Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders

doi:10.1016/S1058-2746(09)80022-0

Journal of Shoulder and Elbow Surgery

Volume 3, Issue 6, November–December 1994, Pages 371-380

https://doi.org/10.1016/S1058-2746(09)80022-0 Get rights and content

Shoulder proprioception was measured in 90 subjects who were assigned to three experimental groups: group 1 (n = 40), healthy college-age subjects; group 2 (n = 30), patients with anterior instability; and group 3 (n = 20), patients who have had surgical reconstruction. Kinesthesia and joint position sense were measured with a specially designed proprioception testing device. The results revealed no significant differences in proprioception between dominant and nondominont shoulders in group 1 for any test condition. Significant differences (p < 0.05) were revealed between the unstable and uninvolved shoulder for both kinesthesia and joint position sense in group 2. No significant mean differences were revealed between the surgical and contralaterol shoulder in group 3 under any test condition. This series of studies provides evidence that proprioceptive deficits caused by partial deafferentiation result when copsuloligomentous structures are damaged. Reconstructive surgery appears to restore some of these proprioception characteristics.

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Proprioception is our sense of body awareness, including the sub-category of active joint position sense (AJPS). AJPS is fundamental to joint stability and movement coordination. Despite its importance, there remain few confident ways to measure upper limb AJPS in a clinic.
To assess a new AJPS clinical tool, the Upper Limb Proprioception Reaching Test (PRO-Reach; seven targets), for discriminant validity, intra-rater and absolute reliability.
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Seventy-five healthy participants took part in a single session with 2 consecutive evaluations (E1 and E2) (within-day reliability). Twenty participants were randomly selected to perform a dominant shoulder fatigue protocol (discriminant validity), whereafter a third evaluation was repeated (E3). The PRO-Reach was analyzed with paired t tests (discriminant validity), intra-class correlation coefficients (ICCs) and minimal detectable change [MDC]) (intra-rater: within-day and between-trial relative and absolute reliability).
The PRO-Reach supports moderate (mostly superior targets) to excellent (mostly inferior targets) reliability. Between-trial ICCs (T1/T2/T3) varied between 0.72 and 0.90, and within-day (E1/E2) ICCs between 0.45 and 0.72, with associated MDC₉₅ values (3.9–5.0 cm). The overall scores (seven targets) supported the strongest within-day reliability (ICC = 0.77). The inferior targets demonstrated the highest between-trial and within-day reliability (ICCs = 0.90 and 0.72). A fatigue effect was found with the superior and superior-lateral targets (P < .05).
The inferior targets and overall scores demonstrate the strongest reliability. The use of the PRO-Reach tool may be suitable for clinical use upon further psychometric testing amongst pathological populations.
Level III cross-sectional study.
Ageing and joint position sense of the asymptomatic shoulder: An observational study
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This study aimed to quantify the extent to which age was associated with joint position sense (JPS) of the asymptomatic shoulder as measured by joint position reproduction (JPR) tasks and assess the reproducibility of these tasks.
120 Asymptomatic participants aged 18–70 years each performed 10 JPR-tasks. Both contralateral and ipsilateral JPR-tasks were evaluated on accuracy of JPR under active- and passive conditions at two levels within the shoulder forward flexion trajectory. Each task was performed three times. In a subgroup of 40 participants, the reproducibility of JPR-tasks was assessed one week after initial measurement. Reproducibility of JPR-tasks was evaluated by both reliability (intra-class correlation coefficients (ICC’s)) and agreement (standard error of measurement (SEM)) measures.
Age was not associated with increased JPR-errors for any of the contralateral or ipsilateral JPR-tasks. ICC’s ranged between 0.63 and 0.80 for contralateral JPR-tasks, and from 0.32 to 0.48 for ipsilateral tasks, except for one ipsilateral task where the reliability was similar to contralateral tasks (0.79). The SEM was comparable and small for all JPR-tasks, ranging between 1.1 and 2.1.
No age-related decline in JPS of the asymptomatic shoulder was found, and good agreement between test and re-test measurements for all JPR-tasks as indicated by the small SEM.
Patients with recurrent anterior shoulder instability exhibit altered glenohumeral and scapulothoracic joint kinematics during upper limb movement: A prospective comparative study
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Altered shoulder kinematics in patients with recurrent anterior shoulder instability remains poorly understood. This prospective study aimed to quantify in vivo glenohumeral and scapulothoracic joint kinematics and joint-contact positions in patients with shoulder instability and healthy controls.
Twenty patients with recurrent anterior shoulder instability (mean 28 years) and five patients without shoulder pathology (mean 39 years) were scanned using open CT in six static upper limb positions including 90° of abduction, combined abduction and external rotation, 90° of flexion, lift-off position (i.e. reaching behind the back) and the neutral shoulder with external rotation. Image datasets were digitally reconstructed to quantify shoulder joint kinematics and glenohumeral translation.
At 90° of abduction, instability patients demonstrated significantly less glenohumeral abduction and a reciprocal increase in upward scapulothoracic rotation compared to controls (mean difference: 13.3°, p = 0.038). With the shoulder in combined abduction and external rotation, instability patients showed a significant increase in glenohumeral rotation and a reciprocal decrease in scapulothoracic rotation compared to controls (mean difference: 5.0°, p = 0.042). There were no significant differences in humeral head translation in the sagittal plane (anterior-posterior axis) for all motions tested (p > 0.05).
Scapulothoracic and glenohumeral kinematics are significantly different between patients with recurrent anterior shoulder instability and those with a healthy shoulder. Instability patients compensate for reduced glenohumeral function during abduction by increasing scapular rotation. With the shoulder in combined abduction and external rotation position, greater glenohumeral joint angles without significantly increased humeral head translation suggest altered neuromuscular control in the unstable shoulder.
The effect of neck muscle fatigue on shoulder humeral rotation joint position sense
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Cervical extensor muscle (CEM) fatigue causes decrements in upper limb proprioceptive accuracy during constrained single-joint tasks. This study used a novel humeral rotation joint position sense (JPS) measurement device to compare JPS accuracy in participants who received acute CEM fatigue vs. non-fatigued controls.
Participants had vision occluded and were passively guided into postures of internal humeral rotation from a baseline posture before and after a CEM fatigue or control protocol. Mixed model repeated measures ANOVAs were used to verify fatigue and compared absolute, constant, and variable JPS error between groups.
CEM fatigue was verified via pre-post reduction in CEM strength, and myoelectric indicators of fatigue. However, between-group comparisons of absolute, constant, and variable JPS error were not statistically significant, despite having large effect sizes.
Contrary to prevailing literature, unconstrained humeral rotation JPS did not appear to be affected by CEM fatigue in this study. However, between-group differences in JPS error were dwarfed by inter-trial variability, which likely arose due to the unconstrained nature of this task, conflating chances for a Type II error. Future research should perform a kinematic analysis of task constraints to highlight potential compensatory mechanisms obscuring significant findings in this otherwise robust effect.
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Proprioceptive feedback is a reflex dislocation prevention mechanism that contributes to shoulder joint stability. In patients with Bankart lesions, the anteroinferior glenohumeral ligament complex is damaged and reduces the likelihood of tensile stress. As a result, proprioceptive feedback does not work, which leads to instability. Surgical reconstruction is indicated to restore proprioception, but the details of recovery after arthroscopic surgery are unknown. The purpose of this study is to investigate whether arthroscopic Bankart repair can improve the position sense of the shoulder.
We used the isokinetic dynamometer Biodex System 3 (Biodex, Shirley, NY, USA) to investigate preoperative and postoperative joint position sense in 140 shoulders (137 men, 3 women) undergoing arthroscopic Bankart repair for traumatic shoulder joint instability. The control subjects comprised 40 shoulders of healthy volunteers (all men). Active position sense was measured by setting the shoulder external rotation to 75° based on 90° abduction and neutral internal/external rotation position. Reproductive angle inaccuracy (RAI) was measured thrice, and the mean value was calculated. The RAI was measured preoperatively, 6 months and 1 year postoperatively, and at the final observation (range, 16-96 months; mean, 31.5 months).
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Anterior shoulder stabilization surgery is the preferred method to treat shoulder instability in athletes; however, a variety of surgical techniques exist. The rehabilitation specialist needs to have a basic understanding of each procedure to properly protect healing structures while restoring range of motion, strength, and functional abilities. Few evidence-based guidelines exist for rehabilitation after anterior shoulder stabilization, and those that are available are specific to the standard arthroscopic approach. Further, even less guidance is available for the later stages of rehabilitation and return to sports preparation and decision making. In this review article, rehabilitation considerations and alterations for variations of anterior shoulder stabilization surgery are presented. The importance of individualizing late-stage rehabilitation and incorporating core and lower extremity exercises as appropriate is also discussed. Lastly, rationale for criteria-based return to sports assessments to aid clinical decision making is presented.

View all citing articles on Scopus

: 1994 Charles S. Neer Award for Outstanding Basic Science Research, American Shoulder and Elbow Surgeons.

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Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders

Brain Res

Clin Sports Med

Brain Res

Brain Res

J Biomech

Neurosci Res

Op Tech Orthop

T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types

J Bone Joint Surg [Am]

Joint laxity and proprioception in the knee

Phys Sports Med

Proprioception in the anterior cruciate ligament deficient knee

Am J Sports Med

Joint kinesthesia in the highly trained knee

J Sports Med

Joint proprioception in normal, osteoarthritic and replaced knees

J Bone Joint Surg [Br]

The effect of joint compression on stability of the glenohumeral joint

Trans Orthop Res Soc

Anterior stability of the glenohumeral joint: a dynamic model

Am J Sports Med

Slowly adapting receptors on cat knee joint: can they signal joint angle?

J Neurophysiol

Histological evaluation of the trophism and proprioceptivity of untreated anterior cruciate ligament lesions (pt 1). Biological ACL reconstruction with patellar tendon (pt 2). Failure of biological ACL reconstruction with semitendinosus (pt 3)

Knee joint cruciate ligament substitution: the Lindemann procedure

S Afr J Surg

The responses of slowly adapting mechanoreceptors in cat knee joint to tetanic contraction of hind limb muscles

Q J Exp Physiol

The etiology and prevention of functional instability of the foot

J Bone Joint Surg [Br]

Joint sense muscle sense and their combination as position sense, measured at the distal interphalangeal joint of the middle finger

J Physiol (Lond)

Position sense following joint injury

J Sports Med

Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability

J Bone Joint Surg [Am]

Neurohistological findings after experimental anterior cruciate ligament allograft transplantation

Arch Orthop Trauma Surg

The contribution of muscle afferent to kinesthesia shown by vibration induced illusion of movements and effect of paralysing joint afferents

Brain

A complete electromyographic analysis of the shoulder during pitching

Am J Sports Med

Properties of ruffini afferents revealed by stress analysis of isolated sections of cats knee capsule

J Neurophysiol

Ruffini mechanoreceptors in isolated joint capsule: reflexes correlated with strain energy density

Somatosensory Res

Properties of Golgi-Mazzoni afferents in cat knee joint capsule as revealed by mechanical studies of isolated joint capsules

J Neurophysiol