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Recurrent Posterior
Shoulder Instability
Abstract
Recurrent posterior shoulder instability is an uncommon
condition. It is often unrecognized, leading to incorrect diagnoses,
delays in diagnosis, and even missed diagnoses. Posterior
instability encompasses a wide spectrum of pathology, ranging
from unidirectional posterior subluxation to multidirectional
instability to locked posterior dislocations. Nonsurgical treatment
of posterior shoulder instability is successful in most cases;
however, surgical intervention is indicated when conservative
treatment fails. For optimal results, the surgeon must accurately
define the pattern of instability and address all soft-tissue and bony
injuries present at the time of surgery. Arthroscopic treatment of
posterior shoulder instability has increased application, and a
variety of techniques has been described to manage posterior
glenohumeral instability related to posterior capsulolabral injury.
Recurrent posterior shoulder in-
stability is an uncommon condi-
tion that is often unrecognized, lead-
ing to incorrect diagnoses, delays in
diagnosis, and even missed diag-
noses.1
Posterior instability encom-
passes a wide spectrum of pathoanat-
omy that may affect the labrum,
capsule, rotator interval, and bony ar-
chitecture of the shoulder. Recurrent
posterior subluxation is the most
common type of posterior instability.
Background and
Epidemiology
Glenohumeral instability is com-
mon, affecting approximately 2% of
the general population.2
However,
posterior instability occurs in only
2% to 5% of those with shoulder in-
stability.3 Trauma is thought to be
the underlying cause in approxi-
mately half of patients with posteri-
or instability.3
Although posterior
dislocation represents only 4% of all
joint dislocations,4
it is often easily
missed on clinical examination. Spe-
cific imaging assessment is impor-
tant. Recurrent posterior sublux-
ation, which may present with
instability symptoms or simply as
pain, is more common, particularly
in those who participate in high-risk
athletic activities.
Relevant Anatomy and
Biomechanics
The shoulder is the most mobile, but
also the least stable, joint in the
body because less than one third of
the humeral head articulates with
the glenoid. Stability is conferred by
a series of static and dynamic soft-
tissue restraints that maintain the
articulation of the humeral head
with the glenoid while simulta-
neously providing for a large range of
motion.5
Peter J. Millett, MD, MSc
Philippe Clavert, MD
G. F. Rick Hatch III, MD
Jon J. P. Warner, MD
Dr. Millett is Co-Director, Harvard
Shoulder Service/Sports Medicine,
Brigham & Women’s Hospital,
Massachusetts General Hospital,
Boston, MA, and Assistant Professor,
Department of Orthopaedic Surgery,
Harvard Medical School. Dr. Clavert is
Associate Professor, Department of
Orthopaedics, CHRU Hautepierre,
Strasbourg, France. Dr. Hatch is
Assistant Professor, Sports Medicine/
Shoulder & Elbow Services, Department
of Orthopaedic Surgery, USC Keck
School of Medicine, Los Angeles, CA.
Dr. Warner is Professor, Department of
Orthopaedics, Harvard Medical School,
Boston, MA, and Chief, Harvard
Shoulder Service, Department of
Orthopedics, Massachusetts General
Hospital.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Millett, Dr. Clavert, Dr. Hatch, and
Dr. Warner.
Reprint requests: Dr. Millett, Steadman
Hawkins Clinic, 181 West Meadow
Drive, Vail, CO 81657.
J Am Acad Orthop Surg 2006;14:464-
476
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
464 Journal of the American Academy of Orthopaedic Surgeons
Static Restraints
Articular factors such as joint
congruency, glenoid version, and hu-
meral retrotorsion contribute to
static joint stability. Bony abnormal-
ities such as glenoid retroversion or
posterior glenoid erosion can be pre-
disposing causative factors for poste-
rior shoulder instability.1
The glenoid labrum, a wedge-
shaped fibrous structure consisting
of densely packed collagen bundles,
increases the depth and surface area
of the glenoid. It serves as an anchor
point for the capsuloligamentous
structures, deepens the glenoid con-
cavity, and reduces glenohumeral
translation with arm motion.6 La-
bral excision decreases the depth of
the socket by 50% and reduces resis-
tance to instability by 20%.6
The glenohumeral ligaments are
thickened fibrous bands within the
joint capsule; these ligaments act at
the end ranges of motion and pro-
vide static stability. Their function
is dependent on the position of the
arm and the direction of the force ap-
plied.7 For example, when the arm is
adducted, the superior glenohu-
meral ligament (SGHL) and coraco-
humeral ligament (CHL) limit infe-
rior translation and external
rotation of the humeral head. Addi-
tionally, the SGHL and the CHL re-
sist posterior translation of the hu-
meral head when the shoulder is in
flexion, adduction, and internal ro-
tation. The inferior glenohumeral
ligament (IGHL) complex is com-
posed of discrete anterior and poste-
rior bands with an interposed axil-
lary pouch that acts like a
hammock, undergoing reciprocal
tightening and loosening depending
on arm position. The posterior band
of the IGHL complex is the main re-
straint to posterior translation of the
humeral head when the arm is ab-
ducted.
The posterior capsule is defined
as the area superior to the posterior
band of the IGHL complex. The
posterior capsule is the thinnest
(≤1 mm) and perhaps weakest por-
tion of the shoulder capsule. It may
limit posterior translation when the
arm is flexed, adducted, and inter-
nally rotated.
The rotator interval plays a role
in static stability and is defined by
the borders of the supraspinatus su-
periorly, the subscapularis inferi-
orly, the coracoid process medially,
and the biceps and humerus later-
ally. The SGHL, medial glenohu-
meral ligament, and CHL provide
variable reinforcement to the rota-
tor interval. The rotator interval and
its constituents provide stability
against inferior and posterior trans-
lations, particularly when the arm is
adducted and externally rotated.8
Evidence suggests that deficiencies
in the rotator interval can contrib-
ute to instability in patients with
excessive inferior or posterior trans-
lation.9
In some individuals, the ro-
tator interval may be composed of
loosely arranged collagen, whereas
in others, it may be completely
devoid of tissue. This represents a
rotator interval “capsular defect”
that may need to be addressed in
the symptomatic shoulder, but it
may also be considered a normal
anatomic variant in the stable
shoulder.
Dynamic Restraints
Dynamic stability is provided by
the rotator cuff, the deltoid, and the
biceps tendon through a concavity-
compression effect on the humeral
head within the glenoid socket.10 Of
the four muscles of the rotator cuff,
the subscapularis provides the great-
est resistance to posterior transla-
tion.10,11
In addition, dynamic stabil-
ity of the shoulder also is provided
by the trapezius, serratus anterior,
teres major, and latissimus dorsi
muscles. Scapulothoracic motion
must be properly coordinated with
glenohumeral motion so that the
glenoid can be appropriately posi-
tioned to provide a stable platform
beneath the humeral head.
Definitions: Laxity and
Instability
The term instability is reserved for
symptomatic shoulders—specifical-
ly, the sensation of the humeral head
translating in the glenoid, which is
frequently associated with pain and
discomfort.12 Instability is defined as
pathologic joint translation that
causes symptoms, or as the inability
to keep the humeral head centered
within the glenoid cavity during ac-
tive motion. Laxity is defined as a
specific translation for a particular
direction or rotation.13 Individuals
may have significant laxity and yet
remain asymptomatic. Conversely,
others with only minimal degrees of
laxity may have significant symp-
toms of instability. The distinction
is important. Frequently, patients
with excessive shoulder laxity sus-
tain a traumatic injury and subse-
quently develop symptoms of insta-
bility. Individuals with recurrent
posterior subluxation generally have
symptomatic pain yet may or may
not have symptoms of instability.
Classification of
Posterior Instability
Posterior shoulder instability can be
classified by direction, degree, cause,
and volition. Unidirectional posteri-
or subluxation is the most frequent
form of posterior instability. Posteri-
or instability also can occur as bidi-
rectional or multidirectional insta-
bility.14
The degree of posterior instabili-
ty can range from mild subluxation
to frank dislocation. Recurrent pos-
terior subluxation is the most com-
mon form.
Posterior instability may be trau-
matic (acquired) or atraumatic. The
traumatic type is the more common
form.1 This can occur as a single
traumatic event with the shoulder in
an “at risk” position (ie, flexion, ad-
duction, and internal rotation) or as
a culmination of multiple, smaller
traumatic episodes. For example, an
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 465
electrical shock producing posterior
dislocation is a classic example of a
single traumatic event. An offensive
lineman with the arms in the block-
ing position would typify a predispo-
sition to recurrent posterior sublux-
ation because of the repetitive
loading. Posterior instability occur-
ring secondary to overhead sports
presents more insidiously because of
the gradual capsular failure from re-
petitive microtrauma. Common pro-
vocative activities include the back-
hand stroke in racket sports, the
pull-through phase of swimming,
and the follow-through phases in a
throwing activity or golf.
Posterior instability in the set-
ting of an atraumatic history should
alert the clinician to the possibility
of an underlying collagen disease or
bony abnormality (eg, glenoid hypo-
plasia, excessive glenoid retrover-
sion). In such situations, surgical in-
tervention should be approached
cautiously.
Finally, posterior instability may
be defined by its volitional compo-
nent. Involuntary posterior instabil-
ity typically results from a traumat-
ic event (acute or repetitive) and
most commonly manifests as mild
subluxation. The symptoms do not
occur willfully and usually are not
controllable. Voluntary posterior in-
stability occurs when a patient can
willfully dislocate or subluxate the
shoulder. Two different patterns
have been described—voluntary
muscular and voluntary positional
posterior instability. In voluntary
muscular (or habitual) posterior in-
stability, an underlying muscular
imbalance typically exists that
allows voluntary subluxation/
dislocation of the shoulder with the
arm in adduction. Patients with ha-
bitual voluntary posterior instabili-
ty are generally considered poor sur-
gical candidates. However, patients
with the second voluntary form, po-
sitional voluntary posterior instabil-
ity, can respond well to surgery pro-
vided they do not have underlying
psychiatric or secondary gain is-
sues.15 Typically, these individuals
have instability when the arm is
flexed and adducted. Although these
individuals may be able to voluntar-
ily reproduce their instability, they
usually avoid the provocative ma-
neuvers.15
Evaluation
History
Although posterior shoulder in-
stability is uncommon, an aware-
ness of the disorder, together with a
thoughtful evaluation beginning
with the clinical history, usually
leads to the proper diagnosis. The
first step is to inquire about a histo-
ry of trauma. In the case of a single
traumatic episode, the direction of
the applied force and the position of
the arm at the time of injury may
provide insight into the diagnosis.
Classically, posterior subluxation
occurs with a traumatic event when
the arm is in an at-risk position (eg,
forward flexion, adduction, internal
rotation).16
A fall or blow to the arm
while in an at-risk position can re-
sult in a posterior labral detachment
(reverse Bankart lesion).16
Repetitive
stresses on the posterior capsule, ei-
ther from sports or other activities,
may lead to acquired posterior sub-
luxation.
Patients with recurrent posterior
subluxation most commonly report
pain and feelings of weakness. Insta-
bility symptoms may or may not be
present. With careful questioning,
the direction, frequency, and severi-
ty of the patient’s symptoms can be
ascertained. Overhead athletes often
describe insidious pain that may oc-
cur in the later phases of their sport-
ing activities, when muscle fatigue
and dynamic stability are compro-
mised. Mechanical symptoms, such
as giving way, slipping, popping,
catching, or clicking, are less com-
mon than in anterior instability. Vo-
litional components should be as-
sessed.
Physical Examination
The physical findings of patients
with posterior instability often are
more subtle than those of patients
with anterior instability. Active and
passive ranges of motion usually are
normal and symmetric. The posteri-
or joint line may be tender to palpa-
tion. Crepitus is sometimes noted as
the arm is internally rotated.
Strength testing is usually symmet-
ric, except in rare cases of posterior
rotator cuff muscle deficiency or
nerve injury with external rotation
weakness. In these cases, atrophy of
the posterior rotator cuff muscles
may be apparent on inspection.
Patients should be assessed for
generalized ligamentous laxity by
evaluating the contralateral shoul-
der, elbows, and knees, and by test-
ing the patient’s ability to oppose the
thumb to the forearm. In addition,
sulcus testing should be performed.
The sulcus can be quantified by the
distance from the greater tuberosity
to the acromion. A sulcus sign
>2 cm is virtually pathognomonic
for multidirectional instability, but
pain and symptoms of inferior insta-
bility must also be present for this
diagnosis. If the sulcus does not re-
duce as the arm is externally rotated,
it should be considered pathologic,
with a defect in the rotator interval
that should be addressed at the time
of surgery.
Scapulohumeral rhythm and
scapulothoracic mechanics should
be assessed to exclude the possibili-
ty of scapular winging, which is fre-
quently confused with posterior in-
stability.17 In some instances, a
compensatory scapular winging may
occur. As the scapula wings, it effec-
tively anteverts the glenoid and dy-
namically increases the bony stabil-
ity.17 In such instances, a thorough
neurologic examination should be
performed with appropriate neuro-
logic testing, as indicated.
Specific Posterior
Instability Tests
The posterior stress test (Figure 1)
Recurrent Posterior Shoulder Instability
466 Journal of the American Academy of Orthopaedic Surgeons
is performed with the individual in
the supine position; the arm is flexed
to 90° and internally rotated. The ex-
aminer axially loads the humerus
against the posterior glenoid by
pushing the arm posteriorly with
one hand while the other hand is ap-
plied to the back of the shoulder.
The posterior stress test is positive
when a subluxation of the humeral
head over the glenoid rim is palpat-
ed or observed.
The jerk test (Figure 2) is per-
formed with the patient sitting up-
right; the arm is flexed 90° and in-
ternally rotated, and the elbow is
flexed to 90°. A posterior force is
generated by applying an axial load
to the humerus by pushing on the
flexed elbow. In patients with signif-
icant laxity, this will cause a poste-
rior dislocation or subluxation of
the glenohumeral joint. The arm is
then extended and, as this occurs,
the glenohumeral joint will reduce
with a jerk. If a painful relocation oc-
curs, the jerk test is positive. Usu-
ally the reduction is observed as
there is a sudden change in velocity
as the humeral head reenters the
glenoid fossa.
The load and shift test (Figure 3,
A) is performed with the patient
seated upright, arm at the side. The
humeral head and proximal hu-
merus are grasped and compressed
into the glenoid socket, and anterior
and posterior stress is applied with
grading of the degree of translation.
This test is used to determine the
amount of glenohumeral transla-
tion, but it is difficult to accurately
quantitate results. A 50% displace-
ment of the humeral head is consid-
ered the upper limit of normal. It is
not unusual to find symmetric pos-
terior translation between the af-
fected and unaffected shoulders.5,14
The modified load and shift test
(Figure 3, B) is performed with the
patient supine and the affected
Figure 1
Posterior stress test. A posterior force is applied through the humerus. The test is
positive if there is palpable crepitus or subluxation. Often pain is elicited, but this is
not as specific a finding.
Figure 2
Jerk test. A, A posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. This
will cause the humeral head to subluxate posteriorly out of the glenoid socket. B, As the arm is brought into extension, a clunk
will be felt as the humerus reduces into the glenoid cavity.
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 467
shoulder at the edge of the examin-
ing table. The shoulder is positioned
in the scapular plane and in neutral
rotation. Manual force is placed at
the ipsilateral elbow to concentrical-
ly reduce the humeral head. Anteri-
or and posterior forces are then
applied to the proximal humerus in
varying degrees of rotation and ele-
vation with grading of the amount of
translation.14
The load and shift and
modified load and shift tests are typ-
ically graded as follows: grade 0,
minimal translation; grade 1, hu-
meral head translates to the glenoid
rim; grade 2, humeral head trans-
lates over the glenoid rim but spon-
taneously reduces; and grade 3, hu-
meral head dislocates and does not
spontaneously reduce.
Imaging
Radiographs
Plain radiographs of the shoulder
should include true anteroposterior
views in neutral, internal, and exter-
nal rotation; a transscapular view or
Y view; and an axillary view. These
views are needed to ensure that the
joint is located, to evaluate the pos-
terior glenoid rim, and to look for
impaction fractures of the humeral
head. In addition to humeral head
position, these studies demonstrate
glenoid rim morphology (hypoplasia,
excessive retroversion, and/or frac-
ture of the posterior glenoid rim).
However, most individuals with re-
current posterior instability do not
have bony abnormalities. For those
with a volitional component, dy-
namic radiographs can confirm the
diagnosis (Figure 4).
Multiplanar Imaging
Computed tomography (CT) or
magnetic resonance imaging (MRI)
is essential to assess the version and
morphology of the glenoid. These
tests also help detect subtle anterior
Figure 3
A, Load and shift test. The patient is seated upright. A compressive force is applied through the humeral head to center the
humeral head within the glenoid cavity. Posterior or anterior forces can then be applied to assess the amount of joint translation.
This can be compared with the contralateral shoulder. B, Modified load and shift. The patient is supine. A compressive force is
applied along the long axis of the humerus to center the humeral head in the glenoid cavity. A posterior force can then be applied
to assess the degree of translation of the humeral head.
Figure 4
Axillary radiographs of an individual with voluntary posterior instability showing the
humeral head dislocated (A) and reduced (B).
Recurrent Posterior Shoulder Instability
468 Journal of the American Academy of Orthopaedic Surgeons
humeral head defects and glenoid
fractures. Contrast can enhance the
ability to evaluate the posterior la-
brum and capsule, particularly with
injuries such as capsulolabral disrup-
tions or lateral capsular injuries.18
Contrast also enhances assessment
of the superior labrum. For surgical
candidates, it is critically important
to identify the pathoanatomy so that
the appropriate surgical approach
can be chosen. For example, an indi-
vidual with significant retroversion
of the glenoid will have an unaccept-
ably high failure rate if a soft-tissue
capsulorrhaphy is performed and the
bony abnormality is not addressed.
Preoperative diagnosis helps in sur-
gical planning, particularly as ar-
throscopic treatment becomes more
popular. Depending on the surgeon’s
skill level, some injuries (eg, glenoid
erosion, posterior humeral avulsion
of the glenohumeral ligaments, cap-
sular rupture) are more appropriate-
ly addressed through an open surgi-
cal approach.
Although the gadolinium-
enhanced magnetic resonance ar-
throgram provides excellent soft-
tissue detail, we think that a CT
scan with intra-articular contrast
provides the best information with
regard to bony anatomy and articular
orientation. CT is superior in its
ability to determine the glenoid
morphology as well as the degree of
glenoid retroversion. Glenoid retro-
version is best measured on axial CT
scan images through the mid-
glenoid; this corresponds with the
first inferior image, on which the tip
of the coracoid process is no longer
visible.19
At this level, glenoid retro-
version between −2° and −8° is con-
sidered normal.19
Initial Treatment
Nonsurgical treatment is successful
for the great majority of patients
with recurrent posterior sublux-
ation. The aim of physical therapy is
to strengthen the dynamic muscular
stabilizers to compensate for the
damaged or deficient static stabiliz-
ers.20 The focus should be on exercis-
es that strengthen the posterior del-
toid, the external rotators, and the
periscapular muscles. These exercis-
es are typically used in conjunction
with activity modification and bio-
feedback. Nonsurgical treatment of
posterior instability is successful in
approximately 65% to 80% of cas-
es.20,21
Surgical Treatment
Open procedures have been the
mainstay of treatment when nonsur-
gical treatment fails and have led to
good results when implemented ap-
propriately1,15,22 During the past de-
cade, the arthroscopic treatment of
posterior shoulder instability has at-
tracted increasing interest as a
means to restore stability without
the morbidity of open surgery. A va-
riety of arthroscopic techniques
have been described to manage pos-
terior glenohumeral instability in re-
lation to posterior capsulolabral in-
jury and redundancy.23-26 The
perceived advantages of the arthro-
scopic approach include less morbid-
ity, shorter surgery time, improved
cosmesis, and less postoperative
pain.27,28
Prerequisites
Because of the multifactorial na-
ture of posterior instability, as well
as the lack of a single consistent “es-
sential pathologic lesion,” the sur-
geon must consider all potential
contributing factors and correct the
relevant pathoanatomy encountered
in that individual case (Table 1). The
best surgical candidates are those
with recurrent, posttraumatic, uni-
directional subluxation. These pa-
tients are also the ideal candidates
for arthroscopic stabilization, either
by suture anchors or simple posteri-
or capsular plication with sutures
(Figure 5). The procedures used to
address posterior instability may be
subdivided into soft-tissue and bony
procedures.
Before any surgical procedure, an
examination under anesthesia is per-
formed. The amount of humeral
head translation on the glenoid sur-
face is graded as follows: 0, stable or
trace laxity; 1, up to 50% transla-
tion; 2, dislocatable with spontane-
ous reduction; and 3, dislocates and
does not spontaneously reduce. Sul-
Table 1
Surgical Decision Making for Posterior Instability According
to Pathoanatomy
Pathologic Lesion Procedure of Choice
Posterior Bankart lesion Arthroscopic or open posterior Bankart
repair
Excessive capsulolabral laxity Arthroscopic or open posterior capsular
shift ± rotator interval closure
Glenoid erosion Posterior glenoid bone grafting
Increased glenoid retroversion Posterior opening wedge glenoid osteot-
omy
Figure 5
Arthroscopic photograph of a posterior
capsulolabral disruption (posterior or
reverse Bankart lesion). The probe is in
the defect.
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 469
cus testing and passive range of mo-
tion are compared with the opposite
shoulder.
Soft-Tissue Procedures
Open Posteroinferior Capsular
Shift
The open posteroinferior capsular
shift procedure is best for patients
with recurrent posttraumatic sub-
luxation and those with involuntary,
recurrent, atraumatic subluxation.
The procedure also may be indicated
in those with recurrent voluntary
positional posterior subluxation.15
Positioning
The procedure may be performed
under general anesthesia, regional
anesthesia alone, or general anes-
thesia combined with a regional an-
esthetic. The patient is positioned
on a full-length beanbag, in the later-
al decubitus position (Figure 6, A). A
mechanical arm holder from the op-
posite side of the operating table can
be helpful to support the arm in in-
ternal or external rotation.
Incision
The shoulder is approached poste-
riorly; we prefer the incision in the
posterior axillary fold. The deltoid
Figure 6
Open posteroinferior capsular shift. A, The patient is positioned in the lateral decubitus position in a beanbag. A posterior axillary
incision is used (broken line). B, The deltoid is split in line with its fibers to expose the underlying infraspinatus and teres minor.
Inset, Split in the infraspinatus and the location of the T-plasty in capsule. C, The infraspinatus is split and a T-shaped
capsulotomy is performed. The capsule is opened just lateral to the labrum. D, The capsulotomy is performed at the glenoid
side. Labral detachments are repaired. E, The inferior capsule is shifted superiorly. F, This is reinforced with the superior limb of
the capsule.
Recurrent Posterior Shoulder Instability
470 Journal of the American Academy of Orthopaedic Surgeons
can then be split in line with its fi-
bers, detached from its origin on the
scapular spine, or abducted and ele-
vated to reach the infraspinatus over
the joint line (Figure 6, B). The in-
fraspinatus is then split at the level
of the equator of the glenoid to ex-
pose the underlying posterior gleno-
humeral joint capsule. Care is taken
not to divide the muscle more than
1.5 cm medial to the glenoid in order
to avoid damage to the branches of
the suprascapular nerve to the in-
fraspinatus.
Capsular Shift
The capsule is then divided hori-
zontally from medial to lateral at the
equator of the glenoid. Although
both medial and lateral capsular
shifts have been described,29,30
we
prefer a medially based shift with a
T-plasty of the capsule performed at
the level of the glenoid. The posteri-
or capsule is often quite thin and the
medial capsule is of better quality
than the lateral capsule. We open the
capsule just lateral to the labrum
(Figure 6, C). The remaining capsulo-
labral sleeve is then elevated from
the glenoid rim inferiorly to the six
o’clock position. The joint is in-
spected and any posterior labral inju-
ry is repaired with two or three bio-
absorbable suture anchors (Figure 6,
D). The suture anchors are placed at
intervals along the posterior glenoid
rim, just at the articular margin. The
capsulolabral lesion is then repaired
anatomically, although the labrum
is often quite small.
During capsular repair, the pa-
tient’s arm is positioned in 20° of ab-
duction and in neutral rotation. The
inferior flap of capsule is shifted from
inferior to superior to remove redun-
dancy (Figure 6, E). The superior flap
is then shifted inferiorly over the in-
ferior flap to reinforce the posterior
capsule (Figure 6, F). In the setting of
capsular rupture or insufficiency, the
posterior capsule may be augmented
with the infraspinatus tendon. Non-
absorbable transosseous sutures or
suture anchors are used to repair the
infraspinatus.31 The deltoid is closed
in a side-to-side fashion with
braided, nonabsorbable sutures.
Arthroscopic Posterior
Stabilization
The indications for the arthro-
scopic approach are identical to
those for the open posteroinferior
capsular shift. Ideal candidates are
those with a posterior Bankart le-
sion. Relative contraindications to
arthroscopic treatment of recurrent
posterior instability include failed
prior arthroscopic stabilization pro-
cedures, humeral avulsions of the
glenohumeral ligaments, or gross
symptomatic bi- or multidirectional
instability from excessive general-
ized laxity, such as with Ehlers-
Danlos syndrome. A distinction
must be made, however, between
these patients and those who have
multidirectional laxity but remain
symptomatic only in the posterior
direction. This latter group makes
up a large number of patients with
recurrent posterior instability, and
they respond well to arthroscopic
stabilization. Absolute contraindica-
tions to arthroscopic stabilization
are the rare individuals with either
glenoid erosion (acquired or develop-
mental) or excessive glenoid retro-
version. In these settings, bony pro-
cedures are required to reconstruct
or reorient the glenoid.
Patient Positioning
The procedure can be performed
in either the lateral decubitus or
beach chair position. For the lateral
decubitus position, the arm is placed
in a traction device (Arthrex Star
Sleeve; Arthrex, Naples, FL) with 20°
of abduction and 20° of extension.
Direct lateral traction also can be ap-
plied to the proximal humerus.
Arthroscopic Portals
Three or four portal techniques
can be used, with one or two poste-
rior portals and two anterior portals.
The posterior portal must be placed
slightly lateral to allow access to the
posterior glenoid rim and the pos-
teroinferior capsule. If the posterior
portal position is not ideal, a second
posterior portal can be used. Both an
anterosuperior portal and a midante-
rior portal are created in the rotator
interval region. The former is used
for viewing, and the latter for instru-
mentation and suture passage (Fig-
ure 7, A).
Arthroscopic Shift
A significant capsulolabral injury
(posterior Bankart lesion) can be
repaired with suture anchors; other-
wise the capsular redundancy,
which is more typically encoun-
tered, can be reduced with a poste-
rior capsular shift. The shift begins
at the 6 o’clock position. Using a
shuttling-type angled instrument,
the capsule is grasped 10 to 15 mm
lateral to the glenoid rim and is
shifted to the labrum with three to
five sutures (Figure 7, B through D),
depending on the size of the shoul-
der, the laxity present, and the de-
gree of shift desired. For patients
with significant inferior laxity, a ro-
tator interval closure is performed
to provide additional stability
against inferior translation.8 We per-
form the rotator interval closure as a
capsular closure, plicating the mid-
dle glenohumeral ligament to the
superior glenohumeral ligament.
Bony Procedures
In the setting of severe glenoid
dysplasia or retroversion, defined as
retroversion >20° (Figure 8, A), an
opening wedge posterior glenoid os-
teotomy is indicated. For patients
with significant focal posterior gle-
noid defects, a bone block or bony
glenoid reconstruction is indicated.
Although corrective humeral rota-
tional osteotomies have been de-
scribed in several European series,
they are not widely used in North
America.
Opening Wedge Glenoid
Osteotomy
Patients are positioned in the lat-
eral decubitus position, and expo-
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 471
sure is similar to that described for
the open capsular shift. The postero-
medial neck of the glenoid is ex-
posed. An autologous tricortical
bone graft is used. The width of the
graft is variable depending on the de-
gree of correction (10 to 25 mm) and
should be contoured in a wedge fash-
ion (Figure 8, B). The osteotomy
should be incomplete, leaving the
anterior glenoid cortex intact to
maintain stability. When the desired
correction has been obtained, the tri-
cortical bone graft is inserted to cor-
rect the retroversion. The graft may
be press-fit (our preference) or se-
cured by screws (Figure 8, D). Resid-
ual capsular redundancy may then
be treated, as described. This is a
technically challenging procedure;
numerous complications have been
reported, including intra-articular
fracture, nerve injury, loss of reduc-
tion, and hardware problems.
Posterior Bone Graft
For patients with acquired focal
glenoid defects, the glenoid can be
reconstructed with an anatomic
intra-articular bone graft to restore
the glenoid arc, or with an extra-
articular bone graft that serves as
a buttress for the humeral head (Fig-
ure 9). We prefer the extra-articular
approach, advancing the capsule an-
terior and medial to the graft to serve
as a soft-tissue interposition. Care
must be taken to avoid either medi-
al placement with ineffective but-
tressing or excessive lateral place-
ment with impingement on the
humeral head.32
The preferred graft
source is the inner table of the iliac
crest.
Postoperative
Rehabilitation
Postoperative management requires
the use of an orthosis to maintain
abduction, neutral rotation, and ex-
tension of the shoulder. The elbow
should be positioned posterior to the
plane of the body to decrease tension
on the repair. Immobilization is
maintained for 4 to 6 weeks, depend-
ing on the degree of instability, the
quality of the tissue, and the securi-
ty of the repair. At 6 weeks, active
assisted range-of-motion exercises
are started. Strengthening is delayed
until the third postoperative month.
Collision sports should be avoided
for the first 6 months.
Results
Published results are summarized in
Table 2. Although initial surgical re-
sults were so poor that some authors
concluded that recurrent posterior
Figure 7
Arthroscopic posterior stabilization technique. A, Portal placement using a three-
portal technique. The arthroscope is initially introduced into the posterior portal but
is then switched to the anterosuperior portal to visualize the posterior capsule.
The posterior capsule is addressed as viewed arthroscopically from the
anterosuperior portal. The superior aspect of the glenoid is oriented to the bottom
of the page and the inferior aspect oriented to the top. B, The capsule is being
shifted to the labrum using a shuttling-type suture passer, which is gentle on the
tissues. C, Both limbs of a permanent suture are retrieved through the posterior
cannula and tied. D, The steps are repeated from inferior to superior, with three to
five sutures typically being used.
Recurrent Posterior Shoulder Instability
472 Journal of the American Academy of Orthopaedic Surgeons
instability should not be treated sur-
gically,1
most of the early failures
and recurrences resulted from a lack
of knowledge of the pathoanatomy
and the relevant biomechanics. Im-
proved patient selection and surgical
techniques have led to better out-
comes.
Fronek et al30 and Hurley et al21
reported a 63% to 91% success rate
with nonsurgical treatment, with no
limitations in activities of daily liv-
ing and only moderate disability in
sports activities. Many of these pa-
tients had positive examination
findings for posterior instability but
did not require any further treat-
ment. Fronek et al30 also reported
good results with open posterior cap-
sulorrhaphy. Hawkins et al1
advocat-
ed the use of the infraspinatus ten-
don to reinforce the capsule and
reported an 85% success rate at aver-
age follow-up of 7 years (range, 2 to
15 years). Pollock and Bigliani32 re-
ported an overall satisfactory rate of
80% with this procedure at average
follow-up of 5 years. When revision
cases were excluded, the success rate
improved to 96%, highlighting the
importance of meticulous soft-tissue
repair at the first surgery.
Over the last decade, advances in
arthroscopy have made this ap-
proach quite attractive. Although a
variety of techniques has been de-
scribed, the key features include re-
storing the labrum and eliminating
capsular redundancy. In 1998, Wolf
and Eakin25 reported success in 16 of
17 patients who underwent an ar-
throscopic posterior capsular plica-
tion for unidirectional posterior in-
stability. Eleven returned to their
preinjury level of function, and there
were no reported complications. An-
toniou et al16
reported on 41 patients
with posterior instability treated
with an arthroscopic posteroinferior
capsulolabral augmentation proce-
dure. Thirty-five patients noted im-
provement, although 28 actually re-
ported a perception of shoulder
stiffness. Williams et al23
reported on
27 shoulders (26 patients) with trau-
matic posterior Bankart lesions sur-
gically treated with arthroscopic re-
pair using bioabsorbable tack
fixation; 55% of patients (11 pa-
tients) were American football play-
ers. Symptoms of pain and instabil-
ity were eliminated in 24 patients
(92%). Two patients required addi-
tional surgery.
Kim et al24 reported on 27 shoul-
ders (27 patients) with traumatic
unidirectional recurrent posterior
subluxation treated with arthroscop-
ic labral repair and posterior capsular
shift using suture anchors. In all cas-
es, symptoms were preceded by a
traumatic event. Symptoms of pain
and instability were eliminated in
Figure 8
Posterior opening wedge osteotomy. Significant retroversion (>20°) of the glenoid,
as shown here (A), is best addressed with this procedure. The opening wedge
osteotomy should be performed using a standard posterior approach. The
osteotomy (B) should begin approximately 10 mm medial to and parallel to the
articular surface. Stacking multiple broad flat osteotomes (C) helps achieve
distraction posteriorly while the anterior cortex is preserved. Care should be taken
to avoid an intra-articular fracture. The tricortical graft from the iliac crest may be
press-fit (our preference) or carefully secured with small fragment screws (D).
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 473
all patients except one, who had re-
current instability. Postoperatively,
all patients had improved shoulder
scores. Twenty-six of 27 were able to
return to their prior sports with lit-
tle or no limitation.24
Thermal shrinkage of the capsu-
lar tissues also has been advocated to
shrink the patulous posterior cap-
sule.33 Reported results for this tech-
nique vary from failure rates as low
as 4%33
to as high as 60%,34
with
capsular insufficiency present in up
to 33%.35 There have been alarming
reports of capsular necrosis and cap-
sular rupture.35 We have found the
visual response of capsular shrink-
age at the time of arthroscopy to be
variable and the clinical results of
thermal capsulorrhaphy to be unpre-
dictable, with unacceptably high
failure rates. For these reasons, this
technique is not recommended.
The surgical treatment of volun-
tary posterior instability remains
controversial. Recurrence after soft-
Figure 9
A, A posterior glenoid bone graft can be used for erosions and osseous defects to
restore concavity to the glenoid. B, Care must be taken to position the graft
appropriately to effectively lengthen the articular arc while avoiding abutment of the
graft on the humeral head.
Table 2
Results and Complications Reported After Posterior Instability Surgery
Study Procedure (No. of Patients) Recurrence
Complications (Other
Than Recurrence)
Neer and Foster29
Open posterior inferior capsular shift 0% (0/15) DJD 1 patient
Hawkins et al1
Glenoid osteotomy (17), reverse Putti-Platt
(6), biceps transfer (3)
50% (13/26) DJD with glenoid
osteotomy 35 patients
Hurley et al21
Reverse Putti-Platt without bone block 73% (16/22) DJD 2 patients
Fronek et al30 Open medial-based posterior shift (6) and
with bone block (5)
9% (1/11) 1 superficial infection
McIntyre et al26 Arthroscopic posterior shift with sutures
tied over clavicle or scapular spine
25% (5/20) Recurrence only
Wolf and Eakin25 Arthroscopic posterior shift with and
without suture anchors
7% (1/14) Recurrence only
Antoniou et al16
Arthroscopic posterior shift with and
without suture anchors
15% (6/41) 28 subjective stiffness
with normal range of
motion
Fuchs et al15 Open lateral-based posterior inferior shift
with and without bone grafting (1) or
osteotomy (3)
23% (6/26) 8 discomfort, 1 anterior
subcoracoid
impingement
Williams et al23 Arthroscopic posterior Bankart repair with
bioabsorbable tack fixation
7% (2/27) Recurrence only
Kim et al24
Arthroscopic posterior Bankart repair and
posterior shift with suture anchors
4% (1/27) Recurrence only
DJD = degenerative joint disease
Recurrent Posterior Shoulder Instability
474 Journal of the American Academy of Orthopaedic Surgeons
tissue procedures has been reported
to vary from 0% (0/15 patients)29 to
72% (18/25 patients).21
A conserva-
tive nonsurgical approach is advo-
cated in these patients. Fuchs et al15
reported good to excellent results in
24 of 26 shoulders (92%) with volun-
tary posterior instability treated
with open surgery.
Complications and
Pitfalls
The complications of surgery are in-
cluded in Table 2 and are procedure-
specific and technique-dependent.
Recurrence is the most frequently re-
ported complication.1,30 Recurrence
may result from a new injury or from
a failure of the initial procedure. In-
dividuals with traumatic recurrence
of the instability usually have better
results after revision surgery than do
patients with atraumatic recurrence
of the posterior instability.
Stiffness after surgery for posteri-
or instability presents as loss of in-
ternal rotation. It is infrequently re-
ported in the literature, and its
incidence may be underestimated.30
In certain circumstances, stiffness
may be acceptable to maintain sta-
bility, but it is likely to be patient-
specific. For example, internal rota-
tion losses of 10° may have few
functional consequences for most
individuals, but they may be devas-
tating for certain populations, such
as professional baseball pitchers,
tennis players, or swimmers who, re-
spectively, need to throw a ball, hit
a serve, or pull a stroke at high
speed. The phenomenon of subcora-
coid impingement also may occur
when excessive posterior capsular
tightness creates an obligate anteri-
or shift of the humeral head and
causes the subscapularis and anteri-
or soft tissues to impinge on the cor-
acoid.36
Excessive tightness can have ma-
jor consequences on joint kinemat-
ics and joint reactive forces, creating
shearing forces on the glenoid rim
that result in cartilage erosion and
early osteoarthrosis.37 This has been
called capsulorrhaphy arthropathy.
Osteoarthrosis is also a complica-
tion that has been reported after pos-
terior glenoid osteotomy and poste-
rior glenoid bone grafting. This
complication is usually the result of
an intra-articular fracture or im-
pingement of the humeral head on
the glenoid rim or the bone block.
Both the axillary38 and suprascap-
ular nerves39 are at risk during open
surgery for posterior instability. Inju-
ries may occur during sharp dissec-
tion, tissue retraction, and suture
placement.
Summary
The diagnosis and management of
posterior shoulder instability remain
challenging. Posterior instability is
uncommon, and the diagnosis may
be subtle. The most common pre-
senting complaint is pain. Thorough
evaluation and appropriate imaging
will demonstrate the pathoanatomy,
which can be variable and may in-
volve soft-tissue and/or bony ele-
ments. Careful classification of the
instability will yield insight into the
natural history and help guide treat-
ment. In the great majority of indi-
viduals, nonsurgical treatment is the
preferred initial management. In
those who fail conservative mea-
sures, surgery may be indicated.
Careful preoperative planning, sur-
gery targeted at the specific pathol-
ogy, and thoughtful aftercare can
maximize the chance for success and
minimize the risk of complications.
Individuals with voluntary instabil-
ity, multidirectional instability, or
bony defects will require a more care-
ful assessment of the cause of the in-
stability. If an extended rehabilitation
program is unsuccessful, combined
soft-tissue and bony procedures may
be needed to restore stability.
References
Evidence-based Medicine: Level II
prospective comparative studies are
references 23 and 34. The remaining
references are level III and IV case-
control series or level V (references
3, 12, and 19) expert opinion. There
are no prospective, blinded, random-
ized studies reported.
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Hawkins RJ, Koppert G, Johnston G:
Recurrent posterior instability (sub-
luxation) of the shoulder. J Bone
Joint Surg Am 1984;66:169-174.
2. Hovelius L: Incidence of shoulder dis-
location in Sweden. Clin Orthop
Relat Res 1982;166:127-131.
3. Arciero RA, Mazzocca AD: Traumatic
posterior shoulder subluxation with
labral injury: Suture anchor tech-
nique. Tech Shoulder Elbow Surg
2004;5:13-24.
4. McLaughlin HL: Posterior dislocation
of the shoulder. J Bone Joint Surg Am
1952;24:584-590.
5. Warner JJ, Caborn D, Berger R, Fu F,
SeelM:Dynamiccapsuloligamentous
anatomy of the glenohumeral joint.
J Shoulder Elbow Surg 1993;2:115-
133.
6. Lippitt S, Matsen F: Mechanisms of
glenohumeral joint stability. Clin
Orthop Relat Res 1993;291:20-28.
7. Turkel SJ, Panio MW, Marshall JL,
Girgis FG: Stabilizing mechanisms
preventing anterior dislocation of the
glenohumeral joint. J Bone Joint Surg
Am 1981;63:1208-1217.
8. Harryman DT II, Sidles JA, Harris SL,
Matsen FA III: The role of the rotator
interval capsule in passive motion
and stability of the shoulder. J Bone
Joint Surg Am 1992;74:53-66.
9. Cole BJ, Rodeo SA, O’Brien SJ, et al:
The anatomy and histology of the ro-
tator interval capsule in the shoulder.
Clin Orthop Relat Res 2001;390:129-
137.
10. Lee SB, An KN: Dynamic glenohu-
meral stability provided by three
heads of the deltoid muscle. Clin
Orthop Relat Res 2002;400:40-47.
11. Kido T, Itoi E, Lee SB, Neale PG, An
KN: Dynamic stabilizing function of
the deltoid muscle in shoulders with
anterior instability. Am J Sports Med
2003;31:399-403.
12. Matsen FA, Thomas SC, Rockwood
CA, Wirth MA: Glenohumeral insta-
bility, in Rockwood CA, Matsen FA,
Wirth MA, Harryman DT (eds): The
Shoulder. Philadelphia, PA: WB Saun-
ders, 1998, pp 611-755.
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 475
13. Ryu RK, Dunbar WH V, Kuhn JE, Mc-
Farland EG, Chronopoulos E, Kim TK:
Comprehensive evaluation and treat-
ment of the shoulder in the throwing
athlete. Arthroscopy 2002;18(9 suppl
2):70-89.
14. Hawkins RJ, Schutte JP, Janda DH,
Huckell GH: Translation of the gleno-
humeral joint with the patient under
anesthesia. J Shoulder Elbow Surg
1996;5:286-292.
15. Fuchs B, Jost B, Gerber C: Posterior-
inferior capsular shift for the treat-
ment of recurrent, voluntary posteri-
or subluxation of the shoulder.
J Bone Joint Surg Am 2000;82:16-25.
16. Antoniou J, Duckworth DT, Harryman
DT II: Capsulolabral augmentation for
the management of posteroinferior in-
stability of the shoulder. J Bone Joint
Surg Am 2000;82:1220-1230.
17. Warner JJ, Navarro RA: Serratus ante-
rior dysfunction: Recognition and
treatment. Clin Orthop Relat Res
1998;349:139-148.
18. Oh CH, Schweitzer ME, Spettell CM:
Internal derangements of the shoul-
der: Decision tree and cost-
effectiveness analysis of conventional
arthrography, conventional MRI, and
MR arthrography. Skeletal Radiol
1999;28:670-678.
19. Gerber A, Apreleva M, Warner JJP:
Basic science of glenohumeral insta-
bility, in Norris TR (ed): Orthopaedic
Knowledge Update: Shoulder and
Elbow 2. Rosemont, IL: American
Academy of Orthopaedic Surgeons,
2002, pp 13-22.
20. Burkhead WZ Jr, Rockwood CA Jr:
Treatment of instability of the shoul-
der with an exercise program. J Bone
Joint Surg Am 1992;74:890-896.
21. Hurley JA, Anderson TE, Dear W,
Andrish JT, Bergfeld JA, Weiker GG:
Posterior shoulder instability: Surgi-
cal versus conservative results with
evaluation of glenoid version. Am J
Sports Med 1992;20:396-400.
22. Misamore GW, Facibene WA: Posteri-
or capsulorrhaphy for the treatment of
traumatic recurrent posterior sublux-
ations of the shoulder in athletes.
J Shoulder Elbow Surg 2000;9:403-
408.
23. Williams RJ III, Strickland S, Cohen
M, Altchek DW, Warren RF: Arthro-
scopic repair for traumatic posterior
shoulder instability. Am J Sports
Med 2003;31:203-209.
24. Kim SH, Ha KI, Park JH, et al: Arthro-
scopic posterior labral repair and cap-
sular shift for traumatic unidirection-
al recurrent posterior subluxation of
the shoulder. J Bone Joint Surg Am
2003;85:1479-1487.
25. Wolf EM, Eakin CL: Arthroscopic cap-
sular plication for posterior shoulder
instability. Arthroscopy 1998;14:153-
163.
26. McIntyre LF, Caspari RB, Savoie FH
III: The arthroscopic treatment of pos-
terior shoulder instability: Two-year
results of a multiple suture technique.
Arthroscopy 1997;13:426-432.
27. Green MR, Christensen KP: Arthro-
scopic versus open Bankart proce-
dures: A comparison of early morbid-
ity and complications. Arthroscopy
1993;9:371-374.
28. Cole BJ, L’Insalata J, Irrgang J, Warner
JJ: Comparison of arthroscopic and
open anterior shoulder stabilization:
A two to six-year follow-up study.
J Bone Joint Surg Am 2000;82:1108-
1114.
29. Neer CS II, Foster CR: Inferior capsu-
lar shift for involuntary inferior and
multidirectional instability of the
shoulder: A preliminary report.
J Bone Joint Surg Am 1980;62:897-
908.
30. Fronek J, Warren RF, Bowen M: Poste-
rior subluxation of the glenohumeral
joint. J Bone Joint Surg Am 1989;71:
205-216.
31. Gerber C, Schneeberger AG, Beck M,
Schlegel U: Mechanical strength of re-
pairs of the rotator cuff. J Bone Joint
Surg Br 1994;76:371-380.
32. Pollock RG, Bigliani LU: Recurrent
posterior shoulder instability: Diag-
nosis and treatment. Clin Orthop
Relat Res 1993;291:85-96.
33. Lyons TR, Griffith PL, Savoie FH III,
Field LD: Laser-assisted capsulorrha-
phy for multidirectional instability of
the shoulder. Arthroscopy 2001;17:
25-30.
34. D’Alessandro DF, Bradley JP, Fleischli
JE, Connor PM: Prospective evalua-
tion of thermal capsulorrhaphy for
shoulder instability: Indications and
results. Two- to five-year follow-up.
Am J Sports Med 2004;32:21-33.
35. Wong KL, Williams GR: Complica-
tions of thermal capsulorrhaphy of
the shoulder. J Bone Joint Surg Am
2001;83(suppl 2 Pt 2):151-155.
36. Harryman DT II, Sidles JA, Clark JM,
McQuade KJ, Gibb TD, Matsen FA III:
Translation of the humeral head on
the glenoid with passive glenohu-
meral motion. J Bone Joint Surg Am
1990;72:1334-1343.
37. Gerber C, Ganz R, Vinh TS: Gleno-
plasty for recurrent posterior shoulder
instability: An anatomic reappraisal.
Clin Orthop Relat Res 1987;216:70-
79.
38. Bryan WJ, Schauder K, Tullos HS: The
axillary nerve and its relationship to
common sports medicine shoulder
procedures. Am J Sports Med 1986;
14:113-116.
39. Warner JP, Krushell RJ, Masquelet A,
Gerber C: Anatomy and relationships
of the suprascapular nerve: Anatomi-
cal constraints to mobilization of the
supraspinatus and infraspinatus mus-
cles in the management of massive
rotator-cuff tears. J Bone Joint Surg
Am 1992;74:36-45.
Recurrent Posterior Shoulder Instability
476 Journal of the American Academy of Orthopaedic Surgeons

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Recurrent Posterior Shoulder Instability | Orthopaedic Surgeon | Vail Colorado

  • 1. Recurrent Posterior Shoulder Instability Abstract Recurrent posterior shoulder instability is an uncommon condition. It is often unrecognized, leading to incorrect diagnoses, delays in diagnosis, and even missed diagnoses. Posterior instability encompasses a wide spectrum of pathology, ranging from unidirectional posterior subluxation to multidirectional instability to locked posterior dislocations. Nonsurgical treatment of posterior shoulder instability is successful in most cases; however, surgical intervention is indicated when conservative treatment fails. For optimal results, the surgeon must accurately define the pattern of instability and address all soft-tissue and bony injuries present at the time of surgery. Arthroscopic treatment of posterior shoulder instability has increased application, and a variety of techniques has been described to manage posterior glenohumeral instability related to posterior capsulolabral injury. Recurrent posterior shoulder in- stability is an uncommon condi- tion that is often unrecognized, lead- ing to incorrect diagnoses, delays in diagnosis, and even missed diag- noses.1 Posterior instability encom- passes a wide spectrum of pathoanat- omy that may affect the labrum, capsule, rotator interval, and bony ar- chitecture of the shoulder. Recurrent posterior subluxation is the most common type of posterior instability. Background and Epidemiology Glenohumeral instability is com- mon, affecting approximately 2% of the general population.2 However, posterior instability occurs in only 2% to 5% of those with shoulder in- stability.3 Trauma is thought to be the underlying cause in approxi- mately half of patients with posteri- or instability.3 Although posterior dislocation represents only 4% of all joint dislocations,4 it is often easily missed on clinical examination. Spe- cific imaging assessment is impor- tant. Recurrent posterior sublux- ation, which may present with instability symptoms or simply as pain, is more common, particularly in those who participate in high-risk athletic activities. Relevant Anatomy and Biomechanics The shoulder is the most mobile, but also the least stable, joint in the body because less than one third of the humeral head articulates with the glenoid. Stability is conferred by a series of static and dynamic soft- tissue restraints that maintain the articulation of the humeral head with the glenoid while simulta- neously providing for a large range of motion.5 Peter J. Millett, MD, MSc Philippe Clavert, MD G. F. Rick Hatch III, MD Jon J. P. Warner, MD Dr. Millett is Co-Director, Harvard Shoulder Service/Sports Medicine, Brigham & Women’s Hospital, Massachusetts General Hospital, Boston, MA, and Assistant Professor, Department of Orthopaedic Surgery, Harvard Medical School. Dr. Clavert is Associate Professor, Department of Orthopaedics, CHRU Hautepierre, Strasbourg, France. Dr. Hatch is Assistant Professor, Sports Medicine/ Shoulder & Elbow Services, Department of Orthopaedic Surgery, USC Keck School of Medicine, Los Angeles, CA. Dr. Warner is Professor, Department of Orthopaedics, Harvard Medical School, Boston, MA, and Chief, Harvard Shoulder Service, Department of Orthopedics, Massachusetts General Hospital. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Millett, Dr. Clavert, Dr. Hatch, and Dr. Warner. Reprint requests: Dr. Millett, Steadman Hawkins Clinic, 181 West Meadow Drive, Vail, CO 81657. J Am Acad Orthop Surg 2006;14:464- 476 Copyright 2006 by the American Academy of Orthopaedic Surgeons. 464 Journal of the American Academy of Orthopaedic Surgeons
  • 2. Static Restraints Articular factors such as joint congruency, glenoid version, and hu- meral retrotorsion contribute to static joint stability. Bony abnormal- ities such as glenoid retroversion or posterior glenoid erosion can be pre- disposing causative factors for poste- rior shoulder instability.1 The glenoid labrum, a wedge- shaped fibrous structure consisting of densely packed collagen bundles, increases the depth and surface area of the glenoid. It serves as an anchor point for the capsuloligamentous structures, deepens the glenoid con- cavity, and reduces glenohumeral translation with arm motion.6 La- bral excision decreases the depth of the socket by 50% and reduces resis- tance to instability by 20%.6 The glenohumeral ligaments are thickened fibrous bands within the joint capsule; these ligaments act at the end ranges of motion and pro- vide static stability. Their function is dependent on the position of the arm and the direction of the force ap- plied.7 For example, when the arm is adducted, the superior glenohu- meral ligament (SGHL) and coraco- humeral ligament (CHL) limit infe- rior translation and external rotation of the humeral head. Addi- tionally, the SGHL and the CHL re- sist posterior translation of the hu- meral head when the shoulder is in flexion, adduction, and internal ro- tation. The inferior glenohumeral ligament (IGHL) complex is com- posed of discrete anterior and poste- rior bands with an interposed axil- lary pouch that acts like a hammock, undergoing reciprocal tightening and loosening depending on arm position. The posterior band of the IGHL complex is the main re- straint to posterior translation of the humeral head when the arm is ab- ducted. The posterior capsule is defined as the area superior to the posterior band of the IGHL complex. The posterior capsule is the thinnest (≤1 mm) and perhaps weakest por- tion of the shoulder capsule. It may limit posterior translation when the arm is flexed, adducted, and inter- nally rotated. The rotator interval plays a role in static stability and is defined by the borders of the supraspinatus su- periorly, the subscapularis inferi- orly, the coracoid process medially, and the biceps and humerus later- ally. The SGHL, medial glenohu- meral ligament, and CHL provide variable reinforcement to the rota- tor interval. The rotator interval and its constituents provide stability against inferior and posterior trans- lations, particularly when the arm is adducted and externally rotated.8 Evidence suggests that deficiencies in the rotator interval can contrib- ute to instability in patients with excessive inferior or posterior trans- lation.9 In some individuals, the ro- tator interval may be composed of loosely arranged collagen, whereas in others, it may be completely devoid of tissue. This represents a rotator interval “capsular defect” that may need to be addressed in the symptomatic shoulder, but it may also be considered a normal anatomic variant in the stable shoulder. Dynamic Restraints Dynamic stability is provided by the rotator cuff, the deltoid, and the biceps tendon through a concavity- compression effect on the humeral head within the glenoid socket.10 Of the four muscles of the rotator cuff, the subscapularis provides the great- est resistance to posterior transla- tion.10,11 In addition, dynamic stabil- ity of the shoulder also is provided by the trapezius, serratus anterior, teres major, and latissimus dorsi muscles. Scapulothoracic motion must be properly coordinated with glenohumeral motion so that the glenoid can be appropriately posi- tioned to provide a stable platform beneath the humeral head. Definitions: Laxity and Instability The term instability is reserved for symptomatic shoulders—specifical- ly, the sensation of the humeral head translating in the glenoid, which is frequently associated with pain and discomfort.12 Instability is defined as pathologic joint translation that causes symptoms, or as the inability to keep the humeral head centered within the glenoid cavity during ac- tive motion. Laxity is defined as a specific translation for a particular direction or rotation.13 Individuals may have significant laxity and yet remain asymptomatic. Conversely, others with only minimal degrees of laxity may have significant symp- toms of instability. The distinction is important. Frequently, patients with excessive shoulder laxity sus- tain a traumatic injury and subse- quently develop symptoms of insta- bility. Individuals with recurrent posterior subluxation generally have symptomatic pain yet may or may not have symptoms of instability. Classification of Posterior Instability Posterior shoulder instability can be classified by direction, degree, cause, and volition. Unidirectional posteri- or subluxation is the most frequent form of posterior instability. Posteri- or instability also can occur as bidi- rectional or multidirectional insta- bility.14 The degree of posterior instabili- ty can range from mild subluxation to frank dislocation. Recurrent pos- terior subluxation is the most com- mon form. Posterior instability may be trau- matic (acquired) or atraumatic. The traumatic type is the more common form.1 This can occur as a single traumatic event with the shoulder in an “at risk” position (ie, flexion, ad- duction, and internal rotation) or as a culmination of multiple, smaller traumatic episodes. For example, an Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 465
  • 3. electrical shock producing posterior dislocation is a classic example of a single traumatic event. An offensive lineman with the arms in the block- ing position would typify a predispo- sition to recurrent posterior sublux- ation because of the repetitive loading. Posterior instability occur- ring secondary to overhead sports presents more insidiously because of the gradual capsular failure from re- petitive microtrauma. Common pro- vocative activities include the back- hand stroke in racket sports, the pull-through phase of swimming, and the follow-through phases in a throwing activity or golf. Posterior instability in the set- ting of an atraumatic history should alert the clinician to the possibility of an underlying collagen disease or bony abnormality (eg, glenoid hypo- plasia, excessive glenoid retrover- sion). In such situations, surgical in- tervention should be approached cautiously. Finally, posterior instability may be defined by its volitional compo- nent. Involuntary posterior instabil- ity typically results from a traumat- ic event (acute or repetitive) and most commonly manifests as mild subluxation. The symptoms do not occur willfully and usually are not controllable. Voluntary posterior in- stability occurs when a patient can willfully dislocate or subluxate the shoulder. Two different patterns have been described—voluntary muscular and voluntary positional posterior instability. In voluntary muscular (or habitual) posterior in- stability, an underlying muscular imbalance typically exists that allows voluntary subluxation/ dislocation of the shoulder with the arm in adduction. Patients with ha- bitual voluntary posterior instabili- ty are generally considered poor sur- gical candidates. However, patients with the second voluntary form, po- sitional voluntary posterior instabil- ity, can respond well to surgery pro- vided they do not have underlying psychiatric or secondary gain is- sues.15 Typically, these individuals have instability when the arm is flexed and adducted. Although these individuals may be able to voluntar- ily reproduce their instability, they usually avoid the provocative ma- neuvers.15 Evaluation History Although posterior shoulder in- stability is uncommon, an aware- ness of the disorder, together with a thoughtful evaluation beginning with the clinical history, usually leads to the proper diagnosis. The first step is to inquire about a histo- ry of trauma. In the case of a single traumatic episode, the direction of the applied force and the position of the arm at the time of injury may provide insight into the diagnosis. Classically, posterior subluxation occurs with a traumatic event when the arm is in an at-risk position (eg, forward flexion, adduction, internal rotation).16 A fall or blow to the arm while in an at-risk position can re- sult in a posterior labral detachment (reverse Bankart lesion).16 Repetitive stresses on the posterior capsule, ei- ther from sports or other activities, may lead to acquired posterior sub- luxation. Patients with recurrent posterior subluxation most commonly report pain and feelings of weakness. Insta- bility symptoms may or may not be present. With careful questioning, the direction, frequency, and severi- ty of the patient’s symptoms can be ascertained. Overhead athletes often describe insidious pain that may oc- cur in the later phases of their sport- ing activities, when muscle fatigue and dynamic stability are compro- mised. Mechanical symptoms, such as giving way, slipping, popping, catching, or clicking, are less com- mon than in anterior instability. Vo- litional components should be as- sessed. Physical Examination The physical findings of patients with posterior instability often are more subtle than those of patients with anterior instability. Active and passive ranges of motion usually are normal and symmetric. The posteri- or joint line may be tender to palpa- tion. Crepitus is sometimes noted as the arm is internally rotated. Strength testing is usually symmet- ric, except in rare cases of posterior rotator cuff muscle deficiency or nerve injury with external rotation weakness. In these cases, atrophy of the posterior rotator cuff muscles may be apparent on inspection. Patients should be assessed for generalized ligamentous laxity by evaluating the contralateral shoul- der, elbows, and knees, and by test- ing the patient’s ability to oppose the thumb to the forearm. In addition, sulcus testing should be performed. The sulcus can be quantified by the distance from the greater tuberosity to the acromion. A sulcus sign >2 cm is virtually pathognomonic for multidirectional instability, but pain and symptoms of inferior insta- bility must also be present for this diagnosis. If the sulcus does not re- duce as the arm is externally rotated, it should be considered pathologic, with a defect in the rotator interval that should be addressed at the time of surgery. Scapulohumeral rhythm and scapulothoracic mechanics should be assessed to exclude the possibili- ty of scapular winging, which is fre- quently confused with posterior in- stability.17 In some instances, a compensatory scapular winging may occur. As the scapula wings, it effec- tively anteverts the glenoid and dy- namically increases the bony stabil- ity.17 In such instances, a thorough neurologic examination should be performed with appropriate neuro- logic testing, as indicated. Specific Posterior Instability Tests The posterior stress test (Figure 1) Recurrent Posterior Shoulder Instability 466 Journal of the American Academy of Orthopaedic Surgeons
  • 4. is performed with the individual in the supine position; the arm is flexed to 90° and internally rotated. The ex- aminer axially loads the humerus against the posterior glenoid by pushing the arm posteriorly with one hand while the other hand is ap- plied to the back of the shoulder. The posterior stress test is positive when a subluxation of the humeral head over the glenoid rim is palpat- ed or observed. The jerk test (Figure 2) is per- formed with the patient sitting up- right; the arm is flexed 90° and in- ternally rotated, and the elbow is flexed to 90°. A posterior force is generated by applying an axial load to the humerus by pushing on the flexed elbow. In patients with signif- icant laxity, this will cause a poste- rior dislocation or subluxation of the glenohumeral joint. The arm is then extended and, as this occurs, the glenohumeral joint will reduce with a jerk. If a painful relocation oc- curs, the jerk test is positive. Usu- ally the reduction is observed as there is a sudden change in velocity as the humeral head reenters the glenoid fossa. The load and shift test (Figure 3, A) is performed with the patient seated upright, arm at the side. The humeral head and proximal hu- merus are grasped and compressed into the glenoid socket, and anterior and posterior stress is applied with grading of the degree of translation. This test is used to determine the amount of glenohumeral transla- tion, but it is difficult to accurately quantitate results. A 50% displace- ment of the humeral head is consid- ered the upper limit of normal. It is not unusual to find symmetric pos- terior translation between the af- fected and unaffected shoulders.5,14 The modified load and shift test (Figure 3, B) is performed with the patient supine and the affected Figure 1 Posterior stress test. A posterior force is applied through the humerus. The test is positive if there is palpable crepitus or subluxation. Often pain is elicited, but this is not as specific a finding. Figure 2 Jerk test. A, A posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. This will cause the humeral head to subluxate posteriorly out of the glenoid socket. B, As the arm is brought into extension, a clunk will be felt as the humerus reduces into the glenoid cavity. Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 467
  • 5. shoulder at the edge of the examin- ing table. The shoulder is positioned in the scapular plane and in neutral rotation. Manual force is placed at the ipsilateral elbow to concentrical- ly reduce the humeral head. Anteri- or and posterior forces are then applied to the proximal humerus in varying degrees of rotation and ele- vation with grading of the amount of translation.14 The load and shift and modified load and shift tests are typ- ically graded as follows: grade 0, minimal translation; grade 1, hu- meral head translates to the glenoid rim; grade 2, humeral head trans- lates over the glenoid rim but spon- taneously reduces; and grade 3, hu- meral head dislocates and does not spontaneously reduce. Imaging Radiographs Plain radiographs of the shoulder should include true anteroposterior views in neutral, internal, and exter- nal rotation; a transscapular view or Y view; and an axillary view. These views are needed to ensure that the joint is located, to evaluate the pos- terior glenoid rim, and to look for impaction fractures of the humeral head. In addition to humeral head position, these studies demonstrate glenoid rim morphology (hypoplasia, excessive retroversion, and/or frac- ture of the posterior glenoid rim). However, most individuals with re- current posterior instability do not have bony abnormalities. For those with a volitional component, dy- namic radiographs can confirm the diagnosis (Figure 4). Multiplanar Imaging Computed tomography (CT) or magnetic resonance imaging (MRI) is essential to assess the version and morphology of the glenoid. These tests also help detect subtle anterior Figure 3 A, Load and shift test. The patient is seated upright. A compressive force is applied through the humeral head to center the humeral head within the glenoid cavity. Posterior or anterior forces can then be applied to assess the amount of joint translation. This can be compared with the contralateral shoulder. B, Modified load and shift. The patient is supine. A compressive force is applied along the long axis of the humerus to center the humeral head in the glenoid cavity. A posterior force can then be applied to assess the degree of translation of the humeral head. Figure 4 Axillary radiographs of an individual with voluntary posterior instability showing the humeral head dislocated (A) and reduced (B). Recurrent Posterior Shoulder Instability 468 Journal of the American Academy of Orthopaedic Surgeons
  • 6. humeral head defects and glenoid fractures. Contrast can enhance the ability to evaluate the posterior la- brum and capsule, particularly with injuries such as capsulolabral disrup- tions or lateral capsular injuries.18 Contrast also enhances assessment of the superior labrum. For surgical candidates, it is critically important to identify the pathoanatomy so that the appropriate surgical approach can be chosen. For example, an indi- vidual with significant retroversion of the glenoid will have an unaccept- ably high failure rate if a soft-tissue capsulorrhaphy is performed and the bony abnormality is not addressed. Preoperative diagnosis helps in sur- gical planning, particularly as ar- throscopic treatment becomes more popular. Depending on the surgeon’s skill level, some injuries (eg, glenoid erosion, posterior humeral avulsion of the glenohumeral ligaments, cap- sular rupture) are more appropriate- ly addressed through an open surgi- cal approach. Although the gadolinium- enhanced magnetic resonance ar- throgram provides excellent soft- tissue detail, we think that a CT scan with intra-articular contrast provides the best information with regard to bony anatomy and articular orientation. CT is superior in its ability to determine the glenoid morphology as well as the degree of glenoid retroversion. Glenoid retro- version is best measured on axial CT scan images through the mid- glenoid; this corresponds with the first inferior image, on which the tip of the coracoid process is no longer visible.19 At this level, glenoid retro- version between −2° and −8° is con- sidered normal.19 Initial Treatment Nonsurgical treatment is successful for the great majority of patients with recurrent posterior sublux- ation. The aim of physical therapy is to strengthen the dynamic muscular stabilizers to compensate for the damaged or deficient static stabiliz- ers.20 The focus should be on exercis- es that strengthen the posterior del- toid, the external rotators, and the periscapular muscles. These exercis- es are typically used in conjunction with activity modification and bio- feedback. Nonsurgical treatment of posterior instability is successful in approximately 65% to 80% of cas- es.20,21 Surgical Treatment Open procedures have been the mainstay of treatment when nonsur- gical treatment fails and have led to good results when implemented ap- propriately1,15,22 During the past de- cade, the arthroscopic treatment of posterior shoulder instability has at- tracted increasing interest as a means to restore stability without the morbidity of open surgery. A va- riety of arthroscopic techniques have been described to manage pos- terior glenohumeral instability in re- lation to posterior capsulolabral in- jury and redundancy.23-26 The perceived advantages of the arthro- scopic approach include less morbid- ity, shorter surgery time, improved cosmesis, and less postoperative pain.27,28 Prerequisites Because of the multifactorial na- ture of posterior instability, as well as the lack of a single consistent “es- sential pathologic lesion,” the sur- geon must consider all potential contributing factors and correct the relevant pathoanatomy encountered in that individual case (Table 1). The best surgical candidates are those with recurrent, posttraumatic, uni- directional subluxation. These pa- tients are also the ideal candidates for arthroscopic stabilization, either by suture anchors or simple posteri- or capsular plication with sutures (Figure 5). The procedures used to address posterior instability may be subdivided into soft-tissue and bony procedures. Before any surgical procedure, an examination under anesthesia is per- formed. The amount of humeral head translation on the glenoid sur- face is graded as follows: 0, stable or trace laxity; 1, up to 50% transla- tion; 2, dislocatable with spontane- ous reduction; and 3, dislocates and does not spontaneously reduce. Sul- Table 1 Surgical Decision Making for Posterior Instability According to Pathoanatomy Pathologic Lesion Procedure of Choice Posterior Bankart lesion Arthroscopic or open posterior Bankart repair Excessive capsulolabral laxity Arthroscopic or open posterior capsular shift ± rotator interval closure Glenoid erosion Posterior glenoid bone grafting Increased glenoid retroversion Posterior opening wedge glenoid osteot- omy Figure 5 Arthroscopic photograph of a posterior capsulolabral disruption (posterior or reverse Bankart lesion). The probe is in the defect. Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 469
  • 7. cus testing and passive range of mo- tion are compared with the opposite shoulder. Soft-Tissue Procedures Open Posteroinferior Capsular Shift The open posteroinferior capsular shift procedure is best for patients with recurrent posttraumatic sub- luxation and those with involuntary, recurrent, atraumatic subluxation. The procedure also may be indicated in those with recurrent voluntary positional posterior subluxation.15 Positioning The procedure may be performed under general anesthesia, regional anesthesia alone, or general anes- thesia combined with a regional an- esthetic. The patient is positioned on a full-length beanbag, in the later- al decubitus position (Figure 6, A). A mechanical arm holder from the op- posite side of the operating table can be helpful to support the arm in in- ternal or external rotation. Incision The shoulder is approached poste- riorly; we prefer the incision in the posterior axillary fold. The deltoid Figure 6 Open posteroinferior capsular shift. A, The patient is positioned in the lateral decubitus position in a beanbag. A posterior axillary incision is used (broken line). B, The deltoid is split in line with its fibers to expose the underlying infraspinatus and teres minor. Inset, Split in the infraspinatus and the location of the T-plasty in capsule. C, The infraspinatus is split and a T-shaped capsulotomy is performed. The capsule is opened just lateral to the labrum. D, The capsulotomy is performed at the glenoid side. Labral detachments are repaired. E, The inferior capsule is shifted superiorly. F, This is reinforced with the superior limb of the capsule. Recurrent Posterior Shoulder Instability 470 Journal of the American Academy of Orthopaedic Surgeons
  • 8. can then be split in line with its fi- bers, detached from its origin on the scapular spine, or abducted and ele- vated to reach the infraspinatus over the joint line (Figure 6, B). The in- fraspinatus is then split at the level of the equator of the glenoid to ex- pose the underlying posterior gleno- humeral joint capsule. Care is taken not to divide the muscle more than 1.5 cm medial to the glenoid in order to avoid damage to the branches of the suprascapular nerve to the in- fraspinatus. Capsular Shift The capsule is then divided hori- zontally from medial to lateral at the equator of the glenoid. Although both medial and lateral capsular shifts have been described,29,30 we prefer a medially based shift with a T-plasty of the capsule performed at the level of the glenoid. The posteri- or capsule is often quite thin and the medial capsule is of better quality than the lateral capsule. We open the capsule just lateral to the labrum (Figure 6, C). The remaining capsulo- labral sleeve is then elevated from the glenoid rim inferiorly to the six o’clock position. The joint is in- spected and any posterior labral inju- ry is repaired with two or three bio- absorbable suture anchors (Figure 6, D). The suture anchors are placed at intervals along the posterior glenoid rim, just at the articular margin. The capsulolabral lesion is then repaired anatomically, although the labrum is often quite small. During capsular repair, the pa- tient’s arm is positioned in 20° of ab- duction and in neutral rotation. The inferior flap of capsule is shifted from inferior to superior to remove redun- dancy (Figure 6, E). The superior flap is then shifted inferiorly over the in- ferior flap to reinforce the posterior capsule (Figure 6, F). In the setting of capsular rupture or insufficiency, the posterior capsule may be augmented with the infraspinatus tendon. Non- absorbable transosseous sutures or suture anchors are used to repair the infraspinatus.31 The deltoid is closed in a side-to-side fashion with braided, nonabsorbable sutures. Arthroscopic Posterior Stabilization The indications for the arthro- scopic approach are identical to those for the open posteroinferior capsular shift. Ideal candidates are those with a posterior Bankart le- sion. Relative contraindications to arthroscopic treatment of recurrent posterior instability include failed prior arthroscopic stabilization pro- cedures, humeral avulsions of the glenohumeral ligaments, or gross symptomatic bi- or multidirectional instability from excessive general- ized laxity, such as with Ehlers- Danlos syndrome. A distinction must be made, however, between these patients and those who have multidirectional laxity but remain symptomatic only in the posterior direction. This latter group makes up a large number of patients with recurrent posterior instability, and they respond well to arthroscopic stabilization. Absolute contraindica- tions to arthroscopic stabilization are the rare individuals with either glenoid erosion (acquired or develop- mental) or excessive glenoid retro- version. In these settings, bony pro- cedures are required to reconstruct or reorient the glenoid. Patient Positioning The procedure can be performed in either the lateral decubitus or beach chair position. For the lateral decubitus position, the arm is placed in a traction device (Arthrex Star Sleeve; Arthrex, Naples, FL) with 20° of abduction and 20° of extension. Direct lateral traction also can be ap- plied to the proximal humerus. Arthroscopic Portals Three or four portal techniques can be used, with one or two poste- rior portals and two anterior portals. The posterior portal must be placed slightly lateral to allow access to the posterior glenoid rim and the pos- teroinferior capsule. If the posterior portal position is not ideal, a second posterior portal can be used. Both an anterosuperior portal and a midante- rior portal are created in the rotator interval region. The former is used for viewing, and the latter for instru- mentation and suture passage (Fig- ure 7, A). Arthroscopic Shift A significant capsulolabral injury (posterior Bankart lesion) can be repaired with suture anchors; other- wise the capsular redundancy, which is more typically encoun- tered, can be reduced with a poste- rior capsular shift. The shift begins at the 6 o’clock position. Using a shuttling-type angled instrument, the capsule is grasped 10 to 15 mm lateral to the glenoid rim and is shifted to the labrum with three to five sutures (Figure 7, B through D), depending on the size of the shoul- der, the laxity present, and the de- gree of shift desired. For patients with significant inferior laxity, a ro- tator interval closure is performed to provide additional stability against inferior translation.8 We per- form the rotator interval closure as a capsular closure, plicating the mid- dle glenohumeral ligament to the superior glenohumeral ligament. Bony Procedures In the setting of severe glenoid dysplasia or retroversion, defined as retroversion >20° (Figure 8, A), an opening wedge posterior glenoid os- teotomy is indicated. For patients with significant focal posterior gle- noid defects, a bone block or bony glenoid reconstruction is indicated. Although corrective humeral rota- tional osteotomies have been de- scribed in several European series, they are not widely used in North America. Opening Wedge Glenoid Osteotomy Patients are positioned in the lat- eral decubitus position, and expo- Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 471
  • 9. sure is similar to that described for the open capsular shift. The postero- medial neck of the glenoid is ex- posed. An autologous tricortical bone graft is used. The width of the graft is variable depending on the de- gree of correction (10 to 25 mm) and should be contoured in a wedge fash- ion (Figure 8, B). The osteotomy should be incomplete, leaving the anterior glenoid cortex intact to maintain stability. When the desired correction has been obtained, the tri- cortical bone graft is inserted to cor- rect the retroversion. The graft may be press-fit (our preference) or se- cured by screws (Figure 8, D). Resid- ual capsular redundancy may then be treated, as described. This is a technically challenging procedure; numerous complications have been reported, including intra-articular fracture, nerve injury, loss of reduc- tion, and hardware problems. Posterior Bone Graft For patients with acquired focal glenoid defects, the glenoid can be reconstructed with an anatomic intra-articular bone graft to restore the glenoid arc, or with an extra- articular bone graft that serves as a buttress for the humeral head (Fig- ure 9). We prefer the extra-articular approach, advancing the capsule an- terior and medial to the graft to serve as a soft-tissue interposition. Care must be taken to avoid either medi- al placement with ineffective but- tressing or excessive lateral place- ment with impingement on the humeral head.32 The preferred graft source is the inner table of the iliac crest. Postoperative Rehabilitation Postoperative management requires the use of an orthosis to maintain abduction, neutral rotation, and ex- tension of the shoulder. The elbow should be positioned posterior to the plane of the body to decrease tension on the repair. Immobilization is maintained for 4 to 6 weeks, depend- ing on the degree of instability, the quality of the tissue, and the securi- ty of the repair. At 6 weeks, active assisted range-of-motion exercises are started. Strengthening is delayed until the third postoperative month. Collision sports should be avoided for the first 6 months. Results Published results are summarized in Table 2. Although initial surgical re- sults were so poor that some authors concluded that recurrent posterior Figure 7 Arthroscopic posterior stabilization technique. A, Portal placement using a three- portal technique. The arthroscope is initially introduced into the posterior portal but is then switched to the anterosuperior portal to visualize the posterior capsule. The posterior capsule is addressed as viewed arthroscopically from the anterosuperior portal. The superior aspect of the glenoid is oriented to the bottom of the page and the inferior aspect oriented to the top. B, The capsule is being shifted to the labrum using a shuttling-type suture passer, which is gentle on the tissues. C, Both limbs of a permanent suture are retrieved through the posterior cannula and tied. D, The steps are repeated from inferior to superior, with three to five sutures typically being used. Recurrent Posterior Shoulder Instability 472 Journal of the American Academy of Orthopaedic Surgeons
  • 10. instability should not be treated sur- gically,1 most of the early failures and recurrences resulted from a lack of knowledge of the pathoanatomy and the relevant biomechanics. Im- proved patient selection and surgical techniques have led to better out- comes. Fronek et al30 and Hurley et al21 reported a 63% to 91% success rate with nonsurgical treatment, with no limitations in activities of daily liv- ing and only moderate disability in sports activities. Many of these pa- tients had positive examination findings for posterior instability but did not require any further treat- ment. Fronek et al30 also reported good results with open posterior cap- sulorrhaphy. Hawkins et al1 advocat- ed the use of the infraspinatus ten- don to reinforce the capsule and reported an 85% success rate at aver- age follow-up of 7 years (range, 2 to 15 years). Pollock and Bigliani32 re- ported an overall satisfactory rate of 80% with this procedure at average follow-up of 5 years. When revision cases were excluded, the success rate improved to 96%, highlighting the importance of meticulous soft-tissue repair at the first surgery. Over the last decade, advances in arthroscopy have made this ap- proach quite attractive. Although a variety of techniques has been de- scribed, the key features include re- storing the labrum and eliminating capsular redundancy. In 1998, Wolf and Eakin25 reported success in 16 of 17 patients who underwent an ar- throscopic posterior capsular plica- tion for unidirectional posterior in- stability. Eleven returned to their preinjury level of function, and there were no reported complications. An- toniou et al16 reported on 41 patients with posterior instability treated with an arthroscopic posteroinferior capsulolabral augmentation proce- dure. Thirty-five patients noted im- provement, although 28 actually re- ported a perception of shoulder stiffness. Williams et al23 reported on 27 shoulders (26 patients) with trau- matic posterior Bankart lesions sur- gically treated with arthroscopic re- pair using bioabsorbable tack fixation; 55% of patients (11 pa- tients) were American football play- ers. Symptoms of pain and instabil- ity were eliminated in 24 patients (92%). Two patients required addi- tional surgery. Kim et al24 reported on 27 shoul- ders (27 patients) with traumatic unidirectional recurrent posterior subluxation treated with arthroscop- ic labral repair and posterior capsular shift using suture anchors. In all cas- es, symptoms were preceded by a traumatic event. Symptoms of pain and instability were eliminated in Figure 8 Posterior opening wedge osteotomy. Significant retroversion (>20°) of the glenoid, as shown here (A), is best addressed with this procedure. The opening wedge osteotomy should be performed using a standard posterior approach. The osteotomy (B) should begin approximately 10 mm medial to and parallel to the articular surface. Stacking multiple broad flat osteotomes (C) helps achieve distraction posteriorly while the anterior cortex is preserved. Care should be taken to avoid an intra-articular fracture. The tricortical graft from the iliac crest may be press-fit (our preference) or carefully secured with small fragment screws (D). Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 473
  • 11. all patients except one, who had re- current instability. Postoperatively, all patients had improved shoulder scores. Twenty-six of 27 were able to return to their prior sports with lit- tle or no limitation.24 Thermal shrinkage of the capsu- lar tissues also has been advocated to shrink the patulous posterior cap- sule.33 Reported results for this tech- nique vary from failure rates as low as 4%33 to as high as 60%,34 with capsular insufficiency present in up to 33%.35 There have been alarming reports of capsular necrosis and cap- sular rupture.35 We have found the visual response of capsular shrink- age at the time of arthroscopy to be variable and the clinical results of thermal capsulorrhaphy to be unpre- dictable, with unacceptably high failure rates. For these reasons, this technique is not recommended. The surgical treatment of volun- tary posterior instability remains controversial. Recurrence after soft- Figure 9 A, A posterior glenoid bone graft can be used for erosions and osseous defects to restore concavity to the glenoid. B, Care must be taken to position the graft appropriately to effectively lengthen the articular arc while avoiding abutment of the graft on the humeral head. Table 2 Results and Complications Reported After Posterior Instability Surgery Study Procedure (No. of Patients) Recurrence Complications (Other Than Recurrence) Neer and Foster29 Open posterior inferior capsular shift 0% (0/15) DJD 1 patient Hawkins et al1 Glenoid osteotomy (17), reverse Putti-Platt (6), biceps transfer (3) 50% (13/26) DJD with glenoid osteotomy 35 patients Hurley et al21 Reverse Putti-Platt without bone block 73% (16/22) DJD 2 patients Fronek et al30 Open medial-based posterior shift (6) and with bone block (5) 9% (1/11) 1 superficial infection McIntyre et al26 Arthroscopic posterior shift with sutures tied over clavicle or scapular spine 25% (5/20) Recurrence only Wolf and Eakin25 Arthroscopic posterior shift with and without suture anchors 7% (1/14) Recurrence only Antoniou et al16 Arthroscopic posterior shift with and without suture anchors 15% (6/41) 28 subjective stiffness with normal range of motion Fuchs et al15 Open lateral-based posterior inferior shift with and without bone grafting (1) or osteotomy (3) 23% (6/26) 8 discomfort, 1 anterior subcoracoid impingement Williams et al23 Arthroscopic posterior Bankart repair with bioabsorbable tack fixation 7% (2/27) Recurrence only Kim et al24 Arthroscopic posterior Bankart repair and posterior shift with suture anchors 4% (1/27) Recurrence only DJD = degenerative joint disease Recurrent Posterior Shoulder Instability 474 Journal of the American Academy of Orthopaedic Surgeons
  • 12. tissue procedures has been reported to vary from 0% (0/15 patients)29 to 72% (18/25 patients).21 A conserva- tive nonsurgical approach is advo- cated in these patients. Fuchs et al15 reported good to excellent results in 24 of 26 shoulders (92%) with volun- tary posterior instability treated with open surgery. Complications and Pitfalls The complications of surgery are in- cluded in Table 2 and are procedure- specific and technique-dependent. Recurrence is the most frequently re- ported complication.1,30 Recurrence may result from a new injury or from a failure of the initial procedure. In- dividuals with traumatic recurrence of the instability usually have better results after revision surgery than do patients with atraumatic recurrence of the posterior instability. Stiffness after surgery for posteri- or instability presents as loss of in- ternal rotation. It is infrequently re- ported in the literature, and its incidence may be underestimated.30 In certain circumstances, stiffness may be acceptable to maintain sta- bility, but it is likely to be patient- specific. For example, internal rota- tion losses of 10° may have few functional consequences for most individuals, but they may be devas- tating for certain populations, such as professional baseball pitchers, tennis players, or swimmers who, re- spectively, need to throw a ball, hit a serve, or pull a stroke at high speed. The phenomenon of subcora- coid impingement also may occur when excessive posterior capsular tightness creates an obligate anteri- or shift of the humeral head and causes the subscapularis and anteri- or soft tissues to impinge on the cor- acoid.36 Excessive tightness can have ma- jor consequences on joint kinemat- ics and joint reactive forces, creating shearing forces on the glenoid rim that result in cartilage erosion and early osteoarthrosis.37 This has been called capsulorrhaphy arthropathy. Osteoarthrosis is also a complica- tion that has been reported after pos- terior glenoid osteotomy and poste- rior glenoid bone grafting. This complication is usually the result of an intra-articular fracture or im- pingement of the humeral head on the glenoid rim or the bone block. Both the axillary38 and suprascap- ular nerves39 are at risk during open surgery for posterior instability. Inju- ries may occur during sharp dissec- tion, tissue retraction, and suture placement. Summary The diagnosis and management of posterior shoulder instability remain challenging. Posterior instability is uncommon, and the diagnosis may be subtle. The most common pre- senting complaint is pain. Thorough evaluation and appropriate imaging will demonstrate the pathoanatomy, which can be variable and may in- volve soft-tissue and/or bony ele- ments. Careful classification of the instability will yield insight into the natural history and help guide treat- ment. In the great majority of indi- viduals, nonsurgical treatment is the preferred initial management. In those who fail conservative mea- sures, surgery may be indicated. Careful preoperative planning, sur- gery targeted at the specific pathol- ogy, and thoughtful aftercare can maximize the chance for success and minimize the risk of complications. Individuals with voluntary instabil- ity, multidirectional instability, or bony defects will require a more care- ful assessment of the cause of the in- stability. If an extended rehabilitation program is unsuccessful, combined soft-tissue and bony procedures may be needed to restore stability. References Evidence-based Medicine: Level II prospective comparative studies are references 23 and 34. The remaining references are level III and IV case- control series or level V (references 3, 12, and 19) expert opinion. There are no prospective, blinded, random- ized studies reported. Citation numbers printed in bold type indicate references published within the past 5 years. 1. Hawkins RJ, Koppert G, Johnston G: Recurrent posterior instability (sub- luxation) of the shoulder. J Bone Joint Surg Am 1984;66:169-174. 2. Hovelius L: Incidence of shoulder dis- location in Sweden. Clin Orthop Relat Res 1982;166:127-131. 3. Arciero RA, Mazzocca AD: Traumatic posterior shoulder subluxation with labral injury: Suture anchor tech- nique. Tech Shoulder Elbow Surg 2004;5:13-24. 4. McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;24:584-590. 5. Warner JJ, Caborn D, Berger R, Fu F, SeelM:Dynamiccapsuloligamentous anatomy of the glenohumeral joint. J Shoulder Elbow Surg 1993;2:115- 133. 6. Lippitt S, Matsen F: Mechanisms of glenohumeral joint stability. Clin Orthop Relat Res 1993;291:20-28. 7. Turkel SJ, Panio MW, Marshall JL, Girgis FG: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:1208-1217. 8. Harryman DT II, Sidles JA, Harris SL, Matsen FA III: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. 9. Cole BJ, Rodeo SA, O’Brien SJ, et al: The anatomy and histology of the ro- tator interval capsule in the shoulder. Clin Orthop Relat Res 2001;390:129- 137. 10. Lee SB, An KN: Dynamic glenohu- meral stability provided by three heads of the deltoid muscle. Clin Orthop Relat Res 2002;400:40-47. 11. Kido T, Itoi E, Lee SB, Neale PG, An KN: Dynamic stabilizing function of the deltoid muscle in shoulders with anterior instability. Am J Sports Med 2003;31:399-403. 12. Matsen FA, Thomas SC, Rockwood CA, Wirth MA: Glenohumeral insta- bility, in Rockwood CA, Matsen FA, Wirth MA, Harryman DT (eds): The Shoulder. Philadelphia, PA: WB Saun- ders, 1998, pp 611-755. Peter J. Millett, MD, MSc, et al Volume 14, Number 8, August 2006 475
  • 13. 13. Ryu RK, Dunbar WH V, Kuhn JE, Mc- Farland EG, Chronopoulos E, Kim TK: Comprehensive evaluation and treat- ment of the shoulder in the throwing athlete. Arthroscopy 2002;18(9 suppl 2):70-89. 14. Hawkins RJ, Schutte JP, Janda DH, Huckell GH: Translation of the gleno- humeral joint with the patient under anesthesia. J Shoulder Elbow Surg 1996;5:286-292. 15. Fuchs B, Jost B, Gerber C: Posterior- inferior capsular shift for the treat- ment of recurrent, voluntary posteri- or subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25. 16. Antoniou J, Duckworth DT, Harryman DT II: Capsulolabral augmentation for the management of posteroinferior in- stability of the shoulder. J Bone Joint Surg Am 2000;82:1220-1230. 17. Warner JJ, Navarro RA: Serratus ante- rior dysfunction: Recognition and treatment. Clin Orthop Relat Res 1998;349:139-148. 18. Oh CH, Schweitzer ME, Spettell CM: Internal derangements of the shoul- der: Decision tree and cost- effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography. Skeletal Radiol 1999;28:670-678. 19. Gerber A, Apreleva M, Warner JJP: Basic science of glenohumeral insta- bility, in Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2002, pp 13-22. 20. Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoul- der with an exercise program. J Bone Joint Surg Am 1992;74:890-896. 21. Hurley JA, Anderson TE, Dear W, Andrish JT, Bergfeld JA, Weiker GG: Posterior shoulder instability: Surgi- cal versus conservative results with evaluation of glenoid version. Am J Sports Med 1992;20:396-400. 22. Misamore GW, Facibene WA: Posteri- or capsulorrhaphy for the treatment of traumatic recurrent posterior sublux- ations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403- 408. 23. Williams RJ III, Strickland S, Cohen M, Altchek DW, Warren RF: Arthro- scopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209. 24. Kim SH, Ha KI, Park JH, et al: Arthro- scopic posterior labral repair and cap- sular shift for traumatic unidirection- al recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487. 25. Wolf EM, Eakin CL: Arthroscopic cap- sular plication for posterior shoulder instability. Arthroscopy 1998;14:153- 163. 26. McIntyre LF, Caspari RB, Savoie FH III: The arthroscopic treatment of pos- terior shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13:426-432. 27. Green MR, Christensen KP: Arthro- scopic versus open Bankart proce- dures: A comparison of early morbid- ity and complications. Arthroscopy 1993;9:371-374. 28. Cole BJ, L’Insalata J, Irrgang J, Warner JJ: Comparison of arthroscopic and open anterior shoulder stabilization: A two to six-year follow-up study. J Bone Joint Surg Am 2000;82:1108- 1114. 29. Neer CS II, Foster CR: Inferior capsu- lar shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897- 908. 30. Fronek J, Warren RF, Bowen M: Poste- rior subluxation of the glenohumeral joint. J Bone Joint Surg Am 1989;71: 205-216. 31. Gerber C, Schneeberger AG, Beck M, Schlegel U: Mechanical strength of re- pairs of the rotator cuff. J Bone Joint Surg Br 1994;76:371-380. 32. Pollock RG, Bigliani LU: Recurrent posterior shoulder instability: Diag- nosis and treatment. Clin Orthop Relat Res 1993;291:85-96. 33. Lyons TR, Griffith PL, Savoie FH III, Field LD: Laser-assisted capsulorrha- phy for multidirectional instability of the shoulder. Arthroscopy 2001;17: 25-30. 34. D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM: Prospective evalua- tion of thermal capsulorrhaphy for shoulder instability: Indications and results. Two- to five-year follow-up. Am J Sports Med 2004;32:21-33. 35. Wong KL, Williams GR: Complica- tions of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am 2001;83(suppl 2 Pt 2):151-155. 36. Harryman DT II, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA III: Translation of the humeral head on the glenoid with passive glenohu- meral motion. J Bone Joint Surg Am 1990;72:1334-1343. 37. Gerber C, Ganz R, Vinh TS: Gleno- plasty for recurrent posterior shoulder instability: An anatomic reappraisal. Clin Orthop Relat Res 1987;216:70- 79. 38. Bryan WJ, Schauder K, Tullos HS: The axillary nerve and its relationship to common sports medicine shoulder procedures. Am J Sports Med 1986; 14:113-116. 39. Warner JP, Krushell RJ, Masquelet A, Gerber C: Anatomy and relationships of the suprascapular nerve: Anatomi- cal constraints to mobilization of the supraspinatus and infraspinatus mus- cles in the management of massive rotator-cuff tears. J Bone Joint Surg Am 1992;74:36-45. Recurrent Posterior Shoulder Instability 476 Journal of the American Academy of Orthopaedic Surgeons