Rehab of the Unstable ShoulderChris Sawyer, PTChildren’s Mercy Hospital

Epidemiology•Shoulder is a joint evolved for mobility

•Instability is usually defined as a clinical syndrome that occurs when laxity produces symptoms

•Dislocation & subluxation of GH joint occurs relatively frequently in athletes

Epidemiology•Rowe found a bimodal distribution of

shoulder dislocation with peaks in the 2nd and 6th decades with 98% of those cases being anterior dislocations

•Hovelius found traumatic injury to be the most common cause of shoulder instability, accounting for 95% of anterior dislocations

Epidemiology •Rowe found that 70% of those that

experience a dislocation can expect a recurrent dislocation within 2 years of the initial injury

•Recurrence is highly age-dependent

•In patients younger than 20 years of age, recurrent dislocations rates have been reported as high as 90% in the athletic population

Anatomical Considerations

Anatomical ConsiderationsMiddle glenohumeral ligament

Primarily effective at 45° abduction Helps limit external rotation, inferior and

anterior humeral tranlsation.Superior glenohumeral ligament

Plays minor role in preventing anterior instability

Primarily limits inferior translation and external rotation of the adducted arm

Anatomical ConsiderationsInferior glenohumeral ligament

Heavily involved in maintaining shoulder stability

With an anterior and posterior band, it supports the humeral head like a hammock

Primary stabilizer limiting anterior, posterior & inferior humeral translation at 90° abduction

Detachment of anterior band from glenoid and labrum is known as the Bankart Lesion.

Anatomical Considerations

Anatomical ConsiderationsRotator Cuff

EMG Studies show that all (with deltoid) are active throughout full ROM of flexion, abduction and elevation

Co-contraction helps hold humeral head in center of glenoid throughout arc of motion

Create GH compressive force that helps stabilize joint

Anatomical Considerations•Scapulothoracic stability has been

emphasized as an important component of GH stability.

•Dysfunction can lead to failure of scapular rotation beneath the humeral head, permitting abnormal translation

•Trapezius, serratus anterior and rhomboids all influence scapular movements

Patient Evaluation•History

▫Traumatic vs Atraumatic dislocation▫Symptoms▫General laxity▫Party Trick?

Patient Evaluation•Physical Exam

▫Muscle atrophy and scapular winging▫ROM assessment▫Special tests

Sulcus Sign Load and Shift Apprehension Test

Rehabilitation•No scientific studies available to support

one specific rehab regimen in preference to another

•Key to pain-free shoulder function for sporting activities is functional stability or a balance between stabilizers of the shoulder and forces applied to the shoulder

•Rehab should aim to optimize the performance of the dynamic stabilizers

Rehabilitation•Dynamic compression—1st mechanism of

functional stability▫Sub-scapularis co-contracts with

infraspinatus and teres minor to center and compress humeral head into glenoid fossa

▫Interior fibers of rotator cuff co-contract with anterior deltoid to help keep head centered in fossa

Rehabilitation•Dynamic ligament tension—2nd mechanism

of functional stability• Rotator cuff tendons blend with shoulder capsule

at their point of insertion and serve to tighten capsule on contraction

•Reactive neuromuscular control—3rd mechanism of functional stability▫Involves exercising the unstable shoulder in

positions that maximally challenge dynamic stabilizers---Plyometrics helps to retrain neuromuscular control

Rehabilitation•Provision of stable platform under

humeral head requires the scapula and humerus to move in synchrony and allows orientation of glenoid to adjust in responses to changes in arm position▫Trapezius and serratus anterior contribute

to 2 importan force couples that produce scapular elevation

Exercises•Subscapularis

▫Internal rotation activities Isometric against wall, sidelying, prone,

standing•Infraspinatus

▫External rotation activities Isometric against wall, sidelying, prone,

standing•Teres Minor

▫External rotation activities Isometric against wall, sidelying, prone,

standing

Exercises•Anterior deltoid

▫Forward flexion exercises Supine, prone, standing forward flexion-thumb up Push ups---wall, counter, floor

•Serratus Anterior Serratus punches, push up plus, rows

•Latissimus Dorsi Lat pulls, seated press ups

•Rhomboids Rows, scap squeezes, standing horizontal abd

Exercises•“Other” strengthening ex’s

▫PNF patterns---active-assisted, wall wash, t-band

▫Ceiling swiss ball walks▫Ball walk outs▫Shoulder geometry, alphabets▫Standing abduction with forearms pressed

against wall

Evidenced Based Practice• Postacchini et al

▫92% rate of recurrence with a mean of 7 re-dislocations in patients who had a traumatic dislocation at the age of 14-17

▫86% rate of recurrence with a mean of 2.3 re-dislocations in patients who had an atraumatic dislocation between 14-16

▫Bankart lesion found in 80% of cases—each of these patients had a tramautic primary dislocation at the age of 14-17

Evidenced Based Practice•Postacchini et al (cont)

▫7/28 patients had surgery (5 traumatic, 2 atraumatic)—all 5 traumatic dislocators reported no issues of recurrence and had stable shoulder on exam, both atraumatic dislocators continued to have recurrence issues and were unstable on exam

▫21/28 did not have surgery---all reported issues with recurrence and/or had clinical signs indicating anterior or multidirectional instability

Evidenced Based Practice•Burkhead et al

▫140 shoulders in 115 patients that had a dx of traumatic or atraumatic recurrent anterior, posterior or multidirectional instability were treated with specific set of strengthening exercises

▫12/74 (16%) that had traumatic subluxation had good or excellent results from exercise regimen

▫53/66 (80%) that had atraumatic subluxation had good or excellent results with exercise regimen

Evidenced Based Practice•Hovelius et al & DeBerardino et al

▫300 patients with anterior dislocations who did not have surgery

▫Follow up 8-10 years after initial dislocation▫55% rate of recurrence

•Combo of multiple studies from 1996-2000▫120 patients with anterior dislocations who

undwent open bankart repair▫Follow up 2.5-12 years after initial dislocation▫6% rate of recurrence

References• Bahu, M., Trentacosta, N., Vorys, G., Covey, A., Ahmad,

C.: Multidirectional Instability: Evaluation and Treatment Options. Clinics in Sports Med., 27: 671-689, Oct. 2008

• Bonci, C., Sloan, B., Middleton, K.: Nonsurgical/Surgical Rehabiliation of the Unstable Shoulder. Journal of Sport Rehabilitation. 1:146-171. 1992

• Burkhead, W., Rockwood, C.: Treatment of Instability of The Shoulder with an Exercise Program. Journal of Bone and Joint Surgery. 74A: 890-896. 1992

• Dodson, C., Cordasco, F.: Anterior Glenohumeral Joint Dislocations. Orthopedic Clin N AM. 39: 507-518. 2008

References• Mallon, W., Speer, K.: Multidirectional Instability:

Current Concepts. Journal of Shoulder and Elbow Surgery. 4: 54-64. 1995.

• Postacchini, F., Gumina, S., Cinotti, G.: Anterior Shoulder Dislocation in Adolescents. Journal of Shoulder and Elbow Surgery. 9: 470-474. 2000.

• Walton, J., Paxinos, A., Tzannes, A., Callanan, M., Hayes, K., Murrell, G.: The Unstable Shoulder in the Adolescent Athlete. The American Journal of Sports Medicine. 30:758-767. 2002

• Wang, R., Arciero, R.: Treating the Athlete with Anterior Shoulder Instability. Clinical Sports Medicine. 27: 631-648. 2008