subtracting the total score from 2100, and then
dividing the result by 2100.
Because the ASES scale does not measure stability, we also
added a subjective stability scale (0-10, with 0 being completely stable and 10 being completely unstable) at follow-up.
A subjective strength scale (0-3, with 3 being normal
strength) and a subjective range of motion (ROM) scale
(0-3, with 3 being full motion) were used at final follow-up
Figure 1. An axial cut of a T2-weighted MRI arthrogram of a
right shoulder demonstrating a large capsular volume.
as well. Findings at the time of surgery and surgical procedures performed were also noted, along with the aforementioned outcome measures.
Operative Treatment
Patients who met our inclusion criteria and who had failed
nonoperative management were selected for arthroscopic
reconstruction. All surgeries were performed by the senior
author (JPB). The degree and type of reconstructive procedure performed were based on the findings of the preoperative workup, examination under anesthesia (EUA), and
the intraoperative findings at the time of arthroscopy
(Figures 1 and 2).
Before the arthroscopic procedure was started, all patients
underwent a thorough EUA and comparison with the contralateral shoulder. Special attention was given to examining for anterior, posterior, and inferior shoulder laxity.
Glenohumeral translation was graded according to the criteria of Altchek et al.1 Inferior laxity was also assessed and
determined to be positive if there was a grade 2+ sulcus
sign on examination that failed to tighten with external
rotation of the shoulder. This information was correlated
with preoperative MRI findings, preoperative symptoms of
instability, and surgical findings of patulous capsule, inferior glenohumeral ligament injuries, labral injuries, and
widened rotator intervals. The surgery was performed
under interscalene block alone or general endotracheal
anesthesia with interscalene block for perioperative pain
control. The patient was positioned in the standard lateral
decubitus position. The shoulder was placed in 45° of abduction and 20° of forward flexion. A posterior portal was created slightly inferior and lateral to the standard posterior
portal, followed by the establishment of an anterior portal.
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1714 Baker et al
The American Journal of Sports Medicine
Figure 2. A view from the posterior portal of the anterior
labrum before suture capsulolabral plication.
The anterior portal was placed high in the rotator interval,
from an inside-to-outside fashion via a switching stick. A
diagnostic arthroscopy was performed, systematically evaluating the labrum, capsule, biceps tendon, subscapularis,
rotator interval, rotator cuff, and articular surfaces with the
arm in and out of traction. The posterior shoulder was
evaluated with the arthroscope in the anterior portal, looking specifically for a patulous posterior capsule, capsular
tears, labral fraying, and posterior labral tears.
The type of capsulolabral reconstruction/shift was
selected based on patient expectations, preoperative clinical examination, EUA, and pathologic findings at diagnostic arthroscopy. Anterior-inferior and anterior instabilities
were always addressed first, followed by a superior labrum,
anterior and posterior repair if necessary. Posterior-inferior
and posterior instabilities were then addressed and followed by a repeat EUA. If residual inferior laxity remained,
the rotator interval was closed. Patients with a patulous
capsule without a discrete labral tear received a capsulolabral plication with or without suture anchors. Those with
labral tears received a capsulolabral plication with suture
anchors. After the capsulolabral repair, the capsule was
evaluated for residual laxity and additional plication
sutures were placed if necessary.
Anterior Instability
The anterior capsule/labrum was evaluated with the
arthroscope in the posterior portal and the anterior portal
was used for instrumentation. The capsule was abraded with
an arthroscopic rasp or motorized synovial shaver with
special care taken to avoid capsular penetration. In the
absence of a labral tear, a 45° suture passer was used to
plicate the capsule 1 cm off the labrum at the 5:30-o’clock
position on the glenoid and then advanced superomedially
to the 4:30-o’clock position on the glenoid. This effectively
advanced the inferior capsule (Figure 3). A total of 4 nonabsorbable capsular plication sutures were placed up the face
of the glenoid with No. 0 PDS suture (Ethicon, Somerville,
New Jersey). This composed a capsulolabral repair without
Figure 3. A final view of the anterior suture capsulolabral
plication.
Figure 4. A view from the anterior portal of the same patient
demonstrating the posterior capsulolabral repair.
anchors and was used in cases of anterior-inferior capsular
laxity even though the labrum was not detached. The
degree of tightening was tailored to the amount of capsular
laxity encountered intraoperatively. Arthroscopic sutures
were tied using an arthroscopic Westin knot.
When the anterior/anterior-inferior labrum was found to
be completely or partially detached, suture anchors were
used to perform the repair/shift. Suture anchors were also
used if the labrum was either absent or deficient to restore
a buttress with the capsular shift. We used 3.0-mm BioFASTak or Bio-Suture Tak suture anchors (Arthrex Inc,
Naples, Florida). The number of suture anchors used was
based on the size of the labral tear (minimum, 3).
Posterior Instability
The arthroscope was placed in the anterior portal and the
instruments were placed in the posterior portal. A similar
approach to that performed for anterior-inferior instability
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Multidirectional Shoulder Instability Treatment 1715
Vol. 37, No. 9, 2009
was employed for posterior-inferior instability patterns. If
no labral injury was noted, a posterior-inferior capsular
plication and shift were performed without anchors beginning at the 6:30-o’clock position on the posterior-inferior
labrum. A total of 4 nonabsorbable capsular plication
sutures were placed by advancing up the glenoid similarly
to the anterior-inferior procedure, with the degree of tightening tailored to the amount of capsular laxity encountered
intraoperatively. When the posterior labrum was found to
be completely or partially detached, suture anchors were
used to perform the repair (Figure 4). Once the capsulolabral repair was completed, posterior capsular laxity
was again reassessed. Patients with continued capsular
laxity subsequently underwent further capsulorrhaphies
with sutures placed in the capsule in the intervals between
the suture anchors.
Rotator Interval Closure
Following the reconstructions previously described, an
EUA was performed to assess for residual inferior laxity
via testing of the sulcus sign and evaluation of the capsule arthroscopically. If present, the rotator interval was
closed arthroscopically with the arm position remaining
unchanged. The anterior cannula was withdrawn until just
outside the capsule. Approximately 1 cm lateral to the glenoid, a crescent suture passer was used to pierce the capsule and a No. 0 PDS suture was passed into the joint.
Based on the amount of residual inferior laxity, the rotator
interval was closed to further restore inferior stability
using a 22° BirdBeak suture passer (Arthrex Inc) to pierce
the capsule at a distance from the prior capsular stitch and
retrieve the PDS suture. An arthroscopic Westin knot was
then tied to complete the rotator interval closure.
TABLE 1
Summary of Patient Demographics (Total 43 Shoulders)
Gender: men, 25; women, 18
Mean age: 19.09 ± 5.3 years (range, 14-39)
Average follow-up: 33.5 ± 8.7 months (range, 24-65)
Level of participation: high school, 22 (51%); college, 11 (26%);
recreational, 10 (23%)
Arm: dominant, 23; nondominant, 20
Origin of injury: traumatic, 22; atraumatic, 21
TABLE 2
Primary Sports at the Time of Injury
(Total 43 Shoulders)
Sport
No.
Football
Basketball
Softball/baseball
Swimming
Golf
Wrestling
Cheerleading
Volleyball
Dancing
Martial arts
Gymnastics
Hockey
10
6
6
4
4
3
3
2
2
1
1
1
strength, and endurance comparable with that of the contralateral side before return to competition. Depending
on the sport, most athletes were allowed to return to competition at or around 6 months postoperatively.
Postoperative Rehabilitation
Immediately after surgery, the rehabilitation protocol
employed the use of an UltraSling (DonJoy, Carlsbad,
California) that immobilized the shoulder in approximately 30° of abduction and protected the shoulder joint.
Cryotherapy was used initially for edema control. On the
first postoperative day, the patient began active wrist and
elbow flexion and extension exercises as well as gentle
pendulums and passive scaption exercises. Patients were
immobilized for 4 to 6 weeks depending on the amount of
postoperative stiffness seen at follow-up. If the shoulder
was developing stiffness, formal physical therapy was
begun at 4 weeks. After sling immobilization was discontinued, gentle passive ROM exercises were advanced and
active-assisted ROM exercises as well as isometric internal and external rotation exercises were initiated. Range
of motion was progressed to full passive and active ROM
by 2 to 3 months postoperatively. At this time, capsular
stretching exercises were started and isotonic strengthening continued, with emphasis on the rotator cuff. At 4
months postoperatively, patients were progressed into the
functional phase of rehabilitation with plyometrics, more
aggressive strengthening, and overhead lifting as tolerated. In general, athletes had to achieve painless ROM,
RESULTS
Patient Demographics
Complete demographics are shown in Table 1. There were
24 men and 16 women with an average age at surgery of
19.1 years (range, 14-39). The mean follow-up was 33.5
months (range, 24-65). The dominant shoulder was noted
to be involved in 23 (53%) of the cases. All patients were
athletes who competed at either the high school, collegiate,
or organized recreational level. There were 21 patients
(22 shoulders) who competed at a high school level, 10 collegiate athletes (11 shoulders), and 9 patients (10 shoulders) involved in organized recreational sports. The most
common sports in the patient population included football
(10), basketball (6), softball/baseball (6), swimming (4), and
golf (4). A complete list of sports is shown in Table 2. Four
patients had undergone a total of 4 previous operations
including 3 arthroscopic thermal capsulorrhaphy procedures and 1 open anterior capsulorrhaphy. Twenty-one
patients (22 shoulders) described the onset of their shoulder difficulties as resulting from a traumatic injury.
Although many patients described having a dislocation as
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1716 Baker et al
The American Journal of Sports Medicine
their initial injury, only 7 of these were confirmed radiographically or by emergency department records. Of the
21 patients who described a traumatic origin, the average
time from injury to surgery was 7.6 months (range, 1-41).
Nineteen patients (21 shoulders) could not recall a traumatic
injury to their shoulder and were classified as atraumatic.
Surgical Findings
All of the 43 shoulders (100%) had a redundant inferior
capsule. Overall, 16 shoulders (37%) had capsular redundancy anteriorly, posteriorly, and inferiorly. The remainder of shoulders demonstrated a spectrum of injury
patterns and pathologic abnormalities. Anteriorly, there
were a total of 23 Bankart lesions present in 54% of the
shoulders. Of these lesions, 4 were associated with concurrent anterior capsular redundancy and 19 were the only
anterior injury noted. Twenty shoulders (47%) had anterior capsular redundancy only. Therefore, 24 shoulders
(56%) had a redundant anterior capsule regardless of
labral injury. Posteriorly, 23 shoulders (53%) had a patulous posterior capsule only, 3 shoulders (7%) demonstrated
posterior capsular redundancy and incomplete labral
stripping, 3 shoulders (7%) were noted to have a posterior
labral detachment in addition to the capsular lesion, 9
shoulders (21%) had a reverse Bankart lesion only, and 5
(12%) demonstrated incomplete labral stripping only.
Therefore, 29 shoulders (67%) had a patulous posterior
capsule regardless of labral injury.
In the group of 22 shoulders with a traumatic onset of
symptomatic instability, 15 shoulders demonstrated anterior labral detachment, 5 shoulders had anterior capsular
redundancy, and 2 shoulders had anterior capsular redundancy and labral injury. Posteriorly, 7 shoulders had labral
detachment, 3 shoulders had labral stripping, 9 shoulders
had capsular redundancy, and 3 shoulders demonstrated
capsular redundancy and labral lesions.
In the group of 21 shoulders with an atraumatic onset of
symptomatic instability, 4 shoulders demonstrated anterior labral detachment, 15 shoulders had anterior capsular
redundancy, and 2 shoulders had anterior capsular redundancy and labral lesions. Posteriorly, 2 shoulders had
labral detachment, 2 shoulders had labral stripping, 14
shoulders had capsular redundancy, and 3 shoulders demonstrated capsular redundancy and labral stripping.
Three patients were noted to have a type 2 superior
labrum, anterior and posterior tear that was repaired concurrently. There were no associated full-thickness rotator
cuff tears or subacromial space abnormalities.
Surgical Procedures
Patients with a patulous capsule without a discrete labral
tear received a capsulolabral plication with or without
suture anchors. Those with labral tears or a deficient
labrum received a capsulolabral plication with suture
anchors. After the capsulolabral repair the capsule was
evaluated for residual laxity and additional plication
sutures were placed if necessary. Treatment was individualized to each patient and was based on symptoms in the
clinic as well as the EUA and arthroscopic findings.
Anteriorly, 22 shoulders (51%) had a capsulorrhaphy performed with anchors, 16 shoulders (37%) had a capsulorrhaphy performed without anchors, and 5 shoulders (12%)
had a capsulorrhaphy performed with anchors and additional plication sutures. Posteriorly, 21 shoulders (49%)
had a capsulorrhaphy performed with anchors, 13 shoulders (30%) had a capsulorrhaphy performed without
anchors, and 9 shoulders (21%) had a capsulorrhaphy performed with anchors and additional plication sutures. The
rotator interval was closed in 10 shoulders (23%). In the
group of 16 shoulders that had isolated capsular redundancy anteriorly, posteriorly, and inferiorly, capsulorrhaphy with suture alone was performed in 9 patients.
Three shoulders had an anterior and posterior capsulorrhaphy performed with anchors only and 2 shoulders had
an anterior suture capsulorrhaphy and a posterior capsulorrhaphy performed with anchors. One shoulder had an
anterior repair with suture only and a posterior repair
with anchors and additional plication sutures, and the
remaining shoulder had an anterior repair with anchors
and additional plication sutures and a posterior repair
with suture only. In these 16 shoulders with isolated capsular redundancy, the rotator interval was closed in 6
shoulders (38%). In one patient a subacromial bursectomy
was performed for visualization of the bursal side of the
rotator cuff that failed to demonstrate a full-thickness
tear. No patient required repair of a partial-thickness
rotator cuff tear.
Stability
At the time of latest follow-up using a subjective stability
scale (0-10, with 10 being completely unstable), the mean
stability score for the 43 shoulders was 1.8 (range, 0-7). At
the time of latest follow-up, using this subjective stability
scale, 32 shoulders (74%) scored excellent (0-2); 8 (19%),
good (3-4); 1 (2%), satisfactory (5-6); and 2 (5%), poor (≥7).
Forty shoulders (93%) thus had excellent or good stability
at the time of latest follow-up. Similar results were found
in the traumatic and atraumatic subgroups (Table 3).
Pain
Using a subjective pain scale (0-10, with 10 being the worst
pain), the mean postoperative pain score for the 43 shoulders was 1.12 (range, 0-5). For the 22 traumatic shoulders,
the mean pain score was 1.20 (range, 0-5) and for the 21
atraumatic shoulders the mean pain score was 1.02 (range,
0-5) (Table 3).
Function
Using a functional scale based on the ASES system (0-30,
with 0 being the worst function), the mean postoperative
functional score for the 43 shoulders was 27.5 (range,
21-30). The mean postoperative functional scores for the
traumatic and atraumatic cohorts were 28.32 (range,
21-30) and 26.62 (range, 21-30), respectively (Table 3).
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Multidirectional Shoulder Instability Treatment 1717
Vol. 37, No. 9, 2009
TABLE 3
Summary of Patient Results (Total 43 Shoulders) at Latest Follow-upa
Outcome Measure
All Patients
Traumatic ASES
(0-100, 0 being worst)
WOSI (0-100, 0 being worst)
Stability
(0-10, 0 being most stable)
Pain
(0-10, 0 being no pain)
Function
(0-30, 0 being worst)
Range of motion
(0-3, 3 being full motion)
Strength
(0-3, 3 being full strength)
91.37 ± 8.98
(59.86-100)
91.09 ± 9.28
(72.9-100)
1.81 ± 2.06
(0-7)
1.12 ± 1.24
(0-5)
27.49 ± 2.60
(21-30)
2.40 ± 0.66
(1-3)
2.63 ± 0.53
(1-3)
91.09 ± 8.83
(59.86-100)
93.72 ± 10.29
(72.9-100)
1.89 ± 2.32
(0-6)
1.20 ± 1.23
(0-5)
28.32 ± 2.48
(21-30)
2.55 ± 0.67
(1-3)
2.64 ± 0.58
(1-3)
Atraumatic
88.85 ± 8.31
(59.86-100)
89.32 ± 8.70
(74.5-98.6)
1.74 ± 1.85
(0-7)
1.02 ± 1.20
(0-5)
26.62 ± 2.56
(21-30)
2.14 ± 0.57
(1-3)
2.57 ± 0.51
(2-3)
a
All values are listed as the mean results with the corresponding standard deviations. The range of results follows in parentheses. ASES,
the American Shoulder and Elbow Surgeons standardized shoulder assessment score; WOSI, the University of Western Ontario Shoulder
Instability Index percentage score.
All 40 patients stated they were able to return to normal
activities of daily living. No patient returned to restricted
activities of daily living.
Range of Motion
Using a subjective ROM scale (0-3: 0 = poor, 1 = limited,
2 = satisfactory, 3 = full), at the time of latest follow-up, the
mean ROM score for the 43 shoulders was 2.4 (range, 1-3).
Nineteen shoulders (44%) had full ROM and 20 shoulders
(47%) had satisfactory ROM. Therefore, 39 shoulders (91%)
had satisfactory or full ROM and 4 shoulders (9%) had
limited ROM at the time of latest follow-up. Similar results
were found in the traumatic and atraumatic subgroups
(Table 3).
Strength
Using a subjective strength scale (0-3: 0 = none, 1 = markedly decreased, 2 = slightly decreased, 3 = normal), at the
time of latest follow-up, the mean strength score for the 43
shoulders was 2.6 (range, 1-3). Twenty-seven shoulders
(63%) had normal strength, 15 shoulders (35%) had
slightly decreased strength, and 1 shoulder (2%) had
markedly decreased strength. For the 22 traumatic shoulders the mean strength score was 2.6 (range, 1-3), and for
the 21 atraumatic shoulders the mean strength score was
2.6 (range, 2-3) (Table 3).
ASES Scores
Using the standardized ASES shoulder scale (0-100, with
100 being best), the mean ASES score for the 43 shoulders
at latest follow-up was 91.4 (range, 59.86-100). The mean
ASES scores for the traumatic and atraumatic groups
were 91.1 (range, 59.86-100) and 88.8 (range, 59.86-100),
respectively (Table 3).
WOSI Scores
Using the standardized WOSI index, the mean WOSI percentage score for the 43 shoulders was 91.1 (range, 72.9-100).
The mean WOSI scores for the traumatic and atraumatic
groups were 93.7 (range, 72.9-100) and 89.3 (range,
74.5-98.6), respectively (Table 3).
Return to Sport
At the time of the latest follow-up for the 40 patients in the
study, 26 (65%) returned to the same level of sport, 5 (12%)
returned to a limited level, and 9 (23%) did not return to
their previous sport. On further study of the 9 patients
who did not return to sport, 2 patients did not return
because they had completed their collegiate eligibility, 1
patient had transferred schools, and 1 patient did not
return for reasons unrelated to her shoulder. Therefore, of
the remaining 36 patients only 5 patients were unable to
resume athletic competition secondary to the condition of
their shoulder. Thus, 31 of 36 athletes (86%) were able to
return to sport. The 5 patients who were unable to return
included a high school wrestler, a collegiate swimmer, a
high-level recreational swimmer, a high school cheerleader,
and a high school basketball player.
Failures
Using the ASES scoring system, there were 2 failures
(4.7%) (score ≤70) when taking function and pain into
account in our 43 shoulders at the time of latest follow-up.
Because the ASES scale does not measure stability, failures can also be judged by clinical instability. Using the
stability scale, 2 (4.7%) of the 43 shoulders were failures
(score >5) at the time of latest follow-up. All 40 patients
(100%) thought their surgery was worthwhile and they
would have it again.
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1718 Baker et al
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Four shoulders (9.3%) met at least one of the criteria to
be defined as a failure based on either the ASES score or
the standardized stability scale. These 4 patients included
a high school cheerleader, 2 female high school basketball
players, and a collegiate football player. Only 1 of the
patients sustained a traumatic reinjury postoperatively.
The surgical findings included a patulous capsule anteriorly, posteriorly, and inferiorly in all 4 patients. Two
patients had undergone previous thermal capsulorrhaphy
procedures. The operative procedures performed by us
included 2 capsulorrhaphies with suture only, 1 capsulorrhaphy with anchors, and 1 capsulorrhaphy with anchors
and additional plication sutures. Only 1 of these patients
opted for a revision procedure. The patient was a football
player who had been treated previously with a thermal
capsulorrhaphy by another surgeon. He underwent capsulolabral plication with suture and was able to return to
the same level of sport until 2 years postoperatively when
he sustained a traumatic anterior dislocation in a game.
He experienced multiple subluxation episodes after this,
despite playing in a brace. At revision diagnostic arthroscopy he was noted to have a Bankart lesion. He was successfully treated with an open inferior capsular shift with
Bankart repair, rotator interval closure, and a Bristow
procedure because of his 2 previously failed surgeries.
Complications
There were no neurovascular injuries, superficial or deep
infections, or cases of adhesive capsulitis in the study
population.
DISCUSSION
Neer and Foster20 first reported on their preliminary
results of an inferior capsular shift to treat shoulders with
involuntary inferior and MDI in 1980. An important distinction was made between the repairs of unidirectional
anterior or posterior instability and the repair of a shoulder with MDI. The major pathologic feature of MDI was
determined to be excessive inferior capsular redundancy.
The authors introduced the concept of an inferior capsular
shift designed to reduce the capsular volume on all sides
by overlapping and reinforcing the capsule on the side of
the greatest instability and restoring balanced tension to
the inferior and opposite capsular side. Forty shoulders in
36 patients diagnosed with MDI were treated with a
humerus-based open inferior capsular shift. Only one
patient subsequently developed recurrent instability. Since
then, several studies have reported high returns to sport in
athletes after an open inferior capsular shift in patients
with MDI of the shoulder.1-4,22
More recently, as arthroscopic techniques and technology
have advanced, several authors have reported on the arthro­
scopic treatment of MDI.** Arthroscopy allows for improved
visualization of associated intra-articular lesions and can
aid the surgeon in correctly determining the instability
**References 6, 8, 10, 11, 14, 15, 17, 18, 24, 25, 27.
pattern.17 The arthroscopic techniques are based on the
concept of the inferior capsular shift described by Neer and
Foster20 to treat the primary condition of inferior capsular
redundancy. In 1997 McIntyre et al17 reported on 19
patients with MDI, all of whom had been traumatically
injured, who were treated arthroscopically with a multiplesuture technique. The average follow-up was 34 months
(range, 25-52). Multiple sutures were used to shift the
anterior and posterior capsule superiorly, thus eliminating
the pathologic inferior capsular redundancy present in all
patients. The average postoperative score was 91 of 100 on
the Tibone and Bradley26 outcome scale. Thirteen of 14
patients (92.9%) returned to their previous level of competition, and there was one recurrence of instability that was
treated successfully with a revision arthroscopic capsular
shift. The authors thought that MDI represented a spectrum of pathologic changes and described 3 subgroups of
patients with the diagnosis of MDI but with different
pathologic entities seen at arthroscopy. The first group was
composed of male athletes involved in contact sports who
demonstrated anterior and posterior Bankart lesions.
Male athletes with a Bankart lesion and associated
increased posterior laxity, inferior laxity, or both, composed
the second group. The third group of patients consisted of
predominately female athletes with excessive global capsular laxity and a history of microtrauma.
Treacy et al27 reported on 25 patients with atraumatic
multidirectional instability treated with an arthroscopic
capsular shift with transglenoid technique at an average of
60 months (range, 36-80) of follow-up. The average Bankart
score was 95 (range, 50-100). All 8 athletes with remaining
eligibility were able to return to sport. The authors noted
a spectrum of injury and theorized that traumatic injuries
superimposed on asymptomatic capsular laxity could
result in symptomatic instability. They recommended that
management should focus on treatment of both the traumatic labral tears and atraumatic capsular laxity for optimal results.27
In the largest published series of arthroscopic treatment
of MDI, Gartsman et al8 reported on 47 patients at an average follow-up of 35 months (range, 26-67). Twenty-six
patients developed instability atraumatically and 21
patients described a traumatic onset. All patients were
noted to have a large capsular volume and an abnormal
inferior capsule. A Bankart lesion was noted in 10 patients
(21%), a frayed or separated inferior labrum was found in 5
patients (11%), and a separated or frayed posterior labrum
was noted in 8 patients (17%). Pan-capsular suture plication
was performed in all patients. Suture anchors were used to
repair labral detachments when present or to plicate the
capsule if the labrum was either deficient or absent. Goodto-excellent results were reported in 44 of 47 patients (94%)
based on the Rowe score. One patient (2%) developed postoperative instability. Twenty-two of 26 patients (85%)
returned to previous levels of sporting activity.
Hewitt et al10 reported on 30 shoulders in 27 patients
treated with an arthroscopic pan-capsular plication. The
average follow-up was 57 months (range, 25-100). Patients
requiring concurrent labral repair were excluded. Anteriorinferior instability was noted in 6 patients, posterior-inferior
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Multidirectional Shoulder Instability Treatment 1719
Vol. 37, No. 9, 2009
instability in 4 patients, and global instability in 20 patients.
Good-to-excellent results were noted in 83% of patients
based on the Rowe score. Ninety-seven percent of patients
returned to sport; however, 20% returned at a limited level.
The majority of reports of shoulder instability correctly
distinguish between traumatic unidirectional and classic
atraumatic MDI of the shoulder. However, it is becoming
increasingly recognized that there is a spectrum of disease
when describing shoulder instability.3,13,27 Athletes often fall
within this spectrum as they may have some element of
generalized ligamentous laxity in addition to the repetitive
microtrauma and stress on the capsule related to their athletic endeavors. Superimposed major traumatic injuries may
result in symptomatic instability in the previously asymptomatic athlete. Pollock et al22 noted that there appeared to
be more than one etiologic factor in the majority of their
patients. Gartsman et al8 also described a spectrum of glenohumeral pathologic lesions, suggesting a variable and
multifactorial origin of MDI. Although there were 22 shoulders with a traumatic cause for instability and 21 shoulders
without a clear history of trauma in the present study, many
athletes in both groups participated in overhead throwing
sporting activities, which can inflict repetitive microtrauma
on the glenohumeral capsular ligaments and thus further
blur the distinction between the separate groups.
Similar to other published reports, our study notes a
wide variety of anterior and posterior glenohumeral lesions
in addition to the universal findings of inferior capsular
laxity. Bankart lesions were seen in 23 shoulders (53%)
with and without associated anterior capsular redundancy.
Posterior labral lesions including incomplete stripping and
detachment were seen in 20 shoulders (47%). All patients
in our series had anterior and posterior pathologic changes
either through isolated labral lesions, isolated capsular
redundancy, or a combination of both. In accordance with
our findings and those of other authors, the clinical spectrum of MDI represents a wide variety of pathologic lesions
seen at arthroscopy.8 Arthroscopic management of all
observed pathologic lesions is critical to obtaining an optimal result. Repair of the labral detachments must also
include the restoration of appropriate capsular tension.3 A
capsulolabral plication with a capsular shift appropriately
restores the capsular tension, reduces the redundant capsular volume, and balances the anterior and posterior
bands of the inferior glenohumeral ligament. Plication of
the capsule to the labrum also restores and augments the
labral buttress, deepens the glenoid concavity, and increases
stability through concavity compression.8,10 If the labrum is
detached or deficient, suture anchors provide an efficient
means to concurrently plicate the capsule and repair or
restore the labrum. Suture anchors were used in 34 shoulders (79%) in this series.
The rotator interval was closed in 10 shoulders in our
series. Interval closure was performed if excessive inferior translation remained after performance of the pancapsulolabral plication. Only one shoulder in which rotator
interval closure was performed rated as a failure. Gartsman
et al8 performed rotator interval closure in 28 of 47 patients
for the same indication. The authors believed repair of the
rotator interval was an essential portion of their operative
management. Treacy et al27 recommended rotator interval
closure in all patients with MDI. Hewitt et al10 performed
interval closure in only 2 of the 30 shoulders treated with
pan-capsular plication. Their specific indication was a positive sulcus sign in adduction and external rotation.
Four failures (9%) were identified on the basis of either an
ASES score ≤70 or a stability score ≥5. As mentioned previously, all 4 shoulders demonstrated anterior, posterior, and
inferior capsular redundancy as the operative finding.
Because none of the 4 patients demonstrated any discrete
labral tears, we were inclined to perform a pan-capsulolabral
plication without suture anchors. Two patients were treated
with pan-capsular plication with suture only, a third patient
was treated with an anterior suture capsulorrhaphy and
posterior capsulorrhaphy with anchors, and the fourth
patient with an anterior suture capsulorrhaphy and posterior capsulorrhaphy with anchors and additional plication
sutures. It is possible that had we used anchors for all capsulorrhaphies to perform a more aggressive capsular shift,
these patients would not have had failed results.
Consideration should be given to the use of suture
anchors to ensure an adequate capsular shift to restore
capsular tension and restore the capsulolabral buttress if
there is any concern regarding possible residual capsular
laxity. The rotator interval was closed in only one of the
failed procedures. Additional rotator interval closure could
have addressed any unrecognized residual inferior instability. An additional reason these patients could have had
failed results was poor recognition of tissue quality. Half of
these patients with failures had previous thermal capsular
shrinkage procedures and might have been better served
with an open operation. The senior author (JPB) has reported
previously on finding a thin and attenuated capsule at revision surgery after thermal capsulorrhaphy of the shoulder.5
Of the 40 total patients in our study, 26 (65%) returned
to the same level of sport, 5 (12%) returned to a limited
level, and 9 (23%) were unable to return to their previous
sport. Four patients did not return because of either loss of
eligibility, transfer of schools, or other nonmedical-related
reasons. Only 5 patients were unable to resume athletic
competition secondary to the condition of their shoulder.
Therefore, 31 of the 36 patients who desired to return were
able to accomplish that goal. Our 86% rate of return to
sport is similar to that of other previous reports from the
literature for open surgery, which has documented return
rates ranging from 84% to 94%.1−3,22 and for arthroscopic
surgery, which has documented return rates ranging from
85% to 100%.8,10,17,27 Although the present study is retrospective, all patients presented for operative intervention
because of inability to effectively compete in their athletic
endeavors. The athlete’s ability to return to sport is perhaps
the major indicator of success or failure of this procedure.
Although objective measurements can be made regarding
residual glenohumeral laxity, strength, and ROM, an athlete’s ability to return to competition may be a more pertinent outcome measurement in this population.
Comparison of these results with those of other studies
is difficult because of lack of a consistent definition of
MDI16 in the literature. We defined multidirectional instability as instability in more than one direction (including
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1720 Baker et al
The American Journal of Sports Medicine
inferior instability) based on the elicited history, physical
examination, evaluation under anesthesia, and confirmatory findings at arthroscopy demonstrating inferior capsular redundancy as well as anterior and posterior lesions
associated with instability. We included patients with
lesions of both traumatic and atraumatic origin. Previous
reports of arthroscopic repair have included only those
lesions of traumatic17 or atraumatic origin, or eliminated
patients requiring labral repair.10 Although all patients in
this study carried the single diagnosis of MDI, a wide variety of pathologic lesions was seen at arthroscopy. This was
similar to the report by Gartsman et al.8 We agree that the
clinical spectrum of MDI may be represented by a spectrum of anatomical lesions.7 Limitations of our study
include the lack of preoperative patient-reported scores
and the heterogeneous study population, but these issues
are inherent to most retrospective studies and can make
comparisons between studies difficult.
Arthroscopic repair of visualized labral detachments and
combined capsulorrhaphy to restore capsular tension produced significant improvements in pain and stability in the
athletes in our study. Intraoperative assessment is critical
to determining not only the labral injury, but also the degree
of capsular laxity. These findings dictate the method of
repair and degree of capsular plication. The use of anchors
for capsulolabral repair/capsulorrhaphy appears to be a safe
option with low risk of recurrence, even for patients without
discrete labral tears. Eighty-six percent of athletes were
able to return to their sports. All patients were satisfied by
the procedure and would have it again. In conclusion,
arthroscopic repair in athletes with symptomatic MDI
appears to be an effective, reproducible treatment option.
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