Diagnosis and Treatment of Thrower’s Shoulder - Revision history

Alexandre.laedermann at 20:41, 27 January 2020

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Alexandre.laedermann at 16:56, 6 January 2020

2020-01-06T16:56:47Z

Alexandre.laedermann at 23:10, 4 January 2020

2020-01-04T23:10:59Z

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Alexandre.laedermann at 23:05, 4 January 2020

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Alexandre.laedermann at 23:01, 4 January 2020

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Alexandre.laedermann: /* Microinstablity theory */

2020-01-04T22:40:49Z

Microinstablity theory

Alexandre.laedermann: /* Anterior subacromial impingement theory */

2020-01-04T22:40:25Z

Anterior subacromial impingement theory

← Older revision		Revision as of 20:41, 27 January 2020
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−	[[Category:Shoulder]]	+	[[Category:Shoulder]]<ref>Reproduced from Barth J, Graveleau N, Jouve F, Barthélémy R. Diagnostic et traitement de l'épaule du lanceur. In: Société Française D'Arthroscopie PJ, Hulet C., ed. L’arthroscopie. Paris: Elsevier Masson; 2015, with permission.</ref>
−
−	~~''Written by Alexandre Lädermann''~~<ref>Reproduced from Barth J, Graveleau N, Jouve F, Barthélémy R. Diagnostic et traitement de l'épaule du lanceur. In: Société Française D'Arthroscopie PJ, Hulet C., ed. L’arthroscopie. Paris: Elsevier Masson; 2015, with permission.</ref>

	=='''Bullet points'''==		=='''Bullet points'''==

← Older revision		Revision as of 16:56, 6 January 2020
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		+	[[Category:Shoulder]]
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	''Written by Alexandre Lädermann''<ref>Reproduced from Barth J, Graveleau N, Jouve F, Barthélémy R. Diagnostic et traitement de l'épaule du lanceur. In: Société Française D'Arthroscopie PJ, Hulet C., ed. L’arthroscopie. Paris: Elsevier Masson; 2015, with permission.</ref>		''Written by Alexandre Lädermann''<ref>Reproduced from Barth J, Graveleau N, Jouve F, Barthélémy R. Diagnostic et traitement de l'épaule du lanceur. In: Société Française D'Arthroscopie PJ, Hulet C., ed. L’arthroscopie. Paris: Elsevier Masson; 2015, with permission.</ref>

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 ====Arthroscopic rotator cuff repair====
-If the aim is a return to sports activity at the same level, the literature reports better results for debridement rather than repair. There is, however, a selection bias. It seems that the indication for repair relates more to the size of the partial-thickness articular tear (> 50% of its insertion or Ellman grades 2 and 3), indicating a serious development of the thrower’s shoulder pain. Therefore, whereas repairing the rotator cuff results in a good functional index allowing return to sports, it may also spell the sudden end of the professional athlete’s career.
+If the aim is a return to sports activity at the same level, the literature reports better results for debridement rather than repair. There is, however, a selection bias. It seems that the indication for repair relates more to the size of the partial-thickness articular tear (> 50% of its insertion or Ellman grades 2 and 3), indicating a serious development of the thrower’s shoulder pain. Therefore, whereas repairing the rotator cuff results in a good functional index allowing return to sports, it may also spell the sudden end of the professional athlete’s career.<ref>Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears. Am J Sports Med 2011;39:114-20.</ref><ref>Sonnery-Cottet B, Edwards TB, Noel E, Walch G. Rotator cuff tears in middle-aged tennis players: results of surgical treatment. Am J Sports Med 2002;30:558-64.</ref>
 ====Derotational osteotomy====
-This is an invasive procedure reserved only for top level young athletes who are motivated and aware of the risks. In any case, the patient must be informed of all possible complications. The indications remain exceptional.
+This is an invasive procedure reserved only for top level young athletes who are motivated and aware of the risks. In any case, the patient must be informed of all possible complications. The indications remain exceptional.<ref>Riand N, Levigne C, Renaud E, Walch G. Results of derotational humeral osteotomy in posterosuperior glenoid impingement. Am J Sports Med 1998;26:453-9.</ref>
-. Riand N, Levigne C, Renaud E, Walch G. Results of derotational humeral osteotomy in posterosuperior glenoid impingement. Am J Sports Med 1998;26:453-9.[[File:1562639058298-lg.jpg|center|thumb|386x386px|''Figure 38. Derotational osteotomy. Postoperative X-ray of a derotational osteotomy.'']]
+[[File:1562639058298-lg.jpg|center|thumb|386x386px|''Figure 38. Derotational osteotomy. Postoperative X-ray of a derotational osteotomy.'']]
 =='''Conclusion'''==

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 '''Specific tests for superior labral tear from anterior to posterior (SLAP) lesions'''
-The literature is particularly rich on this subject, with almost as many different tests as publications. Despite the often-flattering initial reliability of their promoters, it should be noted that few of these tests are used by other practitioners. Meserve et al., In their 2009 meta-analysis, retain only 6 valid articles out of 198 initially identified (defined by the presence of a descriptive MRI, arthroscopic or arthrotomy reference to the tear, a test used by at least two authors, and the exclusion of cadaveric studies). In the end only the three best tests were retained, which could be consequently adopt.
+The literature is particularly rich on this subject, with almost as many different tests as publications. Despite the often-flattering initial reliability of their promoters, it should be noted that few of these tests are used by other practitioners. Meserve et al., In their 2009 meta-analysis, retain only 6 valid articles out of 198 initially identified (defined by the presence of a descriptive MRI, arthroscopic or arthrotomy reference to the tear, a test used by at least two authors, and the exclusion of cadaveric studies). In the end only the three best tests were retained, which could be consequently adopt.<ref>Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Am J Sports Med 2009;37:2252-8.</ref>
 '''Dynamic Labral Shear test (O’Driscol test)'''
-Shoulder is placed in the extreme abducted and externally rotated position. From this position a valgus stress is applied and a positive response is signified by pain at the shoulder.
+Shoulder is placed in the extreme abducted and externally rotated position. From this position a valgus stress is applied and a positive response is signified by pain at the shoulder.<ref>Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 2012;21:13-22.</ref>
 '''Active compression test (better known as O’Brien’s test)'''
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 '''Kim’s test'''
-Also worthy of mention is Kim's test (Figure), which seems promising but needs to be validated. The patient is supine with the arm abducted at 120 degrees. The examiner takes the patient's wrist with one hand and the elbow flexed at 90 degrees in the other. The shoulder is brought into external rotation. The patient is then asked to flex his elbow against resistance. Deep pain indicates the presence of a superior labral tear from anterior to posterior (SLAP) lesion.
+Also worthy of mention is Kim's test (Figure), which seems promising but needs to be validated. The patient is supine with the arm abducted at 120 degrees. The examiner takes the patient's wrist with one hand and the elbow flexed at 90 degrees in the other. The shoulder is brought into external rotation. The patient is then asked to flex his elbow against resistance. Deep pain indicates the presence of a superior labral tear from anterior to posterior (SLAP) lesion.<ref>Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy 2001;17:160-4.</ref>
-. Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy 2001;17:160-4.[[File:1562635831790-lg.jpg|center|thumb|600x600px|''Figure 23. '''Kim test.''' The patient is supine, arm abducted at 120 degrees. The examiner takes the patient's wrist with one hand and elbow, flexed at 90 degrees, with the other, and the shoulder externally rotated. The patient is then asked to flex his elbow against resistance. Deep pain indicates the presence of a SLAP lesion.'']]
+[[File:1562635831790-lg.jpg|center|thumb|600x600px|''Figure 23. '''Kim test.''' The patient is supine, arm abducted at 120 degrees. The examiner takes the patient's wrist with one hand and elbow, flexed at 90 degrees, with the other, and the shoulder externally rotated. The patient is then asked to flex his elbow against resistance. Deep pain indicates the presence of a SLAP lesion.'']]
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 Magnetic resonance arthrography (MRA) is standard, because it can also reveal the possible presence of a paraglenoid cyst (Figure) communicating with a labral tear, while allowing analysis of any concomitant tears (rotator cuff, osteochondral), and eliminate other causes of pain (acromioclavicular arthropathy, subacromial bursitis, tears relating to a painful and unstable shoulder).
 [[File:1562637041972-lg.jpg|center|thumb|601x601px|''Figure 29. Magnetic resonance arthrography (MRA) coronal sequence showing a large spinoglenoid cyst.'']]
-Reliability depends on both machine and operator efficacy, but Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.
+Reliability depends on both machine and operator efficacy, but Jung et al. report a sensitivity of 85% and a specificity of 86% for superior labral tears.<ref>Jung JY, Yoon YC, Choi SH, Kwon JW, Yoo J, Choe BK. Three-dimensional isotropic shoulder MR arthrography: comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 T. Radiology 2009;250:498-505.</ref>
-. Jung JY, Yoon YC, Choi SH, Kwon JW, Yoo J, Choe BK. Three-dimensional isotropic shoulder MR arthrography: comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 T. Radiology 2009;250:498-505.
+ABER position further improve sensitivity.<ref>Choi JY, Kim SH, Yoo HJ, et al. Superior labral anterior-to-posterior lesions: comparison of external rotation and active supination CT arthrography with neutral CT arthrography. Radiology 2012;263:199-205.</ref>
 ===='''Isokinetic assessment'''====
-Isokinetic studies (Figure) now permit objective quantification of internal and external rotational forces, and especially the definition of ratios for comparative purposes.
+Isokinetic studies (Figure) now permit objective quantification of internal and external rotational forces, and especially the definition of ratios for comparative purposes.<ref>Codine P, Bernard PL, Pocholle M, Herisson C. [Isokinetic strength measurement and training of the shoulder: methodology and results]. Annales de readaptation et de medecine physique : revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de medecine physique 2005;48:80-92.</ref><ref>Gozlan G, Bensoussan L, Coudreuse JM, et al. [Isokinetic dynamometer measurement of shoulder rotational strength in healthy elite athletes (swimming, volley-ball, tennis): comparison between dominant and nondominant shoulder]. Annales de readaptation et de medecine physique : revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de medecine physique 2006;49:8-15.</ref>
 [[File:1562637043024-lg.jpg|center|thumb|600x600px|''Figure 30. Isokinetic shoulder assessment.'']]
 A mechanical isokinetic assessment, while not perfectly simulating throwing conditions, does ensure a reliable, reproducible method for analyzing ratios and their imbalance, with linear tracking over time (to track progress, etc.). It is of major interest because it must be standardized, just as the articular amplitudes must be perfectly symmetrical before considering surgery or return to sports (with or without surgery).

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 Since surgery rarely allows return to sports at the same level, prevention plays an important part. Kibler et al. are very critical when analyzing the results of surgical treatment, which are highly variable, probably due to the very different selection of patients from one author to another, but there is also no precise postoperative follow-up of the tears treated, their localization, concomitant pathologies, and the type of postoperative rehabilitation protocol. Patient motivation is also difficult to gauge. It is therefore important to identify shoulders at risk, typically where one shoulder is lower than the other, with internal or glenohumeral rotation deficits (Figure) and scapular dysfunctions or ‘SICK scapula’ (please refer to clinical examination).
 [[File:1562634000435-lg.jpg|center|thumb|600x600px|''Figure 15. Internal rotational deficit or glenohumeral internal rotation deficit (GIRD) and increased total range of motion deficit total range of motion deficit with external hyperrotation at the expense of internal hyporotation. Glenohumeral internal rotation deficit (GIRD) > 20 degrees characterize a shoulder at risk.'']]
-Scapulothoracic dyskinesia is characterized by detachment of the medial scapular rim, observing the comparative posterior scapulothoracic movements, while the patient raises and lowers both upper limbs in the scapular plane. Stiffness of the pectoralis minor can also be identified. Kibler et al. show that glenohumeral internal rotation deficit (GIRD) and SICK (please refer Clinical Examination/Inspection section) disrupt glenohumeral kinematics. They establish a direct relationship between these dysfunctions and the occurrence of tears, although it is not known how they are causally linked. But they do indicate a strong correlation with increased risk of injury, and that preventive rehabilitation reduces these risks.
+Scapulothoracic dyskinesia is characterized by detachment of the medial scapular rim, observing the comparative posterior scapulothoracic movements, while the patient raises and lowers both upper limbs in the scapular plane. Stiffness of the pectoralis minor can also be identified. Kibler et al. show that glenohumeral internal rotation deficit (GIRD) and SICK (please refer Clinical Examination/Inspection section) disrupt glenohumeral kinematics. They establish a direct relationship between these dysfunctions and the occurrence of tears, although it is not known how they are causally linked. But they do indicate a strong correlation with increased risk of injury, and that preventive rehabilitation reduces these risks.<ref>Kibler WB, Kuhn JE, Wilk K, et al. The disabled throwing shoulder: spectrum of pathology-10-year update. Arthroscopy 2013;29:141-61 e26.</ref>
-. Kibler WB, Kuhn JE, Wilk K, et al. The disabled throwing shoulder: spectrum of pathology-10-year update. Arthroscopy 2013;29:141-61 e26.
+For example, preventive internal rotation stretching (Figure) reduces the risk of injury by 38%.<ref>Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531-9.</ref>
 '''Sleeper stretch'''
 [[File:1562634001655-lg.jpg|center|thumb|600x600px|''Figure 16. Self-stretching using sleeper stretch.'']]
-Regarding motion of the glenohumeral joint, the range in internal and external rotation should remain constant between the dominant and the non-dominant arm, with a shift in the external rotation sector of the dominant arm in overhead throwers (Figure).
+Regarding motion of the glenohumeral joint, the range in internal and external rotation should remain constant between the dominant and the non-dominant arm, with a shift in the external rotation sector of the dominant arm in overhead throwers (Figure).<ref>Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 2003;19:404-20.</ref>
-. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 2003;19:404-20.
+The rotational 180 degrees rule has not been confirmed (Figure), as the mean values of the range of motion is around twice smaller in tennis and handball players.<ref>Lädermann A, Chague S, Kolo FC, Charbonnier C. Kinematics of the shoulder joint in tennis players. Journal of science and medicine in sport 2016;19:56-63.</ref><ref>Levigne C, Garret J, Grosclaude S, Borel F, Walch G. Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes. Clin Orthop Relat Res 2012;470:1571-8.</ref>
 '''Total range of motion'''
@@ Line 181: / Line 171: @@
 Even if, in order to increase throwing power, the athlete moves their total rotational range of motion towards an external hyper-rotation, at the expense of internal rotation. In comparative terms, a GIRD > 20 degrees and a total range of motion asymmetry > 5 degrees represent a shoulder at risk.
-The deceleration phase after throwing is the movement most likely to initiate tears. The main role of the external rotators is to brake and dissipate all the energy accumulated during the acceleration phase, which is transmitted by the rotation of the trunk and lower limbs and concentric internal rotators. It is therefore in eccentric contraction that the external rotators will play this part.Repeated eccentric overload stresses result in intramuscular microtears with chronic inflammation, leading to progressive loss of strength and breaking power; hence the imbalance between the external rotators to internal rotators ratio and the occurrence of injuries. Internal rotators work differently because they are stretching during the cocking phase and concentrically contracting during the acceleration phase.
+The deceleration phase after throwing is the movement most likely to initiate tears. The main role of the external rotators is to brake and dissipate all the energy accumulated during the acceleration phase, which is transmitted by the rotation of the trunk and lower limbs and concentric internal rotators. It is therefore in eccentric contraction that the external rotators will play this part.Repeated eccentric overload stresses result in intramuscular microtears with chronic inflammation, leading to progressive loss of strength and breaking power; hence the imbalance between the external rotators to internal rotators ratio and the occurrence of injuries. Internal rotators work differently because they are stretching during the cocking phase and concentrically contracting during the acceleration phase.<ref>Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Jr., Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med 2010;38:1375-82.</ref>
-. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Jr., Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med 2010;38:1375-82.
+The vast majority of studies show ratios unfavorable to external rotators on the dominant side, between 0.6 and 0.8. In asymptomatic throwers, the internal rotators are stronger than the external rotators on the dominant side, with an average external rotators to internal rotators ratio of 2:3 (ranging from 60% to 80%). Byram et al., in a population of professional baseball pitchers, showed that external rotator weakening (with a low external rotators to internal rotators ratio) significantly increases the likelihood of injury. It is therefore important to rebalance these ratios by strengthening the external rotators to prevent injuries. In case of pain, Wilk et al. recommend a minimum ratio of 66% to allow recovery.<ref>Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Jr., Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med 2010;38:1375-82.</ref><ref>Mikesky AE, Edwards JE, Wigglesworth JK, Kunkel S. Eccentric and concentric strength of the shoulder and arm musculature in collegiate baseball pitchers. Am J Sports Med 1995;23:638-42.</ref><ref>Wilk KE, Andrews JR, Arrigo CA, Keirns MA, Erber DJ. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. Am J Sports Med 1993;21:61-6.</ref>
-The vast majority of studies show ratios unfavorable to external rotators on the dominant side, between 0.6 and 0.8. In asymptomatic throwers, the internal rotators are stronger than the external rotators on the dominant side, with an average external rotators to internal rotators ratio of 2:3 (ranging from 60% to 80%). Byram et al., in a population of professional baseball pitchers, showed that external rotator weakening (with a low external rotators to internal rotators ratio) significantly increases the likelihood of injury. It is therefore important to rebalance these ratios by strengthening the external rotators to prevent injuries. In case of pain, Wilk et al. recommend a minimum ratio of 66% to allow recovery.
+Proprioception is more difficult to quantify than range of motion and muscle strength, but some studies have shown that external hyper-rotation, hyperlaxity and repeated trauma to the joint capsule on the thrower’s dominant side are accompanied by worsening spatial perception of the limb, that can explain loss of control injuries.<ref>Allegrucci M, Whitney SL, Lephart SM, Irrgang JJ, Fu FH. Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports. The Journal of orthopaedic and sports physical therapy 1995;21:220-6.</ref><ref>Blasier RB, Carpenter JE, Huston LJ. Shoulder proprioception. Effect of joint laxity, joint position, and direction of motion. Orthop Rev 1994;23:45-50.</ref>
-. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Jr., Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med 2010;38:1375-82.
+Some authors, such as Kibler et al. or Wilk et al. recommend specific, preventive or curative rehabilitation (pre- or postoperative, using a protocol of stretching, proprioception and muscle strengthening).<ref>Kibler WB, Kuhn JE, Wilk K, et al. The disabled throwing shoulder: spectrum of pathology-10-year update. Arthroscopy 2013;29:141-61 e26.</ref><ref>Wilk KE, Andrews JR, Arrigo CA, Keirns MA, Erber DJ. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. Am J Sports Med 1993;21:61-6.</ref>
 Theory of the cascade of pathological events or posterosuperior instability and superior labral tear from anterior to posterior (SLAP) lesion pathogenesis.
-Starting in 1998, Burkhart, Morgan and Kibler collaborated on a consensual explanation unifying the abovementioned findings. The authors constructed a rational, biomechanical interpretation in the form of a cascade of events involving all the symptoms and tears in thrower’s shoulder. They summarized all the throwing athlete’s dysfunctions and pathologies and conceptualized a theory which, while certainly rational, remains very theoretical because the lack of validation on cadaveric or clinical models (difficult to achieve) make it unverifiable. Nevertheless, they reject both the micro-instability and biomechanical impingement theories.
+Starting in 1998, Burkhart, Morgan and Kibler collaborated on a consensual explanation unifying the abovementioned findings. The authors constructed a rational, biomechanical interpretation in the form of a cascade of events involving all the symptoms and tears in thrower’s shoulder. They summarized all the throwing athlete’s dysfunctions and pathologies and conceptualized a theory which, while certainly rational, remains very theoretical because the lack of validation on cadaveric or clinical models (difficult to achieve) make it unverifiable. Nevertheless, they reject both the micro-instability and biomechanical impingement theories.<ref>Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 2003;19:404-20.</ref><ref>Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes. The "dead arm" revisited. Clinics in sports medicine 2000;19:125-58.</ref>
 '''Suprascapular neuropathy in repetitive overhead athletes'''
@@ Line 255: / Line 225: @@
 '''Relocation test.'''
-[[File:1562635352307-lg.jpg|center|thumb|300x300px|''Figure 19. The patient is positioned supine, with the elbow flexed to 90 degrees and abducted to 90 degrees. The physician then applies an external rotation force to the shoulder, if the patient reports apprehension in any way, the apprehension test is considered to be positive. At this point, the therapist may apply a posteriorly directed force to the shoulder - if the patient's apprehension or pain is reduced in this position, the Jobe’s Relocation test is considered to be positive. It is important to note that the therapist should always release the relocation force before releasing the patient back into neutral rotation for risk of shoulder dislocation.'']]
+[[File:1562635352307-lg.jpg|center|thumb|300x300px|''Figure 19. The patient is positioned supine, with the elbow flexed to 90 degrees and abducted to 90 degrees. The physician then applies an external rotation force to the shoulder, if the patient reports apprehension in any way, the apprehension test is considered to be positive. At this point, the therapist may apply a posteriorly directed force to the shoulder - if the patient's apprehension or pain is reduced in this position, the Jobe’s Relocation test is considered to be positive. It is important to note that the therapist should always release the relocation force before releasing the patient back into neutral rotation for risk of shoulder dislocation.'']]<ref>Jobe F, Tibone J, Jobe C, Kvitne R. The shoulder in sports. In: Rockwood CA MF, eds. , ed. The shoulder. Philadelphia: WB Saunders; 1990:961-90.</ref>
 '''Articular range of motion tests'''

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 ====Microinstablity theory====
-In 1979, Frank Jobe et al. developed the ‘microinstability’ theory, in which anterior instability was caused by repetitive stretching of the anterior capsuloligamentous structures through repeated arm cocking movements. Although success has been reported in 68% of cases with capsular ligamentous retention procedures, the results of capsular tightening were mediocre.
+In 1979, Frank Jobe et al. developed the ‘microinstability’ theory, in which anterior instability was caused by repetitive stretching of the anterior capsuloligamentous structures through repeated arm cocking movements. Although success has been reported in 68% of cases with capsular ligamentous retention procedures, the results of capsular tightening were mediocre.<ref>Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 1991;19:428-34.</ref>
 '''Frank Jobe’s theory'''

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 ====Anterior subacromial impingement theory====
-Neer et al. were among the first to propose this theory, but Tibone et al. showed disappointing results for open acromioplasty, with only 22% of throwers resuming activity at the same performance level.<ref>Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41-50.</ref>
+Neer et al. were among the first to propose this theory, but Tibone et al. showed disappointing results for open acromioplasty, with only 22% of throwers resuming activity at the same performance level.<ref>Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41-50.</ref><ref>Tibone JE, Jobe FW, Kerlan RK, et al. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin Orthop Relat Res 1985:134-40.</ref>
 ====Microinstablity theory====