Given its complexity, there is no consensus regarding the assessment of non-traumatic shoulder instability (NTSI) to this day. We, therefore, conducted a scoping review to map the existing white and grey literature regarding diagnostic and assessment tools for the NTSI population.
Method
We followed the Arksey and O'Malley five-stage guideline for the conduct of scoping reviews and searched through 12 electronic databases for English-language articles and reviews from 2000 to 2024 related to NTSI's diagnosis and assessment tools.
Results
Among the 3426 identified studies, 58 were included (describing 59 different interventions). Case–control studies (43.1%, 25/58) and narrative reviews (34.5%, 20/58) were the most prevalent. Diagnostic imaging was the most studied intervention (35.6%, 21/59). Twenty-seven studies specified a direction of instability, of which 59% (16/27) were multidirectional instability. Non-traumatic shoulder instability often affects young individuals, with complex symptoms, including neuromotor deficits, muscular imbalances and kinematic alterations, involving psycho-behavioural and somatosensory components.
Discussion
Non-traumatic shoulder instability's aetiologies and clinical manifestations are multifactorial. The prevalence and incidence of this dysfunction are probably underestimated. Clinical history is crucial to retrace a complex and chronic dysfunction. The use of orthopaedic shoulder tests and the routine use of imaging currently appear to have limited relevance as a first-line approach.
NooraniAGoldringMJaggiA, et al.BESS/BOA patient care pathways: atraumatic shoulder instability. Shoulder Elbow2019; 11: 60–70.
2.
KuhnJE. A new classification system for shoulder instability. Br J Sports Med2010; 44: 341–346.
3.
KuhnJEHelmerTTDunnWR, et al.Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elbow Surg2011; 20: 548–556.
4.
RockwoodC. Subluxation of the shoulder: the classification, diagnosis and treatment. Orthop Trans1979; 4: 306.
5.
ThomasSCMatsenFA. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am1989; 71: 506–513.
6.
LewisAKitamuraTBayleyJIL. The classification of shoulder instability: new light through old windows!. Curr Orthop2004; 18: 97–108.
7.
HettrichCMCroninKJRaynorMB, et al.Epidemiology of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elbow Surg2019; 28: 95–101.
8.
Fernández-MatíasRLluch-GirbésEBatemanM, et al.Assessing the use of the frequency, etiology, direction, and severity classification system for shoulder instability in physical therapy research – A scoping review. Phys Ther Sport2024; 66: 76–84.
9.
JaggiAHerbertRDAlexanderS, et al.Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial. Br J Sports Med2023; 57: 1484–1489.
10.
BurkheadWZJRockwoodCAJ. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am1992; 74: 890–896.
11.
WarbySAFordJJHahneAJ, et al.Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol. BMJ Open2016; 6: e013083.
12.
WarbySAPizzariTFordJJ, et al.The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review. J Shoulder Elbow Surg2014; 23: 128–142.
13.
GrantMJBoothA. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J2009; 26: 91–108.
14.
TriccoACLillieEZarinW, et al.PRISMA Extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med2018; 169: 467–473.
15.
PetersMDJMarnieCTriccoAC, et al.Updated methodological guidance for the conduct of scoping reviews. JBI Evid Implement2021; 19: 3–10.
16.
OuzzaniMHammadyHFedorowiczZ, et al.Rayyan – a web and mobile app for systematic reviews. Syst Rev2016; 5: 210.
GodinKStapletonJKirkpatrickSI, et al.Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada. Syst Rev2015; 4: 138.
19.
HowardAJ.Complex shoulder instability: a combined study of functional MRI, electromyography and 3-D motion analysis. PhD, University of Liverpool. 2016. DOI: 10.17638/03001767.
20.
BardenJMBalykRRasoVJ, et al.Atypical shoulder muscle activation in multidirectional instability. Clin Neurophysiol2005; 116: 1846–1857.
21.
HaJYChoiYHLeeS, et al.Evaluation of inferior capsular laxity in patients with atraumatic multidirectional shoulder instability with magnetic resonance arthrography. Korean J Radiol2019; 20: 947–955.
22.
KimS-HNohK-CParkJ-S, et al.Loss of chondrolabral containment of the glenohumeral joint in atraumatic posteroinferior multidirectional instability. J Bone Joint Surg Am2005; 87: 92–98.
23.
CelentanoAPortaMCalviM, et al.Magnetic resonance arthrography in patients with multidirectional instability: could inferior capsulsar width be considered the cornerstone in the diagnosis of non-traumatic shoulder instability?Skeletal Radiol2022; 51: 2299–2305.
24.
SchaeffelerCWaldtSBauerJS, et al.MR Arthrography including abduction and external rotation images in the assessment of atraumatic multidirectional instability of the shoulder. Eur Radiol2014; 24: 1376–1385.
25.
LeeHJKimNRMoonSG, et al.Multidirectional instability of the shoulder: rotator interval dimension and capsular laxity evaluation using MR arthrography. Skelet Radiol2013; 42: 231–238.
26.
von Eisenhart-RotheRMayrHOHinterwimmerS, et al.Simultaneous 3D assessment of glenohumeral shape, humeral head centering, and scapular positioning in atraumatic shoulder instability: a magnetic resonance-based in vivo analysis. Am J Sports Med2010; 38: 375–382.
27.
HsuY-CPanR-YShihY-YI, et al.Superior-capsular elongation and its significance in atraumatic posteroinferior multidirectional shoulder instability in magnetic resonance arthrography. Acta Radiol2010; 51: 302–308.
28.
InuiHSugamotoKMiyamotoT, et al.Three-dimensional relationship of the glenohumeral joint in the elevated position in shoulders with multidirectional instability. J Shoulder Elbow Surg2002; 11: 510–515.
29.
ZhuWLuWZhangL, et al.Arthroscopic findings in the recurrent anterior instability of the shoulder. Eur J Orthop Surg Traumatol2014; 24: 699–705.
30.
SchulzCUAnetzbergerHGlaserC. Coracoid tip position on frontal radiographs of the shoulder: a predictor of common shoulder pathologies?Br J Radiol2005; 78: 1005–1008.
31.
BalkeMLiemDDedyN, et al.The laser-pointer assisted angle reproduction test for evaluation of proprioceptive shoulder function in patients with instability. Arch Orthop Trauma Surg2011; 131: 1077–1084.
32.
EshojHIngwersenKGLarsenCM, et al.Intertester reliability of clinical shoulder instability and laxity tests in subjects with and without self-reported shoulder problems. BMJ Open2018; 8: e018472.
33.
MoroderPErnstbrunnerLPomwengerW, et al.Anterior shoulder instability is associated with an underlying deficiency of the bony glenoid concavity. Arthroscopy2015; 31: 1223–1231.
34.
KatthagenJCTahalDSMontgomerySR, et al.Association of traumatic and atraumatic posterior shoulder instability with glenoid retroversion and outcomes after arthroscopic capsulolabral repair. Arthroscopy2017; 33: 284–290.
35.
InuiHSugamotoKMiyamotoT, et al.Glenoid shape in atraumatic posterior instability of the shoulder. Clin Orthop Relat Res2002; 403: 87–92.
36.
KimS-HParkJ-CParkJ-S, et al.Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med2004; 32: 1849–1855.
37.
WeishauptDZanettiMNyffelerRW, et al.Posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Skelet Radiol2000; 29: 204–210.
38.
HowardAPowellJLGibsonJ, et al.A functional magnetic resonance imaging study of patients with polar type II/III complex shoulder instability. Sci Rep2019; 9: 6271.
39.
CastagnaACesariEGiganteA, et al.Age-related changes of elastic fibers in shoulder capsule of patients with glenohumeral instability: a pilot study. Biomed Res Int2018; 2018: 8961805.
40.
AlexanderCM. Altered control of the trapezius muscle in subjects with non-traumatic shoulder instability. Clin Neurophysiol2007; 118: 2664–2671.
41.
WernerAWLichtenbergSSchmitzH, et al.Arthroscopic findings in atraumatic shoulder instability. Arthroscopy2004; 20: 268–272.
42.
LebeMBurnsSAFalworthM, et al.Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int2021; 5: 955–959.
43.
DanzingerVSchulzEMoroderP. Epidemiology of functional shoulder instability: an online survey. BMC Musculoskelet Disord2019; 20: 281.
44.
KondoTHashimotoJNobuharaK, et al.Radiographic analysis of the acromion in the loose shoulder. J Shoulder Elbow Surg2004; 13: 404–409.
45.
von Eisenhart-RotheRMJagerAEnglmeierKH, et al.Relevance of arm position and muscle activity on three-dimensional glenohumeral translation in patients with traumatic and atraumatic shoulder instability. (Abstract). J Orthop Sports Phys Ther2003; 33: 60.
46.
FrancavillaGSuteraRIovaneA, et al.Role of MR arthrography in shoulder micro-instability: personal experience. Med Dello Sport2010; 63: 547–556.
47.
MoroderPDanzingerVMaziakN, et al.Characteristics of functional shoulder instability. J Shoulder Elbow Surg2020; 29: 68–78.
48.
TurabiRHorselyIBirchH, et al.Does grip strength correlate with rotator cuff strength in patients with atraumatic shoulder instability?Bull Fac Phys Ther2022; 27: 1.
49.
JaggiANooraniAMaloneA, et al.Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg2012; 6: 101–107.
50.
JaggiAMaloneAACowanJ, et al.Prospective blinded comparison of surface versus wire electromyographic analysis of muscle recruitment in shoulder instability. Physiother Res Intl2009; 14: 17–29.
51.
WarbySAWatsonLFordJJ, et al.Multidirectional instability of the glenohumeral joint: etiology, classification, assessment, and management. J Hand Ther2017; 30: 175–181.
52.
ChambersLAltchekDW. Microinstability and internal impingement in overhead athletes. Clin Sports Med2013; 32: 697–707.
53.
MerollaGCercielloSChillemiC, et al.Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol2015; 25: 975–985.
54.
HegedusEJMichenerLASeitzAL. Three key findings when diagnosing shoulder multidirectional instability: patient report of instability, hypermobility, and specific shoulder tests. J Orthop Sports Phys Ther2020; 50: 52–54.
55.
SadiJTorchiaEFaberKJ, et al.Posterior shoulder instability classification, assessment, and management: an international Delphi study. J Orthop Sports Phys Ther2020; 50: 373–380.
56.
JohnsonSMRobinsonCM. Shoulder instability in patients with joint hyperlaxity. J Bone Joint Surg Am2010; 92: 1545–1557.
57.
Valencia MoraMIbanMHerediaJ, et al.Physical exam and evaluation of the unstable shoulder. Open Orthop J2017; 11: 946–956.
58.
JaggiAAlexanderS. Rehabilitation for shoulder instability – current approaches. Open Orthop J2017; 11: 957–971.
59.
BahuMJTrentacostaNVorysGC, et al.Multidirectional instability: evaluation and treatment options. Clin Sports Med2008; 27: 671–689.
BarrettC. The clinical physiotherapy assessment of non-traumatic shoulder instability. Shoulder Elbow2015; 7: 60–71.
62.
LädermannADenardPJCollinP, et al.Single assessment numeric evaluation for instability as an alternative to the Rowe score. J Shoulder Elbow Surg2021; 30: 1167–1173.
63.
BerginD. Imaging shoulder instability in the athlete. Magn Reson Imaging Clin N Am2009; 17: 595–615. v.
TannenbaumESekiyaJK. Evaluation and management of posterior shoulder instability. Sports Health2011; 3: 253–263.
66.
TzannesAMurrellGAC. Clinical examination of the unstable shoulder. Sports Med2002; 32: 447–457.
67.
SpanhoveVVan DaeleMVan den AbeeleA, et al.Muscle activity and scapular kinematics in individuals with multidirectional shoulder instability: a systematic review. Ann Phys Rehabil Med2021; 64: 101457.
68.
HillAMBullAMJRichardsonJ, et al.The clinical assessment and classification of shoulder instability. Curr Orthop2008; 22: 208–225.
69.
WalzDMBurgeAJSteinbachL. Imaging of shoulder instability. Semin Musculoskelet Radiol2015; 19: 254–268.
70.
SandersTGMorrisonWBMillerMD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med2000; 28: 414–434.
GismervikSØDrogsetJOGranvikenF, et al.Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord2017; 18: 41.
75.
WhiteheadNAMohammedKDFulcherML. Does the Beighton score correlate with specific measures of shoulder joint laxity?Orthop J Sports Med2018; 6: 2325967118770633.
76.
MalekSReinholdEJPearceGS. The Beighton score as a measure of generalised joint hypermobility. Rheumatol Int2021; 41: 1707–1716.
77.
HegedusEJGoodeACampbellS, et al.Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med2008; 42: 80–92. discussion 92.
78.
MaySChance-LarsenKLittlewoodC, et al.Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. Physiotherapy2010; 96: 179–190.
79.
CalvertEChambersGKReganW, et al.Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol2009; 62: 558–563.
80.
KarelYHJMVerkerkKEndenburgS, et al.Effect of routine diagnostic imaging for patients with musculoskeletal disorders: a meta-analysis. Eur J Intern Med2015; 26: 585–595.
81.
ZadroJRO’KeeffeMFerreiraGE, et al.Diagnostic labels for rotator cuff disease can increase people’s perceived need for shoulder surgery: an online randomized controlled trial. J Orthop Sports Phys Ther2021; 51: 401–411.
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