1.    Voluntary dislocators—may signify underlying psychiatric disturbance or improper habitual muscle firing pattern

2.    Noncompliant or poorly motivated patients—may have issues of secondary gain

1.    Chronic overuse in an athletic patient with episodes of instability after minor trauma.

2.    Patient with preexistent laxity becomes symptomatic with minimal trauma or even activities of daily living.

3.    Relatively rare subgroup of patients with genetic or heritable hypermobility (e.g., Ehlers-Danlos syndrome, Marfan’s syndrome, etc.).

4.    Clinical history can often be vague, complex, and difficult to sort out.

1.    May have systemic ligamentous laxity—hyperextension of elbows, thumbs, knees, etc.

2.    Sulcus sign, anterior and posterior load-and-shift tests, anterior and posterior apprehension tests, jerk test. Determine primary direction of instability—anterior, posterior, or multidirectional.

3.    Important to reproduce symptoms with provocative testing—laxity alone is not an indicator of instability. Examine both shoulders for comparison.

1.    Plain radiographs may demonstrate humeral head defects and glenoid lesions.

2.    MRI, contrast enhanced MRI, or double-contrast CT arthrogram may demonstrate increased capsular volume and capsular or ligamentous injury.

1.    Standard arthroscopy equipment

2.    Suture hooks (Linvatec): curved right, left, and crescent hooks (15, 20, and 25 mm)

3.    #1 PDS, Panacryl, or Ethibond suture

4.    Shaver blades: 4 mm whisker; 4 mm aggressive; 4 mm well-hooded barrel burr

5.    Arthroscopic periosteal elevator

6.    Cannulas: 8.5 mm threaded and 5 mm universal

7.    Switching sticks

8.    Suture anchor insertion instrument set (Mitek)

9.    Arthroscopic knot pusher and suture cutter

1.    General

2.    Regional block (interscalene)

1.    Lateral decubitus on beanbag, with patient leaning back 20 to 30 degrees.

2.    Operating room table: Rotated 120 degrees to place anesthesia out of way, below the level of the umbilicus. This gives the surgeon 180 degrees of access to the shoulder.

3.    Traction: This technique necessitates a twin traction configuration. A distal traction of 10 lbs at 20 degrees of abduction, 20 degrees of forward flexion, and a proximal traction of 15 lbs at a right angle to the axis of the distal traction. This internally rotates the arm and distracts the glenohumeral joint.