Interprofessional Inconsistencies in the Diagnosis of Shoulder Instability: Survey Results of Physicians and Rehabilitation Providers

Abstract

Background Clinicians of many specialties within sports medicine care for athletes with shoulder instability, but successful outcomes are inconsistent. Consistency across specialties in the diagnosis of shoulder instability is critical for care of the athlete, yet the extent of divergence in its diagnosis is unknown. Hypothesis Physicians differ from rehabilitation providers in which findings they deem clinically important to differentiate shoulder instability from impingement, and in how they diagnose athlete scenarios with atraumatic shoulder instability. Study Design Cross-sectional study. Methods Physicians (orthopaedic surgeons, primary care sports medicine physicians) and rehabilitation providers (physical therapists, athletic trainers) were asked via an online survey to rate clinical factors used to diagnose shoulder instability. Clinicians were also asked to diagnose two athlete scenarios with concurrent clinical findings of atraumatic shoulder instability and impingement, differentiated by the absence or presence of a positive sulcus sign. Results Responses were recorded from 888 clinicians. Orthopaedic surgeons (N=170) and primary care sports medicine physicians (N=108) ranked physical examination factors as more important for the diagnosis of shoulder instability than patient history factors, whereas physical therapists (N=379) and athletic trainers (N=231) preferred patient history factors. Orthopaedic surgeons differed from physical therapists and athletic trainers in their clinical diagnoses for both scenarios ( P ≤0.001). Conclusion A lack of consistency exists among sports medicine clinicians in recognizing which clinical factors are important when used to diagnose shoulder instability and in diagnoses given with concurrent findings of impingement. Level of Evidence Level 3.

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability

“…Consistent with the previous literature, a high degree of consensus was achieved in the diagnostic workup of AGHI. 4,5,41 This was most evident in the use of physical examination maneuvers, such as the apprehension and relocation tests, which saw 100% and 90% agreement on use, respectively. A recent consensus statement from the Anterior Shoulder Instability International Consensus Group (ASI-ICG) aligns with this finding, with 95% agreement on appropriate physical examination maneuvers.…”

“…Areas of debate include diagnostic methodologies, 4,5 when nonoperative management may be appropriate, 6,7 and what operative interventions yield the greatest patient benefit based on specific prognostic factors for the prevention of recurrent AGHI. [8][9][10][11] Clinical frameworks, such as the instability severity index score (ISIS), 12 have emerged and been validated [13][14][15] to facilitate decision making.…”

Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population

“…Shoulder instability can be defined as undesirable translation of the humeral head in the glenoid fossa leading to pain or discomfort [2]. It can occur after structural damage to the glenohumeral joint following traumatic dislocations or repetitive microtrauma, or be attributable to ligamentous laxity and/or abnormal muscle patterning [3,4].…”

Current Evidence in Shoulder Instability in the Paediatric and Adolescent Population

“…Shoulder instability can be defined as undesirable translation of the humeral head in the glenoid fossa leading to pain or discomfort [2]. It can occur after structural damage to the glenohumeral joint following traumatic dislocations, repetitive microtrauma, or be attributable to ligamentous laxity and/ or abnormal muscle patterning [3].…”