Skip to main content

Shoulder Instability: Diagnosis and Classification

  • Chapter
  • First Online:
Shoulder Arthroscopy

Abstract

Shoulder instability is a common source of pain and physical dysfunction, especially in the athletic population. The growth in knowledge about this disease has remarked its complexity, as multiple factors affect prognosis after treatment, leading to an intense debate about the features that should guide therapeutic indications. The first step in the decision-making process should be an accurate diagnosis of the instability that ideally provides information about direction, severity, etiology, and other issues. Provocative tests have capital importance to confirm the diagnosis. Classification of the instability is the second step, although none of the systems described have global acceptance. A new classification model is described, which mainly focuses on orientating therapeutic decisions.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Krøner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg. 1989;108(5):288–90.

    Article  PubMed  Google Scholar 

  2. Cuéllar R, Ruiz-Ibán MA, Cuéllar A. Anatomy and biomechanics of the unstable shoulder. Open Orthop J. 2017;11:919–33.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Kuhn JE. A new classification system for shoulder instability. Br J Sports Med. 2010;44(5):341–6.

    Article  PubMed  Google Scholar 

  4. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470–7.

    Article  CAS  PubMed  Google Scholar 

  5. Owens BD, Agel J, Mountcastle SB, Cameron KL, Nelson BJ. Incidence of glenohumeral instability in collegiate athletics. Am J Sports Med. 2009;37:1750–4.

    Article  PubMed  Google Scholar 

  6. Owens BD, Duffey ML, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB. The incidence and characteristics of shoulder instability at the United States military academy. Am J Sports Med. 2007;35:1168–73.

    Article  PubMed  Google Scholar 

  7. Leroux T, Wasserstein D, Veillette C, et al. Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med. 2014;42:442–50.

    Article  PubMed  Google Scholar 

  8. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;11:2326–36.

    Article  Google Scholar 

  9. Olds M, Ellis R, Donaldson K, Parmar P, Kersten P. Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med. 2015;49(14):913–22.

    Article  CAS  PubMed  Google Scholar 

  10. Lebus GF 5th, Raynor MB, Nwosu SK, Wagstrom E, Jani SS, Carey JL, Hettrich CM, Cox CL, Kuhn JE; MOON Shoulder Group. Predictors for surgery in shoulder instability: a retrospective cohort study using the FEDS system. Orthop J Sports Med. 2015;3(10):2325967115607434.

    Google Scholar 

  11. Wasserstein D, Dwyer T, Veillette C, Gandhi R, Chahal J, Mahomed N, Ogilvie-Harris D. Predictors of dislocation and revision after shoulder stabilization in Ontario, Canada, from 2003 to 2008. Am J Sports Med. 2013;41(9):2034–40.

    Article  PubMed  Google Scholar 

  12. Bateman DK, Black EM, Lazarus MD, Abboud JA. Outcomes following arthroscopic repair of posterior labral tears in patients older than 35 years. Orthopedics. 2017;40(2):e305–11.

    Article  PubMed  Google Scholar 

  13. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-Sachs lesion. Arthroscopy. 2000;16(7):677–94.

    Article  CAS  PubMed  Google Scholar 

  14. Dickens JF, Slaven SE, Cameron KL, Pickett AM, Posner M, Campbell SE, Owens BD. Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events. Am J Sports Med. 2019;47(5):1082–9.

    Article  PubMed  Google Scholar 

  15. Rowe CR, Pierce DS, Clark JG. Voluntary dislocations of the shoulder. J Bone Joint Surg. 1973;55A:445–60.

    Article  Google Scholar 

  16. Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. World J Orthop. 2016;7:776–84.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Su F, Kowalczuk M, Ikpe S, Lee H, Sabzevari S, Lin A. Risk factors for failure of arthroscopic revision anterior shoulder stabilization. J Bone Joint Surg Am. 2018;100(15):1319–25.

    Article  PubMed  Google Scholar 

  18. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755–63.

    Article  PubMed  Google Scholar 

  19. Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res. 2002;400:65–76.

    Article  Google Scholar 

  20. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Juul-Kristensen B, Rogind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology (Oxford). 2007;46:1835–41.

    Article  CAS  PubMed  Google Scholar 

  22. McFarland EG, Kim TK, Park HB, Neira CA, Gutierrez MI: The effect of variation in definition on the diagnosis of multidirectional instability of the shoulder. J Bone Joint Surg Am 2003;85-A:2138–2144.

    Google Scholar 

  23. Hippensteel KJ, Brophy R, Smith MV, Wright RW. Comprehensive review of provocative and instability physical examination tests of the shoulder. J Am Acad Orthop Surg. 2019;27(11):395–404.

    Article  CAS  PubMed  Google Scholar 

  24. Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008;24(9):974–82.

    Article  PubMed  Google Scholar 

  25. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88:1467–74.

    Article  PubMed  Google Scholar 

  26. Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy. 2004;20(7):712–20.

    Article  PubMed  Google Scholar 

  27. Kim SH, Park JS, Jeong WK, Shin SK. The Kim test: a novel test for posteroinferior labral lesion of the shoulder--a comparison to the jerk test. Am J Sports Med 2005;33(8):1188–1192.

    Google Scholar 

  28. Gagey OJ, Gagey N. The hyperabduction test. J Bone Joint Surg Br. 2001;83:69–74.

    Article  CAS  PubMed  Google Scholar 

  29. Schär MO, Dellenbach S, Pfirrmann CW, Raniga S, Jost B, Zumstein MA. Many shoulder MRI findings in elite professional throwing athletes resolve after retirement: a clinical and radiographic study. Clin Orthop Relat Res. 2018;476(3):620–31.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Jost B, Zumstein M, Pfirrmann CW, Zanetti M, Gerber C. MRI findings in throwing shoulders: abnormalities in professional handball players. Clin Orthop Relat Res. 2005;434:130–7.

    Article  Google Scholar 

  31. Bernageau J, Patte D, Debeyre J, Ferrane J. Value of the glenoid profile in recurrent luxations of the shoulder. Rev Chir Orthop Reparatrice Appar Mot. 1976;62(2 suppl):142–7.

    CAS  PubMed  Google Scholar 

  32. Bigliani LU, Newton PM, Steinmann SP, Connor PM, Mcllveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26(1):41–5.

    Article  CAS  PubMed  Google Scholar 

  33. Murachovsky J, Bueno RS, Nascimento LG, Almeida LH, Strose E, Castiglia MT, de Oliveira HC, Ikemoto RY. Calculating anterior glenoid bone loss using the Bernageau profile view. Skelet Radiol. 2012;41(10):1231–7.

    Article  Google Scholar 

  34. Jankauskas L, Rüdiger HA, Pfirrmann CW, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder Elb Surg. 2010;19(1):151–6.

    Article  Google Scholar 

  35. Vopat BG, Cai W, Torriani M, Vopat ML, Hemma M, Harris GJ, Schantz K, Provencher MT. Measurement of glenoid bone loss with 3-dimensional magnetic resonance imaging: a matched computed tomography analysis. Arthroscopy. 2018;34(12):3141–7.

    Article  PubMed  Google Scholar 

  36. Walter WR, Samim M, LaPolla FWZ, Gyftopoulos S. Imaging quantification of glenoid bone loss in patients with glenohumeral instability: a systematic review. AJR Am J Roentgenol. 2019;5:1–10.

    Google Scholar 

  37. Kuhn JE, Helmer TT, Dunn WR, Throckmorton VTW. Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elb Surg. 2011;20(4):548–56.

    Article  Google Scholar 

  38. Thomas SC, Matsen FA 3rd. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am. 1989;71(4):506–13.

    Article  CAS  PubMed  Google Scholar 

  39. Lewis A, Kitamura T, Bayler JIL. The classification of shoulder instability: new light through old windows! Curr Orthop. 2004;18:97–108.

    Article  Google Scholar 

  40. Hettrich CM, Cronin KJ, Raynor MB, Wagstrom E, Jani SS, Carey JL, Cox CL, Wolf BR, Kuhn JE. Epidemiology of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elb Surg. 2019;28(1):95–101.

    Article  Google Scholar 

  41. Calvo-Díaz A, Arce G, Calvo-Crespo E, Soler-Romagosa F, Golanó-Álvarez P, Martínez-Martín A, Herrera-Rodríguez A. La clasificación MIQ: Buscando el consenso para clasificar el hombro inestable. Cuadernos de Artroscopia. 2009;16(fasc. 1):38.

    Google Scholar 

  42. Calvo A, Zurita N, Rodríguez A, Carnero P. In: Milano G, Grasso A, Calvo A, Brzóska R, editors. Failure posterior instability repair: case example. Berlin: Springer; 2018. p. 41–4.

    Google Scholar 

  43. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elb Surg. 2007;16(5):649–56.

    Article  Google Scholar 

  44. Shaha JS, Cook JB, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. Clinical validation of the glenoid track concept in anterior glenohumeral instability. J Bone Joint Surg Am. 2016;98(22):1918–23.

    Article  PubMed  Google Scholar 

  45. Provencher MT, Peebles LA. Editorial commentary: rotator interval closure of the shoulder continues to be a challenge in consensus on treatment. Arthroscopy. 2018;34(11):3109–11.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to thank Dr. Carlos Vaquero-Comino, for his contribution to the radiological images.

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Calvo Díaz, Á., de Soto, P.C.M., Uroz, N.Z. (2023). Shoulder Instability: Diagnosis and Classification. In: Milano, G., Grasso, A., Brzóska, R., Kovačič, L. (eds) Shoulder Arthroscopy. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-66868-9_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-66868-9_14

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-66867-2

  • Online ISBN: 978-3-662-66868-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics