Labrum (instability) Classifications

Silliman & Hawkins Classification

Silliman J, Hawkins RJ, CORR ,291:7-19,1993

1. Voluntary
2. Involuntary:
   1. Anterior
      1. Traumatic – Acute / chronic
      2. Subluxation / dislocation
      3. Atraumatic – overuse / hyperlaxity
   2. Posterior
      1. Traumatic – Acute / chronic
      2. Subluxation / dislocation
      3. Atraumatic- overuse / hyperlaxity
   3. MDI
      1. Traumatic- Acute / chronic
      2. Subluxation / dislocation
      3. Atraumatic- overuse / hyperlaxity
         

Gleno-humeral Translation: Hawkins

Hawinks R et al, Orthop Trans, 12: 727,1988

Grade 1:     0-25% translation - minimal

Grade 2:     25-50% translation - humeral head translates up to the glenoid rim

Grade 3:     > 50% translation - up to the rim and over

Recurrent instability: Neer and Foster classification

Neer II CS, JBJS (A) 62:897-908, 1980

1.     Atraumatic - congenital laxity: generalised joint laxity
                         No labral/ bony changes
                         ill defined 1st dislocation
2.    Traumatic- one major injury: no joint laxity
                       specific labral/ humeral head/ glenoid lesion
                       definite injury, needs reduction
3.    Acquired- repeated minor events:   repeated minor injury

                    increased joint volume
                    Labral / bone changes develop late
                    Threat of MDI

Shoulder instability: Matsen’s classification

Matsen EA et al, Clin Sports Med,10:783-788, 1991

TUBS:     Trauma
            Unidirectional
            Bankart
            Surgery

AMBRII:   Atraumatic
            Multidirectional   
            Bilateral
            Rehabilitation
            Inferior capsule and Interval

Shoulder instability: Gerber’s classification

Gerber C et al, CORR, 400:65-76, 2002

Class A: Static Instabilities

• Class A1:     static superior subluxation
• Class A2:     static anterior subluxation
• Class A3:     static posterior subluxation
• Class A4:     static inferior subluxation

Class B: Dynamic Instabilities

• Class B1:     chronic locked dislocation of the shoulder
• Class B2:   Unidirectional instability without hyperlaxity
• Class B3:     Unidirectional instability with hyperlaxity
• Class B4:     multidirectional instability without hyperlaxity
• Class B5:     multidirectional instability with hyperlaxity
• Class B6:     multidirectional or unidirectional instability with voluntary instability

Class C: Voluntary dislocations

Shoulder instability: Bayley classification

Bayley I, In: The 17th Congress of the European Society for the Surgery of the Shoulder  and the Elbow, Germany 2003.

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1. Traumatic structural
       a. acute
       b. persistent
       c. recurrent
2.  Atraumatic structural
       a. recurrent
3.  Non-structural (muscle patterning)

a. recurrent

b. persistent

Anterior-inferior instability: Habermeyer classification

In: Schulterchirurgie. Edited by Habermeyer P, 237-271, Urban and Fischer, 2002

1. Bankart line

• Classic Bankart lesion
• Double labral lesion- labrum detached from glenoid and IGHL
• Bony Bankart lesion

2. Perthe’s Line

• Classic Perthes- labrum detached from the glenoid rim with IGHL (which is detached sub-periosteally from scapular neck)
• ALPSA leion
• Triple labral lesion-labrum avulsed from glenoid rim, from IGHL with subperiosteal detachment of IGHL from scapular neck
• Extralabral ligament lesion- IGHL avulsed from glenoid, labrum intact

3. Capsular line

• Non Bankart lesion- hypoplastic labrum, IGHL inserts on medial scapular neck
• Substantial defect of IGHL - intra-ligamentous defects and elongation of IGHL
• Quattro labral lesion- avulsion and wear of entire labrum-ligament complex
• HAGL lesion- humeral avulsion of IGHL, associated with subscap tears

4. GLAD lesion 

• chondral lesion at transition zone to labrum, no labral detachment

Posterior Shoulder instability: Ramsey and Klimkiewicz

In: Disorders of the Shoulder: diagnosis and Management. Edited by Iannotti J, 295-319,  Lippincott Williams and Wilkins, 1999

1.Posterior dislocation

• Acute posterior dislocation
• Chronic locked posterior dislocation

2. Recurrent posterior dislocation

• Volitional- psychogenic
• Dysplastic- glenoid / humeral head retroversion
• Acquired - soft tissue / bony deficiency

Glenoid rim lesions: Bigliani classification

Bigliani L U et al, Am J of Sports Med, 26:41-45, 1998

Type 1: united fragment attached to seperated labrum

Type 2: malunited fragment detached from labrum

Type 3A: anterior glenoid deficiency < 25%

Type 3B: anterior glenoid deficiency > 25%

Hill-Sachs lesion: Arthroscopic classification  by Calandra

Calandra JJ et al, Arthroscopy, 5:254-257, 1989

Grade 1: defect in articular surface down to, but not including subchondral bone

Grade 2: defect in articular surface including subchondral bone

Grade 3: large defect in subchondral bone

Hill-Sachs lesion: Classification by Burkhart and De Beer

Burkhart SS, De Beer JF, Arthroscopy, 16:677-694, 2000

Engaging Hill Sachs lesion:

• lesion that presents its long axis parallel to the anterior glenoid rim in a functional position of 90 deg abduction and external rotation of the shoulder.
• Engagement occurs over the anterior rim

Non- Engaging Hill Sachs lesion:

• lesion that presents its long axis at a diagonal to the anterior glenoid rim in a functional position of 90 deg abduction and
• external rotation of the shoulder.
• Lesion passes diagonally across the anterior glenoid thus engagement does not occur

Stages of evolution of labrum / capsule lesions in post traumatic anterior instability: Gleyze and Habermeyer

Habermeyer P et al, JSES, 8: 66-74, 1999

Stage 1:     Isolated labrum detachment on a periosteal hinge (Bankart lesion)

Stage 2:     Combined IGHL and labral detachment lesion (Perthes lesion)

Stage 3:     Triple lesion with degenerative changes of the detached structures

Stage 4:     Quadruple lesion- labrum / ligament complex progressively disappears

Shoulder dysfunction in the overhand throwing athlete: Jobe’s classification

Jobe EW et al, Orthop Rev 18: 963-975, 1989

Group 1:

• pure impingement
• no instability

Group 2:

• Primary instability due to chronic labrum / capsule microtrauma
• Secondary impingement:  internal / subacromial

Group 3:

• Primary instability due to ligamentous hyperlaxity
• Secondary impingement:  internal / subacromial

Group 4:

• Primary instability (traumatic)
• no impingement

Arthroscopic classification of labrum / capsule lesions in post-traumatic chronic anterior instability : Boileau

In: Nice Shoulder Course, Edited by Boileau P, 35-46 , Nice, 2003

Labral lesions:

1. Classic bankart lesion
2. Bankart lesion with detachment of superior labrum and biceps anchor
3. Bankart lesion with detachment of posterior labrum
4. Circumferential labrum detachment
5. Absent Bankart lesion

Ligament lesions:

1. Isolated detachment of IGHL from glenoid
2. detachment of IGHL from glenoid with intraligamentous tears; detachment of IGHL from glenoid and humeral side with intra-ligamentous tears
3. Pure intra-ligamentous lesion of the IGHL without glenoid / humeral side detachment

Scapular Dyskinesis: Kibler Classification

Kibler WB et al, J Am Acad of Orthop Surg, 11:142-151, 2003

Type 1: prominent inferior medial scapular border. Motion around transverse axis

Type 2: Prominent entire medial scapular border. Abnormal rotation around vertical axis

Type 3: Prominent superior medial border of scapula, superior translation of entire scapula