Title for systematic review

The effectiveness of arthroscopic versus open shoulder stabilization in the management

of traumatic anterior glenohumeral instability
Centre conducting the review
Centre for Allied Health Evidence: A Collaborating Centre of the Joanna Briggs Institute,
in collaboration with the Centre for Health, Exercise and Sports Medicine (CHESM),
School of Physiotherapy, The University of Melbourne
Contact for review / primary reviewer
Dr Andrea BIALOCERKOWSKI
School of Physiotherapy
The University of Melbourne VIC 3010
phone
03 8344 6435
fax
03 8344 1988
email
aebial@unimelb.edu.au
Review panel
Team leaders
o Dr Andrea Bialocerkowski - School of Physiotherapy, The University of
Melbourne / Centre for Allied Health Evidence
o Dr Rana Hinman Centre for Health, Exercise and Sports Medicine
(CHESM), School of Physiotherapy, The University of Melbourne
o Mr Choong W Ng Centre for Health, Exercise and Sports Medicine
(CHESM) Research, School of Physiotherapy, The University of
Melbourne
Expert review panel
CHESM Research Group a multidisciplinary group of 15-20 researchers who meet on a
weekly basis to discuss and critically appraise current musculoskeletal research studies.
Commencement date
November 2004
Expected completion date
November 2005

Background
Anterior glenohumeral instability is a common consequence of a traumatic anterior
shoulder dislocation. The shoulder is the most commonly dislocated joint in the body,
accounting for approximately 45% of all joint dislocations.1 Shoulder dislocations have
been reported to affect about 2% of the population2 and as much as 98% of these shoulder
dislocations are anterior displacements.3 Although the young and the old have
comparable primary incidence rates of shoulder dislocations, recurrent instability is agedependent and occurs more frequently in younger patients.4,5 Kralinger et al6 found that
patients between 21 and 30 years old have a significantly higher risk for recurrent
dislocations. Recurrent dislocation rates greater than 90% have been reported for patients
younger than 30 years old.4,7,8
As a result of the trauma and mechanism of anterior shoulder dislocation, a broad
spectrum of pathology is attributed to the development of anterior glenohumeral
instability. The most common pathological finding is the detachment of the capsulolabral
complex from the anterior glenoid rim and scapular neck, known as a Bankart lesion.
Bankart lesions are present in approximately 87% of all traumatic anterior glenohumeral
instability.9 Other pathologies that could contribute to anterior glenohumeral instability
include superior-labral anterior and posterior (SLAP) lesions10, ventral capsule (capsular
mechanism) or glenohumeral ligaments insufficiency,11,12 long head of biceps tendon
pathology,13 large Hill-Sachs (posterolateral humeral head fractures) compression
fractures and rotator interval capsule (between the inferior border of supraspinatus tendon
to the superior border of subscapularis tendon) insufficiency.14 However these lesions,
when present in isolation, rarely account for recurrent anterior shoulder dislocations.15
But when occurring in combination, with a Bankart lesion, surgical procedures that
address the Bankart lesion, without restoring capsuloligamentous tension or other
pathologies, are likely to have a poor success rate.15
In initial shoulder dislocations, conservative management has always been the treatment
of choice. However, the high incidence of recurrent instability in young patients has
prompted surgeons to consider surgical shoulder stabilization as a primary management
option.6,16 When conservative management fails to prevent recurrent instability, surgical
shoulder stabilization is recommended. Consistent low rates of recurrent instability
(<10%) following open shoulder stabilization, have led to this method being advocated as
the gold standard in the treatment of traumatic anterior glenohumeral instability.17,18
However the advent and rapid development of arthroscopy from a diagnostic to a surgical
interventional tool, has challenged open shoulder stabilization as the method of choice.
Arthroscopic shoulder stabilization has been reported to offer several advantages over
open shoulder stabilization. These advantages include reduced post-surgical morbidity
and pain, shorter surgery time, improved cosmesis and greater post-surgical range of
motion, especially external rotation.17,19 Today, a broader definition of success not only
encompasses the restoration of glenohumeral stability but also a painless and functional
shoulder range of motion specific to the demands of the individual. Arthroscopic
shoulder stabilization may therefore better meet these demands.

It is presently unclear which method of surgical stabilization is superior (if any) for the
management of traumatic anterior glenohumeral instability. The variable and conflicting
outcomes reported in the published literature prove difficult to interpret. In addition, there
are inconsistent and contradictory indications and recommendations for arthroscopic
shoulder stabilization.20
There have been attempts by authors to collate the results of arthroscopic studies (case
series)21 as well as comparative studies of arthroscopic with open shoulder stabilization22,
in the management of anterior glenohumeral instability. Freedman et al22 performed a
meta-analysis comparing the success of arthroscopic techniques to open shoulder
stabilization. However, the requirement of a meta-analysis to contain a clinically
homogenous patient population and consistent outcome measures, may have resulted in
the exclusion of some important studies and thus influenced the conclusion. Similar to the
study by Freedman et al22, the main focus of this systematic review is to determine if
arthroscopic shoulder stabilization is equally effective as open shoulder stabilization in
the management of traumatic anterior glenohumeral instability. However this review will
serve to update and complement the findings of Freedman et al22, through an exhaustive
and explicit search strategy and a rigorous methodological analysis of the published
literature. In line with the notion of evidence-based practice, this review aims to
synthesize the available research evidence in an attempt to guide clinical decisionmaking.

Objectives
The objective of this systematic review is to compare the effect of arthroscopic
stabilization with open surgical stabilization for the management of traumatic anterior
glenohumeral instability. We aim to address the following questions that are of clinical
interest:
1. Is arthroscopic stabilization equally effective as open surgical stabilization in the
management of anterior glenohumeral instability for:
a. The general population?
b. Population sub-groups?
2. Are there any differences in the outcome of various arthroscopic techniques
(suture anchors, bioabsorbable tacks, transglenoid sutures and metallic fixators)
for shoulder stabilization, compared with open surgical stabilization?
3. What factors and prognostic indicators are considered when deciding between
arthroscopic versus open surgical stabilization for the management of anterior
glenohumeral instability?
Definitions
Trauma: physical injury caused by violent or disruptive action23
Glenohumeral instability: lack of ability to resist unwanted glenohumeral translation and
maintain the humeral head in congruence with the glenoid fossa, leading to the loss of
comfort and function of the joint as a result of apprehension, recurrent subluxations or
dislocations
Shoulder stabilization: the process of making firm and steady24 of a previously unstable
shoulder
Arthroscopy: the examination of the interior of a joint, performed by inserting a specially
designed endoscope through a small incision23
Open operation: a surgical procedure that provides a full view of the structures or organs
involved through membranous or cutaneous incisions23

Criteria for considering studies for this review

Types of studies
Quantitative primary studies published between January 1984 December 2004 that
compare arthroscopic with open shoulder stabilization for the management of traumatic
anterior glenohumeral instability will be sourced for this review. Study designs such as
randomized controlled trials, quasi-randomized controlled trials, case-control and cohort
studies, which represent levels II and III in the NHMRC 2000 Hierarchy of Evidence will
be included.25 Case series will be excluded from this review because of the lack of a
comparison group. No language restrictions will be applied.
Types of participants
Patients with traumatic anterior glenohumeral instability, confirmed by one or more of
the following: a history of trauma precipitating anterior dislocation/subluxation,
radiological evidence, clinical examination, examination under anaesthesia (EUA) and
arthroscopy will be included.26 By definition, traumatic anterior glenohumeral instability
may include first-time dislocators as well as patients with recurrent dislocations,
subluxation or a positive apprehension test. Patient groups that are specifically 40 years
and older will be excluded from the study because of a higher rate of associated rotator
cuff pathology within this age-group.26,27 Patients with multidirectional instability and
any other concomitant shoulder pathology will also be excluded to eliminate potential
confounding factors that could affect the outcome of the stabilization procedures for the
management of traumatic anterior glenohumeral instability.
Types of interventions
Interventions will include all types of arthroscopic shoulder stabilization techniques such
as suture anchors, bioabsorbable tacks, transglenoid sutures and metallic fixators, with or
without additional suture plication of the capsule, compared with open surgical shoulder
stabilization techniques, for the management of traumatic anterior glenohumeral
instability. Studies that applied non-anatomical surgical procedures i.e. Putti-Platt,
Bristow will be excluded because, they do not correct the underlying pathological lesion;
they alter normal shoulder kinematics; have high complication rates and are infrequently
performed in clinical practice today.15,26,28,29
Types of outcome measures
A minimum follow-up period of 2 years will be sought because most recurrences of
instability usually occur within the first 2 years post-stabilization.3 Outcome measures
will be divided into primary and secondary. All studies must contain the primary outcome
measures while the secondary outcome measures may not be reported in every paper but
will be also collated.
The primary outcome measures sought will be:
1. Recurrence rate of instability
2. At least one functional shoulder outcome measure

The secondary outcome measures included in this review will be:

1.
2.
3.
4.
5.

Return to pre-injury level of activity

Range of motion particularly external rotation
Complication rates
Total costs of the procedures
Other outcome measures reported

Search strategy
The Evidence Based Medicine (EBM) Reviews Database that consists of the Cochrane
Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effect
(DARE), Cochrane Central Register of Controlled Trial Register (CCTR) and American
College of Physicians (ACP) Journal Club, and the Joanna Briggs Institute (JBI) website
have been searched for any systematic review publication on this topic that is similar. No
such reviews were found at the commencement of preparation of this protocol. Since
then, Freedman et al22 has published a meta-analysis on this topic. This secondary study,
neglects to evaluate the quality of the papers included, and evidence was sourced from
only two databases. Thus this work aims to complement the results of this recent
systematic review.
To ensure the search strategy is exhaustive, we aim to identify as many published
research studies as possible and research theses. A total of 11 databases (Medline,
Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary
Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest
Medical Library, Evidence-Based Medicine (EBM) Reviews, Physiotherapy Evidence
Database (PEDro), TRIP database, PubMed, ISI Current Contents Connect) will be
searched to maximize the number of relevant published studies. All databases will be
accessible via The University of Melbourne Library except for PEDro and TRIP, which
will be accessed via the Internet, and AMED, which will be accessed via the University
of South Australia Library. Three additional databases (Proquest Digital Dissertations,
Open Archives Initiative Search Engine (myOAI), the Australian Digital Thesis program
(ADP)) that index theses, will be searched to identify theses relevant to this topic.
Databases may contain indexing terms, otherwise known as Medical Subject Headings
(MeSH), and have variable ability to combine searches. Databases with indexing terms
(Medline and CINAHL) have been grouped together, and similar search strategies will be
used across these databases (Appendix I). Individual search strategies have been
developed for other databases based on their ability to combine search terms (Appendix
I). A clear definition of traumatic anterior glenohumeral instability, its synonyms and
subheadings were carefully considered prior to the search to ensure that all relevant
studies were identified (Table 2, Appendix 1).
Conference proceedings will not included as hand searching on available publications
might depend on their availability and could be difficult to obtain. Experts in the field
will not be contacted to obtain further possible unpublished studies as this might be
subject to bias, and the ease of access amongst different researchers may vary towards
different experts.

Methods of the review

Determination for inclusion in the review
All studies gained from the search strategies will be reviewed against the inclusion
criteria for eligibility by two independent reviewers (AB, CN) (Appendix II). Any arising
conflicts will be discussed, together with a third researcher (RH) to reach consensus for
inclusion. Potentially eligible studies, whose titles and abstracts provide insufficient
information to determine suitability for inclusion, will be obtained in full-text. The fulltext version of all the included studies will be subsequently collected and used to verify
the inclusion of these studies prior to proceeding to their evaluation, by the two
independent reviewers (AB, CN).
Data extraction
The citations of eligible papers will be entered into a Microsoft Excel (2003) database. A
description of each included study will then undertaken and the following information
will be extracted and tabulated:

Type of study (study design) according to NHMRC Hierarchy of Evidence 25

Number of participants
o Number of shoulders
o Drop-out rates and reasons
Type of participant e.g. age, gender, sports participation etc
Description of arthroscopic or open surgical shoulder stabilization procedure
Outcome assessment
o Types of measures used including their validity and reliability
o Time of outcome assessment
Main results
o Recurrence rate, functional outcome and other outcomes
o Complication rate
o Others reported

Evaluation of the quality of studies

1. Critical appraisal of the included studies will start by ranking the studies
according to the NHMRC Hierarchy of Evidence.25 This determines the
magnitude of bias within each study design.25
2. The studies will be evaluated for methodological quality. This will be performed
using the PEDro Scale, a standardised, validated critical appraisal tool that
provides an overview of the quality of the studies in a continuum.30 The scale is
scored out of 10, with 10 indicating the highest quality and 0 indicating the
poorest quality (Table 1 and Appendix III).

TABLE 1
Physiotherapy Evidence Database (PEDro) Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Eligibility criteria were specified

Subjects were randomly allocated to groups
Allocation was concealed
The groups were similar at baseline regarding the most important prognostic
indicators
There was blinding of all subjects
There was blinding of all therapists who administered the therapy
There was blinding of all assessors who measured at least one key outcome
Measures of at least one key outcome were obtained from more than 85% of
the subjects initially allocated to groups
All subjects for whom outcome measures were available received the treatment
or control condition as allocated or, where this was not the case, data for at
least one key outcome was analysed by "intention to treat"
The results of between-group statistical comparisons are reported for at least
one key outcome
The study provides both point measures and measures of variability for at
least one key outcome

Total Points

Yes/No
1
1
1
1
1
1
1
1

1
1
10

Physiotherapy Evidence Database (PEDro)

(http://www.pedro.fhs.usyd.edu.au/scale_item.html)
Data Analysis
Findings regarding the Hierarchy of Evidence, study quality and nature of the study /
population / results will be summarised in a narrative format. In particular, the results of
the studies will be considered with respect to the quality of the evidence. This aspect of
the systematic review was not undertaken by Freedman et al22. Thus this work aims to
complement the results of this recent systematic review. It may also be appropriate to
undertake meta-analysis of the data (using REVman), if there are adequate number of
studies investigating the effects of the same intervention, which use consistent outcome
measures.

References
1. Kazar B and Relovszky E. Prognosis of primary dislocation of the shoulder. Acta
Orthop Scand 1969; 40: 216-24.
2. Hovelius L.Incidence of shoulder dislocation in Sweden. Clin Orthop 1982; 166:
127-31
3. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg 1956;
38A: 957-77
4. Deitch J, Mehlman CT, Foad SL, Obbehat A and Mallory M. Traumatic anterior
dislocations in adolescents. Am J Sports Med 2003; 31: 758-63
5. Walton J, Paxinos A, Tzannes A et al. The unstable shoulder in the adolescent
athlete. Am J Sports Med 2002; 30: 758-67
6. Kralinger FS, Golser K, Wischatta R, Wambacher M and Sperner G. Predicting
recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002; 30:
116-20
7. Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults: 5year prognosis. J Bone Joint Surg 1987; 69A: 393-99
8. Rowe CR. Acute and recurrent anterior shoulder dislocations of the shoulder. Clin
Orthop North Am 1980; 11: 253-70
9. Hintermann B and Gachter A. Arthroscopic findings after shoulder dislocation.
Am J Sports Med 1995; 23: 545-51
10. Warner JJP, Kann S and Marks P: Arthroscopic repair of combined Bankart and
superior labral detachment anterior and posterior lesions: Technique and
preliminary results. Arthroscopy 1994; 10: 383-91
11. Moseley HF and Overgaard B (1962): The anterior capsular mechanism in
recurrent anterior dislocation of the shoulder. J Bone Joint Surg 1962; 44B: 91327
12. Rowe CR and Sakellarides HT. Factors related to recurrences of anterior
dislocations of shoulder. Clin Orthop 1961; 20: 40-47
13. Rodosky MW, Harner CD and Fu FH. The role of the long head of biceps muscle
and superior glenoid labrum in anterior stability of the shoulder. Arthroscopy
1994; 10: 383-91

10

14. Harryman DT II, Sidles JA, Harris SL et al. The role of the rotator interval
capsule in passive motion and stability of the shoulder. J Bone Joint Surg 1992;
74A: 53-66
15. Levine WN and Flatow EL. The pathophysiology of shoulder instability. Am J
Sports Med 2000; 28: 910-17
16. Handoll HHG, Aimaiyah MA and Rangan A. Surgical versus non-surgical
treatment for acute anterior shoulder dislocation (Cochrane Review). The
Cochrane Library Issue 2, 2004
17. Rowe CR, Patel D and Southmayd WW. The Bankart procedure: A long-term
end-result study J Bone Joint Surg 1978; 60A: 1-16
18. Jobe FW, Giangarra CE, Kvitne RS and Glousman RE. Anterior capsulolabral
reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med
1991; 19: 428-34
19. Green MR and Christensen KP. Arthroscopic versus open Bankart procedures: A
comparison of early morbidity and complications. Arthroscopy 1993; 9: 371-74
20. Karlsson J, Magnusson L, Ejerhed L et al. Comparison of open and arthroscopic
stabilization for recurrent shoulder dislocation in patients with a Bankart lesion.
Am J Sports Med 2001; 29: 538-42
21. Nelson BJ and Arcerio RA. Arthroscopic management of glenohumeral
instability. Am J Sports Med 2000; 28: 602-14
22. Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR Jr. Open Bankart repair
versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for
Recurrent Anterior instability of the shoulder: a meta-analysis. Am J Sports Med
2004; 32: 1520-27
23. Mosbys Medical Dictionary. (6th ed.) Mosby, 2002
24. Miller-Keane Excyclopedia & Dictionary of Medicine, Nursing & Allied Health.
(6th ed.) W.B. Saunders, 1997
25. National Health and Medical Research Council (NHMRC). How to use the
evidence: assessment and application of scientific evidence. Canberra: National
Health and Medical Research Council, 2000
26. Matsen FA, Titelman RM, Lippitt SB, Rockwood CA, Wirth MA. Glenohumeral
instability The Shoulder 2004; 2: 730-43

11

27. Sonnabend DH. Treatment of primary anterior shoulder dislocation in patients

older than 40 years of age. Conservative versus operative. Clin Orthop 1994; 304:
74-77
28. Lusardi DA, Wirth MA, Wurtz D and Rockwood CA, Jr. Loss of external rotation
following anterior capsulorrhaphy of the shoulder. J Bone Joint Surg 1993; 75A:
1185-92
29. MacDonald PB, Hawkins RJ, Fowler PJ and Miniaci A. Release of the
subscapularis for internal rotation contracture and pain after anterior repair for
recurrent anterior dislocation of the shoulder. J Bone Joint Surg 1992; 74A: 73437
30. Physiotherapy Evidence Database (PEDro)
http://www.pedro.fhs.usyd.edu.au
Accessed 23/09/2004

12

Appendix I Search Strategy

Databases were grouped together based on their search function characteristics. Similar
search strategies for each of these database groups were developed according to Brettle
and Grant (2004).
Group 1: Databases where papers were listed under and searched by Medical Subject
Headings (MeSH) otherwise known as indexing terms, as well as by keywords. These
databases had functions that allowed the MeSH and keywords used in the search to be
combined using an appropriate combining term (AND or OR). They also utilized
truncation symbols (e.g.?,$) that can be applied to keywords. (MEDLINE, CINAHL)
Group 2: Databases where papers were searched by keywords only and had limited
ability for combination of keyword searches with an AND or OR. Wherever possible,
truncation symbols were applied. (ISI Web of Science, ISI Current Contents Connect,
Expanded Academic ASAP, Proquest Medical Library, Allied Health and
Complementary Medicine Database (AMED), Evidence Based Medicine (EBM)
Reviews)
Group 3: Databases where papers were searched by keywords only and had no ability for
combining searches. A single term, shoulder dislocation or shoulder instability were
searched for separately. (PEDro, TRIP Database, PubMed, Proquest Digital Dissertations,
myOAI, ADT)
Group 1
TABLE 2
Keywords and Medical Subject Headings (MeSH) for Medline and CINAHL
Keyword

Medline MeSH

CINAHL MeSH

Glenohumeral

Shoulder Joint
Shoulder Dislocation
Joint Instability

Glenohumeral Joint
Joint Instability
Shoulder
Dislocations

Instability

Joint Instability

Joint Instability
Shoulder
Shoulder Dislocation

Shoulder

Shoulder
Shoulder Joint
Shoulder Dislocation

Shoulder
Shoulder Joint
Shoulder Dislocation

Dislocation

Dislocations

Dislocations

Trauma

Wound and Injuries

Trauma

Reconstruction

Reconstructive Surgical Procedures

Stabilisation

Joint Instability
Dislocations

Joint Instability

Arthroscop$(y)

Arthroscopy

Arthroscopy

Surgery

Surgery

Operative Surgery

13

Medline
1

Shoulder.mp. [mp=title, original title, abstract, name of substance, mesh subject

heading]

2 Shoulder Joint/
3 Glenohumeral.mp.
4 1 or 2 or 3
5 Joint Instability.mp. or Joint Instability/
6

(unstable or dislocation$ or sublux$).mp. [mp=title, original title, abstract, name of

substance, mesh subject heading]

7 5 or 6
8 4 and 7
9 Shoulder Dislocation/
10 8 or 9
11 Trauma$.mp. or "Wounds and Injuries"/
12 Anter$.mp.
13 10 and 11 and 12
14 stabili?ation.mp.
15 arthroscop$.mp. or Arthroscopy/
16 SURGERY/ or Surgery.mp.
17 Reconstruction.mp. or Reconstructive Surgical Procedures/
18 14 or 15 or 16 or 17
19 13 and 18
CINAHL
1 Shoulder.mp. [mp=title, cinahl subject headings, abstract, instrumentation]
2 Shoulder Joint/
3 Glenohumeral.mp.
4 Glenohumeral Joint/
5 1 or 2 or 3 or 4
6 Joint Instability.mp. or Joint Instability/

14

7 Dislocation.mp. or Dislocations/
8 Subluxation.mp. or SUBLUXATION/
9 unstable.mp.
10 6 or 7 or 8 or 9
11 5 and 10
12 Shoulder Dislocation/
13 11 or 12
14 stabilisation.mp.
15 stabilization.mp.
16 14 or 15
17 open.mp.
18 arthroscopy.mp. or ARTHROSCOPY/
19 arthroscopic.mp.
20 surgery.mp. or Surgery, Operative/
21 reconstruction.mp.
22 17 or 18 or 19 or 20 or 21
23 13 and 22
Group 2
ISI Web of Science
1 Shoulder Dislocation
2 Shoulder Instability
3 1 or 2
4 Anterior
5 3 and 4
6 Arthroscopy
7 Arthroscopic
8 6 or 7
9 5 and 8

15

ISI Current Contents Connect

#1 SHOULDER
#2 INSTABILITY
#3 DISLOCATIONS
#4 #1 AND #2
#5 #1 AND #3
#6 #4 OR #5
#7 ANTERIOR
#8 #6 AND #7
#9 ARTHROSCOPY
#10 ARTHROSCOPIC
#11 #9 OR #10
#12 #8 AND #11
Evidence Based Medicine (EBM) Reviews
1 Shoulder.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
2 Glenohumeral.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
3 Glenohumeral Joint.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
4 Shoulder Joint.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
5 1 or 2 or 3 or 4
6 Joint Instability.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
7 Unstable.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
8 Subluxation.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
9 Dislocation$.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw]
10 6 or 7 or 8 or 9
11 5 and 10
Allied and Complementary Health Medicine Database (AMED)
1 Shoulder
2 Glenohumeral
3 1 or 2
4 Instability

16

5 Dislocation
6 4 or 5
7 Reconstruction
8 Stabilisation
9 7 or 8
10 3 and 6 and 9
Expanded Academic ASAP and Proquest Medical Library
1 Shoulder Dislocation
2 Shoulder Instability
3 1 or 2
Group 3
Physiotherapy Evidence Database (PEDro), TRIP Database, PubMed, Proquest Digital
Dissertations, myOAI, ADT
1 Shoulder Dislocation
Or
1 Shoulder Instability

Reference
Brettle A, Grant MJ. Finding the Evidence for practice: A Workbook for Health
Professionals. Edinburgh: Churchill Livingstone, 2004

17