Anterior Shoulder Subluxation

(Multiple Episode) (W/Surgical Reconstruction) (Football)

Four Phase Rehabilitation

William Lutz

April 29, 2013

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Anterior Shoulder Reconstruction Rehabilitation Protocol (Bankart Procedure)

Overview:

The glenohumeral joint is inherently predisposed to instability because of its bony architecture.

This instability comes as a consequence of the shoulder’s large range of motion. With

glenohumeral subluxations, there is excessive translation of the humeral head without

complete separation of the joint surfaces. Subluxation is a brief, temporary incidence in which

the humeral head quickly returns to its normal position relative to the glenoid after

displacement. The excessive movement of a glenohumeral subluxation often occurs with a tear

of the glenoid labrum and produces a permanent anterior defect called a Bankart lesion where

the inferior glenohumeral ligament is avulsed from labrum or along a portion of the labrum.

The goal of anterior shoulder reconstruction surgery is to facilitate the restoration of a stable

and functional shoulder that enables the athlete to return to his/her pre-injury activity level.

The Bankart procedure involves tightening the ligamentous capsule of the shoulder and

suturing it in place to prevent recurrent subluxation. The objective again is to maintain maximal

range of motion realizing that this is not always assured as motion is lost as a consequence of

increased stability. A proper rehabilitation program is essential for an athlete to regain range of

motion and a stable shoulder post-operatively. The idea in rehab is to push the athlete as

aggressively as possible while maintaining athlete safety in a controlled manner. The estimated

time frame for return to play activity is roughly 12 weeks, with unrestricted activity beginning

around 20 weeks. Progression for this rehab protocol is reliant on reaching several therapeutic

activity checkpoints and not simply based on time since surgery. The athlete, physical therapist,

athletic trainer, physician, and other medical professionals involved must work as a team to

provide the athlete with optimal outcomes. The athlete in this example protocol is a 20 year old

male football player.

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Initial Injury, Pathology, and Surgical Techniques (Section 1)

Mechanism of Injury:

Anterior shoulder instability can occur as a subluxation or a complete

dislocation. A subluxation implies a partial or incomplete dislocation of

the humeral head from the glenoid followed by a spontaneous

relocation. A dislocation occurs when there is no contact between the

articular surfaces of the humeral head and the glenoid fossa. The most

common mechanism of injury of anterior shoulder instability involves an

anterior to posterior directed force to the humorous while the arm is

positioned in shoulder abduction as well as external rotation. This

position occurs commonly in football while tackling or landing on the

field. Anterior shoulder instability can also be the result of gradual onset

and not as a distinct traumatic event. This instability occurs with

repetitive microtrauma to the labrum and capsule and is typical in

overhead throwing athletes.

Pathoanatomy:

Stability of the glenohumeral joint depends on both passive and active mechanisms. Passive

factors include joint conformity, adhesion/cohesion, finite joint volume,

and ligamentous restraints, including the labrum. The ligaments and

capsule contain within them proprioceptive receptors that detect joint

position in space. After an injury such as an anterior shoulder

dislocation or subluxation damaged capsuloligamentous structures lead

to altered proprioception and are only partially restored with repair.

Stabilizers are also affected by congenital factors, such as glenoid

hypoplasia and collagen, which leads to excessive joint laxity. In the end,

the active mechanism responsible for Glenohumeral stability stems

from the rotator cuff muscles (Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis).

Recurrent Instability:

Reccurent instability occurrences induce significant capsular laxity,

articular and labral deficiencies, and bone loss. The Bankart lesion is

the most common pathology but capsular redundancy/deformation

also plays a role. Repeated instability episodes do in fact stretch the

capsule, particularly the inferior glenohumeral ligament. Studies

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measured capsular elongation using MR arthogram and found significant changes specifically

along the anteroinferior and inferior capsule.

Variation in capsular laxity among athletes has led to the blanket classification of “spectrum of

shoulder instability.” At one end of the spectrum is an acute traumatic instability with a Bankart

lesion that often requires surgical treatment. The acronym TUBS is associated for this side of

the spectrum and stands for traumatic, unidirectional, Bankart, and surgery. At the other end of

the spectrum is the condition of the congenitally loose-jointed patient with a profound laxity

and shoulder instability caused by an underlying ineffective joint capsule. The acronym AMBRI

is associated with this and it stands for atraumatic, multidirectional, bilateral, rehabilitation,

inferior capsular shift.

Bone loss is generally associated with recurrence. Hill-Sachs lesions are common in the initial

acute setting and typically occur as the posterior-superior humeral head impacts against the

anterior glenoid rim. The incidence of a Hill-Sachs lesion is 90% in primary dislocation, 100% in

recurrent dislocation, and 25% in shoulder subluxation. [5] Thus, it is vital for bone loss to be

assessed after subluxation because of the roughly one in four chance of a Hill-Sachs lesion.

Surgical Treatment of Anterior Shoulder Instability:

Many studies have reported a recurrence rate of 90% or more in patients younger than 25

years old. The numbers are even higher for athletes in contact sports. There is increasing

evidence to support for surgical treatment after a first time trauma. The main outcomes of

surgical repair are significant reduction in recurrence rate as well as quality-of-life

improvements.

However, the shoulder is such a complex joint that many factors must be considered prior to

surgical intervention. Basics include patient age, activity level, and future desired level of sports

participation. Surgical intervention is indicated for athletes with recurrent unidirectional

shoulder instability. In particular young athletes who play high intensity and contact sports such

as in this case, a young football player. In people younger than 25 years old, the recurrence rate

following conservative non-operative management have been reported to be anywhere from

60 to 90 percent. Recent research indicates an increasing trend in surgical management even

after the first traumatic anterior shoulder episode.

Surgical management should be individualized on the basis of the athlete’s intra-articular

pathology and future activity levels. It is important to note that no surgical measure has a 0%

recurrence rate. Contraindications for surgical management may include brachial plexus and

axillary nerve injuries, deltoid dysfunction and infections.

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There are two main distinctions of the Bankart Repair, open versus closed. Based on

prospective randomized trials and a meta-analysis comparing open versus arthroscopic Bankart

repair, using “modern” suture anchor techniques, found no difference in recurrence rate. [1,3]

This may be because arthroscopic repair enables more effective visualization and capability to

target pathoanatomy with less tissue disturbance, yielding a shorter recovery time.

Contraindications of arthroscopic stabilization arise when there is significant bone loss greater

than 20% defect of the glenoid, humeral head, or an engaging Hill-Sachs lesion and should be

noted in advanced imaging. In cases of excessive bone loss procedures such as the Latarjet-

Bristow procedure yields better results but may cause increased loss of glenohumeral external

rotation.

In the procedure an initial diagnostic shoulder arthroscopy is performed through a posterior

portal. The surgeon looks for other possible pathology and confirms the diagnosis. Indicators

that the surgeon looks for humeral avulsion of the inferior glenohumeral ligament (HAGL) and

anterior labral periosteal sleeve avulsion (ALPSA) lesions, Hill Sachs lesions, as well as recording

the percentage of anterior glenoid bone loss with a calibrated probe. If the diagnosis is

confirmed, two more portals are inserted. The labrum is elevated off the anterior edge of the

glenoid and the anterior glenoid and scapular neck is prepared using a rasp and arthroscopic

shaver. Suture anchors are then placed

into the anterior glenoid near its rim,

beginning with the most inferior anchor

and working superiorly. Sutures are

passed though the labrum and capsular

ligaments to correct the loose tissues as a

result of the recurrent subluxations.

These sutures are then tied from inferior

to superior, restoring the anteroinferior

“hammock” and static stabilizers of the

glenohumeral joint.

Complications after arthroscopic stabilization are uncommon, with recurrent instability the

most common while loss of range of motion and neurovascular injury may also occur. Loss of

motion may be expected due to the exchange of motion for stability.

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Acute Care Measures (Section 2)

The athlete may noticeably self-immobilize his shoulder because of pain and

will hold the arm in internal rotation and adducted against his body.

Examination techniques are designed to provoke or alleviate pain and the

sensation of instability. Passive external rotation of the humorous must be

performed with caution, especially when the shoulder is in 90 degrees of

flexion as this replicates the apprehension or “crank” test. Positive

apprehension test results are followed up with the relocation test for anterior

instability, in which posteriorly-directed manual pressure is applied to the

anterior humeral head to add artificial stability. The anterior release or

“surprise” test should then be performed and is done by suddenly releasing

the posterior pressure applied during the relocation test. Positive findings on

any two of the apprehension, relocation, and anterior release tests highly

predict anterior instability.

History (recurrent subluxations) and the reported mechanism of injury (forced external rotation

while abducted) establish the foundation for the following findings. Onset is chronic in nature

but is often triggered by outside force such as tackling in football. The pain is reported as a

diffuse ache during activities of daily living and the sensation that the shoulder is “loose” when

abducted and externally rotated. Upon visual inspection a flattened deltoid is possible as

chronic cases can cause atrophy of the deltoid muscle group and the scapular muscles. Another

possible atrophy to note is that of rotor cuff muscles. Neurological status assessments using

myotomes and dermatomes should rule out possible nerve pathology. Pain on palpation will

presented as tenderness of the anterior glenohumeral joint. Active range of motion as well as

passive range of motion assessments will find decreased external rotation secondary to

sensation of instability and/or pain. Manual muscle testing may find pain and weakness with

external rotation. Known joint hypermobility is an indicator and will be shown in joint play of

unaffected shoulder and other joints. Hypermobility of the shoulder can be examined using the

Sulcus sign. Positive joint play assessments are an increased anterior glide, although it may not

be easily distinguishable with a bilateral comparison because of the nature of instability in

chronic cases. To rule out possible multidirectional and posterior instability the posterior

apprehension and Jerk tests should also be performed.

Referral to a physician is needed for further examination of the involved glenohumeral

structures. Radiographs of an anterior-posterior, trans-scapular lateral, and axillary view are

first obtained to confirm direction of subluxation and assess for the possibility of a fracture. A

CT and/or MRI must rule out a Hill-Sachs lesion as the lesion is often asymptomatic. With

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recurrent instability, there is almost a certain amount of bone loss. Significant bone loss is

greater than 20% defect of the glenoid.

After a proper diagnosis, the involved shoulder should be immediately immobilized using a sling

with elbow bent and supported at around 90 degrees to limit downward pull of arm.

Cryotherapy should be applied to decrease inflammation by slowing cellular mechanism and

vasoconstriction while also slowing nerve conduction velocity to decrease pain sensation. While

in the ATR Game Ready is preferred because of the combination of cold and intermittent

compression but ice bags at home should be applied 20 minutes of each hour. Removal from

play is needed to prevent further injury. Compression should be applied as it provides a

mechanical therapeutic effect and significantly controls swelling as well as further supports the

area. Elevation is contraindicated as raising the arm will impede the healing process and disrupt

tissues during this phase. Medication may be administered to help control inflammation and

pain. If surgical management is indicated as previously outlined, immobilization should

continue until surgery. Treatment and management decisions will depend on the athletes’ age,

hand dominance, sport, position, level of activity, expectations, and recovery timetable. An

important concept to remember here is that it is impossible to speed up the healing process,

but instead the therapeutic objective is to facilitate optimal healing conditions.

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Immobilization Phase (Section 3) [Weeks 0-3]

Post operatively, it is vital to have a baseline of information to start from to be able to measure

progress. Sources of information include, but are not limited to, athlete, yourself, physician,

medical records, and operative reports. There are ten components that must be evaluated;

injury status (where in the healing cycle), surgical results (how surgery went), joint mobility

(end feels), flexibility (goniometry), neurological status (reflex testing), muscular

strength/endurance (MMT or isokinetics), muscular atrophy (girth measurements of mid-

humerus), postural evaluation (visual compensation), general physical fitness, and psychological

status. All ten of these components enable measurable milestones when progressing and

should be documented throughout all phases of rehab. Irregularities in progression and

individualized pace will occur. To counter this, therapeutic objectives of that day, week, or

month’s rehab plan should focus on the issue until resolved.

Criteria for discharge from hospital usually requires minimal pain and swelling, satisfactory

distal and proximal muscle contractions, and AAROM of the shoulder to 60 degrees of flexion,

45 degrees of abduction, and 0 degrees of external rotation. No external rotation should occur

while the arm is abducted. Exercises that may be done in the hospital to meet this criteria are

gripping exercises with ball or putty, elbow ROM exercises and stretching, pendulum exercises,

isometrics of shoulder flexion, extension, internal and external rotation in the scapular

plane/safe zone, shoulder flexion to 60 degrees and shoulder abduction to 60 degrees as well.

The initial assessment for the athlete is as follows:

1. Injury Status: The Bankart lesion has been surgically repaired but remains in the acute

healing phase.

2. Surgical Results: Surgeon-athletic trainer communication indicates that the surgery was

successful with no complications. No Hill-Sachs or significant bone loss found.

3. Joint Mobility: Joint mobility assessment should not be performed at this phase

because it directly stresses the tissues surgically repaired.

4. Flexibility: Goniometry measurements are 60 degrees of flexion, 45 degrees of

abduction, and 0 degrees of external rotation.

5. Neurological Status: No numbness or tingling reported.

6. Muscular Strength/Endurance: Once the immobilization is removed assessment of

strength and endurance of the surrounding musculature.

7. Muscular Atrophy: Girth measurements are taken at the mid-humerus, both contracted

and relaxed, and provide measurable information for later comparison. Shoulder

displays atrophy compared to normal opposite shoulder.

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8. Postural Evaluation: The athlete has normal posture of the upper extremity, trunk, and

cervical spine.

9. General Physical fitness: Due to the athlete’s football activity, he has very good physical

fitness. The athletic trainer must try to minimize any loss of physical fitness during the

rehabilitation process to enable optimal return to play.

10. Psychological Status: The athlete is not showing symptoms of clinical depression.

Feelings of alienation and failure may be present. He is encouraged by the successful

surgery and is eager to have the immobilization removed so he can continue his

rehabilitation.

The immobilization phase immediately follows surgery and movement of the shoulder is

involuntarily limited by pain, swelling and possible muscle spasm as well as purposely restricted

by immobilization in a sling outside of therapeutic exercises. Therapeutic exercise involving the

shoulder must be done in a limited range of motion to facilitate optimal healing. During this

phase assisting the healing cycle is crucial and modality application generates optimal

conditions. This rehabilitation protocol focuses on logical progressions in therapy and exercises.

The body will adapt to imposed demands and it is important to adequately progress to prevent

injury and optimize healing. To most effectively rehabilitate the athlete, exercises will increase

in intensity as they become easy.

Game Ready for the shoulder, ice bags, protection, rest, ice, compression and medication will

all assist. Biowave, TENS, interferential current are used to help pain. These modalities may be

used throughout the complete rehabilitation process. Elevation is contraindicated because of

limited range of motion. Heating should not be done less than 48 hours after surgery. After 48

hours, heating before therapeutic activities may be done with ultrasound. Moist heat may be

used after ten days post-op. One of the more over looked concepts in the healing process is

nutrition and hydration. The athlete will not be as active as pre-intervention and thus, may not

be as thirsty but continuing proper hydration habits and healthy eating habits in combination

with sleep must be emphasized. The athlete should be instructed to sleep with the immobilizer

on.

Exercises should start in the plane of the scapula because the axes of rotation of the forces

acting on the glenohumeral joint fall in the center of this plane. The least provocative position is

between 20 and 55 degrees of scapular plane abduction while keeping the humerus below 55

degrees prevents impingement. Passive and active assisted range of motion for the

glenohumeral is cautiously performed in a restricted range of motion. Shoulder rotation is done

in 20 degrees of abduction. External rotation is to 30 degrees and internal rotation allowed to

25-30 degrees for the first three to four weeks. By around week six it may be progressed to 50

degrees. Passive forward elevation is progressed to 90 degrees for the first three weeks and

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progressed to 135 degrees by week six. Active assisted forward flexion can be progressed

between weeks three and six to 115 degrees. Avoiding full adduction minimizes excessive stress

across the supraspinatus, coracohumeral and capsuloligamentous complex. As range of motion

improves the ATC should progress outside the safe zones in a safe and controlled manner.

Passive stretching should be done after proper warm up and for 15-30 seconds and repeated 3-

4 times.

Active assisted range of motion exercises should be done in the scapular plane and safe zone as

previously described. PROM exercises and AAROM should be initiated and can be done with

ropes, pulleys, and T/L bars. Rope and pulley exercise is useful in regaining overhead motion.

ROM should be limited to a pain-free arc. Shoulder extensor stretching assisted by L-bar limits

possible joint adhesions while stretching latissimus dorsi, teres major and minor, posterior

deltoid, triceps and the inferior capsule. AAROM shoulder flexor stretch with L-bar stretches

the anterior deltoid, coracobrachialis, pectoralis major, biceps and, as a precautionary, the

anterior joint capsule. AAROM shoulder adductor stretch with L-bar is used to stretch the

latissimus dorsi, teres major/minor, pectoralis major/minor, posterior deltoid, triceps, and

inferior joint capsule. AAROM internal rotators stretch focuses on subscapularis, pectoralis

major, latissimus dorsi, teres major, anterior deltoid, and anterior joint capsule. AAROM

external rotator stretching focuses on infraspinatus, teres minor, posterior deltoid, and the

posterior joint capsule. AAROM horizontal adductor stretching pertains to the pectoralis major,

anterior deltoid, long head of the biceps and anterior joint capsule. Horizontal abductor stretch

is assisted with the unaffected arm and targets, posterior deltoid, infraspinatus, teres minor,

rhomboids, middle trapezius, and the posterior capsule. When manually stretching it is

important to perform with the athlete’s anterior shoulder supported by a table and the ATC’s

free hand to assist in joint stability. Pendulum exercises or Codman’s circumduction exercises

are crucial in reestablishing ROM when motion above 90 degrees is limited.

Isometric strengthening may continue for the flexors, extensors, internal rotators, and external

rotators. Isometrics remain important throughout to prevent sticking points and are useful

when full ROM isotonic exercise exacerbates the condition. Isometric exercise increases

strength ten degrees both ways from the position exercise is done in.

A modified conditioning program with teammates may assist psychologically as well as help

maintain cardiovascular conditioning with exercises such as biking. Being in the same room

even just once a week for a half hour can mean a lot to an injured athlete psychologically as he

is used to spending countless hours together with teammates. The athlete’s reaction to a long-

term rehabilitation is fear and anger. In the athlete’s mind it shows to their teammates and

coaches directly that they are not just slacking off and are still putting in work while injured.

Psychological status is the primary connection to adherence and ultimately represents the x-

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factor between poor results and excellent results. Monitoring and addressing loss of vigor,

irrational thoughts, alienation and other feelings must be done on a daily basis. If the athlete’s

schedule allows, having him stand on the sidelines at practice can also enable them to still feel

connected to the team and gives the goal oriented athlete something to ultimately strive for.

Practice exposure must be monitored as it may depress the athlete because he not on the field.

Therapeutic Objectives:

Promote healing of tissues and in particular sutured capsule

Gradual increase in ROM

Control pain and inflammation

Initiate light muscle contraction

Retard muscle atrophy

Range of motion:

Passive to AAROM – in scapular plane o External rotation (Conservative - must be pain-free) o Internal Rotation o Flx/Ext o Horizontal add/abd (Caution with abd)

Pendulum exercises /Codman’s

Wall walks/climbing

Rope/pulley (Flexion/Scaption)

Manual stretching

Active elbow/wrist/cervical spine flexion/extension ROM exercises

Strength:

Initiate submaximal/pain-free isometrics-all planes (start in scapular plane)

Grip strengthening with putty or ball

Core

General conditioning (biking)

Criteria for progression to restoration phase:

Removal from sling

Sufficient reduction of local symptoms (pain, swelling, inflammation, etc.) to permit safe and effective therapeutic exercise

ROM greater or equal to 55 degrees of flexion, 40 degrees of abduction, and 0 degrees of external rotation

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An acceptable degree of tissue healing to permit therapeutic exercise without aggravation of injury

Restoration Phase (Section 4) [Weeks 4-16]

The restoration phase or phase 2 begins after the athlete has been cleared from

sling/immobilization, sufficient reduction of local symptoms have allowed for safe and effective

exercise, and an adequate degree of tissue healing has taken place. The primary therapeutic

objectives for this phase revolves around regaining full ROM, improve dynamic stability,

establish muscular strength/endurance, and increase neurological function. Appropriate

modality use of thermotherapy before and cryotherapy (Game Ready) post therapy. Electrical

stimulation such as Biowave, IFC and TENS can be used to address pain and can be used

underneath Game Ready. These modalities should be continued throughout the remaining

phases.

Awareness of proprioception, dynamic stabilization restoration, preparatory and reactive

muscle facilitation, and replication of functional activities must be addressed. The end-range

motions in this phase will stress the capsuloligamentous afferents, while midrange motion will

stress the musculotendinous mechanoreceptors.

The post-immobilization assessment:

1. Injury Status: The Bankart lesion has been surgically repaired but remains in the repair

and remodeling healing phases.

2. Surgical Results: The surgery was successful with no complications.

3. Joint Mobility: Joint mobility assessment should not be performed at the beginning of

this phase because it directly stresses the tissues surgically repaired.

4. Flexibility: Goniometry measurements are greater than 60 degrees of flexion, 45

degrees of abduction, and 0 degrees of external rotation.

5. Neurological Status: No numbness or tingling reported. Full contraction ability present.

Proprioception and stabilizing functions are inadequate.

6. Muscular Strength/Endurance: Affected shoulder is weak. Limitations of ROM and pain

inhibit muscular function. Athlete has normal wrist and elbow strength.

7. Muscular Atrophy: Girth measurements are taken at the mid-humerus both contracted

and relaxed and provide measurable information for later comparison. Shoulder

displays atrophy compared to normal opposite shoulder.

8. Postural Evaluation: The athlete has normal posture of the upper extremity, trunk, and

cervical spine.

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9. General Physical fitness: Fitness is decreased after immobilization and must be

addressed.

10. Psychological Status: The athlete is not showing symptoms of clinical depression.

Athlete varies daily but in general is positively motivated. Athlete struggles with loss of

vigor, irrational thoughts, and alienation. Fears of losing his spot on the team, losing

function, and re-injury are present.

Warming up with UBE provides optimal warmth to tissue. Alternatives to UBE are ultrasound

and hot pack and should be done when range of motion is limited.

Grade I and II joint mobs are indicated by pain, decreased ROM, and decrease chance of

adhesions but must be done with extreme caution due to the nature of injury. The humerus is

convex and the glenoid is concave. The resting position is also the “safe zone” and is 55 degrees

of shoulder abduction, horizontal adduction to 30 degrees, and rotated so that forearm is in

horizontal plane. The treatment plane is in the glenoid fossa in the scapular plane. Posterior

glides increase flexion and internal rotation. Anterior glides and inferior glides may be done at

the later part of this phase with great caution to reach criteria for ROM but if the athlete

reports feelings of “looseness” do not continue. Anterior glides increase extension and external

rotation. Inferior glides increase shoulder abduction.

Proper stretching will encourage optimal biomechanics. Stretching should be done for 15-30

seconds and repeated 3-4 times. In addition to passive and AAROM, PNF stretching may be

done to initiate Golgi tendon organ inhibition of muscle spindles to restore ROM. PNF

progression from contract-relax to hold-relax and most complex slow-reversal-hold-relax to

optimize restoration of motion and flexibility. Creep and time under tension are keys for

establishing normal ROM. During this phase the athlete’s passive ROM should be around 155

degrees for flexion, 75 degrees of ER at 90 degrees of abduction, 50 to 65 degrees of ER at 20

degrees of abduction, and around 60-65 degrees of IR. Active shoulder flexion should progress

to 145 degrees.

Closed kinetic chain exercises may begin for proprioceptive, compressive healing principles, and

strengthens the capsular stabilizers more aggressively. Two essential force couples must be

reestablished around the glenohumeral joint: 1) the anterior deltoid along with the

infraspinatus and teres minor in the frontal plane, and 2) the subscapularis counterbalanced by

the infraspinatus and teres minor in the transverse plane. These opposing muscles act to

stabilize the glenohumeral joint by compressing the humeral head within the glenoid because

of their co-contraction. Closed chain exercises should progress starting on a stable surface like a

table to a wall to the floor and end on an unstable surface. Advancing to a less stable surface

like an Airex pad, air bladder, or Bosu ball during therapeutic exercises. Ball against wall

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exercises should start by just stabilizing statically then progress with added perturbation

intensity.

Closed Chain Exercises Progressions

Thumb screws Increase weight, reps, sets, and weight placed on thumb.

Wall climbs Increase height, reps, sets, and weight on fingers.

Push-ups Begin by just leaning on wall push-up while vertical with wall begin angling more as feet become further from wall push-ups on floor or table with weight supported at knees then progress to weight at feet

Ball against wall Add and increase perturbation applied

Weight shifting Quadriped triped on unstable surface (example: AirEx) perturbation applied

Slide board exercises Start on knees go to plank position

Weight shifting with devices BAPS board, increase ball size on ball ab wheel/Fitter slide board

*Exercises will progress differently and at different rates.

Weight bearing exercises should be made more challenging by adding outside

force/perturbation and weight to increase demands of stabilizers. Weight shifting on ab

wheel/Fitter and closed-kinetic-chain strengthening exercises for endurance may be progressed

to if previous closed-chain exercises are pain-free and biomechanically sound. Arm lateral steps

may begin later in this phase and can be progressed with size of box, sets and reps.

Plyometric exercise may be initiated towards the latter portion of the phase. Plyometrics

should focus on the amortization and eccentric phases. The athlete should be instructed to

catch the ball, decelerate it, and then immediately concentrically force the ball away. Chest

passes can be progressed to ball drops as movements become pain free and stable. Standing

wall push-offs offer less stress than push-ups and can begin early in the phase. To increase the

exercise the athletic trainer can stand behind the athlete and push them towards the wall. The

athlete must then decelerate the force and push back as fast as possible and repeat. Ball toss

with trampoline begins with double arm chest pass, double arm overhead, to single arm at 90-

90 supported by table, unsupported 90-90 throws, and ultimately single-arm toss on unstable

surface. Progressing from double arm to single arm limits early stress on affected shoulder. Ball

plyometrics are essential because the catching of the ball creates an overload in external

rotation and forces the athlete to dynamically stabilize and decelerate the force.

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Plyometric Exercises Progression

Chest Pass Increase weight of ball, reps, and sets

Standing Wall Push Offs Push athlete in back

Ball Drop Increase weight of ball, reps, and sets

Early Trampoline Ball Toss Double arm chest pass double arm overhead [increase weight of ball, reps, and sets.

Two-handed ball slams with plyoball Increase set, reps, and weight of ball

Table Supported 90-90 Throws Increase weight of ball, reps, and sets

Advanced Trampoline Ball Toss Unsupported 90-90 throws 90-90 throws on

unstable surface [increase weight of ball, reps,

and sets]

Scapular and rotation cuff stabilization exercises should focus on strength and endurance. Open

chain exercises such as rotator cuff exercises with bands and tubing should progress to focus on

eccentrics. Exercises should focus on strengthening rhomboids, latissimus dorsi, biceps,

supraspinatus, subscapularis, infraspinatus, teres minor and such include diagonal patterns as

well. Push-ups between chairs, ceiling punches, and push-up pluses can be initiated for the

serratus anterior. Light isotonic dumbbell exercise and a shoulder scapular stabilizing program

should begin. I’s, Y’s, T’s, and W’s should be performed with an emphasis on quality over

quantity. These exercises are stabilizing exercises and should have very low weight with high

repetitions. Other exercises for scapular stabilization are 6 count field goals, save the can,

empty can, and lying 3 way reverse raise. Exercises should be done in font of mirrors whenever

possible as visual cues increase form and sense of proprioception.

Progression to multi-angular exercises and sport specific exercises may begin later in the phase.

The Body Blade is excellent for this phase as it can progress from static stabilization to dynamic

stabilization as well as from single plane exercise to multiplanar dynamic exercises. An example

of a scapular strengthening exercise with the Body Blade is to have the athlete oscillate the

blade with both hands and move from an adducted position in front of the body to an elevated

position. Core firing is important during these exercises as the body must dynamically stabilize.

To progress, adding more multiplanar movements and going to single arm movement should be

done. PNF rhythmic contraction also increases dynamic stability. The athlete must isometrically

co-contract shoulder stabilizers to maintain specific position within the ROM while the ATC

repeatedly and unpredictably changes the direction of passive pressure. These exercises are

important neuromuscularly as involuntary dynamic stabilization is needed during play.

AAROM exercises should be continued as described in immobilization phase but must continue

to be stressed to the point of pain. Specific strengthening of the rotator cuff muscles and

scapular stabilizers establish the foundation for efficient exercises. The periscapular muscles

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provide the rotator cuff with optimal length-tension relationships making for more efficient

motion. Manual therapy exercises should be initiated as using PNF techniques assist in

reestablishing neuromuscular control. D1 and D2 patterns may be used but caution towards the

terminal position of D2 flexion as the shoulder is abducted and externally rotated.

When using an isokinetic machine for strengthening the shoulder, exercise should be done in

the scapular plane for reasons explained earlier. Example movements are internal/external

rotation, shoulder abduction/adduction, and D1 pattern. Strength should be 60-70% or better

when compared bilaterally around weeks 10 to 12. By weeks 13 to 16 compared strength

should be 80 to 90%. High strength and endurance levels are needed for progression to next

phase as weak shoulders have high recurrence rates. Isokinetic is both specific and measurable

and enables the ATC to quantify progression status.

Aquatic therapy will begin during this phase because of the physical properties and effects of

water such as buoyancy, hydrostatic pressure, and viscosity. Buoyancy enables for movements

parallel to surface of the water to be supported. Hydrostatic pressure means equal pressure at

a given depth and if greater than diastolic blood pressure decreases swelling. This will not occur

in the shoulder because the shoulder joint is part of the upper body and will not have enough

depth. It is difficult to get enough depth at the shoulder to enable this but mild compression

does assist and pressure centralizes blood flow. Viscosity plays a role as resistance in water is

proportional to the speed of the movement and the surface area of the body part being moved

and plays into drag force which is velocity squared. If movement occurs at equal rate

throughout, resistive force is equal throughout and restores shoulder strength, endurance, and

stability. Deep-water activity may also be integrated for conditioning purposes. The tactile

stimulation offered by water provides optimal proprioceptive and arthrokinematic restoration.

The density of water is greater than area and stimulates cutaneous receptors more effectively.

All planes of movement of the shoulder should be exercised in the pool.

The athlete should be in neck deep (10% weight bearing) water to allow for support of

scapular/thoracic area. To warm up have the athlete walk forwards, backwards, and sideways

while progressing to arm swings. This will help establish normal scapulothoracic motions,

rotation, and rhythm. Starting activities should start at the wall to establish comfort with water

if unfamiliar. Early exercise should stress movement without compensatory shoulder elevation.

Other than standing, prone and supine positions may be used, but with these a flotation device

for cervical, lumbar, and lower-extremity are needed when supine. These positions require

more core stabilization and allow for more functional movements. Activities such as PNF D1 and

D2 patterns should be done within pain-free motion. Another activity is “kayaking.” When the

athlete does a prone kayak movement they must use a snorkel and goggles. Supine position

allows for shoulder extension, internal rotation, and external rotation work at different

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positions of abduction. Remember to be cautious with external rotation combine with

abduction.

As the athlete progresses in aquatic exercise more surface area/resistance can be added with

the use of wings, hydrotone bells, wands, fins, gloves, and other aquatic devices. Around week

16, light swimming exercise may begin and will benefit general conditioning level, shoulder

stability, ROM, and proprioception.

Precautions for aquatic therapy include altered peripheral sensations, respiratory dysfunction

such as asthma, and for some athletes fear or unfamiliarity with water. External sutures must

be healed to prevent infection, irritation, or suture tearing.

General physical fitness must also be addressed. Conditioning programs may include biking,

treading water (using waist floatation device if needed), aquatic kicking exercises, stair stepper,

and light jogging. Holding a football while conditioning when possible can make exercises

functional as well.

Core stabilization represents the foundation for all movements. Functional kinetic-chain rehab

addresses each link in the chain and aims to develop functional strength and neuromuscular

efficiency. A core stabilization program will allow the athlete to gain optimal neuromuscular

control of the lumbo-pelvic-hip complex and facilitates return to activity more quickly and

safely. Important core muscles are stabilizers, not prime movers. There are many options for

core exercises and progress by changing positions, lever arms, and stability surfaces. The key is

to teach athlete to “fire” by pulling navel to back sensation.

Post activity cryotherapy must be done. Game Ready and ice bags are excellent. Ice cups may

also be utilized and can be done in stretched position to focus on specific tissue structures.

NSAIDs and other medications may be used to control inflammation and pain.

Psychologically the athlete must take responsibility for his own rehabilitation. Adherence and

motivation directly correlate to results. The interpersonal relationship between the athlete and

ATC can promote positive psychological status. At this stage the athlete may be down

psychologically but reminding him that other athletes have returned from the same injury gives

positive vicarious perspective. ATC is not a disciplinarian but must work with coaches to fortify

compliance.

Therapeutic Objectives:

Gradual increase to full ROM

Improve upper extremity strength and endurance

Control pain and inflammation

Normalize arthrokinematics

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Need to re-establish kinesthetic awareness o Dynamic balance

Vestibular system Proprioception Coordination of movement Visual stimulation

Towards end of phase begin functional rehab

Therapeutic Exercises:

UBE for warm-up activity

Continue with all previous ROM activities o No limitations on ER – avoid extreme end range ER and abduction

Rope/Pulley (Flex, abd, scaption)

Grade I and II joint mobs

PNF D1 and D2

Manuel stretching and Grade II-III joint mobs

IR/ER at neutral with tubing

Forward flexion, scaption and empty can

Prone horizontal abduction, extension to neutral

Sidelying ER

I’s, Y’s, T’s, and W’s

6 count field goals

PNF Rhythmic contraction stabilization

Body Blade

Bicep, triceps, wrist flx/ext strengthening

Closed Chain exercises (see table above)

Aquatic exercises (all planes of shoulder/D1/D2/kayaking)

Core – establish pelvic neutral

Cardio - biking, treading water, kicking in water, and stair stepper

Criteria for progression to return to activity phase

Sufficient reduction of local symptoms and sufficient extent of wound healing to permit resumption of at least part of the athlete’s regular practice or conditioning activities.

Sufficient restoration of joint range of motion, flexibility, muscular strength, muscular endurance, and arthrokinematics to permit safe resumption of at least part of the athlete’s regular practice or conditioning activities.

Athlete should have isokinetic tests showing 90% strength in the operative arm when compared to non-operative arm.

Satisfactory assurance of adequate protection from re-injury.

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o Protective taping/bracing (for example braces see below or compression wrap) o Playing environment o Modification of condition and practice to minimize risk of re-injury

Satisfactory levels of motivation and confidence on the part of the athlete.

Appointment with physician should confirm adequate stability and no complications.

Return to Activity Phase (Section 5) [Weeks 17 – 22]

In the return to activity phase functional activity and partial or full participation in football

activity represents bulk of rehabilitation. This phase focuses on continuing the restoration of

full range of motion, flexibility, muscular strength/endurance, proprioception,

arthrokinematics, and sport-specific function. Overall physical fitness will continue to be

important as there must be optimal restoration of all components of fitness to meet the criteria

to progress. Proper bracing for limited and full participation must be worn during this phase.

The goal of the brace is to prevent external rotation and abduction.

Post-restoration assessment results:

1. Injury Status: The Bankart lesion has been surgically repaired and is remodeling phase

of healing cycle.

2. Surgical Results: Surgically repaired tissues are strong and of adequate stability.

3. Joint Mobility: The glenohumeral joint is no longer hypermobile and has strong

ligamentous, muscular, and labral stabilization. Athlete is able to complete simple

functional drills that stress structures.

4. Flexibility: The athlete is limited by pain at terminal portions of ROM of the

glenohumeral joint.

5. Neurological Status: No numbness or tingling reported.

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6. Muscular Strength/Endurance: Shoulder strength is less than unaffected shoulder and

scapular/rotator cuff musculature is not strong enough to stabilize against contact.

7. Muscular Atrophy: Muscle size is equal to unaffected and does not display visual

atrophy. Girth measurements of mid humerus measurable express muscular

hypertrophy since immobilization phase atrophy.

8. Postural Evaluation: The athlete has normal posture of the upper extremity and trunk.

9. General Physical fitness: Physical fitness is near or at adequate levels for safe

participation.

10. Psychological Status: Athlete varies daily but in general is positively motivated and

adheres to rehab. Athlete still battles with loss of vigor, irrational thoughts, and

alienation less frequently.

Plyometrics will also be important in this phase as stabilizing and deceleration/acceleration

capabilities must be address. The goal is to increase the neural excitability of the

neuromuscular system so stabilization is more coordinated and prevent displacement when

force is applied. The athlete began basic plyometrics in the previous restoration phase but the

activities must impose higher demands to reach full activity level. Shuttle push offs while seated

should be done and can progress from double arm to single arm. Progression for these

exercises may be done by increasing weight of ball, resistance of Shuttle, sets, and reps.

Plyometric push-ups on boxes enables the athlete to stretch anterior musculature and

facilitates concentric contraction.

Plyometric Exercises Progression

Trampoline ball toss Unsupported 90-90 throws 90-90 throws on unstable surface [increase weight of ball, reps, and sets]

Shuttle push-offs Increase resistance, reps, and sets.

Push-ups with Push-Offs Increase height off the ground clap push-ups clap push-ups on unstable surface [weight vest is another option]

Two-handed ball slams with plyoball Increase set, reps, and weight of ball

Push-ups on boxes. Start on knees full plank position add

weight vest

Closed chain exercises must progress in intensity as well. Weight shifting on an unstable surface

facilitates co-contraction of the shoulder muscles involved in the force couples that collectively

produce dynamic stability by facilitating reflex pathways. Placing the feet at an increased height

so more weight is on the hands will also impose increased demands. Hand positioning may also

be adjusted as the wider the hands the easier it is to maintain stability. Combining excises may

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also begin and an example of this is a triped position with Body Blade in non-weight bearing

hand as the athlete works to stabilize the oscillating blade while performing closed-chain

stabilization. To impose even greater demand have the weight bearing portion on an unstable

surface such as an Airex pad or air bladder.

Closed Chain Exercises Progressions

Push-ups Add weight vest, increase reps and sets, add push-up plus, decrease distance between hands, increase height of legs on plyo ball on stair climber

Ball against wall Add and increase perturbation applied

Weight shifting Quadruped tripod on unstable surface (example: Airex/stability ball) perturbation applied (Body Blade)

Slide board exercises Start on knees go to plank position

Weight shifting with devices BAPS board, increase ball size on ball Fitter slide board

Arm lateral step ups Increase box size, sets, and reps

Upper body treadmill (push/pull) Increase speed, sets, and reps

Isotonic exercises may begin but modification and communication of alterations must be

communicated with strength coach, remember to avoid the combined position of external

rotation and abduction. Exercises that must be modified are fly, pull-downs, push-ups, bench

press, and military press. Push-ups, pull downs, bench press are must be performed with hands

close and the key is to avoid the last 10 to 20 degrees of shoulder extension. Pull downs and

military presses must be modified and performed with wide bars and machines and keep

exercises in front of head to avoid behind head movement. Supine fly should avoid 30 degrees

in the frontal or coronal plane while maintain internal rotation to prevent humeral head stress

on anterior tissues.

If the athlete is a thrower strengthening exercises for throwing should be initiated. Exercises

with dumbbells, tubing, bands, and plyometrics should be already incorporated and increased.

Interval throwing program may be initiated. The throwing progression must start with a short

distance and progress further.

As the athlete gains full strength, endurance, stabilization, and range of motion more rigorous

functional activities begin. Functional activities should impose sport-position demands. The

affected shoulder has 90% of the strength compared isokinetically and stabilizers are strong.

Complete functional rehab aims to improve neuromuscular coordination and agility, strength,

endurance, and flexibility in the context of sport-related activity. Each functional activity should

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be broken into smaller components to allow the athlete to progress from simple to complex. To

functionally test the shoulder assessments should be based on the sport and as the position

demands. The athlete in this protocol is a defensive back. Functional activities play a vital

psychological role as well and can decrease athlete anxiety, deprivation, and apprehension

about return to play.

Participation should be done while braced and supported to prevent abduction combined with

external rotation.

Therapeutic Objectives:

Full painless ROM

Maximize upper extremity strength and endurance

Maximize neuromuscular control

Normalize arthrokinematics

Clinical examination with no impingement signs

Need to re-establish kinesthetic awareness o Dynamic balance

Vestibular system Proprioception Coordination of movement Visual stimulation

Develop new kinesthetic awareness exercises to keep athlete from getting bored

Functional Rehab throughout (connect clinical rehab to playing field)

Range of Motion:

Continue all ROM activities from previous phases

Posterior capsule stretch

Towel internal rotation stretch (see picture)

Manual stretching and Grade II-III joint mobs

Therapeutic Exercises:

Continue all strengthening from previous phases increasing resistance and repetitions

UBE/versa climber for strength and endurance

Initiate isokinetic IR/ER at 45 degrees abduction at high speeds

Progress overhead plyotoss for dynamic stabilization

Progress rhythmic stabilization throughout range of motion

Initiate lat pull downs

Progress PNF to high speed work

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Functional exercises:

Holding of football during jogging/running

Ball punches while holding ball secure

Rolling in both directions

Drive blocking with sled drills

Dummy pushes and tacking (start with stiff arming and progress to tackling)

Up-downs

Tip drills (jump ball is thrown and athlete must jump to catch over opponent)

Fumble drills (landing on ground and securing ball)

Catching drills (Progress to unstable surface, route running, reaction glasses, single arm, and different balls)

Progress to combinations of functional exercises into one drill (example: sled to simulate jamming receiver, to tackling dummy, and then recovering fumble all in sequence)

Progress to controlled drills with opponent

Criteria for progression to maintenance phase:

Optimal restoration of all components of physical fitness

Full normal ROM in all planes at the glenohumeral joint. o 0-180° for flexion o 0-50° for extension o 0-180° for abduction o 0-90° for IR/ER

Pre-injury activity levels

Resumption of complete and unrestricted participation

Maintenance Phase (Section 6) [Weeks 23+]

The maintenance phase is reached when “complete rehabilitation” is achieved and full athlete

activity is resumed. To prevent re-injury, specific conditioning exercises may be done to

maintain shoulder stability. Shoulder strengthening/endurance exercises, stretching, and

scapular stabling exercises still must be done outside of sport participation to prevent re-injury

and maintain proper biomechanics if symptoms reoccur. Progression to this phase requires that

the athlete has full pain-free ROM, normal shoulder strength, pain-free sport-specific activity,

and adequate protective equipment to wear. The athlete is now sound both in body and mind.

The full return to play assessment for the athlete is as follows:

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1. Injury Status: The Bankart lesion has been surgically repaired and is fully healed.

2. Surgical Results: Surgically repaired tissues are strong and of adequate stability of the

shoulder as compared to pre-injury level.

3. Joint Mobility: The glenohumeral joint is no longer hypermobile and has strong

ligamentous, muscular, and labral stabilization.

4. Flexibility: The athlete is at full pain-free ROM in all planes at the glenohumeral joint.

Shoulder ROMs are 0-180° for flexion, 0-50° for extension, 0-180° for abduction, 0-90°

for IR and ER.

5. Neurological Status: No numbness or tingling reported.

6. Muscular Strength/Endurance: Shoulder strength is equal to or exceeds unaffected

shoulder and scapular/rotator cuff musculature is strong enough to stabilize against

contact.

7. Muscular Atrophy: Muscle size is equal to unaffected and does not display visual

atrophy. Girth measurements of mid humerus measurable express muscular

hypertrophy since immobilization phase atrophy.

8. Postural Evaluation: The athlete has normal posture of the upper extremity and trunk.

9. General Physical fitness: Due to the athlete’s football pre-injury activity, general

physical fitness is high and cardiovascular conditioning allows for full participation.

10. Psychological Status: Athlete expresses limited apprehension about participation and

has sound mindset to participate in contact activity. A sense of acknowledgement is felt

as the rehabilitation process is complete. They are confident after completing functional

exercises. The athlete also displays trust that everything has been done to be as

prepared for full return to play as possible.

Therapeutic Objectives:

1) To maintain muscular strength in the affected shoulder equal to, or exceeding the

opposite shoulder.

2) To maintain muscular endurance in the affected shoulder high enough to meet

demands of sport.

3) To maintain flexibility equal to, or exceeding that of the opposite normal limb.

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References:

1. Bottoni CR, Smith EL, Berkowitz MJ, et al. Arthroscopic versus open shoulder

stabilization for recurrent anterior instability: a prospective randomized clinical

trial. Am J Sports Med 2006;34(11):1730-7.

2. Hobby J, Griffin D, Dunbar, et al. Is arthroscopic surgery for stabilization of chronic

shoulder instability as effective as open surgery? A systematic review and meta-

analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg

Br 2007;89(9):1188-96.

3. Jakobsen, BW., et al. (2007). “Primary Repair Versus Conservative Treatment of First-

Time Traumatic Anterior Dislocation of Shoulder: A Randomized Study with 10-

Year Follow-UP.” Journal of Arthroscopic and Related Surgery. Vol 23: 118-123.

4. Prentice, William E. Rehabilitation Techniques for Sports Medicine and Athletic Training.

Boston: McGraw-Hill, 2004.

5. Rowe CR, Zarubs B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg

Am. 1981;63(6):863-72.

6. Starkey, Chad, Sara D. Brown, Jeffrey L. Ryan, and Chad Starkey. Examination of

Orthopedic and Athletic Injuries. Philadelphia: F.A. Davis, 2010.