Pediatric and Adolescent ShoulderInstabil ity

Matthew D. Milewski, MDa,b,*, Carl W. Nissen, MDa,b

KEYWORDS

� Shoulder instability � Multidirectional instability � Arthroscopy � Pediatric� Adolescent

KEY POINTS

� There is a high rate of recurrence after first-time shoulder instability in a young activepopulation.

� Given the high risk of recurrent instability, young, active patients who seek to return tocompetitive contact sports should consider surgical stabilization after a first-timeinstability event.

� Multidirectional instability should be initially treated with conservative treatment.

� Traditional surgical options for shoulder instability utilized open techniques. Newerarthroscopic techniques may now approach the success rates of the traditional treat-ments options.

INTRODUCTION

Shoulder instability in young patients is a well-recognized spectrum of disease, fromcommon traumatic anterior dislocations to recurrent multidirectional instability (MDI).In young adolescent or pediatric patients with open proximal humeral physes, shoul-der instability was believed to be less common than physeal injury, but it may be morecommon than once believed.1,2 Both traumatic and nontraumatic shoulder instabilityin young patients have been found to have a high rate of recurrence, and appropriatetreatment is paramount in reducing the risk of recurrence and facilitating young pa-tients’ return to sports and other physical activities. The spectrum of shoulder insta-bility seen in young athletes is discussed, including epidemiology, anatomy andbiomechanical features, physical examination and imaging, and conservative andoperative treatment strategies.

a Elite Sports Medicine, Connecticut Children’s Medical Center, 399 Farmington Avenue,Farmington, CT 06032, USA; b University of Connecticut School of Medicine, Farmington,CT, USA* Corresponding author. Elite Sports Medicine, Connecticut Children’s Medical Center, 399Farmington Avenue, Farmington, CT 06032.E-mail address: mdmilewski@gmail.com

Clin Sports Med 32 (2013) 761–779http://dx.doi.org/10.1016/j.csm.2013.07.010 sportsmed.theclinics.com0278-5919/13/$ – see front matter � 2013 Elsevier Inc. All rights reserved.

Milewski & Nissen762

EPIDEMIOLOGY

Shoulder instability is common, with a rate of 11.2 per 100,000 person-years, as notedby Simonet and colleagues.3 These investigators found younger male patients to bemost frequently affected. In young ice hockey players, an incidence as high as 7%has been reported.2,4 The classic study by Rowe1 in 1956 reviewing 500 shoulderdislocations found that 20% of these dislocations occurred in patients between theages of 10 and 20 years, but only 8 patients who were younger than 10 years had dis-locations. Wagner and Lyne5 found that 4.7% of the shoulder dislocations in theirstudy occurred in children with open physes. More recent studies have estimatedthat up to 40% of shoulder instability events may occur in patients younger than22 years.2,6

Perhaps more striking than the high incidence of first-time traumatic anterior shoul-der stability is the high rate of recurrence of shoulder instability in young active pa-tients. The rate of recurrence has been estimated to be between 60% and 100% inthese patients.1,4,5,7–10 Rowe1 found the rate of recurrence in patients younger than10 years to be 100%, and 94% if between 10 and 20 years of age. Wagner andLyne5 found an 80% rate of recurrence in 9 patients with open proximal humeralphyses. Hovelius and colleagues10 found a 60% recurrence rate in 12-year-old to16-year-old patients. Deitch and colleagues11 found a recurrence rate of 75% in 32patients between the ages of 11 and 18 years. Lawton and colleagues12 reviewed acohort of 70 shoulders with instability, of which 67% received conservative treatmentwith physical therapy initially. These investigators found that 40% required surgicalstabilization. Hovelius and colleagues6,8 found 55% of patients younger than 22 yearsof age had 2 or more recurrences of instability at 5 year follow-up and 16% of theseyounger patients went on to have instability of the contralateral shoulder at 10 yearfollow-up. Postacchini and colleagues13 found a recurrence rate of 92% in patientsbetween the ages of 14 and 17 years after traumatic instability and a lower recurrencerate of 33% in patients 13 years old or younger, but their series had only 3 patients inthis youngest age group.The incidence and prevalence of MDI are difficult to estimate, given the spectrum of

hyperlaxity and disease that might be present. Emery and Mullaji14 examined 150asymptomatic shoulders in patients between the ages of 13 and 18 years and found57% of boys and 48% of girls had signs of shoulder instability using anterior drawer,posterior drawer, and sulcus tests. Although the incidence of MDI seems to be lessthan the incidence of traumatic anterior shoulder instability, MDI seems to have ahigher incidence in overhead athletes, especially swimmers and gymnasts.15,16

ANATOMYAND BIOMECHANICS OF TRAUMATIC AND NONTRAUMATIC INSTABILITY INYOUNG PATIENTS

The shoulder joint begins to form during the sixth week of gestation through differentgrowth rates, known as the interzone.17 At this early point, the glenoid lip is discernibleand consists of dense fibrous and some elastic tissue, as opposed to fibrocartilagi-nous tissue of the knee meniscus. The shoulder capsule and the ligamentous thicken-ings are visible by the end of the eighth week, increasing in size only throughdevelopment to adult proportions.18 Variations in the final maturation of the glenoidand the capsulolabral tissues do exist but the effects on shoulder function and insta-bility are not fully appreciated.The anatomy of the shoulder and specifically the labrum and glenohumeral liga-

ments are well studied and variable. Although anatomists have documented the pres-ence of the anterior ligamentous structures, it is the surgeons and arthroscopists who

Pediatric and Adolescent Shoulder Instability 763

have refined these descriptions and allowed a better understanding in both the func-tion and position of the capsular thickenings, which have led to modern concepts oftreatment of shoulder instability. One such finding is the patulous inferior recessattached to the diminutive labrum seen in patients with significant joint laxity(Fig. 1). Although still present, the glenohumeral ligaments tighten only after significantrotation of the joint or translation of the humeral head has occurred. Often in theseyoung, ligamentously lax patients, arthroscopic observation of the intra-articularspace shows pristine, smooth articular cartilage, an endless-pool appearance of thelabrum, and thin, almost translucent, shoulder capsules and the ability to sublux thehumeral head over the anterior, inferior, and posterior labral edge. Addressing thediminutive labrum and the expansive capsule in these patients if multidirectional insta-bility issues exist is visibly obvious and is discussed later. Although obvious, the needto create a labral bumper has not been established in the literature. The notion ofcreating a bumper to deepen the glenoid cavity and enhance the ability of glenohum-eral compression to offer joint stability is mechanical founded. We believe from ourexperience that doing so is helpful and use this technique when treating patientswith shoulder instability.The presence of the inferior glenohumeral complex is also clearly shown arthro-

scopically. What is most apparent with regards to the inferior glenohumeral ligament(IGHL) is the reciprocal nature of the complex and its function as a hammock. Theanterior portion fans out with external rotation and the posterior band of the IGHLbecomes cordlike. When this appearance is lacking (or the opposite with internal rota-tion) during a diagnostic arthroscopy of patients with either unidirectional or multi-directional instability, addressing each of the aspects of a patient’s disease isnecessary.

HISTORY

Because there is such a wide spectrum of disease with shoulder instability in youngerpatients, the history and physical examination are paramount in understanding aparticular young patient’s disease and prognosis. Instability patterns are classicallyseparated into either traumatic or atraumatic.Traumatic dislocations occur after falls, altercations, motor or recreational vehicle

accidents, or during sports events, particularly contact sports.19 Owens and col-leagues20 found the highest rates of shoulder instability in football, wrestling, and

Fig. 1. (A) Arthroscopic image of inferior labrum viewed from posterior portal of diminutivelabrum and patulous capsule in a patient with MDI. (B) Arthroscopic image of posteriorlabrum viewed from posterior portal with fraying (arrow) at labral-articular cartilagejunction in a patient with MDI.

Milewski & Nissen764

hockey. In the initial evaluation of the patient with shoulder instability, it is important tounderstand whether an underlying joint laxity was present before the first instabilityevent or whether the instability issue followed a traumatic event. Also, it is importantto note whether they required a formal reduction effort or not and where that occurred(eg, on the field or in the emergency department). Especially in younger patients, it canbe difficult to understand the instability event if there was not a witnessed dislocationor necessary reduction. These younger patients may describe only intense shoulderpain, a dead arm feeling, or occasionally parasthesias in the distal upper extremityassociated with subluxation or dislocation events.Although anterior shoulder instability comprises 90% to 95% of shoulder instability,

posterior shoulder instability can also be present. Posterior instability has been foundin approximately 4% of all traumatic shoulder dislocations.21 A good history can pro-vide essential clues to the primary direction of instability. Pain in the abducted andexternally rotated position, such as the overhead serving position for a racquet sportathlete or reaching overhead or with an outstretched arm for a pass in a basketball orfootball player, usually indicates anterior shoulder instability. Pain with internal rotationand pushing forward such as during a bench press maneuver, a football lineman in hisblocking stance, or pushing open a heavy door may indicate posterior shoulderinstability.The symptoms of recurrent shoulder instability in the context of MDI in the young

patient are even more vague. Atraumatic instability may occur during activities of dailyliving such as reaching overhead to get things from a shelf or during hair washing orgrooming. Atraumatic instability can also occur during sporting events, particularlyduring noncontact sports such as overhead serving in racquet sports, during certainswimming strokes, or during weight-lifting activities. These patients describe occa-sional pain or mechanical symptoms, such as popping in the shoulder, which maybe associated with particular overhead motions. A careful history for recurrent insta-bility in other joints or in the family history may indicate a connective tissue disorder.History of connective tissue disorders such as Ehlers-Danlos syndrome changes theprognosis and potential treatment options for a young patient with recurrent shoulderinstability.Young patients with MDI usually do not require reduction maneuvers to reduce their

shoulder dislocations. They may have pain with everyday activities, such as brushingtheir hair. Numbness in the hand while carrying heavier objects may indicate inferiorshoulder subluxation.22 Even in the setting of MDI, it is important to know which direc-tion of subluxation seems to dominate, because this can affect surgical and nonsur-gical decision making. Previous investigators have attached a poorer prognosis toMDI with a voluntary component.23,24 These investigators have discussed poorer out-comes in patients with MDI secondary to seizure disorders, electrocution, and otherpsychological and medical conditions. Pediatric and adolescent patients have beenincluded in these groups and collectively have been deemed to have poorer prog-nosis. However, the adolescent with MDI with or without a voluntary componentshould probably be viewed separately and, in our opinion, has a better prognosis.

PHYSICAL EXAMINATION

The physical examination for the younger patient with shoulder instability starts withan examination that is used in adults. This process includes an examination of the cer-vical spine and a scapular examination for signs of more central nerve causes of shoul-der weakness and pain. Although cervical spine issues are less common in younghealthy pediatric and adolescent patients, scapular winging is not uncommon in these

Pediatric and Adolescent Shoulder Instability 765

patients and is caused by nerve dysfunction or injury along with muscle weakness,imbalance, and dyskinesia. Similarly, a careful neurovascular examination of thebrachial plexus and specially the axillary nerve is important, because injury to thisnerve is reported in 5% to 35% of fractures and dislocations.25

All patients with traumatic shoulder pain with presumed open physes should beevaluated for proximal humeral physeal injuries. Deformity of the shoulder girdle inthis age group is not universally a dislocation. We recommend radiographic evaluationbefore any reduction maneuvers for shoulder instability, especially in prepubescentpatients. Range of motion and strength should be tested bilaterally in all patientswith a suspected traumatic shoulder injury. This strategy should include testing sen-sory perceptions and strength in axillary, musculocutaneous, ulnar, radial, and mediannerve distributions. Proximally, the cervical spine should be examined for tendernessand range of motion. Spurling sign should also be assessed in patients able to complywith the test.There are a variety of provocative maneuvers to test shoulder instability. These ma-

neuvers include the anterior apprehension test, Jobe relocation test, anterior and pos-terior load-and-shift tests, Kim posterior jerk test, hyperabduction test, and the sulcussign.26 The anterior and posterior load-and-shift tests are generally performed with thepatient supine to stabilize the scapula. The load-and-shift tests involve placing the armin 20� of abduction and forward flexion, matching the plane of the scapular body andgrading the amount of translation of the humeral head. Grade 1 translation is consis-tent with translation to the glenoid rim but not dislocating. Grade 2 translation isconsistent with dislocation over the glenoid rim, but with spontaneous reductionwhen the force is removed. Grade 3 translation is consistent with dislocation eitheranteriorly or posteriorly without spontaneous reduction. The Kim posterior jerk testfor posterior instability involves placing the affected arm at 90� of abduction, whenthe examiner holds the arm and elbow and applies an axial loading force. The armis then elevated 45� while maintaining axial force that pushes the humeral head pos-teriorly and the result is considered positive if posterior pain or a palpable clunk isfelt.27 Hyperlaxity and inferior instability can be tested with the sulcus sign. Downwardtraction is applied to the arm, and if a dimple is seen or palpated between the lateralacromion and the humeral head, the test is considered positive. Humeral headdisplacement greater than 2 cm or the presence of the sulcus sign with the arm in90� of abduction is considered to indicate a higher degree of inferior capsular laxity(Figs. 2A, B and 3).26,28,29 Gagey and Gagey30 developed the hyperabduction testto evaluate for IGHL laxity. Passive glenohumeral abduction past 105� is consideredto indicate inferior laxity.All young patients with suspected glenohumeral instability should be evaluated for

generalized hyperlaxity. The Beighton-Horan scale for joint hyperlaxity combinesincreased laxity at various joints, including the hand, elbow, knee, and trunk(Table 1). A score equal or greater than 4 on a 9-point scale is considered diagnosticfor hyperlaxity. Borsa and colleagues31 found that women are more likely to havehyperlaxity and anterior glenohumeral joint laxity than men.

IMAGING

Evaluation of a young patient with suspected shoulder instability includes a standardtrauma series of radiographs with orthogonal views. This strategy is particularly impor-tant in the young patient with open physes, because of the risk of proximal humeralphyseal fractures mimicking an anteriorly dislocated proximal humerus. A nontrau-matic shoulder radiographic series includes an anterioposterior, scapular Y, and

Fig. 2. Female with multidirectional instability. (A) Patient at rest. (B) Patient after voluntaryanterior and inferior subluxation. Note anterior skin dimpling below the acromion (blackarrow).

Milewski & Nissen766

axillary view. If the young patient is too uncomfortable to comply with the arm posi-tioning for a standard axillary view to confirm glenohumeral reduction, a Velpeauview may be performed. This view is typically performed with the arm at the side ina position of comfort with the patient leaning backwards over the radiograph plateand the beam angled straight downward. The West Point view is useful in suspectedacute or recurrent shoulder instability, because it can best visualize the anterior gle-noid rim.32

Fig. 3. Sulcus sign. (From Curtis RJ. Glenohumeral instability in the child. In: DeLee JC,Drez DJ, Miller MD, editors. Delee & Drez’s orthopedic sports medicine. vol. 1. Philadelphia:Saunders/Elsevier; 2010; with permission.)

Table 1Beighton-Horan joint hypermobility scoring system: a score of greater or equal to 4 out of apossible 9 points usually indicates generalized hypermobility

Small finger Dorsiflex the fifth metacarpophalangealjoint to at least 90�

1 point for each side (left/right)

Thumb Oppose the thumb to volar aspect of theipsilateral forearm

1 point for each side (left/right)

Elbow Hyperextend the elbow to at least 10� 1 point for each side (left/right)

Knee Hyperextend the knee to at least 10� 1 point for each side (left/right)

Trunk/hip Place both hands flat on the floor withthe knees fully extended

1 point

Data from Beighton P, Horan F. Orthopedic aspects of the Ehlers-Danlos syndrome. J Bone JointSurg Br 1969;51(3):444–53.

Pediatric and Adolescent Shoulder Instability 767

Once a proximal humerus fracture is ruled out and glenohumeral reduction isconfirmed, imaging of the young patient with suspected glenohumeral instability oftenincludes magnetic resonance imaging (MRI). As in adults, the addition of intra-articularcontrast is often recommended to improve the diagnostic ability of MRI in diagnosinglabral disease. However, in the acute setting, intra-articular contrast is provided by theblood within the joint. Anterior instability in the young patient is often accompanied bya Bankart lesion or tear, an anterior labral periosteal sleeve avulsion lesion, or moreinfrequently, but important to identify on preoperative imaging, a humeral avulsionof the glenohumeral ligament (HAGL) lesion. Glenoid or humeral-sided bone loss ordeformity (ie, bony Bankart lesions, glenoid fractures, inverted pear glenoidmorphology, and Hill-Sachs deformities) can often be identified on radiographs orMRI but occasionally require evaluation by computed tomography (CT). Recentstudies have shown that MRI can accurately assess glenoid bone loss whencompared with CT scan with or without three-dimensional reconstructions.33,34

Imaging of the shoulder in patients with suspected MDI can be challenging to inter-pret, because the signs of instability that often accompany acute traumatic shoulderinstability, such as labral, capsular, or ligamentous tears, are usually not present.Several imaging findings can be helpful in evaluating the patient with suspectedMDI, although it is especially important in these patients to put the imaging findingsin the appropriate clinical context with their history and physical examination findings.Dewing and colleagues35 found a patulous capsule, increased glenohumeral volume,and labral abnormalities on MR arthrography in patients with MDI. Kim and col-leagues36 found increased rotator interval dimensions in patients with MDI. However,Provencher and colleagues37 found no significant differences in MRI findings of pa-tients with MDI when compared with adult controls, showing the importance of makingthe diagnosis of MDI based on history and physical examination findings.

TREATMENT AND OUTCOMESAcute Management of a Shoulder Dislocation in a Young Athlete

Many providers of sports medicine are faced with the issue of a young patient with asuspected shoulder dislocation seen on the field of play. Although in older, skeletallymature patients, it is reasonable to consider on-field reduction maneuvers if the pro-vider is comfortable and trained in these techniques, in the young patient with openphyses, we recommend that the provider at a minimum should consider appropriateradiographic imaging before reduction attempts to evaluate for a proximal humeralphyseal fracture.38 Once a physeal fracture is ruled out or considered to be of low

Milewski & Nissen768

probability, several reduction maneuvers are possible. These maneuvers includetraction-countertraction, Stimson maneuver, and abduction maneuvers.38 Adequatesedation is recommended in the young patient both for patient comfort and also toreduce the amount of traction or force needed for reduction in this population in orderto minimize further risk to the proximal humeral physis.

Nonoperative Conservative Treatment of Pediatric/Adolescent Anterior ShoulderInstability

Once glenohumeral reduction has been achieved, there are both conservative andoperative treatment options for the management of the pediatric or adolescent patientwith a first-time or recurrent traumatic anterior shoulder instability. Conservative treat-ment may include an initial period of sling or shoulder immobilizer use, followed by ac-tivity modification and physical therapy for range of motion and strengthening. Returnto play is often allowed once painless full range of motion and normal, protectivestrength is achieved. Shoulder harness bracing is often used for young footballplayers, or other contact athletes such as hockey and lacrosse players, who seek toreturn to play during the same season in which the instability has begun. The optionto return to play with an unstable shoulder requires a full understanding by both theplayer and their parents; a player may also have to play in a position that can accom-modate the restrictions of the brace (ie, limited overhead or abducted shoulder posi-tioning). Physical therapy protocols designed for the rehabilitation of anterior shoulderinstability treated nonoperatively focus primarily on scapular stabilization, with rotatorcuff strengthening being added in the later stages of the process.Themain complication associated with conservative management of traumatic first-

time anterior shoulder instability is the risk of recurrent instability. This risk is significantand although one study found this risk to be 21%,39 most reports document this risk tobe 60% or greater.1,5,7,8,11,13,40

Cordischi and colleagues39 followed 14 patients between the ages of 10.9 and13.1 years for an average of 3.4 years after a primary anterior shoulder dislocationand found 3 patients to have recurrent instability. Recurrent instability was associatedwith a HAGL lesion in all 3 cases and no patient had evidence of a discrete labral tearon MRI. Western Ontario Shoulder Instability Index scores were found to be better inthe nonoperative group in this small series.Other studies have found a higher rate of recurrent instability after conservative

treatment of anterior shoulder instability in young patients. In 1956, Rowe1 found a100% risk of recurrent instability in children younger than 10 years. The risk was94% in adolescents between 10 and 20 years of age. Wagner and Lyne5 found an80% recurrence rate in 10 adolescent shoulders between 12 and 16 years of age.Marans and colleagues7 found a 100% recurrence rate with an average of 5 recurrentinstability events in 21 pediatric and adolescent patients between 4 and 16 years ofage. Postacchini and colleagues13 found an 86% recurrence rate in adolescentsbetween 12 and 17 years of age. The rate of recurrence was 92% for adolescents be-tween 14 and 17 years of age but only 33% in patients younger than 13 years. Deitchand colleagues11 found a 75% recurrence rate in 32 adolescents between the ages of11 and 18 years. Echoing the findings of Postacchini and colleagues,13 8 of 15 patients(53%) with open humeral physes had recurrent instability, whereas 15 of 17 patients(88%) with closed humeral physes had recurrent instability. The high rate of recur-rence in adolescents with shoulder instability is similar to the rates observed in lateadolescents/collegiate-age athletes/military recruits seen in other studies.4,41 It is stillunclear whether the rate of recurrence is as high in younger adolescent and prepubes-cent children. If the rate of recurrence in this younger population is lower, as some

Pediatric and Adolescent Shoulder Instability 769

investigators have suggested, it might be hypothesized that younger children and theirfamilies might be more willing to modify activities, especially avoiding contact sports.This hypothesis is similar to the findings by Postacchini and colleagues13 that childrenyounger than 13 years had a lower dislocation rate. However, that study had a smallcohort of this youngest group of patients with traumatic dislocations. Further studiesneed to evaluate whether younger and older adolescents in larger cohorts havedifferent rates of recurrence and seek to identify possible causes.

Nonoperative Conservative Treatment of Pediatric/Adolescent MultidirectionalShoulder Instability

One of the classic tenants of shoulder instability treatment is AMBRI, which refers toatraumatic, MDI, which is often bilateral, with treatment beginning with rehabilitationand if that fails, consideration for inferior capsular shift. Most sports medicine pro-viders consider physical therapy and rehabilitation the first-line treatment of MDI.Burkhead and Rockwood42 classically described good or excellent results with reha-bilitation for 80% of patients with atraumatic instability. Takwale and colleagues43

described 90% good results with specialized physical therapy for involuntary posi-tional instability, which they described as “instability caused by an abnormal unbal-anced muscle action which is involuntary and ingrained,” which usually involvesadolescent patients with posterior instability. Kuroda and colleagues44 studied morethan 300 patients with atraumatic shoulder instability and advocated following thesepatients for several years with conservative treatment. These investigators notedspontaneous recovery of stability in 50 of 450 shoulders (9%) and that spontaneousrecovery was statistically more likely if patients were willing to switch to nonoverheadathletics. It is not clear if these patients still had symptoms but avoided frank instabilitybecause of activity modification. Misamore and colleagues45 followed 64 patients withMDI with an average age of 16 years and found at 2 years follow-up that 34% had elec-ted for surgery. Approximately half of the remaining patients had pain relief and gradedtheir shoulders as having good or excellent stability. At mean 8-year follow-up, 78% ofpatients who had not undergone surgery reported persistent problems with theirshoulders, and only 22% were symptom free. Conservative treatment of MDI canimprove a patient’s shoulder function and provide good or excellent results in manyyoung patients. However, there are some patients for whom this treatment coursemay not fully restore stability or provide complete pain relief. In general, some inves-tigators have recommended at least 6 months of physical therapy and conservativetreatment of MDI of the shoulder in young athletes.

Operative Treatment of Pediatric/Adolescent Anterior Shoulder Instability

Operative intervention is advocated for recurrent instability after traumatic anteriorshoulder dislocations in young patients. It has also been advocated for some youngpatients in high-risk sports or activities as the primary treatment after a first-timeshoulder instability event. The classic studies by DeBernadino and colleagues46 andOwens and colleagues47 showed excellent subjective function and return to sport,with a redislocation rate of 14.3% at longest follow-up after arthroscopic Bankartrepair after first-time traumatic instability in young active patients. However, these pa-tients were collegiate-aged military academy students, and this patient populationmight be different than a younger adolescent population. A few studies have specif-ically examined the results of surgical stabilization for traumatic anterior shoulderinstability in pediatric and adolescent patients.5,7,11–13,48–51 Wagner and Lyne5 re-ported on 7 shoulders in patients between 12 and 16 years of age who required sur-gical stabilization using open techniques between 1965 and 1979. These investigators

Milewski & Nissen770

reported no recurrence after surgery using older techniques such as Magnuson-Stackor Bristow procedures, which have since fallen out of favor for the treatment of primaryshoulder instability. In 1992, Marans and colleagues7 reported on 13 patientswho were an average of 13 years old who underwent open anterior stabilization pro-cedures, including Bankart repair, Putti-Platt procedure, capsular shift, and Bristowprocedure. One recurrent instability event (8% recurrence) was reported after surgeryin a patient who had a Bristow procedure, and this patient underwent a revision with aPutti-Platt procedure. Postacchini and colleagues13 and Lawton and colleagues12 re-ported on pediatric and adolescents treated with open surgical stabilization, and only1 patient had recurrent instability after surgical stabilization. Deitch and colleagues11

reported a higher rate (31%) of recurrence of instability after surgical stabilization butdid not report on the specific surgical procedures performed in this cohort.Newer studies have examined arthroscopic treatment of traumatic shoulder insta-

bility in pediatric and adolescent populations. Mazzocca and colleagues48 examineda late adolescent population between 14 and 20 years of age who were contact andcollision athletes and treated with arthroscopic anterior shoulder stabilization. Theseinvestigators reported a low recurrence rate of 11%, and all of their athletes wereable to return to organized high-school or collegiate sports. Kraus and colleagues50

reported on a series of 6 patients with an average age of 12 years old, in whom 5 of6 cases were treated with arthroscopic stabilization. There were no recurrences ataverage 26-month follow-up and excellent Constant and Rowe scores. Jones andcolleagues49 reported on 32 anterior arthroscopic Bankart repairs in 30 patientstreated at Children’s Hospital of Philadelphia. Half of the patients had failed initialnonoperative management and half had primary surgical stabilization. The averageage of the patients was 15 years, ranged between 11 and 18 years. Overall, therewas a 15.6% rate of recurrence after surgery. Single Assessment Numeric Evaluation(SANE) scores were similar between groups treated with initial conservative treatmentand initial surgical treatment at follow-up. Castagna and colleagues51 reviewed theirresults of arthroscopic stabilization in adolescent athletes aged 13 to 18 years whoplayed overhead or contact sports. These investigators found that 81% of their pa-tients were able to return to their preinjury sport, and the remaining 19% were ableto return to sport but at a lower level secondary to their shoulder. A recurrence rateof 21% was found overall, but this was significantly higher in athletes participatingin water polo (40%) and rugby (33.3%).Overall, arthroscopic stabilization for traumatic anterior shoulder instability seems to

be an effective treatment in younger populations, with recurrence rates that approachthe rates seen in collegiate-age populations. Primary surgical treatment after first-timetraumatic anterior shoulder instability may be considered in adolescent patients, giventhe risk of recurrence in these younger populations, and if patients and their familiesare unable or unwilling to modify the child’s activities and sports.

Operative Treatment of Pediatric/Adolescent Multidirectional Shoulder Instability

Operative treatment of MDI can be considered in young patients who have failed con-servative treatment, including activity modification, physical therapy for strengthening,and scapular stabilization, and who continue to have pain and instability in their shoul-ders that interferes with their daily living or sports. Activity modification should beencouraged in this population as part of the initial conservative management. Opera-tive intervention historically was considered a contraindication in patients with volun-tary instability. We agree that these individuals require more intensive preoperativediscussions and explanations as well as more structured postoperative management.However, we do not believe that this group should be viewed differently from other

Pediatric and Adolescent Shoulder Instability 771

young patients with shoulder instability, apart from the issues mentioned. Theseissues are also important to consider before surgery in patients with connective tissuedisorders and global ligamentous laxity.52

Traditional operative treatment of MDI of the shoulder involved open inferiorcapsular shift, as described by Neer and Foster.28 These investigators reported satis-factory results in 39 of 40 patients. Other investigators have described good resultswith open inferior capsular shift for the treatment of MDI.53–58 The rate of recurrentinstability postoperatively varies from 4% to 26%. In Hamada and colleagues’ se-ries,55 which had the highest recurrence rate of 26%, two-thirds of their recurrencesoccurred in patients with voluntary subluxation (50% of patients with voluntary sublux-ation recurred), and eliminating these patients brought their recurrence down to 14%.Patients were able to return to sport postoperatively between 75% and 100% of the

time, but Choi and Ogilvie-Harris57 did note that only 17% of patients who underwentbilateral inferior capsular shifts were able to return to sport, and Altchek and col-leagues53 stated that throwing athletes noted decreased velocity postoperatively.As improvements and closer examination of the success of older stabilization pro-

cedures occur, technique modifications to Neer and Foster’s original description havebeen described. A subscapularis splitting technique has been described to eliminatethe need to detach and reattach the subscapularis tendon.58 In addition, a glenoid-based T-plasty modification has also been described by Altchek and colleagues.53

Reduction in capsular volume has been considered crucial to the success of theprocedure and is proportional to the amount of capsular shift.59

As the treatment of traumatic shoulder instability has gravitated toward arthroscopictechniques, so has the operative treatment of MDI. Advantages of arthroscopic treat-ment include the ability to address anterior, inferior, and particularly posterior diseaseat the same time and close the rotator interval if deemed necessary.60,61 Initial inves-tigations into arthroscopic treatment of MDI used thermal capsulorrhaphy and showedgood results.62,63 However, this technique has fallen out of favor and is no longerrecommended given the concerns over thermal-induced chondrolysis.64–66

Multiple series have shown good results with arthroscopic treatment of MDI of theshoulder.61,67–70 Recurrence rates are reported to be between 2% and 12%, and sub-jective outcome scores report satisfactory results after 88% to 97% of procedures.Baker and colleagues70 reported that 86% of their patients were able to return tosports, with 65% returning to the same level as previously. The ability to tighten thecapsule and attach it to a solid labrum or to fix the redundant capsular tissue to theglenoid rim via a suture anchor technique with newer techniques and equipmenthave greatly improved the ability to address all aspects of capsular laxity of patientswith MDI. This improvement, as mentioned, allows the surgeon to not only reducecapsular volume but to do so selectively to reflect variations in that laxity.One of the specific improvements in surgical technique that has occurred with the

change to arthroscopic techniques is the ability to address the rotator cuff interval.Although the closure of the rotator interval remains a controversial portion of arthro-scopic management of glenohumeral instability, the addition of a closure in selectedpatients is important and can improve outcomes. Harryman and colleagues71 initiallyshowed that in vitro imbrication to the rotator interval capsule resisted inferior andposterior translation. Others72,73 have shown that rotator interval closure may notaffect posterior stability but can affect anterior stability. However, not all unstableshoulders (traumatic or atraumatic) should have the rotator cuff interval closedroutinely, because that closure may restrict external rotation.72,74–76

Outcomes after arthroscopic treatment of MDI seem to show equivalent resultswith open procedures in adolescent populations. In addition, although many series

Milewski & Nissen772

examining MDI operative treatment include adolescent patients, there are no series toour knowledge studying an exclusively pediatric or adolescent patient populationtreated with surgical intervention for MDI. As surgical techniques evolve to treat thiscomplicated spectrum of shoulder disease, our subjective and objective outcomesmeasures also need to evolve. Although judging success based on recurrence rateis certainly an important component to the outcome after these procedures, furtherrefinement of subjective outcomes aimed especially at pediatric or adolescent popu-lations is needed.

OUR PREFERRED TECHNIQUES

Our preferred treatment of pediatric or adolescent patients who have failed conserva-tive treatment of traumatic or MDI is arthroscopic labral repair and capsulorrhaphy us-ing suture anchor fixation. We use lateral decubitus positioning with an adjustable armholder (Spider arm positioner, Smith & Nephew, Memphis, TN) for arthroscopic shoul-der instability surgery (Figs. 4 and 5). After examination under anesthesia and diag-nostic arthroscopy to document the extent and directions of instability and labral/capsular disease, 4 portals are established (standard posterior viewing, posteroinfe-rior, anterosuperior, and anteroinferior portals). The proper placement of these portalscannot be overemphasized. During the placement of each portal, the ability to maneu-ver within the joint to access all aspects of the joint is imperative and should bechecked. Moving or creating additional portals is not common but should be per-formed if better accessibility is needed. We have found that slight modifications ofthe portal placement, especially posteriorly, make the procedure technically easier.The first of these changes is moving the posterosuperior portal more lateral. Tradition-ally, this portal has been placed inferior and medial to the posterolateral corner of theacromion. We believe that this is an appropriate portal for rotator cuff surgery andother procedures when performing surgery in the beach chair position. However, inthe lateral decubitus position, this portal needs to be slightly inferior and as lateral

Fig. 4. Lateral decubitus positioning for right shoulder arthroscopy (side view). Note the useof Spider arm positioner (Smith & Nephew, Memphis, TN).

Fig. 5. Lateral decubitus positioning for right shoulder arthroscopy (overhead view). Notethe use of Spider arm positioner (Smith & Nephew, Memphis, TN).

Pediatric and Adolescent Shoulder Instability 773

as possible when referenced to the posterolateral corner of the acromion. This strat-egy allows us to gain an angle down onto the posterosuperior labrum, making this aworking portal as well as a viewing portal.The next 3 portals are made under direct visualization with the use of an

18-gauge spinal locator needle. The anterosuperior portal is placed above the bi-ceps initially. During the case, it is slipped below the biceps. This procedure givesus the greatest possible separation between the 2 anterior portals and allows moreease of functioning. The anteroinferior portal is placed just superior to the subsca-pularis tendon and is angled inferiorly. To be sure that this placement is achieved,when using the locator needle, after the needle is in place, we let go of the needle. Ifit remains directed inferior, then we believe that it is appropriately placed. However,if the needle direction shifts superiorly after we let go, we re-establish the skinsurface position to allow a better untethered angle. The posteroinferior portal isplaced as inferiorly as we can. This strategy establishes the greatest separationbetween the posterior portals, as performed anteriorly, and allows us to use thisinferior portal for inferior suture anchor placement and inferior capsular plication(Fig. 6).Adequate mobilization of labral and capsular tissue from the glenoid rim is neces-

sary for appropriate tensioning and providing a bleeding base to allow for healing.For both anterior and posterior lesions or combined lesions, capsulorrhaphy, suture,and suture anchors are placed inferiorly first and capsulolabral tissue is advancedto the glenoid rim using a suture passer (Accu-Pass suture shuttles, Smith & Nephew,Memphis, TN) (Fig. 7). This step is repeated as the repair and capsulorrhaphy is

Fig. 6. Bankart lesion. Arthroscopic view of right shoulder from posterior portal.

Milewski & Nissen774

advanced superiorly either anteriorly or posteriorly as the labral bumper is restored.The arm should be taken out of traction at the conclusion of the repair to test stabilityin all directions.

REHABILITATION

Rehabilitation after arthroscopic anterior stabilization for anterior shoulder instability orpancapsular capsulorrhaphy for MDI generally begins with a period of immobilization.We generally use an Ultra-sling (DonJoy, Vista, CA) for 6 weeks postoperatively or untilnormal range of motion is achieved, whichever comes last. Initial rehabilitation centersaround maintaining finger, wrist, and elbow motion. Isometric periscapular muscleactivation is also begun in the first weeks to assist the early discomfort and smoothertransition to advancing stages of rehabilitation. Range of motion activities begins withphysical therapy and home exercise programs, including pendulum exercises, tableslides, and wall pulleys. Isometric shoulder exercises are begun in weeks 2 to 4 andare advanced to isotonic exercises in weeks 4 to 8. Rotator cuff and scapular strength-ening is begun once the sling has been discontinued and range of motion has beenrestored. Stationary bicycle and elliptical use without use of the arms are allowed

Fig. 7. Anterior Bankart lesion after suture anchor fixation and capsulorrhaphy. (Rightshoulder viewed from posterior portal). Note restoration of bumper anteriorly.

Pediatric and Adolescent Shoulder Instability 775

before sling discontinuation. After the sling has been discontinued, jogging andrunning are allowed. At this point, rehabilitation shifts to more strengthening and plyo-metric exercises. After 3 months and once full range of motion as well as near normalstrength have been achieved, we initiate sport-specific training. Isokinetic strengthtesting of shoulder internal and external rotators, along with endurance and powertesting of the upper extremity is performed before return to sport, which is generallyat the 4-month postoperative point. Return to sports is predicated by achieving theserehabilitative milestones as well as the specific sport that is being played. Noncontact,nonoverhead sports are possible often by the 4-month mark. Contact sports aregenerally not allowed before 6 months postoperatively. Overhead sports also areallowed at the 6-month mark, although we normally initiate a tossing or interval-throwing program at 4 months.Rehabilitation after pancapsular procedures for MDI may be progressed more

slowly given the extent of instability, amount of capsular shift needed, and oftenpoor quality of soft tissue in these cases.

SUMMARY

Instability of the shoulder is a common issue faced by sports medicine providers car-ing for pediatric and adolescent patients. A thorough history and physical examinationcan help distinguish traumatic instability frommultidirectional or voluntary instability. Asystematic understanding of the relevant imaging characteristics and individual pa-tient disease and goals can help guide initial treatment. Given the high risk of recurrentinstability, young, active patients who seek to return to competitive contact sportsshould consider arthroscopic stabilization after a first-time instability event. MDIshould be treated initially with conservative rehabilitation. Patients who fail extensiveconservative treatment may benefit from surgical stabilization. Arthroscopic tech-niques may now approach the results found from traditional open capsular shift pro-cedures. Future studies should be designed to examine the outcomes in solelypediatric and adolescent populations after both conservative and operative treatmentof shoulder instability.

REFERENCES

1. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 1956;38(5):957–77.

2. Cleeman E, Flatow EL. Shoulder dislocations in the young patient. Orthop ClinNorth Am 2000;31(2):217–29.

3. Simonet WT, Melton LJ 3rd, Cofield RH, et al. Incidence of anterior shoulderdislocation in Olmsted County, Minnesota. Clin Orthop Relat Res 1984;(186):186–91.

4. Hovelius L. Shoulder dislocation in Swedish ice hockey players. Am J SportsMed 1978;6(6):373–7.

5. Wagner KT Jr, Lyne ED. Adolescent traumatic dislocations of the shoulder withopen epiphyses. J Pediatr Orthop 1983;3(1):61–2.

6. Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of theshoulder in young patients. A ten-year prospective study. J Bone Joint SurgAm 1996;78(11):1677–84.

7. Marans HJ, Angel KR, Schemitsch EH, et al. The fate of traumatic anterior dislo-cation of the shoulder in children. J Bone Joint Surg Am 1992;74(8):1242–4.

8. Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults.Five-year prognosis. J Bone Joint Surg Am 1987;69(3):393–9.

Milewski & Nissen776

9. Robinson CM, Howes J, Murdoch H, et al. Functional outcome and risk of recur-rent instability after primary traumatic anterior shoulder dislocation in youngpatients. J Bone Joint Surg Am 2006;88(11):2326–36.

10. Hovelius L, Olofsson A, Sandstrom B, et al. Nonoperative treatment ofprimary anterior shoulder dislocation in patients forty years of age and younger.A prospective twenty-five-year follow-up. J Bone Joint Surg Am 2008;90(5):945–52.

11. Deitch J, Mehlman CT, Foad SL, et al. Traumatic anterior shoulder dislocation inadolescents. Am J Sports Med 2003;31(5):758–63.

12. Lawton RL, Choudhury S, Mansat P, et al. Pediatric shoulder instability: pre-sentation, findings, treatment, and outcomes. J Pediatr Orthop 2002;22(1):52–61.

13. Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg 2000;9(6):470–4.

14. Emery RJ, Mullaji AB. Glenohumeral joint instability in normal adolescents. Inci-dence and significance. J Bone Joint Surg Br 1991;73(3):406–8.

15. Bak K. Nontraumatic glenohumeral instability and coracoacromial impingementin swimmers. Scand J Med Sci Sports 1996;6(3):132–44.

16. Meeusen R, Borms J. Gymnastic injuries. Sports Med 1992;13(5):337–56.17. Gardner E, Gray DJ. Prenatal development of the human shoulder and acromio-

clavicular joints. Am J Anat 1953;92(2):219–76.18. O’Brien SJ, Arnoczky SP, Warren RF, et al. Developmental anatomy of the shoul-

der and anatomy of the glenohumeral joint. In: Rockwood CA Jr, Matsen FA 3rd,editors. The shoulder, vol. 1. Philadelphia: WB Saunders; 1990. p. 1–33.

19. Sachs RA, Lin D, Stone ML, et al. Can the need for future surgery for acute trau-matic anterior shoulder dislocation be predicted? J Bone Joint Surg Am 2007;89(8):1665–74.

20. Owens BD, Agel J, Mountcastle SB, et al. Incidence of glenohumeral instabilityin collegiate athletics. Am J Sports Med 2009;37(9):1750–4.

21. McLaughlin H. Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;24(3):584–90.

22. Fabian LM, Levine WN. Shoulder instability in young athletes. In: Ahmad CS, ed-itor. Pediatric adolescent sports injuries. Rosemont (IL): American Academy ofOrthopaedic Surgeons; 2010. p. 57–69.

23. Keiser RP, Wilson CL. Bilateral recurrent dislocation of the shoulder (atraumatic)in a thirteen-year-old girl. Report of an unusual case. J Bone Joint Surg Am1961;43:553–4.

24. Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the shoulder. A prelim-inary report on a clinical, electromyographic, and psychiatric study of twenty-sixpatients. J Bone Joint Surg Am 1973;55(3):445–60.

25. Curtis RJ, Dameron TB, Rockwood CA Jr. Fractures and dislocations of theshoulder in children. In: Rockwood CA Jr, Wilkins KE, King RE, editors. Frac-tures in children. Philadelphia: JB Lippincott; 1991. p. 829–919.

26. Gaskill TR, Taylor DC, Millett PJ. Management of multidirectional instability of theshoulder. J Am Acad Orthop Surg 2011;19(12):758–67.

27. Kim SH, Park JS, Jeong WK, et al. The Kim test: a novel test for posteroinferiorlabral lesion of the shoulder–a comparison to the jerk test. Am J Sports Med2005;33(8):1188–92.

28. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multi-directional instability of the shoulder. A preliminary report. J Bone Joint Surg Am1980;62(6):897–908.

Pediatric and Adolescent Shoulder Instability 777

29. Warner JJ, Deng XH, Warren RF, et al. Static capsuloligamentous restraints tosuperior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20(6):675–85.

30. Gagey OJ, Gagey N. The hyperabduction test. J Bone Joint Surg Br 2001;83(1):69–74.

31. Borsa PA, Sauers EL, Herling DE. Patterns of glenohumeral joint laxity andstiffness in healthy men and women. Med Sci Sports Exerc 2000;32(10):1685–90.

32. Pavlov H, Warren RF, Weiss CB Jr, et al. The roentgenographic evaluation ofanterior shoulder instability. Clin Orthop Relat Res 1985;(194):153–8.

33. Huijsmans PE, Haen PS, Kidd M, et al. Quantification of a glenoid defect withthree-dimensional computed tomography and magnetic resonance imaging: acadaveric study. J Shoulder Elbow Surg 2007;16(6):803–9.

34. Gyftopoulos S, Hasan S, Bencardino J, et al. Diagnostic accuracy of MRI inthe measurement of glenoid bone loss. AJR Am J Roentgenol 2012;199(4):873–8.

35. Dewing CB, McCormick F, Bell SJ, et al. An analysis of capsular area in patientswith anterior, posterior, and multidirectional shoulder instability. Am J SportsMed 2008;36(3):515–22.

36. Kim KC, Rhee KJ, Shin HD, et al. Estimating the dimensions of the rotator inter-val with use of magnetic resonance arthrography. J Bone Joint Surg Am 2007;89(11):2450–5.

37. Provencher MT, Dewing CB, Bell SJ, et al. An analysis of the rotator interval inpatients with anterior, posterior, and multidirectional shoulder instability. Arthros-copy 2008;24(8):921–9.

38. Curtis RJ. Glenohumeral instability in the child. In: DeLee JC, Drez DJ,Miller MD, editors. Delee & Drez’s orthopaedic sports medicine, vol. 1. Philadel-phia: Saunders/Elsevier; 2010. p. 932–46.

39. Cordischi K, Li X, Busconi B. Intermediate outcomes after primary traumaticanterior shoulder dislocation in skeletally immature patients aged 10 to 13 years.Orthopedics 2009;32(9). http://dx.doi.org/10.3928/01477447-20090728-34. pii:orthopsupersite.com/view/asp?rID:42855.

40. Hovelius L. The natural history of primary anterior dislocation of the shoulder inthe young. J Orthop Sci 1999;4(4):307–17.

41. Bottoni CR, Wilckens JH, DeBerardino TM, et al. A prospective, randomizedevaluation of arthroscopic stabilization versus nonoperative treatment in pa-tients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med2002;30(4):576–80.

42. Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder withan exercise program. J Bone Joint Surg Am 1992;74(6):890–6.

43. Takwale VJ, Calvert P, Rattue H. Involuntary positional instability of the shoulderin adolescents and young adults. Is there any benefit from treatment? J BoneJoint Surg Br 2000;82(5):719–23.

44. Kuroda S, Sumiyoshi T, Moriishi J, et al. The natural course of atraumatic shoul-der instability. J Shoulder Elbow Surg 2001;10(2):100–4.

45. Misamore GW, Sallay PI, Didelot W. A longitudinal study of patients with multidi-rectional instability of the shoulder with seven- to ten-year follow-up. J ShoulderElbow Surg 2005;14(5):466–70.

46. DeBerardino TM, Arciero RA, Taylor DC, et al. Prospective evaluation of arthro-scopic stabilization of acute, initial anterior shoulder dislocations in youngathletes. Two- to five-year follow-up. Am J Sports Med 2001;29(5):586–92.

Milewski & Nissen778

47. Owens BD, DeBerardino TM, Nelson BJ, et al. Long-term follow-up of acutearthroscopic Bankart repair for initial anterior shoulder dislocations in youngathletes. Am J Sports Med 2009;37(4):669–73.

48. Mazzocca AD, Brown FM Jr, Carreira DS, et al. Arthroscopic anterior shoulderstabilization of collision and contact athletes. Am J Sports Med 2005;33(1):52–60.

49. Jones KJ, Wiesel B, Ganley TJ, et al. Functional outcomes of early arthroscopicBankart repair in adolescents aged 11 to 18 years. J Pediatr Orthop 2007;27(2):209–13.

50. Kraus R, Pavlidis T, Heiss C, et al. Arthroscopic treatment of post-traumaticshoulder instability in children and adolescents. Knee Surg Sports TraumatolArthrosc 2010;18(12):1738–41.

51. Castagna A, Delle Rose G, Borroni M, et al. Arthroscopic stabilization of theshoulder in adolescent athletes participating in overhead or contact sports.Arthroscopy 2012;28(3):309–15.

52. Jerosch J, Castro WH. Shoulder instability in Ehlers-Danlos syndrome. An indi-cation for surgical treatment? Acta Orthop Belg 1990;56(2):451–3.

53. Altchek DW, Warren RF, Skyhar MJ, et al. T-plasty modification of the Bankartprocedure for multidirectional instability of the anterior and inferior types.J Bone Joint Surg Am 1991;73(1):105–12.

54. Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectionalinstability of the shoulder. J Bone Joint Surg Am 1992;74(10):1516–21.

55. Hamada K, Fukuda H, Nakajima T, et al. The inferior capsular shift operation forinstability of the shoulder. Long-term results in 34 shoulders. J Bone Joint SurgBr 1999;81(2):218–25.

56. Pollock RG, Owens JM, Flatow EL, et al. Operative results of the inferior capsularshift procedure for multidirectional instability of the shoulder. J Bone Joint SurgAm 2000;82(7):919–28.

57. Choi CH, Ogilvie-Harris DJ. Inferior capsular shift operation for multidirectionalinstability of the shoulder in players of contact sports. Br J Sports Med 2002;36(4):290–4.

58. Bak K, Spring BJ, Henderson JP. Inferior capsular shift procedure in athleteswith multidirectional instability based on isolated capsular and ligamentousredundancy. Am J Sports Med 2000;28(4):466–71.

59. Wiater JM, Vibert BT. Glenohumeral joint volume reduction with progressiverelease and shifting of the inferior shoulder capsule. J Shoulder Elbow Surg2007;16(6):810–4.

60. Kim SH, Noh KC, Park JS, et al. Loss of chondrolabral containment of the gle-nohumeral joint in atraumatic posteroinferior multidirectional instability. J BoneJoint Surg Am 2005;87(1):92–8.

61. Kim SH, Kim HK, Sun JI, et al. Arthroscopic capsulolabroplasty for posteroinfe-rior multidirectional instability of the shoulder. Am J Sports Med 2004;32(3):594–607.

62. Lyons TR, Griffith PL, Savoie FH 3rd, et al. Laser-assisted capsulorrhaphyfor multidirectional instability of the shoulder. Arthroscopy 2001;17(1):25–30.

63. Favorito PJ, Langenderfer MA, Colosimo AJ, et al. Arthroscopic laser-assistedcapsular shift in the treatment of patients with multidirectional shoulder insta-bility. Am J Sports Med 2002;30(3):322–8.

64. Anderson K, Warren RF, Altchek DW, et al. Risk factors for early failure after ther-mal capsulorrhaphy. Am J Sports Med 2002;30(1):103–7.

Pediatric and Adolescent Shoulder Instability 779

65. Levine WN, Clark AM Jr, D’Alessandro DF, et al. Chondrolysis following arthro-scopic thermal capsulorrhaphy to treat shoulder instability. A report of twocases. J Bone Joint Surg Am 2005;87(3):616–21.

66. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoul-der. J Bone Joint Surg Am 2001;83(Suppl 2 Pt 2):151–5.

67. McIntyre LF, Caspari RB, Savoie FH 3rd. The arthroscopic treatment of multidi-rectional shoulder instability: two-year results of a multiple suture technique.Arthroscopy 1997;13(4):418–25.

68. Treacy SH, Savoie FH 3rd, Field LD. Arthroscopic treatment of multidirectionalinstability. J Shoulder Elbow Surg 1999;8(4):345–50.

69. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of multidi-rectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy 2001;17(3):236–43.

70. Baker CL 3rd, Mascarenhas R, Kline AJ, et al. Arthroscopic treatment of multi-directional shoulder instability in athletes: a retrospective analysis of 2- to5-year clinical outcomes. Am J Sports Med 2009;37(9):1712–20.

71. Harryman DT 2nd, Sidles JA, Harris SL, et al. The role of the rotator intervalcapsule in passive motion and stability of the shoulder. J Bone Joint Surg Am1992;74(1):53–66.

72. Provencher MT, Mologne TS, Hongo M, et al. Arthroscopic versus open rotatorinterval closure: biomechanical evaluation of stability and motion. Arthroscopy2007;23(6):583–92.

73. Mologne TS, Zhao K, Hongo M, et al. The addition of rotator interval closure afterarthroscopic repair of either anterior or posterior shoulder instability: effect onglenohumeral translation and range of motion. Am J Sports Med 2008;36(6):1123–31.

74. Jost B, Koch PP, Gerber C. Anatomy and functional aspects of the rotator inter-val. J Shoulder Elbow Surg 2000;9(4):336–41.

75. Gerber C, Werner CM, Macy JC, et al. Effect of selective capsulorrhaphy on thepassive range of motion of the glenohumeral joint. J Bone Joint Surg Am 2003;85(1):48–55.

76. Plausinis D, Bravman JT, Heywood C, et al. Arthroscopic rotator interval closure:effect of sutures on glenohumeral motion and anterior-posterior translation. Am JSports Med 2006;34(10):1656–61.