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FACULTEIT GENEESKUNDE EN FARMACIE

Do patients with shoulder instability due to isolated anterosuperior capsuloligamentous lesions have a different postoperative rehabilitation course and outcome than the patients with other capsuloligamentous lesions?

Thesis neergelegd voor het behalen van de graad van Master in de Geneeskunde

Tom Depovere

Academiejaar 2013 - 2014

Promotor: Prof. Dr. N. Pouliart

1

Table of contents

Acknowledgements ...................................................................................................................... 2

Article .......................................................................................................................................... 3

Abstract. .............................................................................................................................................. 3

Introduction. ........................................................................................................................................ 4

Methods and materials. ...................................................................................................................... 6

Results. ................................................................................................................................................ 8

Discussion. ......................................................................................................................................... 15

Conclusion. ........................................................................................................................................ 17

References. ........................................................................................................................................ 18

Appendix ................................................................................................................................... 20

Background information on shoulder anatomy. ............................................................................... 20

2

Acknowledgements

My studies were not possible without the support and help of many people. First I would like

to thank my promotor, Prof. Dr. Nicole Pouliart for her assistance, guidance, support and

dedicated involvement with respect to this paper.

I would especially like to thank my parents and 2 sisters for always offering their endless

support and help during my studies.

Also a thank you for Olivier Beuckelaers who offered me the possibility to combine my

studies with my professional activities and who always supported me.

I could also always count on the support of my friends.

And last but not least I would like to thank my wife and 2 children for their cheerful support

and patience.

3

Article

Abstract.

Introduction. Minor or anterosuperior shoulder instability (SI) is a relatively new concept.

Until now, not many studies investigated the specific pattern of minor shoulder instability.

Moreover, there is to our knowledge not yet a study that compared SI with only isolated

anterosuperior capsuloligamentous lesions (MSI) and SI with at least an anteroinferior

capsuloligamentous lesion (CSI).

Purpose: The purpose of this study was to compare these 2 types of SI in terms of the

postoperative rehabilitation, the return to work and sport, and the outcome after

arthroscopic surgery. Our hypothesis was that the postoperative rehabilitation course and

return to work and sport was longer for patients with MSI and that they had a worse

outcome than patients with CSI.

Methods and materials: 87 patients who underwent an arthroscopic surgery as treatment

for the final diagnosis of SI were willing to return a survey. The subjects were divided in 2

groups. Group I consisted of 29 patients with only anterosuperior capsuloligamentous

lesions. Group II consisted of 58 patients with at least an anteroinferior capsuloligamentous

lesion. The survey included a questionnaire as well as the Oxford Shoulder Instability Score

(OSIS) and the Western Ontario Shoulder Instability index (WOSI).

Results: The pain at rest, night pain and pain during overhead activities (p=0,036)

disappeared slower in group I than group II. The return to normal subjective range of motion

(ROM) shows less differences between the 2 groups. Patients in group I returned slower to

their professional activities (p=0,015) and to their same sport. Group I scored worse on the

OSIS (p=0,034) and WOSI.

Conclusion: We can conclude that patients with MSI have poorer prospects when it comes

to postoperative rehabilitation, return to work and sport, and outcome compared to

patients with the CSI.

Key words: Shoulder instability – Minor shoulder instability – Return to work and sport –

Outcome score.

4

Introduction.

Shoulder instability (SI) is a very frequent pathology of the shoulder that has a variety of

clinical presentations.5 The glenohumeral joint is the most often dislocated joint in the body

due to the combination of a large range of motion (ROM) and an insufficient bony

stabilization. The stability of the shoulder is provided by a complex interaction between

static and dynamic mechanisms.8 When one of these static or dynamic stabilizers is damaged

by trauma or overuse, the shoulder has an increased risk of injuries.5 An imbalance between

the stabilizers can result in a wide spectrum of clinical symptoms.1, 2

SI is usually still

classified in Traumatic Unidirectional Bankart lesion treated with Surgery (TUBS) and

Atraumatic Multidirectional Bilateral treated with Rehabilitation and if surgery is required an

Inferior capsular shift or closure of the rotator Interval (AMBRII). This classification is

however not capable to include all the different types of instability, especially a group of

“subtle” conditions which may be identified as minor shoulder instability (MSI).1

Subtle, occult and anterosuperior instability are all synonyms used in the literature for MSI.2

MSI is a relatively new concept and until now, not many studies investigated the specific

pattern. Castagna et al. defined MSI as shoulder pain secondary to shoulder laxity, which

cannot be defined as TUBS or AMBRII. This pathological condition included an Acquired

Instability in Overstressed Shoulder (AIOS) and an Atraumatic Minor Shoulder Instability

(AMSI).1

MSI can occur in both athletic and non athletic persons under the age of 40.2 It may be

caused by microtrauma (AIOS) or by anatomic variants combined with muscle atrophy

(AMSI).1

AIOS describes a pathological condition that is related to overstress where the

superior part of the capsuloligamentous complex is involved. It is most common in overhead

athletes and young workers who perform heavy overhead work. To date there are various

theories on how these overhead activities can lead to this pathology. They suspect that the

middle glenohumeral ligament (MGHL) plays a major role in the development of AIOS.1 AMSI

is a very rare entity and is rarely described in the literature. These patients have pain of the

shoulder after a period of inactivity like a pregnancy or an immobilization.1 They often

demonstrate anatomical variants of the MGHL such as absence, hypoplasia or a Buford

complex.11, 12

Clinical examination usually reveals a reduced ROM, especially in elevation, due to pain.1, 2, 3

Other standard shoulder tests are not specific for this pathology. Castagna et al. propose in

their study the Castagna test for MSI. In this test the patient is positioned with 45° of

glenohumeral abduction. The arm is in maximal external rotation and the test is positive

when there is pain at the moment of relocation.1

Until now the diagnosis of MSI is most of the time only possible after an arthroscopic

procedure since the symptoms are often not specific and the clinical examination can be

5

confounding.2 According to Castagana et al. patients with MSI complain of pain in the

posterior-superior aspect of the affected, generally dominant, shoulder. The pain is often

diffuse and difficult to pinpoint. Patients also describe snapping and popping, “dead arm”,

painful subluxation or transient locking.1 Nordenson et al. describe that MSI also often

presents as a subacromial impingement syndrome.2

The main pathologic process of MSI can be identified at the level of the anterosuperior part

of the labrum, especially the MGHL complex.1 Castagna et al. believe that the anatomical

variants of the MGHL cannot be totally benign. In MSI this ligament can appear as

hyperemia, fraying, stretching, loosening, thinning, hypoplasia or even absent.1

It is often

difficult to distinguish between a normal variant and a pathological condition, even for an

experienced shoulder surgeon.

An indirect sign of MSI is the distance between the long head of the biceps muscle and the

rotatorcuff. This distance increases in case of MSI. It may seem that the capsular volume has

increased and the drivethrough sign may be positive in patients with MSI.1

An isolated tear in

the anterosuperior labrum can also be a subtle cause of a painful shoulder.3 This injury is

however usually extended to either the origin of the long head of the biceps muscle or

anterior to posterior (Superior Labral Anterior Posterior (SLAP)-lesion).19

The treatment of MSI is surgical repair of the shoulder stability.1, 2

The rehabilitation takes 6 to 9 months. Castagna et al. established a permanent restriction in

external rotation of a few degrees.1 However, this was not the case in the studies of

Nordenson et al. and Garofalo et al.2, 3

Our hypothesis was that the postoperative rehabilitation course and return to work and

sport was longer for the MSI patients and that they had a worse outcome than the patients

with classic shoulder instability (CSI).

The purpose of our retrospective study was to compare the group of patients with MSI with

those with CSI and this for the postoperative rehabilitation course, the time to resume work

and sport, and the outcome after arthroscopic surgery. To the best of our knowledge this

comparison has not been done before.

6

Methods and materials.

Between 1994 and 2012 290 patients underwent a shoulder arthroscopy for the final

diagnosis of any type of SI in our institution. All arthroscopies were performed by 2

experienced shoulder surgeons. The arthroscopic procedure was performed with the

patients in lateral decubitus position with the arm placed in a shoulder holder with traction.

Routine anterosuperior and posterolateral portals were created to inspect the entire joint.

All these 290 patients were invited to participate in our study by means of a letter. Of the

290 patients, 6 patients were deceased and 125 patients could not be reached because of

lack of current contact information. Of the remaining 159 patients, 72 declined to

participate, either because of lack of interest (30) or due to professional time restrictions

(42). Therefore, the present study group consists of 87 patients (figure 1).

Our research population consisted of 49 men (56,3%) and 38 women (43,7%). The mean age

at time of surgery was 31,44 ± 10,40 years (range 16-60). The dominant arm was affected in

59 patients (67,8%). None of the patients was ambidextrous.

The study group was divided into 2 groups based on the injuries determined during the

shoulder arthroscopy. 29 patients (33,3%) had only isolated anterosuperior

capsuloligamentous lesions and they form our study group (group I - MSI). 58 patients

(66,7%) had at least an anteroinferior capsuloligamentous lesion and they form our control

group (group II - CSI)

Figure 1: Flowchart of case selection

Database of 290 patients

who underwent an arthroscopy for the final

diagnosis of any type of SI

6 patients were deceased125 patients could not be

reached72 patients declined to

participate

30 patients because of lack of interest

42 patients due to professional time

restrictions

87 patients were succesfully contacted

29 patients had only isolated anterosuperior

capsuloligamentous lesions (group I - MSI)

58 patients had at least an anteroinferior

capsuloligamentous lesion (group II - CSI)

7

The clinical history, clinical presentation, professional and sport activities as well as

postoperative rehabilitation were evaluated based on the medical files and a self-defined

questionnaire. This questionnaire included questions about the onset of symptoms, the

clinical symptoms, pre- and postoperative professional and sport activities, return to work

and sport, and duration of postoperative rehabilitation. The ROM investigated in this study is

the subjective ROM. This information is only part of the questionnaire since there was no

final clinical examination and insufficient data was available in the medical files. The Oxford

Shoulder Instability Score (OSIS) and the Western Ontario Shoulder Instability index (WOSI)

were used to assess the shoulder function at a final review at time of the study at a mean of

83 months (range 12 months to 240 months) postoperatively. We used the OSIS edition

where the scores of 12 and 60 represent respectively the best and worst scores. In the

edition we used for WOSI a score of 0 (100%) represents the best and 2100 (0%) the worst

score.

Data was analyzed with the use of SPSS Statistics 22 of IBM. Means and crosstables were

performed. Possible significance was reviewed by using the chi-square test and the

independent samples T-test. For all tests a threshold of significance of 0,05 was used.

8

Results.

Patient demographics (table 1) showed that the mean age at time of surgery was

significantly higher in group I (p=0,001). Although the percentage of women in group I was

higher than in group II, the difference was not significant. The dominant arm was affected

more frequently than the non-dominant arm and this was similar in both groups.

Group I Group II

Mean age at time of surgery 36,62 ± 10,48 years

(range 16-56)

28,84 ± 9,41 years

(range 16-60 )

Gender

Female

Male

15 (51,7%)

14 (48,3%)

23 (39,7%)

35 (60,3%)

Affected arm

Dominant arm

Non-dominant arm

21 (72,4%)

8 (27,6%)

38 (65,5%)

20 (34,5%)

Table 1: Patient demographics

At the time of the onset of the symptoms the proportion of the type of work was almost

similar in both groups (figure 2). More than 80% of the patients in both groups had either a

manual or an administrative work. A small portion of patients was either still student or

housewife (without any other professional activity).

Figure 2: Type of work prior to surgery

48,3%

(n: 14)43,1%

(n: 25)

34,5%

(n: 10) 37,9%

(n: 22)

6,9% (n: 2)1,7% (n: 1)

10,3%

(n: 3) 17,2%

(n: 10)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

group I group II

Type of work

student

housewife

administrative work

manual work

9

The majority of patients in both groups practiced an overhead sport (swimming, volleyball,

tennis, basketball, fitness or American football) at the time of the onset of the symptoms

(figure 3). About a fifth of the patients in group I and about a third of the patients in group II

practiced another sport (running, soccer, cycling) and the remaining patients did not practice

a sport. More patients in group II than in group I practiced a sport.

Figure 3: Type of sport prior to surgery

For the majority of the patients in both groups the pain at rest disappeared less than 6

months after the surgery (table 2). But if the pain persisted it was more likely that the pain

remained for more than 12 months for patients in group I while the pain disappeared in

most cases within the year for patients in group II.

Pain at rest Group I Group II

Gone after < 6 months 20 (69,0%) 41 (70,7%)

Gone after 6-12 months 2 (6,9%) 12 (20,7%)

Gone after > 12 months 7 (24,1%) 5 (8,6%)

Table 2: Pain at rest

For more than 50% of the patients in both groups night pain disappeared within 6 months

after the surgery (table 3). The pain remained however for more than 12 months in

approximately a third of the patients in group I.

62,1%

(n: 18)

62,1%

(n: 36)

20,7%

(n: 6)

32,7%

(n: 19)

17,2%

(n: 5)

5,2% (n: 3)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

group I group II

Type of sport

no sport

another sport

overhead sport

10

Night pain Group I Group II




Table 3: Night pain

In 80% of the patients in group II the pain during overhead activities was gone in less than 12

months while this was the case in less than 60% of the patients in group I (table 4). A

significant relationship between our study groups and the time it takes before the pain

during overhead activities disappears (p=0,036) was found.

Pain during overhead activities Group I Group II




Table 4: Pain during overhead activities

The mean OSIS was significantly (p=0,034) lower in group II than in group I. The mean WOSI

was also lower in group II than in group I (table 5). This means that patients in group I have a

worse outcome than patients in group II. Initially, the pain at rest, the night pain and the

pain during overhead activities disappeared during the postoperative rehabilitation but at a

certain point of time in the follow-up the pain returned for respectively 10, 14 and 14

patients. Sensation of pain was one of the topics inquired in both scores which means that it

has a negative influence on the scores.

Group I Group II

OSIS

Mean 30,86 ± 13,38 24,76 ± 11,96

Median 30 21

WOSI

Mean 910,34 ± 575,93 (56,7%) 692,02 ± 515,66 (67,0%)

Median 848 (59,6%) 618 (70,6%)

Table 5: OSIS and WOSI

11

More than 40% of the patients in group I and more than 50% of the patients in group II

returned to their normal subjective ROM in less than 6 months (table 6). More patients in

group I however remain to have a limitation of their subjective ROM for more than 12

months.

Return to normal subjective ROM Group I Group II

After < 6 months 12 (41,4%) 32 (55,2%)

After 6-12 months 7 (24,1%) 11 (18,9%)

After > 12 months 10 (34,5%) 15 (25,9%)

Table 6: Return to normal subjective ROM

Less than 20% of the patients in both groups were unable to return to the same work as

before the surgery (figure 4). In group II all patients who were able to return to the same

work were able to do so within 12 months and most of them even in less than 6 months.

This pronounced trend was not established for group I. In contrast to the patients in group II,

almost 14% of the patients in group I needed more than 12 months to return to their same

work. Overall, we clearly see that patients in group I returned slower to their same

professional activities (p=0,015).

Figure 4: Return to the same work

Tables 7 and 8 show the possible differences for both groups between the patients who

were able to return to their same work after surgery and those who were unable to do so.

Almost all patients who were unable to return to their same work found a different or a

customized job after a period of more than 12 months. In both groups the mean OSIS and

55,2%

(n: 16)

75,9%

(n: 44)

17,2%

(n: 5)

6,9% (n: 4)13,8%

(n: 4)

13,8%

(n: 4)17,2%

(n: 10)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

group I group II

Return to the same work

no return to the same work

> 12 months

6-12 months

< 6 months

12

WOSI was significantly worse for the patients who were not able to return to their same

work (p=0,000). All patients in group II and 75% of the patients in group I who were unable

to return to the same work were manual workers. A significant relationship was established

for group II (p=0,001). We noticed that only the type of work, namely manual work, is a

determining factor in order to be able to resume the same work after surgery. No great

differences were found for the other variables.

Group I: patients able to

return to the same work

after surgery (n=25)

Group I: patients unable to


after surgery (n=4)

Mean age at time of the

surgery 36,56 ± 11,02 37,00 ± 7,39

Gender (f/m) 13/12 2/2

Dominant arm 19 (76,0%) 2 (50,0%)

Type work

Manual work 11 (44,0%) 3 (75,0%)

Administrative work 10 (40,0%) 0 (0 %)

Housewife 1 (4,0%) 1 (25,0%)

Student 3 (12,0%) 0 (0 %)

OSIS

Mean 27,88 ± 11,83 49,50 ±3,70

Median 27 51

WOSI

Mean 786,32 ± 515,24 (62,6%) 1685,50 ± 206,52 (19,7%)

Median 773 (63,2%) 1688 (19,6%) Table 7: Group I – ability to return to the same work

Group II: patients able to



Group II: patients unable

to return to the same work



surgery 28,69 ± 9,97 29,6 ± 6,42

Gender (f/m) 21/27 2/8

Dominant arm 32 (66,7%) 6 (60,0%)

Type work

Manual work 15 (31,3%) 10 (100 %)

Administrative work 22 (45,8%) 0 (0 %)

Housewife 1 (2,1%) 0 (0 %)

Student 10 (20,8%) 0 (0 %)

OSIS

Mean 21,54 ± 9,06 40,20 ± 12,51

Median 20 42

WOSI

Mean 556,75 ± 390,40(73,5%) 1341,30 ±567,56 (36,1%)

Median 528 (74,9%) 1467 (30,1%) Table 8: Group II – ability to return to the same work

13

Almost a third of the patients in group I and a fifth of the patients in group II who practiced a

sport before surgery stopped with their sport after surgery (figure 5). All the other patients

returned to their primary sport. Two times as many patients in group II than in group I were

able to do so in less than 6 months. Approximately 40% of the patients in both groups were

capable to return to their same level of sport in less than 12 months. More than a quarter of

all patients in both groups returned to their same sport after more than 12 months but in

group II more patients were unable to do so at the same level. Some patients in group II

could not remember when they resumed the same level of their sport and the data was also

not reflected in their medical files. Overall, patients in group II seemed to be able to return

sooner to their same level of sport than patients in group I.

Figure 5: Return to the same level of sport

Similar as for the return to the same work tables 9 and 10 show the possible differences for

both groups between the patients who were able to return to their same sport after surgery

and those who were unable to do so. In both groups, the patients unable to return to their

same sport scored worse on both mean OSIS and WOSI. The same percentage of patients in

both groups who practiced an overhead sport were unable to resume their sport (namely 4

out of the 18 patients in group I and 8 of the 36 patients in group II or 22% in both groups).

12,5% (n: 3)

25,5%

(n: 14)

29,2%

(n: 7)

18,2%

(n: 10)

16,7%

(n: 4) 5,5% (n: 3)

12,5% (n: 3) 21,8%

(n: 12)

9,1% (n: 5)

29,2%

(n: 7)

20,0%

(n: 11)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

group I group II

Return to the same level of sport

never returned to the same sport

no data of time to return to the same level of

sport

> 12 months, but at a lower level of the same

sport

> 12 months

6-12 months

< 6 months

14

Group I: patients able to

return to the same sport


Group I: patients unable

to return to the same

sport after surgery (n=7)


surgery

36,71 ± 11,74 36,57 ± 11,75

Gender (f/m) 9/8 3/4

Dominant arm 12 (70,6%) 6 (85,7%)

Type work

Manual work 7 (41,2%) 5 (71,4%)

Administrative work 7 (41,2%) 1 (14,3%)

Housewife 1 (5,9%) 0

Student 2 (11,8%) 1 (14,3%)

Type sport

Overhead sport 14 (82,4%) 4 (57,1%)

Other sport 3 (17,6%) 3 (42,9%)

OSIS

Mean 25,94 ±12,59 36,43 ±13,82

Median 23 42

WOSI

Mean 767,76 ± 612,00 (63,4%) 1019,00 ±464,46 (51,5%)

Median 476 (77,3%) 1016 (51,6%) Table 9: Group I – ability to return to the same sport

Group II: patients able to

return to the same sport


Group II: patients unable

to return to the same

sport after surgery (n=11)


surgery

28,23 ± 8,90 29,18 ± 8,93

Gender (f/m) 20/24 2/9

Dominant arm 32 (72,7%) 4 (36,4%)

Type work

Manual work 18 (40,9%) 6 (54,5%)

Administrative work 18 (40,9%) 4 (36,4%)

Housewife 0 0

Student 8 (18,2%) 1 (9,1%)

Type sport

Overhead sport 28 (63,6%) 8 (72,7%)

Other sport 16 (36,4%) 3 (27,3%)

OSIS

Mean 24,55 ± 11,92 26,27 ± 12,72

Median 21 22

WOSI

Mean 666,82 ±519,68 (68,2%) 806,55 ±536,93 (61,6%)

Median 618 (70,6%) 697 (66,8%) Table 10: Group II – ability to return to the same sport

15

Discussion.

MSI patients have a slower postoperative rehabilitation course, a slower return to work and

sport, and a worse outcome than the CSI patients which confirms our hypothesis.

The mean age at time of surgery was significantly higher (p=0.001) in group I than in group II.

This data of our group I was conform with the 38,3 ± 6,8 years (range 18-59) in the study of

Garofalo et al.. In the study of Nordenson et al. the mean age at time of surgery was lower,

namely 22,5 ± 7,3 years (range: 16-36). One possible reason for this may be that their study

group consisted only of patients with MSI who presented themselves with a subacromial

impingement syndrome.

The female-male ratio and the dominance of the affected arm in our study group was similar

with the data in the studies of Nordenson et al. (female/male-ratio: 10/11; dominant arm:

70%) and Garofalo et al. (female/male-ratio: 12/11; dominant arm: 65,2%). Castagna et al.

noted in his study that MSI generally occurs in the dominant arm.

The 3 types of pain we studied (namely pain at rest, night pain and pain during overhead

activities) disappeared slower in group I than in group II. In both our groups we noticed a

trend that first of all the pain at rest disappears, then the night pain and finally the pain

during overhead activities.

Based on the mean OSIS and WOSI we see that patients in group I have a worse outcome

than patients in group II. However, we must hereby note that the scores are relatively low in

both groups. This can be explained by the fact that the scores of the patients who were not

able to return to their same work or same sport were much worse than the scores of the

patients who were able to do so. There was also a large range of follow-up at the moment

the scores were administrated.

Similar as we noticed for pain, we observed a trend of a slower return to normal subjective

ROM in the patients in group I than those in group II. This tendency was however much less

pronounced than the trend observed for pain. Due to the fact that we did not have enough

data of the specific tests we could not study the observation of Castagna et al. that MSI

patients have a permanent restriction in external rotation of a few degrees.

Notwithstanding the fact that the type of work was similar in both groups, the patients in

group I returned slower to their work. This result can be explained by the fact that they have

a longer postoperative rehabilitation. We cannot compare our results of the MSI patients in

group I with respect to work with other studies since the studies of Nordenson et al. and

Garofalo et al. did not describe results concerning work. Castagna et al. noted however that

AIOS occurs most frequently in overhead athletes or in heavy “overhead young workers”.

16

In group II we established a significant relationship between type of work before surgery and

the ability to return to the same profession after surgery (p=0,001). Type of work before

surgery can possibly be an explanation on why some patients are unable to return to their

same profession. Only manual workers have a risk not to be able to return to their same

professional activity as before surgery. We see that patients who are unable to return to the

same work score significantly worse on both the OSIS and WOSI.

More patients in group II were active in sports than in group I. The percentage of athletic

patients in our group I was higher than the percentage in the study of Nordenson et al.

(75%). These findings confirm that MSI can occur both in athletic and non-athletic persons as

stated by Castagna et al. The results of Nordenson et al. and this study suggest however that

there is a tendency that MSI occurs more in athletic than in non-athletic persons. In both our

groups around two third of the patients practiced an overhead sport. This percentage of

patients who practiced an overhead sport is quite comparable with the 70% of the patients

in the study of Nordenson et al. and our data confirms the statement of Castagna et al.

Just as the return to the same work, patients in group I returned slower to their same level

of sport than the patients in group II. This can, same as for the return to work, be explained

by the fact that they have a longer postoperative rehabilitation. These results are

comparable with other studies. Patients after a Bankart repair can return on average after 6

to 9 months after the repair surgery to their sport while this is rather 12 months for patients

with SLAP lesions.24, 25, 26

No explanation was found for the fact why some patients are unable to return to their same

sport since among the patients who were unable to return to their same sport some of them

practiced overhead sports and some of them other sports. They scored also lower on both

outcome measures.

Our study has several limitations because of its retrospective character and its relatively

small study group. The great range of the follow-up is also a limitation. A strength of our

study is that both groups were operated by only 2 experienced shoulder surgeons. Our study

group is also larger than the study population in the studies of Garofalo et al. (23 patients)

and Nordenson et al. (20 patients) which are to date practically the only studies that

conducted research for MSI. Another important strength is that we compare both types of SI

in 1 study which was not yet established until now.

A suggestion for further research can be to investigate more shoulder related variables (like

time between the onset of symptoms and the diagnosis/surgery, the characteristics of the

clinical symptoms, etc.) in order to find possible determining factors that influence the

ability to return to the same work and sport.

17

Conclusion.

MSI is a relatively new concept and there exist not many studies that already investigated

the specific pattern of MSI. By means of this study, we tried to reveal the differences

between MSI and CSI and this for the postoperative rehabilitation, return to work and sport,

and the outcome. We can conclude that patients with MSI have a slower postoperative

rehabilitation course and they also return slower to work and sport than the CSI patients.

Furthermore the MSI patients have a worse outcome compared to the CSI patients.

18

References.

1. Castagna A., Nordenson U., Garofalo R. en Karlsson J. Minor shoulder instability. The

journal of arthroscopic and related surgery 2007; 23; 211-215.

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20

Appendix

Background information on shoulder anatomy.

Shoulder instability (SI) is a very frequent pathology of the shoulder. The glenohumeral joint

is the most often dislocated joint in the body due to the combination of a large range of

motion (ROM) and an insufficient bony stabilization. As result of this discrepancy the

shoulder needs an important stabilization mechanism. 7

The glenohumeral joint is a ball and socket joint and is well suited for the extreme mobility

due to the mismatch between the big head of the humerus (20-24 cm²) and the small

glenoid fossa (6-7cm²). The cavital glenoidalis only makes contact with a third or fourth of

the caput humeralis.6, 7, 8

This contact area is increased by the labrum glenoidalis (cfr. infra).

Despite this lack of articulating covering, the normal shoulder precisely constrains the head

of the humerus to within 1 to 2 mm of the center of the glenoid cavity throughout most of

the arc of motion. This specific limitation of the center of rotation through the large arc of

motion is the result of an interaction between different stabilizers.5

The stability of the shoulder is provided by a complex and delicate interaction between

various stabilization mechanisms that can be classified in both static as well as dynamic

stabilizers.8 The labrum, the joint capsule and the ligaments are considered to be the static

stabilizers while the rotatorcuff, the deltoid muscle, the biceps muscle and the scapular

muscles are considered to be the dynamic stabilizers.5

The labrum consists of a fibrous peripheral layer and a fibro-cartilaginous transit zone.4, 5

The

blood supply is minimal in the superior and anterosuperior part of the labrum which may

lead to a limited regeneration potential in these regions.8

The labrum is one of the most important stabilizers and is very well studied in the literature.

It has 3 functions.4 Firstly, the labrum increases the stability and this by two mechanisms.

The first mechanism is that the labrum expands the articular surfaces (increase of a third) as

the result of its localization to the glenoid rim, what leads to a larger contact surface. The

second mechanism is that the labrum deepens the concavity of the glenoid cavity in the

superoinferior and anteroposterior faces with an average of respectively 9mm and 5mm.8 A

disruption of the labrum will lead to a reduction of no less than 20% of the resistance to

translation.5 Secondly, the labrum has a neutralizing effect on the stress distribution.

4, 8 A

disruption of the labrum will also lead to overstressed areas.4 Thirdly, the labrum acts as an

anchor point for the capsuloligamentous structures and the long head of the biceps muscle.4,

5, 8 Bankart was of the opinion that the detachment of the anteroinferior glenoid rim was the

essential injury responsible for the high incidence of the recurrent anterior dislocations.5

21

The anterosuperior part of the labrum has various anatomical variations like the superior

sublabral recess, the sublabral foramen and the Buford complex.4, 5, 8

The superior sublabral

recess is a recess that is located at the 12 o’clock position below the anchor of the long head

of the biceps muscle and the anterosuperior rim of the labrum.4 The sublabral foramen is a

groove which is located at the 2 o’clock position between the normal anterosuperior labrum

and the anterior cartilaginous edge of the glenoid.4 In the literature a prevalence of 11,9 to

18,3% has been described for this variant.11, 20

The Buford complex is a third variety that is

characterized by a thick, cordlike middle glenohumeral ligament (MGHL) that attaches at the

superior part of the labrum to the base of the tendon of the biceps, in combination with the

absence of the anterosuperior labrum.4 This variant has a prevalence of 1,5 to 7,5%.

11, 20 It is

sometimes a challenge for the surgeon to distinguish between anatomical variations and

pathological conditions.8 Although it is not clear in the literature, it is likely that there is a

causal relationship between the anatomical variations and superior labral lesions.4

The joint capsule consists of a complex of circular and radially arranged collagen fibers and is

reinforced by multiple reinforcements like the coracohumeral ligament, the superior

glenohumeral ligament (SGHL), the MGHL, the inferior glenohumeral ligament (IGHL) and

the insertion of the rotatorcuff.8 The joint capsule and the different glenohumeral ligaments

are anatomically closely adherent in spite of the fact that they are usually described

separately in the literature. The surface of the joint capsule is about 2 times the surface of

the head of the humerus and allows thereby a large ROM.5

The four most important ligaments for SI are the coracohumeral ligament, the SGHL, the

MGHL and the IGHL.8

The coracohumeral ligament and the SGHL run parallel and have the same function.

Together they form the rotator interval (RI).5, 8, 17, 22

The RI is the space between the anterior

rim of the supraspinatus muscle and the superior rim of the subscapularis muscle. The

tension of the RI is influenced by the coracohumeral ligament, the SGHL and the joint

capsule in between.9 A wide RI can play an important role in inferior, anterior and posterior

instability.8 In addition the coracohumeral ligament and the SGHL are also the major

components of the biceps reflection sling (the pulley system).10, 17

The MGHL is the most variable ligament of the 3 glenohumeral ligaments and is absent in 8

to 30% of the patients.5, 8, 11

The MGHL may occur like a cordlike ligament and this

anatomical variant can be seen as a protective factor against SI.12, 13

The MGHL can also

appear as a thin cover or can even be absent. These 2 conditions are more common in

patients with anteroinferior SI so they can be considered as a predisposing factor.8, 12, 13

The IGHL is the thickest and most consistent ligament of the 3 glenohumeral ligaments and is

often described as a complex of an anterior band, an axillary pouch and a posterior band.5, 8

The rotatorcuff is a group of muscles consisting of the supraspinatus muscle, the

infraspinatus muscle, the teres minor muscle and the subscapularis muscle and acts as a

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dynamic control mechanism of the head of the humerus.5 The rotatorcuff is very important

for the shoulder stability and tears of the rotatorcuff and glenohumeral instability are

related to each other.15

Rotatorcuff activation results in humeral head rotation and

depression in positions of abduction.5

The long head of the biceps muscle runs intra-articular and consists of two different types of

fibers.5 The biomechanically important fibers insert on the supraglenoid tubercle while the

remaining fibers insert variable on the labrum and have essentially a forming function.16

Pathological lesions of the long head of the biceps muscle can lead to Superior Labral

Anterior Posterior (SLAP)-lesions.8

The deltoid muscle has also a stabilizing effect on the glenohumeral joint due to its

contraction which results in a relative compression on the articular surfaces. This stabilizing

effect increases when the shoulder becomes instable.

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