A t the casualty department.. in Scandinavia, 7-10% of the injuries are ankle sprains. This injury is the most common injury in sports (13,20). Eightyfive percent of the sprains involve plantar flexion and supination. In 65% of the sprains, the injury is located only in the anterior talofibular ligament. With more violent inversion force, 20% also suffer damage to the calcaneofibular ligament. The calcaneofibular and the posterior talofibular ligaments are seldom r u p tured alone (14).Traditional sprains of the ankle have been classified into three grades. Grade 1 injury (mild) involves stretching of the ligament without macroscopic tearing, mild swelling, or tenderness, and no mechanical instability of the joint. Grade 2 injury (moderate) involves a macroscopic tear of the ligament with moderate pain, swelling, and tenderness, but no instability of the joint. Grade 3 injury (severe) involves a complete rupture of the ligaments with severe swelling and tenderness (6,10,13

At an average follow-up of 3.7 years we assessed the results of non-operative treatment of 84 symptomatic shoulders in 59 patients with a diagnosis of multidirectional shoulder instability. Sixty-two shoulders had received no previous surgical treatment (group A) while 22 had failed to respond to surgical treatment before the rehabilitation programme (group B).Subjectively 11 of the non-operated shoulders (group A) were cured and 27 improved, 23 of the shoulders remained the same and one was worse at follow-up. According to the age and gender adjusted Constant score, 38 of the non-operated shoulders had either no disability or only mild disability, nine had moderate disability, while the remaining 15 had severe or total disability. These figures were far worse in group B. In group A only four shoulders required operation, while in group B seven required operation following rehabilitation.Patients who had had previous shoulder surgery, those with a work related injury and those with psychological problems were less likely to benefit from the rehabilitation programme.Résume Nous avons suivi pendant 3.7 ans 84 épaules chez 59 patients avec une instabilité multidirectionnelle traitée par un programme de rééducation. Soixante-deux épaules (groupe A) ne recevaient aucun traitement chirurgical, et 22 épaules (groupe B) ont eu un traitement chirurgical inefficace avant la rééducation. Dans le groupe A, 11 sont sans symptôme, 27 sont améliorés, 23 restent sans changement, et une est aggravé. Selon le score de Constant, 38 épaules n'avaient aucune insuffisance ou avaient des signes cliniques très modérés, neuf avaient des signes modérés et 15 avaient une instabilité sérieuse. Les résultats dans le groupe B ont été beaucoup plus mauvais. Dans groupe A quatre épaules et dans le groupe B sept épaules ont été opérées après la rééducation. Les patientes qui étaient traités chirurgicalement á cause d'un accident du travail ont fait leur programme de rééduca-tion avec moins de succès.

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Patients suffering from generalised convulsions may dislocate their shoulders either anteriorly or posteriorly. Those with anterior dislocation are likely to have recurrent episodes because of secondary bony damage to the anterior rim of the glenoid and head of the humerus. In such patients there is high rate of failure of the standard soft-tissue stabilisation procedures. We have therefore devised a bone buttress operation in which autograft or allograft is secured to the deficient anterior glenoid and shaped to form an extension of its articular surface. We report our experience in 14 patients with grandma! epilepsy and recurrent anterior dislocation of the shoulder. After the bone buttress operation there were no further dislocations and all patients were satisfied despite a small restriction in their range of movement. We believe this to be the operation of choice for patients with this difficult problem.

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