Multidirectional instability of the shoulder: a systematic review with a novel classification.

Purpose: A variety of instabilities are grouped under multidirectional instability (MDI) of the shoulder. This makes understanding its diagnostic process, presentation and treatment difficult due to lack of evidence-based consensus. This review aims to propose a novel classification for subtypes of MDI. Methods: A systematic search was performed on PubMed Medline and Embase. A combination of the following 'MeSH' and 'non-MesH' search terms were used: (1) Glenohumeral joint[tiab] OR Glenohumeral[tiab] OR Shoulder[tiab] OR Shoulder joint[tiab] OR Shoulder[MeSH] OR Shoulder joint[MeSH], (2) Multidirectional[tiab], (3) Instability[tiab] OR Joint instability[MeSH]. Sixty-eight publications which met our criteria were included. Results: There was a high degree of heterogeneity in the definition of MDI. Thirty-one studies (46%) included a trauma etiology in the definition, while 23 studies (34%) did not. Twenty-five studies (37%) excluded patients with labral or bony injuries. Only 15 (22%) studies defined MDI as a global instability (instability in all directions), while 28 (41%) studies considered MDI to be instability in two directions, of which one had to include the inferior direction. Six (9%) studies included the presence of global ligamentous laxity as part of the definition. To improve scientific accuracy, the authors propose a novel AB classification which considers traumatic etiology and the presence of hyperlaxity when subdividing MDI. Conclusion: MDI is defined as symptomatic instability of the shoulder joint in two or more directions. A comprehensive classification system that considers predisposing trauma and the presence of hyperlaxity can provide a more precise assessment of the various existing subtypes of MDI. Level of Evidence: III.